ESBD_File_323695_Attachment G 5.3.2023.docx

ATTACHMENT G

CONFLICT OF INTEREST ANALYSIS FORM

RFX 701-2X-XXX, Descriptive Project Title

The Texas Education Agency (TEA) will not accept information provided in other areas of the response in lieu of full completion of this form. TEA recommends this completed form and responsive attachments be incorporated into a separate and distinct section of the response. Failure to furnish this information will result in disqualification from further consideration. Attach additional pages if more space is needed to complete the form.

It is the policy of the State of Texas and TEA that a state officer or employee may not have a direct or indirect interest, including financial and other interest, or engage in a business transaction or professional activity, or incur an obligation of any nature that conflicts with the proper discharge of the officer or employee’s duties in the public interest (Texas Gov’t Code §572.001(a)). TEA is committed to vetting any conflict of interest or the appearance of any conflict of interest that may arise in the procurement process. TEA will use information in this document to review conflicts of interest or potential conflicts of interest for this procurement.

SECTION A: RESPONDENT INFORMATION

1. List the members (names and titles) of the respondent’s board of directors, advisory council, or governing board. (If the respondent does not have a board of directors, advisory council, or governing board, then enter N/A.)

2. List the respondent’s executive or senior leadership (names and titles). (If the respondent is a sole proprietor or does not have executive or senior leadership, then enter N/A.)

3. Complete the table below for any individual not already listed in 1. or 2. above who owns more than $25,000 of the fair market value of the respondent’s business entity, or holds shares, stocks, or other direct/indirect participation in more than 10% of profits, proceeds, or capital gains. (If not applicable, then enter N/A.)

4. Attach the respondent’s organizational chart.

5. Attach resumés of all project leadership and proposed staff providing services as part of this response.

6. Complete the table below for current or former TEA officials or employees who are or have been employed by the respondent. (If the respondent has never employed a current or former TEA official or employee, then enter N/A.)

with TEA Job Title/Function with TEA

with respondent

SECTION B: SUBCONTRACTOR AND SUPPLIER INFORMATION

1. Complete the table below for ALL proposed subcontractors and suppliers included in this response. (If the respondent will not subcontract any part of the proposed services or goods, then enter N/A and skip to Section C.)

2. Attach organizational charts for all proposed subcontractors and suppliers in this response.

3. Attach resumes of all proposed subcontractor and supplier staff providing services or goods as part of this response.

4. Complete the table below for current or former TEA officials or employees who are or have been employed by proposed subcontractors or suppliers. (If the proposed subcontractors or suppliers have never employed a current or former TEA official or employee, then enter N/A.)

with TEA Job Title/Function with TEA Employment Dates with subcontractor or supplier Job Title/Function with subcontractor or supplier

SECTION C: GIFTS, DONATIONS, FAVORS, SERVICES, OR BENEFITS

1. Please list below any gift or donation the respondent, a proposed subcontractor, or a proposed supplier has offered to a TEA official or employee during the two calendar years before submitting a response to this solicitation. You are required to state the date the gift or donation was offered, provide a description of the gift or donation, and provide the monetary value. Indicate whether the value is an estimated or actual value. List the individual at TEA you corresponded with regarding the gift or donation. (If the respondent, proposed subcontractors, or proposed suppliers did not offer gifts or donations, then enter N/A.)

(actual or estimated) Agency Contact

2. Has the respondent or any proposed subcontractor or supplier requested a meeting with TEA senior officials in the past calendar year? (Senior official is defined as Commissioner, Deputy Commissioner, Associate Commissioner, and Executive Director.) If yes, list the date of meeting, the purpose of the meeting, and TEA senior official who attended. (If no meetings were requested, then enter N/A.)

Please attach the following items here:

1. Respondent’s organizational chart.

2. Resumes of all project leadership and proposed staff providing services as part of this response.

3. Resumes of all proposed subcontractor and supplier staff providing services or products as part of this response.

Name & Title of Authorized Representative Completing Form: ______

Organization Name: _________________________________________