ESBD_File_352773_Exhibit A Respondent Information.docx

Department of Information Resources Request for Offer Request RFO-001-FY24 Electronic Procurement Solution and Implementation Services Exhibit A Respondent Information This form must be filled out in its entirety and signed by an officer or agent empowered to contractually bind the Respondent.

1) A) Legal Entity Name:

B) Company Assumed Name (DBA):

2) Comptroller of Public Accounts Respondent Identification Number: _____________________

3) DUNS # ____________________________ ____________________________

4) Federal Employer Identification Number (FEIN) _____________________________

5) Parent company name (if applicable) _____________________________

6) Principal place of business Address:

City:

State:

Zip Code:

7) Facility responsible for servicing the contract Address:

City:

State:

Zip Code:

NOTE: Respondents are encouraged to provide multiple contact persons in order to ensure critical information is received and acted upon timely. Updates to contact information should be provided throughout the duration of the procurement process. DIR is not responsible for a Respondent’s failure to timely respond due to outdated contact information.

8) Contact Person(s) regarding Respondent’s Response to the RFO Name:

Address:

City, State, Zip:

Phone Number:

Fax:

Email:

9) Contact Person(s) responsible for contract negotiation (if different from above) Name:

Address:

City, State, Zip:

Phone Number:

Fax:

Email:

10) Officer or Agent empowered to contractually bind the Respondent: (if different from above) Name:

Title:

Address:

Phone Number:

Fax:

Email:

11) Indicate whether your company is a certified Historically Underutilized Business (HUB) with the State of Texas by the CPA.

☐Yes ☐No

12) Year of incorporation: __________

13) Exceptions A. This section contains the format for Respondents to note any exception to any standard provision, term, or condition specified in the RFO. Respondents should note that DIR expects each Respondent to comply with the requirements of this RFO as written. An explanation as to why the Respondent cannot comply with the provision, term, or condition and why the proposed alternative language must be included in the Response. Examples of nonresponsive explanations include:

1. Referencing negotiation of revised language in another DIR or other state agency contract;

2. Referring to an internal division’s need for the revised language without a valid reason as to why the exception is necessary;

3. Indicating the proposed language is “negotiable;” and

4. Referencing an internal Respondent terms and conditions document B. Exceptions must include:

1. RFO document title, section number, and section title;

2. Explanation as to why Respondent cannot comply with the term or condition; and

3. Proposed alternate language (redlined against the standard language).

C. If Respondent fails to note any exception within its Response, Respondent may not be allowed to request an exception throughout the procurement process. No new exceptions will be considered after submission of response.

D. Refer to the table below, which outlines the headings from the Exhibit A1. The column labeled “Documents” should be used to identify the specific RFO document, and the “Section” column should be used to identify the specific section within the RFO document that the language addresses. The Respondent must submit, as a separate Microsoft Excel document, the Exhibit A1 Exceptions and name it in accordance with Section 2.15 of the RFO.

E. Respondents are encouraged not to request exceptions to standard contract terms and conditions; DIR, in its sole discretion, may or may not accept the Respondent’s requested exceptions. Exceptions will be one (1) factor considered by DIR in determining best value for the State.

F. If there are no exceptions, the Respondent shall explicitly state in the Microsoft Excel document that the Respondent takes no exception to any part of this RFO.

G. Any exception may result in the Contract not being awarded to the Respondent. DIR reserves the right to exclude a Respondent based upon the quality and substance of any exception(s).

14) Respondent and Subcontractor Conflict of Interest Disclosure List below all current or former employees of Respondent and/or proposed Respondent personnel with conflict of interests as follows:

A. NOTE: Any current or former employees of Respondent who will spend twenty percent (20%) or more of their time on a contract resulting from this RFO and are current or former employees of the State of Texas within the past five (5) years; and B. NOTE: Any proposed Respondent personnel assigned to work directly on any Contract to arise from this RFO twenty percent (20%) or more of their time who are related within two (2) degrees of consanguinity of any current or former employees of the State of Texas. Disclosure of former state employees may be limited to the last five (5) years.

Respondent Personnel:

Subcontractor personnel:

C. Respondent certifies that they are in compliance with Texas Government Code, Title 6, Subtitle B, Section 669.003, relating to contracting with the executive head of a state agency. If Section 669.003 applies, Respondent will complete the following information in order for the Response to be evaluated: Name of Former Executive, Name of State Agency, Date of Separation for State Agency, Position with Respondent, and Date of Employment with Respondent.

15) Proof of Financial Stability All Respondents responding to this RFO and all Respondents that will enter into a contract with DIR must be and remain current in payment of all taxes, including Sales and Franchise Taxes. In general, the Comptroller of Public Accounts must identify the Respondent to be “in good standing” and a Respondent with which the state is authorized to do business.

16) Statement of Compliance A. Checklist for the RFO

1. The following checklist is provided for the convenience of Respondents in their Response preparation process. It is not intended to represent an exhaustive list of the mandatory requirements for this RFO. Respondents must ensure that all mandatory requirements for this RFO are met, even if they are not included in this checklist.

2. A completed checklist shall not be binding on DIR’s administrative review for compliance with the mandatory Response contents specified in this RFO. As step one of the evaluation process, DIR will review all Responses to ensure compliance with the mandatory Response contents as specified in Section 3.8.4 of the RFO and reject any Response that does not comply.

3. All Responses must be received by DIR on or before the date and time specified in Section 3.3 of this RFO. No late Responses will be reviewed.

B. Certification Statement The undersigned hereby certifies on behalf of insert company’s legal name here that RFO-001-FY24; has been read and understood. In submitting its Response insert company’s legal name here represents to DIR the following:

1. Respondent is capable of providing the products and services as described in the RFO;

2. Respondent is offering true and correct pricing and discounts for the products and services;

3. Respondent agrees, if awarded a contract, to abide by the terms and conditions of the resulting contract;

4. as of the date of signature below, Respondent is not listed in the prohibited Respondents list authorized by Executive Order #13224, "Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism”, published by the United States Department of the Treasury, Office of Foreign Assets Control;

5. Respondent and its principals are not suspended or debarred from doing business with the federal government as listed in the System for Award Management (SAM) maintained by the General Services Administration;

6. Respondent certifies, under Texas Government Code, Sections 2155.004 and 2155.006, that the individual or business entity named in this bid or contract is not ineligible to receive the specified contract and acknowledges that this contract may be terminated, and payment withheld if this certification is inaccurate;

7. Respondent certifies that, to the extent applicable to this scope of this RFO, Respondent is in compliance with Health and Safety Code, Chapter 361, Subchapter Y, related to the Computer Equipment Recycling Program, and the related rules found at 30 TAC Chapter 328;

8. Respondent has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted Response;

9. Respondent has not received compensation for participation in the preparation of specifications for this solicitation as required by Texas Government Code, Section 2155.004(a);

10. Respondent has not, nor has anyone acting for Respondent, violated the antitrust laws of the United States or the State of Texas, nor communicated directly or indirectly to any competitor or any other person engaged in such line of business for the purpose of obtaining an unfair price advantage;

11. Respondent is not currently delinquent in the payment of any franchise tax owed the State of Texas and is not ineligible to receive payment under Section 231.006 of the Texas Family Code and acknowledges the Contract may be terminated and payment withheld if this certification is inaccurate, and any Respondent subject to Section 231.006 must include names and social security numbers of each person with at least 25% ownership of the business entity submitting the Response, prior to award. Enter the name and Social Security Numbers for each person below (alternatively, if this section applies, Respondent may make a note here and include Names and Social Security Numbers on a separate page and include it in the electronic folder labeled “Confidential and Proprietary.”

12. Respondent agrees that any payments due under this Contract will be applied towards any debt, including but not limited to delinquent taxes and child support that is owed to the State of Texas;

13. Respondent agrees to comply with Texas Government Code, Section 2155.4441, relating to use of service contracts for products produced in the State of Texas;

14. Respondent certifies it is in compliance with Texas Government Code, Section 669.003, relating to contracting with executive head of a state agency; if Section 669.003 applies, bidder will complete the following information for the bid to be evaluated:

Name of Former Executive:__________________ Name of State Agency:_____________________ Date of Separation from State Agency:_________ Position with Bidder:_______________________ Date of Employment with Bidder:_____________

15. Respondent certifies for itself and its subcontractors that it has identified all current or former, within the last five (5) years, employees of the State of Texas assigned to work on the DIR Contract twenty percent (20%) or more of their time and has disclosed them to DIR and has disclosed or does not employ any relative of a current or former state employee within two (2) degrees of consanguinity, and, if these facts change during the course of the Contract, Respondent certifies it shall disclose for itself and on behalf of subcontractors the name and other pertinent information about the employment of current and former employees and their relatives within two degrees of consanguinity;

16. Respondent represents and warrants that the provision of goods and services or other performance under the Contract will not constitute an actual or potential conflict of interest and certifies that it will not reasonably create the appearance of impropriety;

17. Respondent certifies that if a Texas address is shown as the Principle Place of Business in Exhibit A, Respondent Information Form, Respondent qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part I, Chapter 20;

18. Respondent understands and agrees that Respondent may be required to comply with additional terms and conditions or certifications that an individual Customer may require due to state and federal law (e.g., privacy and security requirements); and

19. Respondent agrees that these representations will be incorporated into any subsequent agreement(s) between Respondent and Customer that result from this RFO;

20. Respondent certifies that there ☐ have / ☐ have not been canceled contracts in the past five (5) years. NOTE: If “have” is checked, Respondent must complete and submit Exhibit A, Attachment 1 hereto; if “have not” is checked, Respondent shall include a statement certifying that they have had no canceled contracts in the past five (5) years.

21. Respondent represents and warrants as required by Texas Government Code section 2270.002, by executing this Contract, that Respondent does not, and will not during the term of this Contract, boycott Israel. Respondent further certifies that no subcontractor of the Respondent boycotts Israel or will boycott Israel during the term of this Contract. Respondent agrees to take all necessary steps to ensure this certification remains true during the term of this Contract; and Respondent certifies, under Texas Government Code, Section 2155.0061, that the individual or business entity named in this bid or contract is not ineligible to receive the specified contract and acknowledges that this contract may be terminated, and payment withheld if this certification is inaccurate.

Signature of Officer or Agent empowered to contractually bind the Respondent (REQUIRED) Title Date

<END OF EXHIBIT A>

Exhibit A Attachment 1 List of Respondent’s Terminated Contracts THIS FORM MUST BE COMPLETED/SIGNED BY RESPONDENT FOR ANY IDENTIFIED CONTRACT TERMINATED WITHIN THE PAST FIVE (5) YEARS REFERENCE AND SUBMITTED WITH THE RESPONDENT’S RESPONSE Respondent may add additional fields as necessary to comply with the required disclosure.

RESPONDENT NAME: __________________________________________________________________

COMPANY NAME

COMPANY ADDRESS

(Street, City, State, Zip Code)

*CONTACT NAME / PHONE

*E-MAIL

DESCRIPTION OF SERVICE:

REASON FOR TERMINATION:

COMPANY NAME

COMPANY ADDRESS

*CONTACT NAME / PHONE

*E-MAIL

DESCRIPTION OF SERVICE:

REASON FOR TERMINATION:

COMPANY NAME

COMPANY ADDRESS

*CONTACT NAME / PHONE

*E-MAIL

DESCRIPTION OF SERVICE:

REASON FOR TERMINATION:

* Note: Do NOT complete these fields if DIR is the Terminated Contract Reference Exhibit A Respondent Information Page 1 of 2 Version 1.0 Rev. 3/21/23