EXHIBIT C - Acknowledgement of Receipt Form.pdf
PDF 216 KB Posted
- Attached to
- Custom Wheelchair
- Solicitation number
- 2603-001
- Issued by
- Texas
About this file
This is an Acknowledgment of Receipt Form for a Request for Proposals issued by the City of Austin, Texas, related to a Custom Wheelchair procurement. The form serves as documentation that proposers have received a complete copy of the solicitation materials, including the title page, Table of Contents, and all exhibits. Proposers must complete the form with their legal business name, tax identification number, business address, contact information, and organizational details, including the number of years providing similar services and a description of staffing and locations. The form requires proposers to acknowledge receipt of addenda and to identify their authorized contract representative and solicitation point of contact.
The form includes mandatory certifications regarding the proposer's financial and legal standing, requiring disclosure of bankruptcy filings within the past five years, delinquent taxes owed to Travis County, and any suspension or debarment status by governmental entities. Proposers must indicate their acceptance of or exceptions to the contract terms and conditions outlined in Exhibit G and provide litigation history for the preceding five-year period, including case names, filing dates, courts, and judgments. The completed and signed form must be included with the proposer's submittal, and all questions must be answered with the option to attach supporting documentation for additional details.
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Exhibit C Acknowledgment of Receipt Form
In acknowledgment of receipt of this Request for Proposals, the undersigned agrees that he/she has received a complete copy, beginning with the title page and Table of Contents and Exhibits.
The acknowledgment of receipt should be signed, returned, and included with the Respondent's submittal. Complete (Legal) Name of Proposer:
Proposer Tax Identification Number:
Business Address:
Telephone Number:
Type of Organization: Individual Partnership Corporation Association
Other (please describe)
If incorporated, state of incorporation:
Date organization was formed (month/year):
The number of years providing services/systems similar to those requested in this Solicitation:
Description of Proposer’s organization, locations, and number of staff (including subcontractors as applicable) that will provide services/support outlined in this Solicitation):
Please certify the following by placing an “X” in the appropriate column:
Certification Yes No Is Proposer/Respondent currently in the process of filing for bankruptcy?
Has Proposer/Respondent filed for bankruptcy within the past five (5) years?
Is the Proposer/Responder delinquent on any taxes owed to Travis County?
Do you certify that the Proposer/Responder is not currently under suspension or debarment by any governmental entity (City of Austin/state/federal government)?
Do you acknowledge that if the Proposer/Responder is currently under suspension or debarment, its submittal may not be considered?
Acknowledged Addenda of
Individual authorized to bind Proposer/Respondent to contract:
Name/Title:
Telephone: E-mail:
Point of contact information for this Solicitation (if different from authorized individual):
Name/Title:
Telephone: E-mail:
Contract Terms and Conditions
The contract terms and conditions identified in the Exhibit G, the Contract Template of this Solicitation, will form the contract resulting from this Solicitation, and the Proposer /Respondent’s submission will be incorporated into the contract. Please identify whether there are any requested exceptions or deviations.
I do not request any exceptions or deviations to the stated contract terms.
I request the following exceptions or deviations to the stated contract terms.
Litigation History:
Description of litigation to which the firm has been a party in the most recent five-year period. Please include the following details:
1) Name of case
2) Date filed
3) Court in which filed
4) Judgment or result
(Continued on Next page)
Important: The Proposer/Respondent must respond to all questions. The Proposer/Respondent may attach additional documents to the questionnaire to provide additional details.
Authorized Respondent Signature Date
Printed Name Title
| Individual authorized to bind Proposer/Respondent to contract: |
| Contract Terms and Conditions |
| Litigation History: |
File details come from the government source that posted it. Updated .