HHS0016834v2 Exhibit D Info Disclosure Financial Form.pdf

Exhibit D Respondent’s Information, Disclosures, and Financial Form

Page 1 of 4 Template Updated: September 2025

Exhibit D

Respondent’s Information, Disclosures, and Financial Form

Part 1: Authorized Respondent Part 2: Respondent’s Primary Contact

Person Signing the Contract:

(Please see requirements for signatory in Exhibit A)

Name:

Title:

Mailing Address:

Telephone:

Fax:

E-mail:

Primary Contact for Proposal Questions:

Name:

Title:

Mailing Address:

Telephone:

Fax:

E-mail:

Part 3: Respondent and Contractor Information (Provide the following information. Attach additional pages if necessary.)

1. Organization’s Legal Name:

2. Doing Business As:

3. Physical Address:

4. Mailing Address:

5. Texas Taxpayer Number:

6. L_e_g_a_l_S_t_a_tu_s_(_c_h_e_c_k_o_n_e_)_: For-Profit Entity or Non-Profit Entity

7. Business Structure (check one): Sole Proprietorship Limited Liability Partnership Partnership* Limited Liability Company Joint Venture Corporation Limited Partnership Other (Specify):

*If the General Partnership operates under an assumed name, then please include an assumed name certificate for the county or counties where the proposed Work will occur or where the business premise is maintained.

8. State of Incorporation or Formation:

9. Name of the Parent Entity if Contractor is a subsidiary organization (if Applicable):

10. State of Incorporation or Formation of Parent Entity and file or registration number of state of formation (if Applicable):

Have you attached additional pages for Part 3? Yes or No

Part 4: Former Employees of a State Agency (Identify all respondent or subcontractor personnel who have worked for HHSC or another Texas health and human services agency in the past two years. Attach additional pages if necessary.)

1. Name of former state employee:

2. Job title at termination of state employment:

3. Date of termination of state employment:

4. Annual rate of compensation at termination:

5. Description of job responsibilities while state employee:

6. If the former state employee worked on matters relating to this Solicitation, describe those matters:

Have you attached additional pages for Part 4? Yes or No

Part 5: Conflicts of Interest (Describe all facts or circumstances that may give rise to a potential conflict of interest, and describe all measures the respondent and its subcontractors will take to ensure that these facts or circumstances do not create an actual conflict of interest. Attach additional pages if necessary.)

Have you attached additional pages for Part 5? Yes or No

Part 6: Financial Stability & Risk (Evaluation Criterion 3.1 and 3.2) (Please provide relevant details regarding the following risks. If the answer to any is yes, provide an explanation with all pertinent details)

1. Is your company currently for sale? Yes or No Explanation:

2. Is your company involved in any transaction to expand or become acquired by another business entity? Yes or No Explanation:

3. Is your company currently in default under any contract or other obligation? Yes or No Explanation:

4. Has a bonding company ever been required to finance completion of a project? Yes or No Explanation:

5. Has your company experienced claims on its payment or performance bonds in the last 2 years?

Yes or No

Explanation:

6. Has your company had any job site incidents in the last 2 years that resulted in death? Yes or No Explanation:

7. What is your firm’s maximum bonding capacity?*

Individual Project $ Aggregate $ Current Backlog $ *Attach a letter of intent from a surety company indicating Respondent’s financial solvency, adequate capitalization, and ability to obtain performance and payment bonds for the entire construction cost of the proposed project. The information submitted must indicate Respondent’s total bonding capacity, available bonding capacity and current backlog.

Part 7: Litigation (Disclose all pending, resolved, or completed litigation, mediation, arbitration, or other alternative dispute resolution procedure involving the respondent within the past 36 months. Include the cause number, court, parties’ names, subject matter, relief sought, amount in controversy, and final disposition or status. Provide the same information for all subcontractors. Attach additional pages if necessary.)

Have you attached additional pages for Part 7? Yes or No

Part 8: Texas Public Information Act (PIA) (Complete this part if you assert one or more parts of the proposal are excepted from disclosure under the PIA.

Attach additional pages if necessary.)

1. Proposal Section:

2. PIA Exception*:

*The most commonly asserted exception is Texas Government Code §552.110 (trade secret, or commercial or financial information confidential by law).

3. Explanation of Why the Exception Applies:

Have you attached additional pages for Part 8? Yes or No