RFO Att A Respondent Information Form.docx

RFO DIR-CPO-TXA-610

State of Texas Department of Information Resources

Texas Agency Network Wireless, Pagers, and Satellite Services, and Related Hardware (TEX-AN-WPS) RFO Attachment A Respondent Information Form Request For Offer

DIR-CPO-TXA-610

This form must be filled out in its entirety and signed by an officer or agent empowered to contractually bind the Respondent.

1. Entity Information Please ensure the legal entity name and address exactly match the name and address associated with the DUNS Number provided below or contact Dun and Bradstreet with corrections prior to responding to this RFO.

Respondent Entity Information

Legal Entity Name:

Company “friendly” Name (DBA):

Parent Company Name (If Applicable):

Texas Comptroller of Public Accounts (CPA) Identification Number:

Dun and Bradstreet (D-U-N-S) Number:

Federal Employer Identification Number (FEIN):

Stock Exchange Name (for common, public stock listings), and Ticker Symbol

Principal Place of Business:

Address:

Facility Responsible for Servicing the Service Agreement

Address:

City/State/Zip Code:

2. Contact Information 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 DIR is not responsible for a Respondent’s failure to timely respond due to outdated contact information.

Contact Person Regarding Respondent’s RFO

Name:

Title:

Email:

Phone:

Address:

City/State/Zip:

Contact Person Regarding Negotiations (if different from above)

Name:

Title:

Email:

Phone:

Address:

Officer or Agent Empowered to Contractually Bind Respondent

Name:

Title:

Email:

Phone:

Address:

3. Respondent and Subcontractor Conflict of Interest Disclosure Please provide all current and former employees of Respondent and/or proposed Respondent personnel with conflicts of interest as follows:

1. Any current or former employees of Respondent who will spend 20% or more of their time on a service agreement resulting from this RFO and are current or former employees of the State of Texas within the past five (5) years; and

2. Any proposed Respondent personnel assigned to work directly on any service agreement to arise from this RFO 20% or more of their time who are related within two 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

Per Reference A:

Current or Former Employees who are Current or Former State Employees Per Reference B:

Respondent Personnel Related to State of Texas Employees

Subcontractor Personnel

Per Reference A:

Current or Former Employees who are Current or Former State Employees Per Reference B:

Respondent Personnel Related to State of Texas Employees

4. Contracting with the Executive Head of a State Agency 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:

Former Executive Information #1

Name of Former Executive:

Name of State Agency:

Date of Separation from State Agency:

Position with Respondent:

Dates of Employment with Respondent:

Former Executive Information #2

Name of Former Executive:

Name of State Agency:

Date of Separation from State Agency:

Position with Respondent:

Dates of Employment with Respondent:

5. 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 Texas 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.

6. Certification Statement The undersigned hereby certifies on behalf of (insert legal name of Entity) ______________________________________________ that ____________________ (insert RFO #) has been read and understood. In submitting its Response (insert legal name of Entity) _______________________________________ certifies that the information contained in its Response is accurate and complete and represents to DIR the following:

1. 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;

2. Respondent certifies that neither it, nor its holding companies or subsidiaries is: (a) listed in Section 889 of the 2019 National Defense Authorization Act; (b) listed in Section 1260H of the 2021 National Defense Authorization Act; or (c) owned by the government of a country on the U.S. Department of Commerce’s foreign adversaries list under 15. C.F.R. Section 791.4; or (d) controlled by any governing or regulatory body located in a country on the U.S. Department of Commerce’s foreign adversaries list under 15 C.F.R. Section 791.4;

3. 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;

4. Respondent certifies, under Texas Government Code, Sections 2155.006 and 2261.053, 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;

5. 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;

6. Respondent, pursuant to Texas Government Code, Section 2155.004(a), has not received compensation for participation in the preparation of specifications for this solicitation;

7. 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;

8. 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;

9. 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;

10. 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;

11. 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;

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

13. 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);

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

15. 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; and

16. The requirements of Subchapter J, Chapter 552, Texas Government Code, may apply to this RFO and Respondent agrees that any resulting contract can be terminated if the Respondent knowingly or intentionally fails to comply with a requirement of that subchapter.

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

Title

Date

State of Texas Department of Information Resources Texas Agency Network Wireless, Pagers, and Satellite Services, and Related Hardware (TEX-AN-WPS) – Attachment A Respondent Information Form Page 2 of 6 State of Texas Department of Information Resources Texas Agency Network Wireless, Pagers, and Satellite Services, and Related Hardware (TEX-AN) – Attachment A Respondent Information Form Page 2 of 2 image1.png