VENDOR INFORMATION FORM BRYAN INDEPENDENT SCHOOL

VENDOR INFORMATION FORM
BRYAN INDEPENDENT SCHOOL DISTRICT
BRYAN, TX
In accordance with Texas Education Code Section 44.033, the Bryan Independent School District
may purchase items in categories whose estimated 12-month aggregate expenditure is between
$10,000 and $25,000 by obtaining three (3) quotes from an established vendor listing. In order to
be contacted for quotes, vendors must complete the following information (including a Felony
Conviction Notification) and return this packet to Bryan ISD, Attn: Purchasing, 101 North Texas
Avenue, Bryan, TX 77803, or by faxing this form to (979) 209-1098.
CATEGORY:
____________________________________________________
Company Name:
_________________________________________________________
Point of Contact:
_________________________________________________________
Address:
_________________________________________________________
_________________________________________________________
City, State Zip Code: _________________________________________________________
Telephone:
_________________________________________________________
Fax:
_________________________________________________________
E-Mail:
_________________________________________________________
Category of Product: _________________________________________________________
Description of Supplies/Products:
FELONY CONVICTION NOTIFICATION
State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History,
Subsection (1), states “a person or business entity that enters into a contract with a school district
must give advance notice to the district if the person or an owner or operator of the business
entity has been convicted of a felony. The notice must include a general description of the
conduct resulting in the conviction of a felony.”
Subsection (b) states “a school district may terminate a contract with a person or business entity
if the district determines that the person or business entity failed to give notice as required by
Subsection (a) or misrepresented the conduct resulting in the conviction. The district must
compensate the person or business entity for services performed before the termination of the
contract.” This Notice Is Not Required of a Publicly-Held Corporation.
I, the undersigned agent for the firm named below, certify that the information concerning
notification of felony convictions has been reviewed by me and the following information furnished
is true to the best of my knowledge.
Vendor’s Name:
________________________________________________________________
Authorized Company Official’s Name (Printed):
________________________________________________________________
A.
My firm is a publicly-held corporation, therefore, this reporting requirement is not
applicable.
Signature of Company Official:
________________________________________________________________
B.
My firm is not owned or operated by anyone who has been convicted of a felony:
Signature of Company Official:
________________________________________________________________
C.
My firm is owned or operated by the following individual(s) who has/have been convicted
of a felony (describe felony conduct):
______________________________________________________________
The undersigned affirms that they are duly authorized to execute this contract, that this company,
corporation, firm, partnership or individual has not prepared this bid in collusion with any terms or
conditions of said bid have not been communicated by the undersigned nor by any employee or
agent to any other person engaged in this type of business prior to the official opening of this bid.
(PLEASE PRINT OR TYPE)
COMPANY: __________________________________________________
ADDRESS: __________________________________________________
CITY, STATE, ZIP CODE _______________________________________
TELEPHONE NO. (
) _______________ FAX NO. (
)__________
SIGNATURE: _________________________________________________
Print Name: _____________________________________________
TITLE: ______________________________________________________
FORM
CONFLICT OF INTEREST QUESTIONNAIRE
CIQ
For vendor doing business with local governmental entity
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code,
by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the vendor meets requirements under Section 176.006(a).
Date Received
By law this questionnaire must be filed with the records administrator of the local governmental
entity not later than the 7th business day after the date the vendor becomes aware of facts
that require the statement to be filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local
Government Code. An offense under this section is a misdemeanor.
1
2
Name of vendor who has a business relationship with local governmental entity.
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not
later than the 7th business day after the date on which you became aware that the originally filed questionnaire was
incomplete or inaccurate.)
3
Name of local government officer about whom the information in this section is being disclosed.
Name of Officer
This section (item 3 including subparts A, B, C, & D) must be completed for each officer with whom the vendor has an
employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional
pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment
income, from the vendor?
Yes
No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local
government officer named in this section AND the taxable income is not received from the local governmental entity?
Yes
No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local
government officer serves as an officer or director, or holds an ownership interest of one percent or more?
Yes
No
D. Describe each employment or business and family relationship with the local government officer named in this section.
4
Signature of vendor doing business with the governmental entity
Date
Adopted 8/7/2015
CERTIFICATE OF INTERESTED PARTIES
FORM
1295
OFFICE USE ONL
Y
ONLY
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
1 Name of business entity filing form, and the city, state and country of the business
entity's place of business.
2
Name of governmental entity or state agency that is a party to the contract for
which the form is being filed.
3
Provide the identification number used by the governmental entity or state agency to track or identify the contract,
and provide a description of the goods or services to be provided under the contract.
4
City, State, Country
(place of business)
Name of Interested Party
5
Nature of Interest (check applicable)
Controlling
Intermediary
Check only if there is NO Interested Party.
6 AFFIDAVIT
I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said _______________________________________________, this the ______________ day
of ________________, 20 _______ , to certify which, witness my hand and seal of office.
Signature of officer administering oath
Printed name of officer administering oath
Title of officer administering oath
ADD ADDITIONAL PAGES AS NECESSARY
Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Adopted 10/5/2015
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion –
Lower Tier Covered Transactions
This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 7 CFR Part 3017, Section 3017.510, Participants’
responsibilities. The regulations were published as Part IV of the January 30, 1989,
Federal Register (pages 4722-4733).
(before completing certification, read attached instructions.)
(1) The prospective lower tier participant certifies, by submission of this proposal, that
neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.
Organization Name
PR/Award Number or Project Number
Name and Title of Authorized Representative
Signature
Date
Instructions For Suspension/Debarment Certification Statement:
1. By signing and dating the certification statement, the bidder certifies that neither it nor
any of its principals (e.g., key employees) has been proposed for debarment,
debarred or suspended by a federal agency on the date signed.
2. The prospective bidder shall provide immediate written notice to the person to which
this proposal is submitted if at any time the prospective bidder learns that its
certification was erroneous when submitted or has become erroneous by reason of
changed circumstances.
3. Federal and State penalties exist for vendors and districts that knowingly enter into
contracts with suspended / debarred person.
Residence Certification
In accordance with Article 601g. as adopted by the 1985 Texas Legislature, the following will apply.
The pertinent portion of the Act has been extracted and is as follows:
Article 601g. State of Political Subdivision Contracts for Construction, Supplies, Services, Bids by
Non-Resident Section 1(a) in this Act:
1. “Governmental agency of the state” means an incorporated city or town, a county, a public
school district, a special-purpose district or authority, or a district, county, or justice of the
peace court.
2. “Nonresident Bidder” means a bidder whose principal place of business is not in this state, but
excludes a contractor whose ultimate parent company or majority owner has its principal place
of business in this state.
3. “Texas Residential Bidder” means a bidder whose principal place of business is in this state,
and includes a contractor whose ultimate parent company or majority owner has its principal
place of business in this state.
The state or governmental agency of the state may not award a contract for general construction,
improvements, services, or public works projects, or purchase of supplies, materials, or equipment to
a nonresident bidder unless the nonresident’s bid is lower than the lowest bid submitted by a
responsible Texas resident bidder by the same amount that a Texas resident bidder would be
required to under bid a nonresident bidder to obtain a comparable contract in the state in which the
nonresident’s principal place of business is located.
I certify that as defined in Article 601g, that:
Company Name:
____________________________________________
_____ Yes, I am a Texas Residence Bidder
_____ No, I am a _____________ Residence Bidder
Printed Name:
____________________________________________
Signature:
____________________________________________
Statement of Non-Collusion and Non-Discrimination
My signature certifies that the accompanying bid:
1. Is not the result of, or affected by an unlawful act of collusion with another person or company
engaged in the same line of business or commerce, or any act of fraud punishable under
current local, state, and/or federal ordinances, statutes, regulations, and/or policies.
Furthermore, I understand that fraud and unlawful collusion are crimes under Federal Law, and
can result in fines, prison sentences, and civil damage awards.
2. During the performance of any contracted awarded, the Seller will not discriminate against any
employee or applicant for employment because of race, religion, color, sex, or national origin,
or handicaps, except where religion, sex, or national origin is a bona fide occupational
qualification reasonably necessary to the normal operations of the Seller. The Seller agrees to
post in conspicuous places, available to employees and applicants for employment, notice
setting forth the provisions of this non-discrimination clause.
3. The Seller, in all solicitations and advertisements for employees placed by, or on behalf of, the
Seller, will state that such Seller is an equal opportunity employer.
4. Notices, advertisements, and solicitations placed in accordance with Federal Law, rule, or
regulation, shall be deemed sufficient for the purpose of meeting the requirements of this
section.
5. The Seller shall include the provisions of the foregoing paragraphs 2, 3, and 4 in every
subcontract or purchase order over $10,000.00 so that the provisions will be binding upon
each subcontractor or vendor.
I hereby certify that I am authorized to sign as a Representative for the Seller:
Name of Seller
_______________________________________
Address:
_______________________________________
City/State/Zip:
_______________________________________
Signature:
_______________________________________
Name (Print):
_______________________________________
Title:
_______________________________________
Date:
_______________________________________
W-9
Form
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Exemptions (see instructions):
Check appropriate box for federal tax classification:
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Trust/estate
Exempt payee code (if any)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Exemption from FATCA reporting
code (if any)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
–
–
–
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
withholding tax on foreign partners’ share of effectively connected income, and
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information
about Form W-9, at www.irs.gov/w9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to
you, payments made to you in settlement of payment card and third party network
transactions, real estate transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN to the person requesting it (the requester) and, when
applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester’s form if it is substantially
similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section
1446 on any foreign partners’ share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S. person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 8-2013)