HomeMy WebLinkAboutContract 57436 CSC No. 57436
FORT WORTH
CITY OF FORT WORTH
COOPERATIVE PURCHASE AGREEMENT
This Cooperative Purchase Agreement ("Agreement") is entered into by and between Shimadzu
Scientific Instruments ("Vendor") and the City of Fort Worth, ("City"), a Texas home rule
municipality.
The Cooperative Purchase Agreement includes the following documents which shall be construed in the
order of precedence in which they are listed:
1. This Cooperative Purchase Agreement;
2. Exhibit A— Seller's Quote, Scope of Services or Purchase Order;
3. Exhibit B—Cooperative Agency Contract(e.g.,NJPA, DIR, BuyBoard); and
4. Exhibit C—Conflict of Interest Questionnaire.
Exhibits A, B, C, and D which are attached hereto and incorporated herein, are made a part of
this Agreement for all purposes. Vendor agrees to provide City with the services and goods included in
Exhibit B pursuant to the terms and conditions of this Cooperative Purchase Agreement, including all
exhibits thereto.
City shall pay Vendor in accordance with the fee schedule in Exhibit A and in accordance with
the provisions of this Agreement. Total payment made under this Agreement for the first year by City
shall not exceed the amount of Thirty-Seven Thousand Nine Hundred Seventy-Nine Dollars and
Twenty-Four Cents ($37,979.24). Vendor shall not provide any additional items or services or bill for
expenses incurred for City not specified by this Agreement unless City requests and approves in writing
the additional costs for such services. City shall not be liable for any additional expenses of Vendor not
specified by this Agreement unless City first approves such expenses in writing.
The term of this Agreement shall begin on April 13, 2022 and end on April 24, 2022. There
will be no options to renew this agreement.
Vendor agrees that City shall,until the expiration of three(3)years after final payment under this
Agreement, or the final conclusion of any audit commenced during the said three years, have access to
and the right to examine at reasonable times any directly pertinent books,documents,papers and records,
including, but not limited to, all electronic records, of Vendor involving transactions relating to this
Agreement at no additional cost to City. Vendor agrees that City shall have access during normal
working hours to all necessary Vendor facilities and shall be provided adequate and appropriate work
space in order to conduct audits in compliance with the provisions of this section. City shall give Vendor
reasonable advance notice of intended audits.
Notices required pursuant to the provisions of this Agreement shall be conclusively determined
to have been delivered when (1) hand-delivered to the other party, its agents, employees, servants or
representatives, (2) delivered by facsimile with electronic confirmation of the transmission, or (3)
received by the other party by United States Mail, registered, return receipt requested, addressed as
follows: OFFICIAL RECORD
CITY SECRETARY
FT.WORTH,TX
To CITY: To VENDOR:
City of Fort Worth Shimadzu Scientific Instruments, Inc
Attn: Reginald Zeno, Interim Assistant City Patrick Fromal, Sr. Vice President
Manager
200 Texas Street Address:
Fort Worth, TX 76102-6314 7102 Riverwood Drive
Facsimile: (817) 392-8654 Columbia, MD 21046
With copy to Fort Worth City Attorney's Office
at same address
The undersigned represents and warrants that he or she has the power and authority to execute this
Agreement and bind the respective Vendor.
CITY OF FORT WORTH:
CONTRACT COMPLIANCE MANAGER:
f� By signing I acknowledge that I am the person
By: Reginald Zeno(Apr 20,2022 09:01 CDT) responsible for the monitoring and administration
Name: Reginald Zeno of this contract,including ensuring all performance
Title: Interim Assistant City Manager and reporting requirements.
Date: Apr 20, 2022
APPROVAL RECOMMENDED: By:
Name: Cynthia Garcia
Title: Assistant Finance Director
By: APPROVED AS TO FORM AND LEGALITY:
Name: Anthony Rousseau
Title: Acting Finance Director
ATTEST: By:
Name: Taylor Paris
Title: Assistant City Attorney
By. J ette S.Goodall(Apr 20,2022 11& CDT) ba4avR4� CONTRACT AUTHORIZATION:
./ Name: Jannette Goodall �aoF F°°Rt4aa M&C: N/A
Od
Title: City Secretary ;�° °�9-i°a
$0°s a=°
$a o�
VENDOR: as ° a
a�nE°')°(°p5op
Shimadzu Scientific Instruments,Inc
By: 1 �1-/
Name: Patrick Fromal
OFFICIAL RECORD
Title: Sr.Vice President
CITY SECRETARY
Date: 4/18/2022 FT.WORTH,TX
Vo SHIMADZU EXHIBIT
Excellence in Science
Customer: Sales Engineer:
Ms. Maria Isabel Carrillo Tommy Cardwell
City of Fort Worth Shimadzu Scientific Instruments
Rolling Hills Water Treatment Plant 8911 S. Sam Houston Pkwy. West
2600 Southeast Loop 820 Suite 160
Fort Worth, TX 76140 Missouri City, TX 77489
Phone: (817) 392-5913 Regional Office: (800) 739-1942 Ext.
Fax: Direct Dial:
E-mail: maria.carrillo@fortworthtexas.gov E-mail: ticardwell@shimadzu.com
Sales Proposal
Quotation: SSI-206526-FOM7
Expiration: 6/30/2022
Quote Description:
Proposed Ship Date: 30 Days/ARO FOB: COLUMBIA Ship Method: BEST WAY
Shipping Terms: PREPAID &ADD Incoterms:
Additional Information:
• All items, unless otherwise noted, are on the schedule for contract number TXMAS-17-6602 which expires April 24,
2022. Please reference this quotation number and include your Agency or Co-Op number on your Purchase
Order.
For proposal questions or modifications, please contact your sales representative.
For Order Placement:
Reference the SSI Quotation Number in the Note to Contractor section of the Texas SmartBuy
purchase order
Please note that state and local taxes, if applicable, Thank you for your interest in Shimadzu Scientific
will be added at invoicing. Instruments.
Forward official tax exempt documentation if applicable.
Shimadzu Scientific Instruments
7102 Riverwood Drive, Columbia, MD 21046 Authorization Signature*
Toll Free: 800-477-1227
Local: 410-381-1227 Fax: 410-381-6781
E-mail: customer.serviceashimadzu.com
Gregory Vandiver Date: 4/13/2022
International: *Sales Proposal is not valid without Authorized Signature.
Fax: 410-309-6130
E-mail: icscCcbshimadzu.com
Page 1 of 5 Quote Created On: 4/13/2022
Company Name: City of Fort Worth
„I S H I MADZU Quote Number: SSI-206526-FOM7
\
Activation Date: 3/25/2022
Excellence in Science Expiration Date: 6/30/2022
Sales Quotation - please reference the quotation when submitting purchase order.
TOC-LC
Product# Qty Description Price Per Ext'd Price On Contract
Unit
1 638-91151-58 1 TOC-LCSH (GSA Only), LabSolutions Version $36,375.00 $29,766.38 Yes
2 071-60821-08 1 100- 115V Power Cord $23.00 $0.00 No
3 630-00999-00 1 ABSORBER W/SODA LIME DISPOSABLE TOC $74.00 $0.00 No
4 638-41204-00 1 AIR PIPING SET,TOC,20 meters length $74.00 $0.00 No
5 220-95281-02 1 Reagents, Enviro, HYDROCHOLORIC ACID $68.00 $0.00 No
(100 ML)W/CERTIFICATE
6 220-95281-01 1 Reagents, Enviro, KHP-POTASSIUM $63.00 $0.00 No
HYDROGEN PHTHALATE(100 G)
7 220-95281-03 1 Reagents, Enviro, PHOSPHORIC ACID(500 $189.00 $0.00 No
ML)W/CERTIFICA
8 220-95281-25 1 Reagents, Enviro,SODIUM BICARBONATE $50.00 $0.00 No
(250 G)W/CERTIFICATE
9 220-95281-26 1 Reagents, Enviro,SODIUM CARBONATE(500 $223.00 $0.00 No
G)W/CERTIFICATE
10 088-52859-65 1 USB Cable for Connecting TOC-L to Computer $32.00 $0.00 No
when using Software
11 638-93140-58 1 ASI-V,Autosampler(100/200 V) $7,881.00 $6,449.17 Yes
12 638-92326-41 1 40 mL Rack Set for ASI-L $1,086.00 $888.69 Yes
13 220-95278-00 1 Vials,ASI, 140-40C/EP/TS,S,40ML VOA TYPE $152.00 $0.00 No
W/LID&SEPTUM.
14 638-56255-41 1 Carrier Gas Pressure Regulator Valve for TOC- $534.00 $0.00 No
L.
15 220-90001-01 1 REGULATOR GAS FOR AIR 19H590,TOC $542.00 $0.00 No
16 638-92464-04 1 Consumable Kit for TOC-LC*H $2,006.00 $0.00 No
17 220-95236-02 1 Solvents, Enviro,WATER FOR TOC(6 L $110.00 $0.00 No
BOTTLES/CASE)Rev6.
18 220-97317-85 1 Dell 3450 Computer, 16Gb RAM, 1 TB SSD, $3,399.00 $0.00 No
MS Office
19 220-97320-10 1 Dell 22" Professional Widescreen Flat Panel $340.00 $0.00 No
20 TIER 2 I&F 1 Tier 2 Installation and Customer $2,307.00 $0.00 No
Familiarization
21 1YW 1 1 YEAR WARRANTY $0.00 $0.00 No
$55,528.00 $37,104.24
Open Market/Incidental Extended Price: $875.00 Quote Extended Price: $47,290.24
On Contract Extended Price: $37,104.24 Total Line Item Discount: $10,186.00
Quote Sub-Total: $37,104.24
Estimated Freight: $875.00
Total Amount: $37,979.24
Page 2 of 5 Quote Created On: 4/13/2022
Company Name: City of Fort Worth
„I S H I MADZU Quote Number: SSI-206526-FOM7
\
Activation Date: 3/25/2022
Excellence in Science Expiration Date: 6/30/2022
By placing an Order for any Products related to this Sales Proposal and Quotation, Customer agrees to the terms
and conditions at httips://www.ssi.shimadzu.com/terms/General-Terms-Conditions-of-Sale.htm� which are
incorporated herein and applicable hereto. SSI reserves the right to update its Terms and Conditions at any time,
however the terms and conditions in effect at the date of delivery of Products related to this Sales Proposal and
Quotation shall apply to that purchase.
Page 3 of 5 Quote Created On: 4/13/2022
Company Name: City of Fort Worth
„I S H I MADZU Quote Number: SSI-206526-FOM7
\
Activation Date: 3/25/2022
Excellence in Science Expiration Date: 6/30/2022
Sales Quotation - please reference the quotation when submitting purchase order.
Line Item Descriptions
Product # Description
TOC-LC
638-91151-58 TOC-LCSH (GSA Only),LabSolutions Version
TOC-LCSH is designed and configured for analysis of wastewater,drinking water,pharmaceutical water,ground water,surface
water,saline water,domestic,and industrial wastewater.This instrument meets or exceeds all specifications according to
Standard Methods 5310B, Environmental Protection Agency(EPA)Methods 415.1&415.3, EPA SW-846 Method 9060A,ASTM
D7573-09,and Pharmaceutical Water for Injection (WFI), Pure Water(PW)according to United States Pharmacopoeia (USP),
Method <643>,and Clean-In-Place TOC application.The TOC-LC utilizes the approved Platinum catalyst, 680-degree Celsius
combustion technique to oxidize aqueous samples.The combustion type TOC eliminates salt interferences and ensures
complete oxidation even with high molecular weight compounds,suspended particles,and refractory compounds.The system
incorporates a Non-Dispersive Infrared (NDIR)detector for maximum sensitivity and durability.The measuring range is from
4ppb to 30,000ppm. External printer not included.
The sample injection systems on Shimadzu TOC analyzers are designed to maintain the precision of the total system.The
syringe and a unique slide type flow switching valve are used for the high precision,sample injection system.The precision or
Coefficient Variation (CV)is less than 1.5%for replicate measurements.Average Analysis time is approximately 3 minutes each
for TC and IC method as described below. Standard feature includes auto-dilution of samples 2-50 times.The auto-dilutor
permits the user to create a 10-point calibration curve from one standard. Standard particulate size is 0.5 mm.The TOC
analyzer is capable of measuring Total Organic Carbon (TOC), Non-Purgeable Organic Carbon (NPOC),Total Carbon (TC),and
Total Inorganic Carbon (TIC or IC).The PC Controlled TOC includes software,but REQUIRES,a PC, monitor, keyboard,and
printer which may be purchased separately from SSI.
071-60821-08 100- 115V Power Cord
630-00999-00 ABSORBER W/SODA LIME DISPOSABLE TOC
638-41204-00 AIR PIPING SET,TOC,20 meters length
Air Pipe Set
220-95281-02 Reagents,Enviro,HYDROCHOLORIC ACID(100 ML)W/CERTIFICATE
HYROCHLORIC ACID(25 ML)W/ CERTIFICATE. 25 mL of ACS Reagent Grade Hydrochloric Acid (HCl)with Certificate of
Analysis. Acid requires dilution for use with TOC.
220-95281-01 Reagents,Enviro,KHP-POTASSIUM HYDROGEN PHTHALATE(100 G)
KHP-POTASSIUM HYDROGEN PHTHALATE(100 G). 100 grams of 99.95% Potassium Hydrogen Phathalate with Certificate of
Analysis
220-95281-03 Reagents,Enviro,PHOSPHORIC ACID(500 ML)W/CERTIFICA
PHOSPHORIC ACID(500 GRAMS)W/CERTIFICATE
220-95281-25 Reagents,Enviro,SODIUM BICARBONATE(250 G)W/CERTIFICATE
Reagents, Enviro,SODIUM BICARBONATE(250 G)W/CERTIFICATE
220-95281-26 Reagents,Enviro,SODIUM CARBONATE(500 G)W/CERTIFICATE
Reagents, Enviro,SODIUM CARBONATE(500 G)W/CERTIFICATE
088-52859-65 USB Cable for Connecting TOC-L to Computer when using Software
638-93140-58 ASI-V,Autosampler(100/200 V)
Autosampler(ASI-V)works with TOC-V Combustion or Wetchemical. Either for stand-alone or PC controlled. Main unit only,
does not include vials,caps or septums. Cannot be used with TOC-VE model.
638-92326-41 40 mL Rack Set for ASI-L
40 mL Rack Set for ASI-L.Vials not included.
220-95278-00 Vials,ASI,140-40C/EP/TS,S,40ML VOA TYPE W/ LID&SEPTUM.
Page 4 of 5 Quote Created On: 4/13/2022
Company Name: City of Fort Worth
„I S H I MADZU Quote Number: SSI-206526-FOM7
\
Activation Date: 3/25/2022
Excellence in Science Expiration Date: 6/30/2022
Vial includes welded lid and septum. Septum is 0.06 silicon rubber.
638-56255-41 Carrier Gas Pressure Regulator Valve for TOC-L.
Optional pressure regulator for TOC-L systems
220-90001-01 REGULATOR GAS FOR AIR 19H590,TOC
TOC GAS REGULATOR FOR AIR 19H590
638-92464-04 Consumable Kit for TOC-LC*H
Consumable Kit for high sensitivity model TOC-L(TOC-LCSH and TOC-LCPH). For new LabSolutions TOC-L*H instruments. NOT
compatible with old TOC-L*H instruments.The kit includes: combustion tube(2),TOC regular sensitivity catalyst(2),TOC high
sensitivity catalyst(1),quartz wool (1g),Teflon 0-ring P10(1 pack of 5 piece in 036-11408-84),Viton 0-ring 4D P10A (1 pack
of 5 pieces in 036-11209-84),Viton 0-ring 4D P20 (1 pack of 5 pieces in 036-11219-84),ceramic fiber(1),8-port valve rotor
(1),halogen scrubber(2),plunger tip (1),and IC reaction solution supply pump head (1).
220-95236-02 Solvents,Enviro,WATER FOR TOC(6 L BOTTLES/CASE) Rev6.
Total Carbon Guaranteed below 100ppb. Meets USP 23, EPA 415.1, EPA 9060A,Standard Methods 5310B,ASTM 02579,AOAC
973.47.
220-97317-85 Dell 3450 Computer,16Gb RAM,1 TB SSD,MS Office
Dell computer suitable for most Shimadzu software packages. It is a small form factor computer(approximately
11.5"x11.5"0.5")and includes an 11'th gen Intel Xeon processor, 16Gb of RAM,a 1 TB SSD,a DVD+ R/W drive, 2 ethernet
ports,Windows 10 Pro,and Microsoft Office Home&Business.
220-97320-10 Dell 22" Professional Widescreen Flat Panel
22"LCD display, resolution to 1680 x 1050,contrast ratio(typical): 1000:1. Brightness(typical): 300 cd/m2,0.282 mm pixel
pitch.
Limited warranty:Three years Advanced Portable Exchange through Dell.
TIER 2 I&F Tier 2 Installation and Customer Familiarization
Tier 2 Installation and Customer Familiarization.
1YW 1 YEAR WARRANTY
1 YEAR WARRANTY
Page 5 of 5 Quote Created On: 4/13/2022
(http://www,comptroller.texas.gov/)
Texas Comptroller of Public
Accounts
Glenn Hegar
Exhibit B
(http://www.txs m a rtb uy.co m)
Bid Postings(http://www.txsmartbuy.com/#esbd) Contracts SPD Applications
Help(http://www.txsmartbuy.com/#help)
2 items
Contract Details: # TXMAS-17-6602
Search for items in this contract(/contract_number/TXMAS-17-6602/ex_search/false)
Number TXMAS-17-6602
Description Scientific Instruments
Category TxSmartBuy
Type TXMAS
Start Date 7/21/2017
End Date 4/24/2022
Fed GS-24F-0031 M
Purchase Category PCC X
Code(Agencies Only)
Optional Renewal Terms No renewals remaining
Purchase Orders Only purchase orders issued through Texas SmartBuy(TSB) are eligible for contract pricing. The Contractor
cannot ship any products or provide services until receipt of a Purchase Order generated by the TSB system.
All purchase orders that include a quote order line(excluding linked item quotes)will be placed on hold
pending Statewide Procurement Division (SPD) review.
Quote order requirements:
1. Items that are available in TSB must be placed through the TSB shopping cart. The TSB shopping cart allows up
to 45 line items. Once 45 line items are added to the TSB shopping cart, the additional order items must be totaled
and entered using the quote order line.
2. State agencies must enter no less than 20 items into the TSB shopping cart before utilizing the quote line option.
Texas SmartBuy Members are encouraged to add items to the TSB cart before utilizing the quote line option.
3. All purchase orders that include a quote order line require the attachment of a completed contractor quote
containing the following:
• Detailed, unit pricing of all contracted items and services.
• The contractor's TXMAS contract number clearly identified.
• Open market, or incidental, items clearly identified.
4. Validation of contract pricing and item availability is the responsibility of the purchaser in determining best value.
When the attachment is confirmed, SPD will release the purchase order to the TXMAS contractor for fulfillment.
5. If approval is requested prior to the order being inputted in TSB, or SPD assistance is requested to validate
pricing or item availability, the information may be submitted to txmasquote@cpa.texas.gov
(mai Ito:txmasquote@cpa.texas.gov).
Customers may only purchase TXMAS goods or services from a TXMAS Contractor online through Texas
SmartBuy. CPA does not authorize any offline sales of this TXMAS contract's goods or services.
IMPORTANT. The services provided by this contract may be a service subject to the provisions of Texas
Government Code Chapter 2254.A state agency, as defined by Texas Government Code Chapter 2254, may
only acquire the services subject to Texas Government Code Chapter 2254 according to the procedures
identified in that chapter. Failure to comply with the provisions of Texas Government Code Chapter 2254
could result in a void contract.
Order Limitation The contractor is not required to accept orders below the minimum listed below. Orders between the minimum and
maximum listed below are subject to the pricing of the underlying contract.
Minimum order: $100
Maximum order: $400,000
State Contracts Prior to purchasing from a TXMAS contract, public procurement personnel must follow applicable procurement
procedures as stated in the Procurement and Contract Management Guide. Agencies must first purchase products
or services offered by WorkQuest, Texas Correctional Industries(TCI), and the Statewide Procurement Division
(SPD)Term Contracts.
CPA Contract Questions regarding contract management issues, price changes, amendments or other post-award concerns
Management should be directed to:
SPD TXMAS Program
Texas Comptroller of Public Accounts(CPA)
Phone: (512)463-3034 option 3
Email:txmas@cpa.texas.gov(mailto:txmas@cpa.texas.gov)
Approved Only products or services listed in the underlying contract may be purchased from this TXMAS contract, with one
Products/Services exception. Incidental, off-schedule items may be purchased as"best value, open market"items provided that they
are necessary for product integration or product completeness. The purchasing entity is responsible for ensuring
that the quoted price for such incidental items is fair and reasonable. These incidental items may be added to the
TXMAS purchase order if they are clearly labeled as"open market(OM), best value" items.
Incidental items may not exceed$5,000.00 OR 50%of the purchase order total,whichever is less.
If the pending order includes incidental items that exceed the stated limits, a request may be submitted to the
Statewide Procurement Division for review and consideration of an exception. Exception requests shall be
submitted to txmasquote@cpa.texas.gov. The request must include a copy of the complete contractor quote
listing all core items and a detailed incidental charge breakdown.
Delivery 120 days ARO
FOB Point Destination, Freight Prepaid and Allowed.
Warranty Details Standard commercial warranty: one year
Compliant Products by Customer reserves the right to require new delivery or a refund in the event that materials or products not meeting
Contractor specifications are discovered after payment has been made.
Rebate Reporting Pursuant to Texas Government Code§2155.510(b), rebates generated from TXMAS contract purchases made in
Requirement for Federal whole or in part with federal funds must be reported by the purchasing agency to the appropriate federal funding
agency. Each quarter of the State's fiscal year(September 1 through August 31), TXMAS contractors rebate
0.73875% of their TXMAS sales to the State of Texas via the Texas Comptroller of Public Accounts(CPA). It is the
purchasing entity's responsibility to report the amount of rebate attributed to federal funds to the federal fund-
provider using the above percent based on the total dollar value of the TXMAS purchase order.
Example:A purchasing entity receives and uses federal funds of$50,000 to purchase items/services on a TXMAS
contract. The purchasing entity must report to the federal fund-provider that a sales rebate of$369.37($50,000
0.73875% =$369.37)will be paid to the State of Texas by the TXMAS contractor.
Contractor Performance The Statewide Procurement Division Contract Management Office (SCMO), a division of the Comptroller of Public
Accounts(CPA), administers a vendor performance program for use by all customers per Texas Government Code
(TGC), §2262.055, and 34 Texas Administrative Code JAC), §20.108. The Vendor Performance relies on the
customer's participation in gathering information on vendor performance. State agency customers shall report
vendor performance on purchases of$25,000 or more from contracts administered by CPA, or any other purchase
of$25,000 or more made through delegated authority granted by CPA JAC 20.108), or purchases exempt from
CPA procurement rules and procedures. State agencies are additionally encouraged to report vendor performance
on purchases under$25,000.
Vendor Performance shall be reported through the CPA VENDOR PERFORMANCE TRACKING SYSTEM.
(https:Hcomptroller.texas.gov/purchasing/programs/vendor-performance-tracking/)
The purpose of the Vendor Performance Tracking System is to:
• Identify vendors that have exceptional performance
•Aid purchasers in making a best value determination based on vendor past performance
• Protect the state from vendors with unethical business practices
• Provide performance scores in four measurable categories for the CMBL vendors
•Track vendor performance for delegated and exempt purchases
Contractor Information
VID: 15210359566
Contractor: Shimadzu Scientific Instruments, Inc.
Contact Name:Jeffrey Kilchenstein
Email:jckilchenstein@shimadzu.com
Phone: (410) 862-1772
Alternate Contact Name: Liz Dozier
Alternate Email: customer.service@shimadzu.com
Alternate Phone: (410) 381-1227
Address: 7102 Riverwood Drive Columbia MD 21046
Texas Comptroller of Public Accounts
Glenn Hegar
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Exhibit C
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received
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).
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.
jJ Name of vendor who has a business relationship with local governmental entity.
2
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 is being disclosed.
N/A
Name of Officer
4J Describe each employment or other business relationship with the local government officer, or a family member of the
officer,as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
Yes F---] 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 or a family member of the officer AND the taxable income is not received from the
local governmental entity?
Yes F---] No
5 Describe each employment or business relationship that the vendor named in Section 1 maintains with 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.
s
❑ Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
7
04/19/2022
Signature of vendor doing business with the governmental entity Date
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
A complete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.Iegis.state.tx.us/
Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.
Local Government Code§176.001(1-a):"Business relationship"means a connection between two or more parties
based on commercial activity of one of the parties. The term does not include a connection based on:
(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(B) a transaction conducted at a price and subject to terms available to the public; or
(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and
that is subject to regular examination by, and reporting to, that agency.
Local Government Code§176.003(a)(2)(A)and(B):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2,500 during the 12-month period
preceding the date that the officer becomes aware that
(i) a contract between the local governmental entity and vendor has been executed;
or
(ii) the local governmental entity is considering entering into a contract with the
vendor;
(B) has given to the local government officer or a family member of the officer one or more gifts
that have an aggregate value of more than$100 in the 12-month period preceding the date the
officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed; or
(ii) the local governmental entity is considering entering into a contract with the vendor.
Local Government Code§ 176.006(a)and (a-1)
(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local governmental entity and:
(1) has an employment or other business relationship with a local government officer of that local
governmental entity,or a family member of the officer,described by Section 176.003(a)(2)(A);
(2) has given a local government officer of that local governmental entity, or a family member of the
officer,one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B),excluding any
gift described by Section 176.003(a-1);or
(3) has a family relationship with a local government officer of that local governmental entity.
(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator
not later than the seventh business day after the later of:
(1) the date that the vendor:
(A) begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(B) submits to the local governmental entity an application,response to a request for proposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity;or
(2) the date the vendor becomes aware:
(A) of an employment or other business relationship with a local government officer, or a
family member of the officer,described by Subsection(a);
(B) that the vendor has given one or more gifts described by Subsection (a);or
(C) of a family relationship with a local government officer.
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021