HomeMy WebLinkAboutContract 57256-R2CSC No. 57256-R2
CITY OF FORT WORTH
CONTRACT RENEWAL NOTICE
January 11, 2024
Ergoflex Systems, Inc. dba Xybix Systems, Inc.
Attn: Doug Herman, VP of Sales
8207 Southpark Circle
Littleton, CO 80120
Re: Contract Renewal Notice
Contract No. CSC No. 57256 (the "Contract")
Renewal Term No. 2: March 16, 2024 to March 15. 2025
The above referenced Contract with the City of Fort Worth expires on March 15, 2024 (the
"Expiration Date"). Pursuant to the Contract, contract renewals are at the sole option of the City.
This letter is to inform you that the City is exercising its right to renew the Contract for an
additional one (1) year period, which will begin immediately after the Expiration Date. All other
terms and conditions of the Contract remain unchanged. Please return this signed
acknowledgement letter, along with a copy of your current insurance certificate, to the
address set forth below, acknowledging receipt of the Contract Renewal Notice. Failure to
provide a signed acknowledgment does not affect the renewal.
Please log onto PeopleSoft Purchasing at http://fortworthtexas.2ov/turchasing to ensure
that your company information is correct and up-to-date.
If you have any questions concerning this Contract Renewal Notice, please contact me at
the telephone number listed below.
Sincerely,
Katva Flores
Sr. Admin Assistant
Katva. F lorestafortworthtexas.l;ov
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Contract Renewal Page 1 of 3
ACCEPTED AND AGREED:
CITY OF FORT WORTH CONTRACT COMPLIANCE MANAGER:
By signing I acknowledge that I am the person
responsible for the monitoring and
administration of this contract, including
ensuring all performance and reporting
By DanaBurghdoff(Jan`17,2024i :26CST) b P P g
requirements.
Name: Dana Burandoff
Title: Assistant Citv Manager
Date: J an 27, 2024
122
ByF aRa`y(Jan 26, 202411:15 CST)
APPROVAL RECOMMENDED: Name: Brenda Rav
i
By7 s Davis (Jan 26, 202412:51 CST) Title: Fire Purchasing Manaver
Name: Jim Davis
Title: Fire Chief APPROVED AS TO FORM AND
LEGALITY:
ATTEST:
PoFF..... a—
p By:
By 7� "^ adan aExpsab Name: Tavlor Paris
lUl �a
Name: Jannette Goodall
Title: Assistant Citv Attornev
Title: Citv Secretary
CONTRACT AUTHORIZATION:
N/A
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Contract Renewal Page 2 of 3
Ergofl
By:
Name:
Title: "ales
Xybix Systems. Inc.
Contract Renewal Page 3 of 3
C `'C No 57256-Rl
CITY OF FORT WORTH
CONTRACT RENEWAL NOTICE
January 31, 2023
Ergoflex Systems, Inc. dba Xybix Systems, Inc.
Attn: Doug Herman, VP of Sales
8207 Southpark Circle
Littleton, CO 80120
Re: Contract Renewal Notice
Contract No. CSC No. 57256-RI (the "Contract")
Renewal Term No. 1: March 16.2023 to March 15.2024
The above referenced Contract with the City of Fort Worth expires on March 15, 2023 (the
"Expiration Date"). Pursuant to the Contract, contract renewals are at the sole option of the City.
This letter is to inform you that the City is exercising its right to renew the Contract for an
additional one (1) year period, which will begin immediately after the Expiration Date. All other
terms and conditions of the Contract remain unchanged. Please return this signed
acknowledgement letter, along with a copy of your current insurance certificate, to the
address set forth below, acknowledging receipt of the Contract Renewal Notice. Failure to
provide a signed acknowledgment does not affect the renewal.
Please log onto PeopleSoft Purchasing at httn:l/fortworthtexas.Rov/nurchasiniz to ensure
that your company information is correct and up-to-date.
If you have any questions concerning this Contract Renewal Notice, please contact me at
the telephone number listed below.
Sincerely,
Brenda Ray
Purchasing Manager
Brenda.ravaa,fortworthtexas. aov
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Contract Renewal Page 1 of 3
CSC No.
ACCEPTED AND AGREED:
CITY OF FORT WORTH CONTRACT COMPLIANCE MANAGER:
By signing I acknowledge that l am the person
responsible for the monitoring and
administration of this contract, including
�Gshi g ensurin all performance and reporting
By:Valerie Waashington (Feb 6, 202310:14 CST) G
requirements.
Name: Valerie Washineton
Title: Assistant City Manager
Date: Feb 6, 2023
By: Mark Rauscher (Feb 6, 2023 08:40 CST)
APPROVAL RECOMMENDED: Name: Mark Rauscher
$y:J s Davis (Feb 6, 2023 09:53 CST) Title: Assistant Fire Director
Name: Jim Davis
Title: Fire Chief APPROVED AS TO FORM AND
LEGALITY:
4,dpU4pn��
ATTEST: poi FORTaa
�o
Pv8 o=A By:
Cpo o
*�
By:
d°04 Name: Taylor Paris
Udaaoa
Name: Jannette Goodall Title: Assistant City Attorney
Title: City Secretary
CONTRACT AUTHORIZATION:
NIA
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Contract Renewal Page 2 of 3
CSC No.
Erizoflex *tams, Inc. dba)Xvbix Svstems. Inc.
i�
Name:
: VP of
Contract Renewal Page 3 of 3
CSC No. 57256
FORT WORTH
SOLE SOURCE AGREEMENT
This SOLE SOURCE AGREEMENT ("Agreement") is made and entered into by and between
the CITY OF FORT WORTH ("City"), a Texas home rule municipal corporation, acting by and through
its duly authorized Assistant City Manager, and ERGOFLEX SYSTEMS, INC. DBA XYBIX
SYSTEMS, INC. ("Vendor"), a Colorado Corporation and acting by and through its duly authorized
representative, each individually referred to as a "party" and collectively referred to as the "parties."
AGREEMENT DOCUMENTS:
The Agreement documents shall include the following:
1.
This Sole Source Services Agreement;
2.
Exhibit A —
Scope of Services or Goods;
3.
Exhibit B —
Price Schedule;
4.
Exhibit C —
Sole Source Exemption;
5.
Exhibit D —
Verification of Signature Authority Form; and
6.
Exhibit E
— Conflict of Interest Questionnaire.
Exhibits A, B, C, D, and E which are attached hereto and incorporated herein, are made a part of this
Agreement for all purposes. In the event of any conflict between the terms and conditions of Exhibits A, B,
C, D, or E and the terms and conditions set forth in the body of this Agreement, the terms and conditions
of this Agreement shall control.
I. Scone of Services. Custom console furniture and installation ("Services"), which are set
forth in more detail in Exhibit "A," attached hereto and incorporated herein for all purposes.
2. Term. This Agreement begins on the date signed by Assistant City Manager ("Effective
Date") and expires one year after ("Expiration Date"), unless terminated earlier in accordance with this
Agreement ("Initial Term"). City will have the option, if mutually agreed upon by Vendor, to renew this
Agreement under the same terms and conditions, for up to Four (4) one-year renewal option(s) (each a
"Renewal Term").
3. Compensation. City will pay Vendor in accordance with the provisions of this Agreement,
including Exhibit "B," which is attached hereto and incorporated herein for all purposes. Total
compensation, for each year, under this Agreement will not exceed Twenty Thousand Five Hundred and
Ninety -Two Dollars and Ninety -Five Cents ($20, 592.95). Vendor will not perform any additional
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 will not be liable for any additional expenses
of Vendor not specified by this Agreement unless City first approves such expenses in writing.
OFFICIAL RECORD
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc. CITY SECRETARY
Page 1 of 22
FT. WORTH, TX
4. Termination.
4.1. Written Notice. City or Vendor may terminate this Agreement at any time and for
any reason by providing the other party with 30 days' written notice of termination.
4.2 Non-anorooriation of Funds. In the event no funds or insufficient funds are
appropriated by City in any fiscal period for any payments due hereunder, City will notify Vendor
of such occurrence and this Agreement will terminate on the last day of the fiscal period for which
appropriations were received without penalty or expense to City of any kind whatsoever, except as
to the portions of the payments herein agreed upon for which funds have been appropriated.
4.3 Duties and Obligations of the Parties. Payment is made at the initiation of the
Services. In the event that this Agreement is terminated prior to the Expiration Date, no refund is
provided. Upon termination of this Agreement for any reason, Vendor will provide City with copies
of all completed or partially completed documents prepared under this Agreement. In the event
Vendor has received access to City Information or data as a requirement to perform services
hereunder, Vendor will return all City provided data to City in a machine-readable format or other
format deemed acceptable to City.
5. Disclosure of Conflicts and Confidential Information.
5.1 Disclosure of Conflicts. Vendor hereby states to the best of its knowledge to City
that Vendor has made full disclosure in writing of any existing or potential conflicts of interest
related to Vendor's services under this Agreement. In the event that any conflicts of interest arise
after the Effective Date of this Agreement, Vendor hereby agrees immediately to make full
disclosure to City in writing.
5.2 Confidential Information. Each party, for itself and its officers, agents and
employees, agrees that it will treat all information provided to it by the other party ("Confidential
Information") as confidential and will not disclose any such information to a third party without
the prior written approval of the other party.
5.3 Public Information Act. City is a government entity under the laws of the State of
Texas and all documents held or maintained by City are subject to disclosure under the Texas Public
Information Act. In the event there is a request for information marked Confidential or Proprietary,
City will promptly notify Vendor. It will be the responsibility of Vendor to submit reasons objecting
to disclosure. A determination on whether such reasons are sufficient will not be decided by City,
but by the Office of the Attorney General of the State of Texas or by a court of competent
jurisdiction.
5.4 Unauthorized Access. Each party must store and maintain Confidential
Information in a secure manner and will not allow unauthorized users to access, modify, delete or
otherwise corrupt Confidential Information in any way. A party must notify the other party
immediately if the security or integrity of any Confidential Information has been compromised or
is believed to have been compromised, in which event, the notifying party will, in good faith, use
all commercially reasonable efforts to cooperate with the other party in identifying what
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 2 of 22
information has been accessed by unauthorized means and will fully cooperate to protect such
Confidential Information from further unauthorized disclosure.
b. Right to Audit. Vendor agrees that City will, 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 financial transaction
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 will
have access during normal working hours to all necessary Vendor facilities and will be provided adequate
and appropriate work space in order to conduct audits in compliance with the provisions of this section.
City will give Vendor reasonable advance notice of intended audits.
7. Indenendent Contractor. It is expressly understood and agreed that Vendor will operate
as an independent contractor as to all rights and privileges and work performed under this Agreement, and
not as agent, representative or employee of City. Subject to and in accordance with the conditions and
provisions of this Agreement, Vendor will have the exclusive right to control the details of its operations
and activities and be solely responsible for the acts and omissions of its officers, agents, servants,
employees, Vendors, and subcontractors. Vendor acknowledges that the doctrine of respondeat superior
will not apply as between City, its officers, agents, servants and employees, and Vendor, its officers, agents,
employees, servants, contractors, and subcontractors. Vendor further agrees that nothing herein will be
construed as the creation of a partnership or joint enterprise between City and Vendor. It is further
understood that City will in no way be considered a Co -employer or a Joint employer of Vendor or any
officers, agents, servants, employees, contractors, or subcontractors. Neither Vendor, nor any officers,
agents, servants, employees, contractors, or subcontractors of Vendor will be entitled to any employment
benefits from City. Vendor will be responsible and liable for any and all payment and reporting of taxes on
behalf of itself, and any of its officers, agents, servants, employees, contractors, or contractors.
8. Liability and Indemnification.
8.1 LIABILITY - VENDOR WILL BE LIABLE AND RESPONSIBLE FOR ANY
AND ALL TANGIBLE AND DIRECT PROPERTY LOSS, PROPERTY DAMAGE AND/OR
PERSONAL INJURY, INCLUDING DEATH, TO ANYAND ALL PERSONS, OF ANY KIND
OR CHARACTER, WHETHER REAL OR ASSERTED, TO THE EXTENT CAUSED BY THE
NEGLIGENT ACT(S) OR OMISSION(S), MALFEASANCE OR INTENTIONAL
MISCONDUCT OF VENDOR, ITS OFFICERS, AGENTS, SERVANTS, EMPLOYEES,
CONTRACTORS, OR SUBCONTRACTORS IN PERFORMANCE OF THE SERVICES. IN
NO EVENT SHALL VENDOR BE LIABLE FOR INDIRECT SPECIAL OR
CONSEQUENTIAL DAMAGES RESULTING FROM VENDOR'S PERFORMANCE OR
FAILURE TO PERFORM PURSUANT TO THIS AGREEMENT OR THE CONTRACT OR
THE FURNISHING, PERFORMANCE, OR USE OF ANY SERVICES SOLD HERETO,
WHETHER DUE TO A BREACH OF CONTRACT, BREACH OF WARRANTY, THE
NEGLIGENCE OF VENDOR OR OTHERWISE.
8.2 GENERAL INDEMNIFICATION - VENDOR HEREBY COVENANTS AND
AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND CITY, ITS OFFICERS,
AGENTS, SERVANTS AND EMPLOYEES, FROMANDAGAINSTANYANDALL CLAIMS
OR LAWSUITS OFANYKIND OR CHARACTER, WHETHER REAL OR ASSERTED, FOR
EITHER TANGIBLE PROPERTY DAMAGE OR LOSS AND/OR PERSONAL INJURY,
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 3 of 22
INCLUDING DEATH, TO ANY THIRD PARTY, ARISING OUT OF OR IN CONNECTION
WITH THIS AGREEMENT, TO THE EXTENT DIRECTL Y CA USED BY THE NEGLIGENT
ACTS OR OMISSIONS OR MALFEASANCE OF VENDOR, ITS OFFICERS, AGENTS,
SERVANTS, EMPLOYEES, CONTRACTORS, OR SUBCONTRACTORS IN
PERFORMANCE OF THE SERVICES.
8.3 INTELLECTUAL PROPERTYINDEMNIFICATION-
9. Assignment and. Subcontracting.
9.1 Assianment. Vendor will not assign or subcontract any of its duties, obligations
or rights under this Agreement without the prior written consent of City. If City grants consent to
an assignment, the assignee will execute a written agreement with City and Vendor under which
the assignee agrees to be bound by the duties and obligations of Vendor under this Agreement.
Vendor will be liable for all obligations of Vendor under this Agreement prior to the effective date
of the assignment.
9.2 Subcontract. If City grants consent to a subcontract, the subcontractor will execute
a written agreement with Vendor referencing this Agreement under which subcontractor agrees to
be bound by the duties and obligations of Vendor under this Agreement as such duties and
obligations may apply. Vendor must provide City with a fully executed copy of any such
subcontract.
10. Insurance. Vendor must provide City with certificate(s) of insurance documenting
policies of the following types and minimum coverage limits that are to be in effect prior to commencement
of any Services pursuant to this Agreement:
10.1 Coverage and Limits
(a) Commercial General Liability:
$1,000,000 - Each Occurrence
$2,000,000 - Aggregate
(b) Automobile Liability:
$1,000,000 - Each occurrence on a combined single limit basis
Coverage will be on any vehicle used by Vendor, or its employees, agents, or
representatives in the course of providing Services under this Agreement. "Any
vehicle" will be any vehicle owned, hired and non -owned.
(c) Worker's Compensation:
Statutory limits according to the Texas Workers' Compensation Act or any other
state workers' compensation laws where the Services are being performed
Employers' liability
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 4 of 22
$100,000 -
Bodily Injury by accident; each accident/occurrence
$100,000 -
Bodily Injury by disease; each employee
$500,000 -
Bodily Injury by disease; policy limit
(d)
10.2 General Requirements
(a) The commercial general liability and automobile liability policies must
include City as an additional insured thereon, with respect to ongoing operations
performed by Vendor for City. The term City includes its employees, officers,
officials, agents, and volunteers in respect to the contracted services.
(b) The workers' compensation policy must include a Waiver of Subrogation
(Right of Recovery) in favor of City.
(d) The insurers for all policies must be licensed and/or approved to do
business in the State of Texas. All insurers must have a minimum rating of A- VII
in the current A.M. Best Key Rating Guide, or have reasonably equivalent financial
strength and solvency to the satisfaction of Risk Management. If the rating is
below that required, written approval of Risk Management is required.
(e) Any failure on the part of City to request required insurance
documentation will not constitute a waiver of the insurance requirement.
(f) Certificates of Insurance evidencing that Vendor has obtained all required
insurance will be delivered to the City prior to Vendor proceeding with any work
pursuant to this Agreement.
11. Compliance with Laws, Ordinances, Rules and Regulations. Vendor agrees that in the
performance of its obligations hereunder, it will comply with all applicable federal, state and local laws,
ordinances, rules and regulations and that any work it produces in connection with this Agreement will also
comply with all applicable federal, state and local laws, ordinances, rules and regulations. If City notifies
Vendor of any violation of such laws, ordinances, rules or regulations, Vendor must immediately desist
from and correct the violation.
12. Non -Discrimination Covenant. Vendor, for itself, its personal representatives, assigns,
contractors, subcontractors, and successors in interest, as part of the consideration herein, agrees that in the
performance of Vendor's duties and obligations hereunder, it will not discriminate in the treatment or
employment of any individual or group of individuals on any basis prohibited by law.
13. Notices. Notices required pursuant to the provisions of this Agreement will 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
Sale Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
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transmission, or (3) received by the other party by United States Mail, registered, return receipt requested,
addressed as follows:
14.
To CITY:
City of Fort Worth
Attn: Assistant City Manager
200 Texas Street
Fort Worth, TX 76102-6314
Facsimile: (817) 392-8654
With copy to Fort Worth City Attorney's Office at
same address
To VENDOR:
Ergoflex Systems, Inc. dba Xybix Systems
8207 SouthPark Circle Littleton CO 80120
Main 303-683-5656
Fax 303-683-5454
15. Solicitation of Emglovees. Intentionally omitted.
16. Governmental Powers. It is understood and agreed that by execution of this Agreement,
City does not waive or surrender any of its governmental powers or immunities.
17. No Waiver. The failure of City or Vendor to insist upon the performance of any term or
provision of this Agreement or to exercise any right granted herein does not constitute a waiver of City's or
Vendor's respective right to insist upon appropriate performance or to assert any such right on any future
occasion.
18. Governing Law / Venue. This Agreement will be construed in accordance with the laws
of the State of Texas.
19. Severability. If any provision of this Agreement is held to be invalid, illegal or
unenforceable, the validity, legality and enforceability of the remaining provisions will not in any way be
affected or impaired.
20. Force Majeure. City and Vendor will exercise their best efforts to meet their respective
duties and obligations as set forth in this Agreement, but will not be held liable for any delay or omission
in performance due to force majeure or other causes beyond their reasonable control, including, but not
limited to, compliance with any government law, ordinance, or regulation; acts of God; acts of the public
enemy; fires; strikes; lockouts; natural disasters; wars; riots; epidemics or pandemics; government action
or inaction; orders of government; material or labor restrictions by any governmental authority;
transportation problems; restraints or prohibitions by any court, board, department, commission, or agency
of the United States or of any States; civil disturbances; other national or regional emergencies; or any other
similar cause not enumerated herein but which is beyond the reasonable control of the Party whose
performance is affected (collectively, "Force Majeure Event"). The performance of any such obligation is
suspended during the period of, and only to the extent of, such prevention or hindrance, provided the
affected Party provides notice of the Force Majeure Event, and an explanation as to how it prevents or
hinders the Party's performance, as soon as reasonably possible after the occurrence of the Force Majeure
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 6 of 22
Event, with the reasonableness of such notice to be determined by the City in its sole discretion. The notice
required by this section must be addressed and delivered in accordance with Section 13 of this Agreement.
21. Headings not Controlling. Headings and titles used in this Agreement are for reference
purposes only, will not be deemed a part of this Agreement, and are not intended to define or limit the scope
of any provision of this Agreement.
22. Review of Counsel. The parties acknowledge that each party and its counsel have
reviewed and revised this Agreement and that the normal rules of construction to the effect that any
ambiguities are to be resolved against the drafting party will not be employed in the interpretation of this
Agreement or Exhibits A, B, and C.
23, Amendments 1 Modifications 1 Extensions. No amendment, modification, or extension
of this Agreement will be binding upon a party hereto unless set forth in a written instrument, which is
executed by an authorized representative of each party.
24. Counterparts. This Agreement may be executed in one or more counterparts and each
counterpart will, for all purposes, be deemed an original, but all such counterparts will together constitute
one and the same instrument.
25. Warranty of Services. Vendor warrants that its Services will be of a high quality and
conform to generally prevailing industry standards. City must give written notice of any breach of this
warranty within thirty (30) days from the date that the Services are completed. In such event, at Vendor's
option, Vendor will either (a) use commercially reasonable efforts to re -perform the Services in a manner
that conforms with the warranty, or (b) refund the fees paid by City to Vendor for the nonconforming
services.
26. Immi ration Nationalitv Act. Vendor must verify the identity and employment eligibility
of its employees who perform- work under this Agreement, including completing the Employment
Eligibility Verification Form (I-9). Upon request by City, Vendor will provide City with copies of all 1-9
forms and supporting eligibility documentation for each employee who performs work under this
Agreement. Vendor must adhere to all Federal and State laws as well as establish appropriate procedures
and controls so that no services will be performed by any Vendor employee who is not legally eligible to
perform such services. City, upon written notice to Vendor, will have the right to immediately terminate
this Agreement for violations of this provision by Vendor.
27. Ownership of Work Product. Intentionally omitted.
28. Signature Authoritv. The person signing this Agreement hereby warrants that they have
the legal authority to execute this Agreement on behalf of the respective party, and that such binding
authority has been granted by proper order, resolution, ordinance or other authorization of the entity. This
Agreement and any amendment hereto, may be executed by any authorized representative of Vendor. Each
party is fully entitled to rely on these warranties and representations in entering into this Agreement or any
amendment hereto.
29. Change in Companv Name or Ownership. Vendor must notify City's Purchasing
Manager, in writing, of a company name, ownership, or address change for the purpose of maintaining
updated City records. The president of Vendor or authorized official must sign the letter. A letter indicating
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 7 of 22
changes in a company name or ownership must be accompanied with supporting legal documentation such
as an updated W-9, documents filed with the state indicating such change, copy of the board of director's
resolution approving the action, or an executed merger or acquisition agreement. Failure to provide the
specified documentation so may adversely impact future invoice payments.
30. No Bovcott of Israel. If Vendor has fewer than 10 employees or this Agreement is for
less than $100,000, this section does not apply. Vendor acknowledges that in accordance with Chapter
2271 of the Texas Government Code, the City is prohibited from entering into a contract with a company
for goods or services unless the contract contains a written verification from the company that it: (1) does
not boycott Israel; and (2) will not boycott Israel during the term of the contract. The terms "boycott Israel"
and "company" has the meanings ascribed to those terms in Section 2271 of the Texas Government Code.
By signing this Agreement, Vendor certifies that Vendor's signature provides written verification to
the City that Vendor: (1) does not boycott Israel; and (2) will not boycott Israel during the term of
the Agreement.
31. Prohibition on Bovcotting Energv Comaanies. Vendor acknowledges that, in
accordance with Chapter 2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S.,
SR 13, § 2, the City is prohibited from entering into a contract for goods or services that has a value of
$100,000 or more that is to be paid wholly or partly from public funds of the City with a company with 10
or more full-time employees unless the contract contains a written verification from the company that it:
(1) does not boycott energy companies; and (2) will not boycott energy companies during the term of the
contract. The terms "boycott energy company" and "company" have the meaning ascribed to those terms
by Chapter 2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To
the extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Vendor certifies that Vendor's signature provides written verification to the City that Vendor:
(1) does not boycott energy companies; and (2) will not boycott energy companies during the term of this
Agreement.
32, Prohibition on Discrimination Against Firearm and Ammunition Industries. Vendor
acknowledges that except as otherwise provided by Chapter 2274 of the Texas Government Code, as added
by Acts 2021, 87th Leg., R.S., S.B. 19, § 1, the City is prohibited from entering into a contract for goods or
services that has a value of $100,000 or more that is to be paid wholly or partly from public funds of the
City with a company with 10 or more full-time employees unless the contract contains a written verification
from the company that it: (1) does not have a practice, policy, guidance, or directive that discriminates
against a firearm entity or firearm trade association; and (2) will not discriminate during the term of the
contract against a firearm entity or firearm trade association. The terms "discriminate," "firearm entity"
and "firearm trade association" have the meaning ascribed to those terms by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the extent that Chapter 2274
of the Government Code is applicable to this Agreement, by signing this Agreement, Vendor certifies that
Vendor's signature provides written verification to the City that Vendor: (1) does not have a practice, policy,
guidance, or directive that discriminates against a firearm entity or firearm trade association; and (2) will
not discriminate against a firearm entity or firearm trade association during the term of this Agreement.
33. Electronic Signatures. This Agreement may be executed by electronic signature, which
will be considered as an original signature for all purposes and have the same force and effect as an original
signature. For these purposes, "electronic signature" means electronically scanned and transmitted versions
(e.g. via pdf file or facsimile transmission) of an original signature, or signatures electronically inserted via
software such as Adobe Sign.
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
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34. Entirety of Agreement. This Agreement, including all attachments and exhibits, contains
the entire understanding and agreement between City and Vendor, their assigns and successors in interest,
as to the matters contained herein. Any prior or contemporaneous oral or written agreement is hereby
declared null and void to the extent in conflict with any provision of this Agreement.
(Signature Page to Follow)
IN WITNESS WHEREOF, the parties hereto have executed this Agreement in multiples.
CITY OF FORT WORTH:
By: Valerie Washington M a r 16,202214:39 CDT)
Name: Valerie Washinaton
Title: Assistant City Manager
Date: Mar 16, 2022
APPROVAL RECOMMENDED:
By: J s Davisr 14, 2022 11:59 CDT)
Name: Jim Davis
Title: Fire Chief
ATTEST:
�]
Tdnnette S. Goodall
By: Jannette S. Goodall (Mar 17, 2022 07:10 CDT)
Name: Jannette Goodall
Title: City Secretary
VENDOR.:
Ergoflex '*nc,ba X ixSystems, Inc.
By:
Name: Nernnam
Title: V `36& �4
Date: f [ of
CONTRACT COMPLIANCE MANAGER:
By signing I acknowledge that I am the person
responsible for the monitoring and administration of
this contract, including ensuring all performance and
reporting requirements.
By: Ryan y(Mar 13, 202223:21 CDT)
Name: Mark Rauscher
Title: Fire Assistant Director
APPROVED AS TO FORM AND LEGALITY:
By:
Name: Tavlor. Paris
Title: Assistant City Attorney
CONTRACT AUTHORIZATION:
M&C: NIA
Form 1295: NIA
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 9 of 22
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
City Secretary Contract No.
EXHIBIT A
SCOPE OF SERVICES
Custom Training. Console for Training Room at FAO. This console furniture will be built into our new
Training Room, where new employees will train on the various equipment and the dispatch process.
In addition: Vendor will ship equipment to City location Fire Communications/Dispatch office at 3000
West Bolt Street. City will prepare space, including removal of any and all equipment, in advance of Vendor
coming to Fort Worth to ensure Vendor can proceed with installation without delay. Vendor will complete
installation within one business day.
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 10 of 22
Xytgx Systems, Ir1-
8207 SourViPark Circle
Littleton CO 80120
Phone: 303-683-5656
Fax: 30—M-6454
tayiom
Terms: 1 % 20 Days, NET 30 Days
QUOTE TO.,
Acet FORWORTX01
Fort Wrath 9-1-1 Communications
505 West Felix Street
Fort Worth TX 76115
City Secretary Contract No.
EXHIBIT B
PRICE SHEDULE
ix
Quote Number:
Quote Date,
30298
3110124z2
xyb
Revision:
E
Orig Croats Date,.
3i1012022
Expires:
61812022
OW #:
0024075
Pa":
SHIP TO:
Fort Worth Pol" Communications Division
3000 W. Bdt St
Fort Worth. TX 76110
USA
Salesperson, BRITTNEY h1USC4iAVE
Phone- (214) 727-1681
Email brmneym@xybtx.com
Phone
Email.
HGAC CONTRACT EC07-20
'Ea& litre
'Tax Exempt
03.10.2022 - R3. Pnevkws 0mitei130t 700. Hart to update dim ru quotxrg witware emx' 'TAM
02.21.2022 - R3. update gums to 14GAC PncffW TAN
02.033.2022 - RI Uppdate cables to Lksptay Port/ TAN
12.01.2021 - R2. update iable to axys/ TAN
01, 07.2021 - R1, LluaterT'AN
01.04,2021- R4, Ommng Qrearkxd TAN
Pandffmc Freight Surcharge
Tvl, lee is rho temporary upcharge we are expenencM for ShOP g naiered
costs and delays
ILlne Part Mum Oasc
Q►F UN Ust Ea. OEsik % W&C. Prtae
Panel System Prgmd by the Linear Foot
1.00 EA $2 7G6.50 47.00 •,. $1 993.07
Grade 3 Fabric
12343-1-SS - 29448in -13.0 LF Q
$212.DDrLF
12343-14}S - 2948In - 3.5 LF
$287.00 LF
Upper Tiles Fabric Color: TBR Grade 3
G2
Lower Tiles Fabc Color. TBb Grade 3
G2
Panel Trim Color Black
1.01 13771, panel 'File 11429-14HX30VY W-Fabric
1.D0 EA $172.00 47.DD% $91.16
OPEN MARKET
1.02 13T71. Panel Zile 11430-14HX315V W-Fabric
1.00 EA $T72,00 47,00% $91.16
OPEN MARKET
2.00 144013,3D, Ad} Table Worksurlam - Corner Dual
1.00 EA $2.313.00 47.00 % $1.225.89
Surface - 66L x 66R - Kahle
Management Included
2.01 15701 L4 Table Base
1.00 EA $6.057.00 47.OD% $3,207.56
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 11 of 22
i of
wo kc:l
S 1,993.D7
591.16
$91,1i3
S:.22&89
53;207.56
Xybix Systerns, Irr-
6207 SouthPark Circle
Littleton CO 80120
Phone: 3D3-683-5658
Fax: 303-683-5454
taylom
f xybix
IouOte I
Terms: 1% 20 Days, NET 30 bays
111-ine Pert Hum Dow
4.00 16744. Monitor Mount 3 - Rollervrsron - Corner
Dual Surface - 66L x 66R
16676 - Std VESA Mount 2 H 12 Knuckle
Qty = 3 To* $2,SBOA0 - OPEN
MARKET
OPEN 'MARKET
Quote Number: 30298
Quote Date:
311012022
Revision:
E
Orig Create Date:
311012022
Expires:
6/802022
Opp if:
0024075
Page: 2 of 3
Qty WM List Ea, Disc, % Disc. Price Not Prical
1.0U EA $4,943.10 47.00% $2.619.79 S2,619.79
4.01
i55o80
Acrylic Cleaning Kid
1,00 EA
$114.00
47,0D,%
$60.42
$60.42
5.00
14340
Display Pohl cable 25 FT Male)Male
6.00 EA
$88.00
47.OD %
S46,64
$279.84
5.01
1613"
1hatadock2- Keyboard Snap -In Cable
1,00 EA
$602.00
47.0G %
$319.06
$349.06
Organizer
Includes:
8 - US8 Parts
1 - RJ45 Pon
8.OD
1179ZMX
Pourer Bar - 10 Outlel Write Black Sticker
1,00 EA
$156.00
47.00
582.68
l $82.68
6.01
11792-OR
Powtor Bar - 10 Outlet Wttt1 Change
1.00 EA
5156.00
47.OD x
S8168
S82.68
Sticker
7.00
16708,
Axys Control System with Fan
1.DO EA
$4.009.00
47.00 `a
$2,124.77
$2.124.77
Base Price; $2,079.00
16707AXS - Neat - S582.00 - OPEN
MARKET
167OWtXS -Task Lights - 5519;00 -
OPEN MARKET
16711AXS - F'ootwell Lighting - $156.00 -
OPEN MARKET
16712AXS - Dawn Bias Lighting -
$155.00 - OPEN MARKET
16713AXS - Arc Lighting - $519.00 -
OPEN MARKET
8.00
15463
Shelf Under Surface 19W x 90 - Metal
1.W EA
$146.00
•47.0%
$77.311
$77.38
0.01
15475 ._.
Shelf Under Surface USB Charging
1.00 EA
$122.00 47.00 %
$64.66
$64.66
Upgrade Assembly
10.00
12033-3t)-
Flip Top Return Worksurface - 24Wx36D
1.DO EA
$516.00
47.01) %
$273.48
$273.48
FT.
11.00
16209
Cable Bridge Corder Angled Left Side
1.DO EA
$229.00
47.00 %
$121.37
$121.37
11.01
101a
Cab4e Bridge Corner Angled Right Side
1,00 EA
$229.00
47.00 %
$121.37
$121.37
11.02
15484-30-
CPU Cabinet - ERGO ACCESS tinder
1.00 EA
$1,485.00 47.00 %
$787.05
$787.05
FT.
Work Surface 24Wx34.5D With Flip Top
Hinge
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 12 of 22
Xybix Systems, Inc. Quote Number: 30298
B207 SouttiPark Circle •
Littleton CO 80120 Quote Date: 3110120 E
Phone: 393-693 5656 Ravlsbn:
Xybix
Floc; 303-693-5454 frig Creata Oahe: 31IM2022
tayiom Expires: GIV2022
Opp M. 0024075
Terms: 1 % 20 Clays, NET 30 Days Pogo; 3 of 3
Line Park Num Oesc Qly WU L1st Ea. DisR % Disc. Price Not Price)
90.00 >6139 Installers Krt Eagle Lme 1.00 EA 50.00 0.00 % $0600 $0.00
90.01 10166 Crating or Cradling Table for Shipment 4.W EA $241,00 0.00 % $201,Q0 $804.00
99.00 01her Other Charges Semites 1.00 EA $0.00 - 0.00 % $0600 $0.00
Lim 1251. Miscallaneous Charge -
Description Exl. Price
1.} LTL - Sid with 1_lilgate 1,380,00
2.) Installation 4,497.02
3.) Parxiemic Freight Sureharr.,e 288655
List Price Tate] $26,506.50 Lines Total $14.427.36
Line Mrsoellaneous Cnarges 56.165.57
Total:
Taxes Total: $0.00
Quote Total: $20,592.95
tote f
All quoted taxes are e911mated. Any 9pphcable house, lees, permits. Ole. must be &Wed to this Quote.
Kole 2.
Where inreallsZon is listed on quote it s based to mn—union labor ens on one trip for urctallapon only. CI1eM t6 responafl* for coordnaaon of
TochnkcAne and othw VentlmnrConhadlora. Wailing broe will be charged a the rate of $75 yet men how OlraNM time and S 1115 per man hW' for 07
plan subsistence experma.
Addl{ioreally Itks quote a based upon a remodel m an &*alrtll Epam snWor new buldno-mrmletely firrahed we a CartlWto of DcCt4wey. Any
prood wrtare the ®enecal Conbraclor I6 still on the lrtb is eublea to addlsonal charges.
We 9pprecIme Irtlb cpp)rginty to awAde this 4". Cur "I Is to stbal&nileil9Improve'wDr 9 oartdltions for your v9wable stag. W'9 Wok Wwwd to
meeting wlih you to review It* vMpoM rn aalat. In the irowAlme plem donY heeftela bo cal U6 wtlh err}• queeticne.
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 13 of 22
EXHIBIT C
SOLE SOURCE EXEMPTION
FORT WORTH
Cris' OF FORT WORTH
CHAPTER 252 E-NTMPTION FOR11
Instructions: Fill out the entire farm trdh detailed information. Once you haver completed this form
provide it to the Purchasing attorney for review. The attorney will retiiew the information you have
provided to determine whether an exemption to Chapter 252's biding requirements is defensil*
If you are priming this form to provide to Legal please do not prm°ide the Primer portion Failure
to prmide sufficient information may result in foriow up questi0m and cause a delay in the
attorney's deternunation
Section 1: General Information
s* Department:
Name of Cc=ct Manager:
Department's Attorney:
Item of Service sought:
Goods:
Service:
Anticipated Amount:
render
Currea?nor Agreement for item'service
CSC or Purchase Order
Projected M&C Date:
FIRE DEPT.
James Tiaater
PARIS. TAILOR
a
1
S 25.000.00
Er¢oflex Svstems. Ind dba Xvbix Svstems
Yes ❑ No 0
LLAI
S21. 268.62
NA
How wX this item or service be used? This console f un=e will be built into our new
Traim= Roam where new FAO emplovees will tram on the various equiGxreni and the
dispatch process.
Page 1 of 7
Sole Source Agreement - and t:rgotlex Systems, Inc. dba Aybix Systems Inc.
Page 14 of 22
Section 2: C laitned ESemptioa and Justification (Outer than sole sow-ce)
NOTE - For a clained sole -source eseutption. complete Section 3.
Please indicate the non -sole -source e%enVnon you believe applies to the purchase and prmide
information to support its applicability. Please refer to the Exenntption Praiser for detailed
informt<ation about conmian *-,.� &,.s:
0 A r.. W -L..: necessary to presen•e or protect the public health or safe;_`- of the City
of Fort Worths residents;
El A procurement necessary because of unforeseen damage to public m2d&iery.
equipment. or other property
A procurement for personaL professional or planning senzces:
A procurement for work that is performd and paid for by the day as the work
Progresses:
Q A purchase of land or a right -of -war.
M Pavmg drainage. street widening. and other public m4 rovenrws. of related azatters. if
at least one-third of the cost is to be paid by or through, special assessments L-ned on
property that win benefit front the niVot,entents:
f l A public mtpro, tnrent project. ahead, is progress. authorised by the voters of the
nnmicrpality- for which there is a. deficiency of fitr& for corl4)1etzng the protect to
accordance with the plans and purposes author urd by the voters.
n A pa-mtent under a contract by which a developer participates in the construction of a
public attprovenrnt as provided by Subchapter C. Chapter 212,
LL Personal propeM- sold.
• at an auction by a state licensed auctioneer;
• at a going out of business sale held in coniohance with Subchapter F.
Chapter 17. Business & Commerce Code:
• by a political subdnision of this state. a state agency of this state. or an
entity of the federal gotvrrmtent: or
• under an interlocal contract for cooperatn't purchasing adnttnfstered by a
regional planning coamtissron established under Chapter 391:
[J Services performed by blind of severely disabled persons:
n Goods purchased by a in hty for subsequent retail sale b4 the nnzaicipality-
Q, Electricity; or
Paget of 7
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 15 of 22
n Achrilisimg other than legal notices.
Please provide details and facts to e.Vlaiin wiry you betievr the exemption applies to the
purchase You may also attach documentation to this form
Section 3: Claimed Sole -Source Exemption wid Justification
NOTE -For any non -sole -source exemption_ connpkte Sectiwi
Please m6cate the sole -source you beheve applies to the purchase and provide
de
to support its appiicabdity. Please refer to the E.xenTtion Primer for detailed
information about contmion exemptions
21 *A procurement of ilems that are available from on one source. tachnding.
• items that are available from otily one source because of patents. copyrights_
secret processes. or natural monopolies:
• fiklis mnannuscrvts. or boobs:
• gas. water. and other utky senices_
• captive replacement parts or components for equipment;
• books. papers. and other library materials for a public Wary that are
available omh, from the persons hokiing exchsiue distribution rights to the
materials: and
• management senwes pro-nded by a nornlxofit organization to a municipal
museum park zoo, or other facility to which the organization has pro-oided
smificant financial of other benefits:
How did vo u determine that the item or sendce is onh• avaibble from one source'
The exstme firnitutre in the can center is provided by X,.fii%_ a custom dispatch frniture
vendor. As the design is orotxietarv. no other vendor could vTovide the euct furniture in use in
the Fife Alarm Office I
Attach screenshots and provide an explanation of any independent research tiou conducted.
through inteniet searches. searching cooperators. or discussions with others knowledgeable ou
the subject matter that corroborate that the item is available only- from a single soturce.
[After verifinz the consoles are a sole source uenu decided would like to purchase the sane ites.
The Fort Worth Fire Devartnent Abrmu Office has S unman• dispatch consoles and six back --
consoles All 14 of those consoles are enact duplicates in rezurds to fiunittjre and ecRivnnem.
This oroaosed console will be for training new emoloyees. As the is for training mawses. the
furniture and equipment slxxtld be exactly the sane as what is currently within the Alarm office
Bunging from a different vendor would make this invossible The e_xistmg furniture m the call
Page 3 of 7
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 16 of 22
center is provided b• Xybcs" a custom dispatch itnurure vendor. As the desum is proprietari. no
other mudor could provide the exact fiimituue r<i use in the Fire Alarm Office. 1
Did you attach a sole source justification letter? ® Yes ❑ No
Describe the uniqueness of the dens or sertyce (e.g. compati�ilidy or patent issues. etc.). Thz a
patented product that cannot be reproduced by another iendor or duplicated by another
inninifactuuer. The patent relates to the desks roller vision monitor nmumtim system which
allows for the monitors to be raised and loitered nAependenth, of the work space desk area as
well as vuIled closer or rushed fiirther astir dependent on the user remnrenrnts. The nxnmts
hold eizht to ten monitors as ilk -ell as nuiltiple controls for ketboards and mice. of which each
console has three. This fiinctionality is inioportant to the departnrpi as we have a wide ranee of
envlorvees with different vision requirenrnts. A.1lowim, the monitors to be moved towards the
user. prevents chanzm displav settings which ukiniateh, lead to tickets and costs
because the nexi user inav not be able to chawe the system backs furiiituue is designed for a
2+7 dispatch operation in our Fire and Police Conmiunication center. As this is also a tram
console and wM be utilized to complete near dispatcher trainmu and contmitinz education
scenario bused tramp- it is miportant tliat the consoles be identicall
Section 4: Attoiue `- De to iinination
With the facts prcrided by tit deparuirnt. is the use of the clamrd exemption defensible if the
Crty were to be challenged on this purchase' Z. Yes ❑'.`o
IV -as there am•t uu attached to this form that eras relied on in niakiu this deterinination'
❑Yes ❑N0
If yes. please explamsSole sowce letter from vendor
Was there ainth= not uxkWed on this forni or attached hereto that was relied on in nial:m this;
detemunation' 51 Yes 0 No.
If res. please explain: discussions with staff conceming patent.
Will the standard terns and conditions apph"
Will the contract require special terms'
Will. the contract require re'.vw by the department attorrieti"
21
IINo
21 Yes
ZL NO.
❑ Yes
❑ No.
Page 4 of 7
Sole Source Agreement - and Ergotlex Systems, Inc. dba Xybix Systems Inc.
Page 17 of 22
Approved By.
- p0ow, Date: 2 25 2
TayU Paris/ Jessim WMiams
Assistant City Attonry
Page 5 of 7
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 18 of 22
EXEMPTION FORM PRIMER
Below are e.Vlanations and examples of comamarm ....u., , that could apply to City purchases.
If you have questicns abort the information proWed or need additional mformatioon. please
contact your departments assigned attorney of the 4�rr..'6r:.mte purchasing attorney
A procurement necessary to presen-e or protect the public health or safety of the
nuuu w ipalit v ' s residents:
FxanVies of actnities that have been found to fall ivithin this exception dude ambulance
senices. solid waste collection and disposaL and first -responder safetyequalxmermt such as
breathing apparatus for firefighters and bullet -Proof ,rsts for police officers.
A procurem rant necessary because of unforeseen damage to public machinery. equ4mrnt_
or other property:
Examples of the type of procurement would mcl ude reparmg or replacing roofs and
windows damaged by had or a tornado But parts and sentices for routine n3amtenance or
replacement of old. w-on out roofs or wamdows would not meet this exception,
A procurement for personal professuonaL or planning senses:
Personal senses are ores that are unique to the imdnmduual pro%iduug them Therefore
personal senices contract catmot generally be sWxomtracted or assigned
Professional senses are not defined under Chapter 2>2. so there is no precise definition
to follmr There is no unnrrsal definition of this term however. "se-rral cases suggest
that it... is 'r... ..,...a,.ely mental or intellectual- rather than physical or manual "' Tex.
AM, Gen Op. JM-940 (1988) (quoting Vagland Casuialn CO. u'. Crab Mater Co, - 160
&W. 2d 102 (Tex_ Civ. App.-Eastland 1942, no wT#) The Texas Attorney General has
also opined that "professional senices" no lounger inckides only the senses of lawyffs.
physicians_ or theoiopams. but also those members of disciplines requiring special
lamowledge or attainment and a high order of learning_ slab and intelligence. Id.
Facts needed to support a professional senice exemption include the specialized
regtnrements of that profession and the mental and intellectual skill required by the person
while performing the sen-re. Purchases of goods are not professional senses.
A procurement of items that are available from onh- one source
This is commonhr referred to as the sole source ;:.: "__ In determining
whether a purchase is of a good or senxe that is aiailable from one source. ),ouu should
not consider price or time to recen a the good or senme. A sole source does not exist solely
on the basis of personal or departmental preference or a desire to beep all =s the same
brand of make. Time mfonmmation needed to support this exert ptiiom is that no other provider
Page 6 of 7
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 19 of 22
can provide the seruice or category of good except for the vendor you are proposing. Some
exanTles of sole source purchases inchide senice agreements when onh• one Meador is
authorized to work on the equipurnt by the n=ufacturer and aI mxmg another vendor
wotdd voO the warranm purchase of a good that is cop-yngited or tradenarbed and only
prodded by one vendor.
Page 7 5f 7
Page 20 of 22
EXHIBIT D
VERIFICATION OF SIGNATURE AUTHORITY
Ergoflex Svstems, Inc. dba Xvbix Svstems
8207 SouthPark Circle Littleton CO 80120
Main 303-683-5656
Execution of this Signature Verification Form ("Form") hereby certifies that the following
individuals and/or positions have the authority to legally bind Vendor and to execute any agreement,
amendment or change order on behalf of Vendor. Such binding authority has been granted by proper order,
resolution, ordinance or other authorization of Vendor. City is fully entitled to rely on the warranty and
representation set forth in this Form in entering into any agreement or amendment with Vendor. Vendor
will submit an updated Form within ten (10) business days if there are any changes to the signatory
authority. City is entitled to rely on any current executed Form until it receives a revised Form that has been
properly executed by Vendor.
1. Name: �ak� �e-rmAlj
Posi n: Q fy 5a lt5
Sign
2. Name:
Position:
Signature
3. Name:
Position:
Signature
Name: 8 a rry C
4
Si ture of President / CEO
Other Title: Pres:a-evrt l Q L4n1e-r
Date: 3 - I i o,
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 21 of 22
EXHIBIT E
CONFLICT OF INTEREST
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by KR. 23, 84th Leg., Regular Session. OFFICE USE ONLY
This questionnaire is being filed in accordancewith Chapter 176, Local Government Code. o,t$ Rt Q,'d
by a vendorwho has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the vendor sheets requirements under Section 176.006(a).
Bylaw 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 it the vendor knowingly violates Section 176.006. Local
Government Code. An offense under this section is a misdemeanor.
J Name of vendor who has business relation shlpwith local governmental entity.
J I I Check this box If you are tiling an update to a previously tiled questionnaire.
(The taw requires that you file an updated completed questionnaire with the appropriate filing authority not
later than the 71h business day after the date on which you became aware that the originally filed quostionnaire was
incomplete or inaccurate.)
3
Name of local government officer about whom the Information In this section is being disclosed.
J
Name of Officer
This section litem 3 including subparts A, 8, C, & D) must be completod 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 CIO 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 receving 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 F71 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 �n this section.
S,qnature of vendor doing business with the governmental entity Crate
Adopted 8/7/2015
Sole Source Agreement - and Ergoflex Systems, Inc. dba Xybix Systems Inc.
Page 22 of 22