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Home My WebLink AboutContract 63840CSC No. 63840 FORT WORTH OFFICIAL RECORD CITY OF FORT WORTH CITY SECRETARY FT. WORTH, Tx COOPERATIVE PURCHASE AGREEMENT This Cooperative Purchase Agreement ("Agreement") is entered into by Master Medical Equipment ("Vendor") and the City of Fort Worth ("City"), a Texas home -rule municipality, individually referred to as "party" and collectively as the "parties." 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 — Savvik Buying Group Contract No. 2024-06 Pricing; 3. Exhibit B — Cooperative Agency Contract Savvik Buying Group Contract No. 2024-06; and 4. Exhibit C — Conflict of Interest Questionnaire Exhibits A, B, and C, 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 A pursuant to the terms and conditions of this Cooperative Purchase Agreement, including all exhibits thereto. If any provisions of the attached Exhibits conflict with the terms herein, are prohibited by applicable law, conflict with any applicable rule, regulation or ordinance of City, the terms in this Cooperative Purchase Agreement shall control. City shall pay Vendor in accordance with the payment terms in Exhibit A and in accordance with the provisions of this Agreement. Total payment made under this Agreement by City shall not exceed One Hundred Thousand Dollars ($100,000.00) annually. 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 Parties will engage in multiple transactions to purchase goods and/or services under this Agreement. For each purchase made pursuant to this Agreement, Vendor must supply a quote for the subject goods and/or services and the quote must conform with the then -current pricing under the underlying cooperative agreement. If the City accepts the quote and places an order for the goods and/or services, that quote shall be considered an addendum to this agreement but is not required to be filed in the City records. The Parties will maintain all quotes for the 3- year Audit period included herein. The term of this Agreement is effective beginning on the date signed by the Assistant City Manager ("Effective Date") and expires on November 8, 2026, with one one-year renewal option at city's discretion. 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. Page 1 of 15 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 or (2) received by the other party by United States Mail, registered, return receipt requested, addressed as follows: To CITY: City of Fort Worth Attn: Assistant City Manager 100 Fort Worth Trail Fort Worth, TX 76102 With copy to Fort Worth City Attorney's Office at the same address To VENDOR: Master Medical Equipment Megan Davis General Manager of Distribution 2345 FE Wright Dr. Jackson, TN 38305 Email: mdavis@mmemed.com 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. To the extent the Agreement requires that City maintain records in violation of the Act, City hereby objects to such provisions and such provisions are hereby deleted from the Agreement and shall have no force or effect. In the event there is a request for information marked Confidential or Proprietary, City shall 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. The Agreement and the rights and obligations of the parties hereto shall be governed by, and construed in accordance with the laws of the United States and state of Texas, exclusive of conflicts of law provisions. Venue for any suit brought under the Agreement shall be in a court of competent jurisdiction in Tarrant County, Texas. To the extent the Agreement is required to be governed by any state law other than Texas or venue in Tarrant County, City objects to such terms and any such terms are hereby deleted from the Agreement and shall have no force or effect. Nothing herein constitutes a waiver of City's sovereign immunity. To the extent the Agreement requires City to waive its rights or immunities as a government entity; such provisions are hereby deleted and shall have no force or effect. To the extent the Agreement, in any way, limits the liability of Vendor or requires City to indemnify or hold Vendor or any third party harmless from damages of any kind or character, City objects to these terms and any such terms are hereby deleted from the Agreement and shall have no force or effect. 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 Chapter 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. Page 2 of 15 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 2276 of the Texas Government Code, 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 Vendor that it: (1) does not boycott energy companies; and (2) will not boycott energy companies during the term of this Agreement. To the extent that Chapter 2276 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. If Vendor has fewer than 10 employees or this Agreement is for less than $100,000, this section does not apply. Vendor acknowledges that except as otherwise provided by Chapter 2274 of the Texas Government Code, 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 Vendor 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. 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. (signature page follows) (remainder of this page intentionally left blank) Page 3 of 15 The undersigned represents and warran hat he or she has the power and authority to execute h Agreement and bind the respective party. CITY OF FORT W TH: By: Name: William Johnson Title: Assistant City Manager Date: 08/20/2025 APPROVAL RECOMMENDED: By: game 1:43:40CDT) Name: Jim Davis Title: Fire Chief a FORTn*& oa a_a $tea By: Name: Jannette Goodall Title: City Secretary VENDOR: Master Medical Equipment By: 4h �I/�� C Name: Megan Davis Title: General Manager of Distribution Date: 8/13/25 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: Name: Brenda Ray Title: Purchasing Manager APPROVED AS TO FORM AND LEGALITY: a)WAdNLd By: 7 Name: Jessika J. Williams Title: Assistant City Attorney CONTRACT AUTHORIZATION: M&C: N/A 1295 Form: N/A OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Page 4 of 15 EXHIBIT A EAGLE COUNTY eubliemenIne SERVICES SaAyAT0U SA�V� V I K'"`5 Eagle County Health Service District, dba Eagle County Paramedic Services Host Public Agency: Eagle County Health Sc— Dcah a t Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 2021-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricina for Automated External Defibrillators Item Description UOM List Price Contract Price Discount% IZOL21000010102011010 New, ZOLL AED Plus Package with AED Cover for Medical Professionals, One CPR-D Padz, One sleeve of Batteries, and Soft Carry Case. 7 Year Manufacturer's Warranty each $2,295.00 $1,385.00 39.651416 IPH1861304-COI Philips FRx AED with Carry Case, Smart Pad 11, 8 Year Manufacturer's Warranty each $2,333.00 $1,815.00 22.203172 IPHIM5066A-CO2 Philips HeartStart OnSite AED with Carry Case, Onsite Pad, battery, 8 Year Manufacturer's Warranty each $1,949.00 $1,325.00 32.016419 ICSG5A-80C-S Cardiac Science Powerheart G5, Fully Auto with Carry Case, Inelli5ense Adult Electrodes, battery, 8 Year Manufacturer's Warranty each $2,957.00 $1,850.00 37.436591 ICSG5S-80C-S Cardiac Science Powerheart G5, Semi Auto with Carry Case, IntelliSense Adult Electrodes, battery, 8 Year Manufacturer's Warranty each $2,957.00 $2,250.00 23.909368 IZOL8511-001101-01 Zoll AED 3 Semi Auto with CPR Um Audit Electrodes, battery, 8 Year Manufacturer's Warranty each $3,924.00 $2,395.00 38.965341 jDFTDCF-A100-EN Defibtech DCF-100 Lifeline AED Package each $1,762.66 $1,125.00 36.176007 jDFTDCF-A320-EN Defibtech Lifeline full -auto AED Package each $1,851.10 $1,195.00 35.44379 IDFTDCF-A2310EN Defibtech Lifeline View AED Package each $2,550.61 $1,495.00 41.38657 Page 5 of 15 EAGLE COUNTY *Public Safit Association Inc `1 PARAMEDIC SERVICES WORKING roar SAV V I K Eagle County Health Service District dba Eagle County Paramedic Services Host Public Agency: Eagle County Health Service District Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 2021-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricina for Automated CPR Devices Item Description UOM List Price Contract Price Discount % DFTRCF-A2000EN Lifeline ARM XR Chest Compression System leach 1 $18,999 1 $12,995.00 1 31.601663251 Page 6 of 15 _ EAGLE COUNTY C � J PARAMEDIC SERVICES Eagle County Health Service District dba Eagle County Paramedic Services Host Public Agency: Eagle County Health Service District Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 2021-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricing for Ventilators Item Description PRT-01198-000 lv+Pro Public Safety Association Inc WORC Nr. FOR YOU /\ SAVVIK UOM List Price Contract Price Discount % leach 1 $12,500.001 $8,200.001 34.41 Page 7 of 15 oblKe Sc FOR Association Inc EAGLE COUNTY 0W •1 PARAMEDIC SERVICES Eagle County Health Service District dba Eagle County Paramedic Services / Host Public Agency: Eagle County Health Service District S AV V.I K . Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 202I-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricina for Other Medical Eauioment Item Description UOM List Price Contract Pr Discount % 1EIT17000-028-0072 Sapphire Multi -Therapy Pump Power Supply Mini Cradle w/ knob key User Manual 2-Year each $2,350.00 $2,000.00 14.893621 IGE8855001-001-01103932 GE MAC 5 each $5,000.00 $4,250.00 15.000001 MAS95164 Rad-G Pulse Oximeter Kit each $650.00 $550.00 15.384621 IGEH8031VA Vscan Air Base Package each $8,990.00 $4,650.00 48.275861 ILAE880061 Laerdal LCSU 4, 300 ml Compact Suction Unit each $769.00 $625.00 18.725621 ISSC74000 S-SCORT III: Dual Mode Charger; 2 Position Regulator; DC Cable Included each $820.63 $695.00 15.308971 Page 8 of 15 EAGLE COUNTY `1 PARAMEDIC SERVICE Eagle County Health Service District dba Eagle County Paramedic Services Host Public Agency. Eagle County Health Service District Marketing Agencies: Savvik Buying Group and Public Safety Association Inc Public Safety Association Inc WOOKING Fon You SAVVIK'" RFB 2021-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricina for Accessories & Other Items Item Description UOM List Price Contract Price Discount % DURCR123A3V Duracell CR123A Batteries for AED Plus pack of 10 $100.00 $25.00 75 ZOL8900-0800-01 CPR-D Padz each $177.45 $142.00 19.97745844 ZOL8900-0402 CPR Stat-Padz Electrode, Single each $78.75 $62.00 21.26984127 CS9131-001 Cardiac Science G3 Electrode each $63.00 $55.00 12.6984127 ABE9146 Cardiac Science G3 Replacement Battery each $398.00 $350.00 12.06030151 CSXELAED001C Intellisense Defibrillation Pads, G5 each $85.00 $83.00 2.352941176 ABEG5 Aftermarket Cardiac Science G5 Battery each $280.00 $265.00 5.357142857 PH1989803139261 Philips FRx SMART Pads II each $69.00 $55.00 20.28985507 PH1989803139311 Philips FRx Pediatric/Infant Key each $121.00 $118.00 2.479338843 PHIM5071A Philips Onsite Adult Pads each $89.00 $70.00 21.34831461 PHIM5072A Philips Onsite Pediatric Pads each $125.00 $110.00 12 PHIM5070A Philips FRx/Onsite AED Battery each $205.00 $165.00 19.51219512 VERT100LOAC-PHY Physio/Stryker Compatible Pads - AED/Defib each $32.00 $31.00 3.125 PHY11141-000100 Lifepak 1000 Battery each $570.00 $550.00 3.50877193 PHY11111-000016 Lifepak 1000 3 Lead ECG Cable each $435.00 $400.00 8.045977011 PHY11113-000004 Quik-Combo Therapy Cable, Lifepak 15 each $645.00 $625.00 3.100775194 PHY21330-001176 Lifepak 15 Lithium -Ion Battery each $715.00 $675.00 5.594405594 PHY11140-000098 Lifepak 15 AC Power Adapter each $2,850.00 $2,695.00 5.438596491 STATLP15CARRYCASE Statpacks Lifepak 15 Carry Case each $249.99 $230.00 7.996319853 ZOL8900-0402 CPR Stat-Padz Electrode, Single - AED/Defib each $129.00 $120.00 6.976744186 ZOL8000-0580-01 Zoll SurePower II Battery, Propaq/ X Series each $1,195.00 $1,180.00 1.255230126 ZOL8000-0025 Zoll R Series 3 Lead Patient Cable each $187.00 $150.00 19.78609626 ZOL8019-0535-01 Zoll Surepower R Series Battery each $996.00 $795.00 20.18072289 ZOL8009-0750 Zoll R Series OneStep Pacing Cable each $1,136.00 $1,075.00 5.36971831 ZOL8000-0312 Zoll R Series Capno 5 EtCO2 Sensor each $6,260.00 $6,150.00 1.757188498 ZOL8900-0224-01 OneStep CPR Complete Electrode, Single each $141.00 $130.00 7.80141844 DFTDCF-200 Defibtech Lifeline Battery Pack, Syr each $229.10 $205.00 10.51942383 DFTDCF-2003 DDU-2000 Series Standard 4-year Battery each $240.45 $215.00 10.58432106 DFTDCF-210 Defibtech Lifeline Battery Pack, 7yr each $267.70 $238.00 11.09450878 DFTDDP-100 Defibtech Lifeline Adult Defib Electrodes each $75.15 $68.00 9.514304724 DFTDDP-200P Defibtech Lifeline Pediatric Pads each $130.25 $116.00 10.94049904 DFTDDP-2001 Lifeline View Adult Pads each $83.05 $75.00 9.692956051 DFTDDP-2002 Lifeline View Pediatric Pads each $136.40 $121.00 11.29032258 Page 9 of 15 EAi rnCOUNTY ,�,PubiicSafetyAssociationIne PAr< � ^"-CSERVICEeS Wou■iNc roe you Eagle County Health Service District, dba Eagle County Paramedic Services S AV V I K" Host Public Agency: Eagle County Health Service District eVY1M4 4epy Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 2021-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Deftbrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricing for Training Item Description ZOL8008-0050-01 Zoll AED Plus Trainer 2 Package uOM List Price Contract Price Discount % each $397.95 $320.00 19.58788793 Page 10 of 15 EAGLE COUNTY ,,Public Sa%ty Auaciadon Inc `1 PARAMEDIC SERVICES WORK�NGro YOU SAVVI K Eagle County Health Service District dba Eagle County Paramedic Services Host Public Agency: Eagle County Health Service District Marketing Agencies: Sawik Buying Group and Public Safety Association Inc RFB 202I-06 Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing Pricina for Service Plans Item Description uOM List Price Contract Price Discount % SC-SAPP-1 1 Year Service Contract for the Eitan Sapphire Pump EA $390.00 $350.00 10.25641026 SC-SAPP-2 2 Year Service Contract for the Eitan Sapphire Pump EA $725.00 $650.00 10.34482759 SC-SAPP-3 3 Year Service Contract for the Eitan Sapphire Pump EA $1,000.00 $900.00 10 SC-SAPP-4 4 Year Service Contract for the Eitan Sapphire Pump EA $1,280.00 $1,150.00 10.15625 SC-SAPP-5 5 Year Service Contract for the Eitan Sapphire Pump EA $1,560.00 $1,400.00 10.25641026 Page 11 of 15 EXHIBIT B ��yyyy EAGLE COUNTY f�,fi SEftVICEaS ,+►�`e,PLtblic Safety Association Inc WORKING FOR YOU AGREEMENT Master Medical Equipment This Agreement is effective November 8, 2024, by and between Eagle County Health Service District, dba Eagle County Paramedic Services (the "Principal Procurement Agency"), Public Safety Association Inc (the "Company") and Master Medical Equipment (the "Supplier"). RECITALS A. The Company, on behalf of the Principal Procurement Agency, issued a Request for Bid for Medical Equipment, RFB 42024-06 ("RFB"), soliciting bids for the supply and support of Medical Equipment such as: Automated External Defibrillators, Cardiac Monitors/Defibrillators, Automated CPR Devices, Ventilators, Video Laryngoscopes, Other Medical Equipment, Training, Accessories, Service Plans and Financing. B. Supplier duly submitted proposal in response to the RFB ("RFB Response"), which outlines Supplier's agreement to or exceptions with the RFB. C. The Principal Procurement Agency, Company and Supplier have negotiated certain amendments or exceptions to the RFB and RFB Response, and desire to enter into this Agreement with the intent of memorializing the final terms of the parties' agreement. AGREEMENT In consideration of the provisions, representations, warranties, covenants and agreements contained in this Agreement, the parties agree to the terms set forth in this Agreement. Agreement: The parties agree that this Agreement, together with the RFB, the Notice to Bidders dated and published on August 22, 2024 and August 29, 2024, the RFB Response, together with all documents specifically referred to therein, as gathered and compiled in that certain binder entitled "Eagle County Paramedic Services, Public Safety Association Inc and Master Medical Equipment" attached hereto (together, all such documents shall be referred to herein as the "Contract Documents"), shall constitute the binding agreement between the Principal Procurement Agency, Company and Supplier for Supplier's provision of products and services to the Company pursuant to the terms therein. 2. Entire Agreement: The parties agree that this Agreement, together with the Contract Documents, represent the only agreement among the parties concerning the subject matter thereof and supersedes all prior agreements, whether written or oral, relating thereto. 3. Modifications: No purported amendment, modification or waiver of any provision in the Agreement and the Contract Documents shall be binding unless set forth in a written document signed by all parties (in case of amendment and modifications) or by the party charged thereby (in the case of waivers). Any waiver shall be limited to the provision hereof and the circumstance or event specifically made subject hereto and shall not be deemed a waiver of any other term hereof or of the same circumstance or event upon any recurrence thereof. 4. Term of Agreement: This agreement is set to expire November 8, 2027. •...�....._• __. ___`"- - �--,.��.«�x•.��.d�ca-+�.�: .:...:�. _...�a..,�..—r�..V'�arxs�...s _ `!�oY.3rn �"d�C�ilkSksolnRY►i'.: �rs:4�i*:� Page 12 of 15 IN WITNESS WHEREOF, the parties have caused the Agreement to be executed on November 8, 2024. Eagle County Health Service District dba, Eagle County Paramedic Services (the "Principal Procurement Agency") By. FM 441— Printed Name: Steve Vardaman Its: Operations Manager Public Safety Association Inc (the "Company") By. Printed: Dane Meyer Its: President Master Medical Equipment (the "Supplier") By: �af-CG 7Cah,crz. Printed Name: ( a "! e, ka s6n e R Its: FAU, %%CW— . N Page 13 of 15 EXHIBIT C CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ 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. Master Medical Equipment J ❑ 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.) J Name of local government officer about whom the information is being disclosed. Name of Officer J 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 X� 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? 71 Yes FX I No J 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. J ❑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). J 8/13/2025 Signature of vendor Loingsiness with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021 Page 14 of 15 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.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 § 176.0010-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 4 176.006(a) and (a-1) (a) Avendor 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 Page 15 of 15