October 1, 2:00PM (CT)

Transcription

1 Dallas County Solicitation Number: Opening Date: AQ October 1, 2:00PM (CT) Submit proposals to: Dallas County - Purchasing Department, 509 Main - 6th Floor - Records Building - Room 623, Dallas, Texas 75202, by the aforementioned opening date: By Fax to: By to: lenora.sevillian@dallascounty.org If faxing or ing, please call Lenora to confirm receipt. ANNUAL QUOTE FOR OUTPATIENT DRUG AND ALCOHOL COUNSELING FOR DALLAS COUNTY COMMUNITY SUPERVISION AND CORRECTIONS DEPARTMENT (DCCSCD) Name and Address of Company/Bidder Submitting Proposal Name of Company: Address: City: State: Zip: Phone Number: Fax Number: Address: Authorizing Company Signature: Name (Type or Print): Title: Address: Federal Tax ID #: Is the Principle Company Owner a Dallas County taxpayer? Is your company certified by the North Central Texas Regional Certification Agency (NCTRCA)? Yes or No

2 Dallas County Community Supervision and Corrections Department (DCCSCD), herein also referenced as CSCD or the DEPARTMENT, is requesting quotations for a non-exclusive ANNUAL QUOTE FOR OUTPATIENT DRUG AND ALCOHOL COUNSELING. Quotes must be submitted on the attached proposal form by returning the Proposal with a price quote, vendors certify and agree that: 1. All charges taxes, insurance, overhead, benefits, permits, licenses, labor, personnel, service, supervision, workmanship, documentation, reporting, manifest, materials, supplies, tools, vehicles, trucks, vacuum, equipment, environmental fees, disposal charges, fuel surcharges, shipping, transportation, freight. mileages, parking and other ancillary fees, tolls, travel time, freight, and all other associated cost including incidentals necessary to perform the scope of work and services the work outlined in this contact are to be included in proposal. Delivery and Services will be F.O.B.: Dallas County as indicated on each designated purchase order. 2. If applicable, a packing list or other suitable shipping documents shall accompany each shipment and shall show: (a) (b) (c) (d) Name and address of vendor Name and address of receiving department Dallas County Purchase Order number and Description of material shipped, including item numbers, quantity, number of containers, and package number, if any. 3. INSURANCE REQUIREMENTS VENDOR shall provide an adequate plan of insurance that provides: (1) coverage to protect DEPARTMENT and the State against all claims, including claims based on violations of civil rights arising from the Services performed by VENDOR; (2) coverage to protect the State from actions by a third party against VENDOR or any subcontractor of VENDOR; and (3) coverage to protect the State from actions by officers, employees, or agents of VENDOR or any subcontractor(s). VENDOR shall maintain the following insurance coverage in full force and effect for the mutual protection and benefit of DEPARTMENT, the State and VENDOR with the amounts and coverage s as required by law, in accordance with the following: A. Claims that may arise out of or result from VENDOR'S actions/omissions/operations hereunder, whether such actions/omissions/operations are by VENDOR or by a subcontractor of VENDOR, or by anyone directly or indirectly employed by or acting on behalf of VENDOR or a subcontractor where liability may arise for: 1. Claims under workers compensation disability benefits, and other similar employee benefit actions; 2. Claims for damages because of bodily injury, occupational sickness or disease, or death of any VENDOR employees; 3. Claims for damages because of bodily injury, sickness or disease or death of any Person other than VENDOR'S employees; 4. Claims for damages insured by usual personal liability coverage that are sustained by (a) any Person as a result of an act directly or indirectly related to the employment of such Person by VENDOR, or by (b) any other Person; 5. Claims for damages because of injury to or destruction of tangible property, including loss of use resulting there from; 6. Claims for damages based on violations of civil rights; 7. Claims for damages arising from fire and lightning and other casualties. B. VENDOR shall obtain and maintain in force insurance coverage in accordance with all applicable law and accepted industry standards during the term they are engaged hereunder. In addition, VENDOR shall maintain a liability insurance policy in an amount not less than $100,000 for each person and $300,000 for each single occurrence for bodily injury or death and $100,000 for each single occurrence for injury to or destruction of property. C. Certifications/policies of insurance shall be filed with DEPARTMENT prior to execution of this AGREEMENT. VENDOR shall notify DEPARTMENT within fifteen (15) days of cancellation of any policy required herein. D. Compliance with the foregoing insurance requirements shall not relieve VENDOR from any liability under the indemnity provisions. 2

3 Indemnification. VENDOR shall indemnify and save the DEPARTMENT, the Texas Board of Criminal Justice, the Texas Department of Criminal Justice, the State of Texas, and its officers, agents and employees (hereinafter, collectively referred to as the "State") harmless from and against any and all claims arising from the conduct, management or performance hereof, including, without limitation, any and all claims arising from any condition herein or arising from any breach or default on the part of VENDOR in the performance of any covenant or agreement on its part to be performed, or arising from any act of negligence of VENDOR, or licensees or arising from any accident, injury or damage whatsoever caused to any person, firm or corporation and from and against all costs, reasonable attorney's fees, expenses and liabilities incurred in or about any such claim, action or proceeding brought against the State by reason of any such claim. In any such action brought against the State, VENDOR, upon notice from the State, shall defend against such action or proceeding by counsel satisfactory to the State, unless such action or proceeding is defended against by counsel for any carrier of liability insurance provided for 4. DISCLOSURE FORM CIQ Effective January 1, 2006, Chapter 176 of the Texas Local Government Code requires that any vendor or person considering doing business with a local government entity disclose in the Questionnaire Form CIQ, the vendor or person's affiliation or business relationship that might cause a conflict of interest with a local government entity. By law, this questionnaire must be filed with the records administrator of Dallas County no later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. The questionnaire is included in this solicitation. By submitting a response to this request, the vendor represents that it is in compliance with the requirements of Chapter 176 of the Texas Local Government Code. Please send completed forms to the Dallas County Clerk at 509 Main Street, 2nd Floor, Dallas, Texas Terms of Agreement: This will be a firm fixed price agreement for a twelve (12) month period beginning the date of award. This contract maybe renewed/extended for two (2) additional, twelve (12) month periods subject to the availability of departmental funding, vendor performance and mutual agreement by all parties. All renewals/extensions shall be based on existing terms, conditions, and price structures set forth in original bid award or as amended in writing by Dallas County Community Supervision and Corrections Department (DCCSCD). 6. The bid award shall be based on, but not necessarily limited to, the following factors: a. Unit Price b Ability of vendor to secure third party funding for the services provided to referred clients.. c. Special Needs and Requirements of CSCD d. Experience of vendor providing similar services e. Vendor's Past Performance Record f. CSCD s Evaluation of Vendor's Ability g. CSCD reserves the right to award to a primary and secondary vendor. 7. The contractor shall submit two invoices upon (receipt/completion) of the (materials/work) (received/performed). The original invoices will be sent to the Dallas County CSCD 133 N. Riverfront Blvd, 9 th floor Dallas, Texas Payments will be processed after the Auditor's Office has been notified by the originating department that the (service/materials) have been (received/performed) in satisfactory condition and no unauthorized substitutions have been made according to the specifications. Invoices must detail the (service/material) (received/performed) and must reference the Dallas County Purchase Order number for speed in processing. 8. The Contractor shall be considered an Independent Contractor and not an agent, servant, employee, or representative of the CSCD in the performance of the work. No term or provision hereof or act of the Contractor shall be construed as changing that status. 9. The Contractor agrees, during the performance of the work, to comply with all applicable codes and ordinances of the appropriate City, County or State of Texas as they may apply, as these laws may now read or as they may hereafter be changed or amended. 10. The Contractor shall obtain from the appropriate City, Dallas County or State of Texas the necessary permit(s), if any, required by the ordinances of the City, County or State for the performance of the Work. 11. The Contractor shall not sell, assign, transfer or convey this Contract, in whole or in part, without the prior written consent of CSCD 3

4 12. Should CSCD authorize the original awardee to subcontract (assign) any portion of this contract, the original awardee will maintain the ultimate legal responsibility for all services according to contract specifications. In the event of a subcontract, the original awardee must maintain a continuous effective business relationship with the subcontractor(s) including, but not limited to, regular payments of all monies owed to any subcontractor. Failure to comply with these requirements, in whole or part, will result in termination of this contract and/or legal ramifications, due to nonperformance. Should CSCD authorize the original contractor to transfer this contract, in whole or part, the secondary contractor will maintain all the legal responsibilities set forth in the context of this contract. 13. In case any one or more of the provisions contained in this Contract shall for any reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability shall not affect any other provision thereof and this Contract shall be considered as if such invalid, illegal, or unenforceable provision had never been contained herein. 14. The parties herein agree that this Contract shall be enforceable in Dallas County, Texas, and if legal action is necessary to enforce it, exclusive venue shall lie in Dallas County, Texas. 15. This Contract shall be governed by and construed in accordance with the laws of the State of Texas and all applicable Federal Laws. 16. This Contract embodies the complete agreement of the parties hereto, superseding all oral or written previous and contemporary agreements between the parties and relating to matters herein, and except as otherwise provided herein cannot be modified without written agreement of the parties. 17. Multi-year service/lease-purchase agreements or any continuing contracts are solicited and awarded based on governmental fiscal funding. If for any reason, funds are not appropriated to continue the service/lease- purchase agreement, the said agreement/contract shall be automatically terminated on the expiration date or date in which the funds have been eliminated. Any/all services/leased equipment will be removed from the respective county department/facilities without penalty to CSCD. Any/all charges incurred as a result of this action are the responsibility of the contractor. 18. Contractors are not officially authorized to begin work and/or deliver items covered under this agreement until formal approval and/or a signed contract is executed by CSCD. CSCD accepts no liability, of any kind, for products/services delivered/furnished without proper authorization. 19. Except for proposals received under Local Government Code and/or , in accordance with the aforementioned statutes, Dallas County will uphold the confidentiality of bidder trade secrets to the extent allotted by law. All confidential information must be clearly identified and separated, by the bidder and prior to submission of the proposal. 20. Non-performance of the bidder in terms of Specifications or Non-compliance with terms of this contract shall be basis for termination of the contract by the CSCD. Termination in whole or part, by the CSCD may be made at its option and without prejudice to any other remedy to which it may be entitled at law or in equity, or elsewhere under this Contract, by giving ten (10) days written notice to the VENDOR with the understanding that all work being performed under this contract shall cease upon the date specified in such notice. CSCD shall not pay for work, equipment, services or supplies which are unsatisfactory. 21. Monetary Restitution - In the event the contract is prematurely terminated due to non-performance and/or withdrawal by the contractor, CSCD reserves the right to seek monetary restitution (to include but not limited to; withholding of monies owed) from the contractor to cover costs for interim services and/or to cover the difference of a higher cost (difference between termination vendor s rate and new company s rate) beginning the date of vendor s termination through the contract expiration date. In the event civil suit is filed to enforce this provision, CSCD will seek its attorney s fees and cost of suit from the Contractor. 22. TERMINATION CSCD may, at its option and without prejudice to any other remedy to which it may be entitled at law or in equity, or elsewhere under this contract, terminate this Contract, in whole or part, by giving 10 days written notice thereof to the Contract with the understanding that all (products/services) being (delivered/performed) under this Contract shall cease upon the date specified in such notice. CSCD shall compensate the Contractor in accordance with the terms of this contract for the (products/services) (delivered/performed) prior to the date specified in such notice. 4

5 23. No official or employee shall have any financial interest, direct or indirect, in any contract with the County or CSCD or be financially interested, directly or indirectly, in the sale to the County or CSCD of any land, materials, supplies or services, except on behalf of the County as an official or employee. Any violation of this section, with knowledge, express or implied, of the person or corporation contracting with the County or CSCD shall render the contract involved voidable by CSCD. It is the responsibility of the contractor during all phases of the contract process to notify the County or CSCD in writing of any potential conflict of interest. 24. In the best interest of the CSCD or County, as determined by the Dallas County Commissioners Court or CSCD, any bidder/proposer who is currently involved, either directly or indirectly, with any litigation against or involving Dallas County or CSCD may be disqualified and/or not considered for an award. 25. Vendor hereby assigns to purchaser any and all claims for overcharges associated with this contract which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq. 26. Each offeror is requested to carefully read the MINORITY BUSINESS POLICY OF DALLAS COUNTY (following the Bid Proposal Section of this specification). 27. FEDERAL DEBARRED VENDORS No products and/or services utilizing Federal funds may be procured from vendors that are listed on the Federal Excluded Parties List. Government requirements for non-procurement suspension and debarment are contained in the OBM guidance 2CFR, part 180 that implements Executive Orders and Debarment and Suspension. Dallas County reserves the right to reject from award consideration and/or terminate any contract with any vendor found to be suspended, ineligible and/or debarred as outlined herein. 28. TWELVE (12) MONTH WAITING PERIOD FOR EMPLOYMENT OF CERTAIN FORMER COUNTY EMPLOYEES In accordance with the County's Transparency Policy, any firm awarded a contract for the Procurement of goods or services shall be prohibited from hiring any individual who has previously worked for the County and in that capacity either evaluated, recommended, approved, monitored, or managed a contract involving that firm no sooner than twelve months after that individual has ceased to work for or be employed by the County. Failure to adhere to such a contractual requirement may result in the termination of the contract with the County. 29. INTERLOCAL AGREEMENT (City/State Participation Program) In accordance with Article of the Texas Government Code, governmental agencies (local, state) may request to utilize County contract by executing an interlocal agreement with Dallas County to do so. Vendors are to indicate on the bid proposal page whether they are willing to extend pricing from this contract to other governmental agencies in accordance with the outlined specifications. Dallas County is indemnified against any and all claims that may arise from Interlocal Agreements entered into by the Contractor and governmental agencies. 30. Nepotism: No person (1)Who is an employee, agent, consultant, officer, or official of the contractor and who exercises or has exercised any functions or responsibilities with respect to assisted contract activities; or (2) Who is in a position to participate in a decision making process or gains inside information with regard to such activities, may obtain a personal or financial interest or benefit, direct or indirect, in any contract, subcontract, or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with whom they have family or business ties, during their tenure. 31. Pursuant to Sec of the Texas Business Organization Code, non-texas entities, including, but not limited to corporations, limited partnerships, and limited liability companies must have an application for registration filed with the Texas Secretary of State and shall provide to Dallas County a Certificate of Status issued by the Texas Secretary of State that serves as official evidence of the entity s existence or authority to transact business in Texas. To transact business with Dallas County, all entities must be in legal compliance pursuant to applicable laws, and shall provide to Dallas County evidence of said compliance. 32. NON EXCLUSIVITY This contract and/or agreement is non-exclusive and shall not in any way preclude Dallas County from entering into similar agreements and/or arrangements with other Vendors, Contractors, or from acquiring similar, equal or like goods and/or services from other entities or sources including state contracts. 5

6 33. Questions or administration of this contract, the Dallas County representative is: Dallas County Purchasing Department Lenora Sevillian P: F: The deadline for submission of written questions regarding this quote will be Friday, September 18, 10:00AM(CT)The official responses to all written communication will be issued in written addendum or posted as general information no later than Friday, September 25, 4:30PM (CT). or fax all questions to lenora.sevillian@dallascounty.org or Please reference the quote number in the subject line, company name, and representative name on all correspondence to Dallas County. Only written responses to written communication shall be considered official and binding to Dallas County. Any oral communication shall be considered unofficial and non-binding. NOTE: All Addendums and any additional applicable correspondence (general information, questions/responses) to this Bid will be made available exclusively through the Dallas County website for viewing/retrieval. Vendors are solely responsible for frequently checking the website for updates to the solicitation. Addendums to this solicitation can be located at the following website: or go to the applicable Bid # and click on the associated addendum or general information hyperlink. DISCLAIMER: DALLAS COUNTY ACTS AS A PASS THROUGH FOR THE COMMUNITY SUPERVISION AND CORRECTIONS DEPARTMENT (CSCD) BIDS AND SOLICITATIONS. ANY PURCHASE ORDERS ISSUED UNDER THIS ANNUAL CONTRACT MUST ADHERE TO THE TERMS AND CONDITIONS SET FORTH BY CSCD. DALLAS COUNTY AND THE DALLAS COUNTY PURCHASING DEPARTMENT DO NOT ASSUME AND EXPRESSLY DISCLAIMS ANY LIABILITY OR RESPONSIBILITY UNDER THIS CONTRACT, INCLUDING FOR PERFORMANCE OR COMPLIANCE. ANY ISSUES OR CONCERNS AFTER THIS BID HAS BEEN AWARDED MUST BE ADDRESSED WITH CSCD, NOT DALLAS COUNTY OR THE DALLAS COUNTY PURCHASING DEPARTMENT. 6

7 PROGRAM DESCRIPTION This program is for the provision of court-mandated drug and alcohol counseling on an outpatient basis for persons currently supervised through Dallas County Community Supervision and Corrections Department (DCCSCD). All clients referred through this program have been evaluated for mental health and substance-related issues and have been court-ordered to complete an Intensive Outpatient Program (IOP). Referrals to this program will be made by DCCSCD upon court approval. In order to be eligible for reimbursement, all clients served through this program must be indigent and ineligible for third-party funding and authorized by DCCSCD prior to receiving services. The primary goals of this program are to effectively address drug and alcohol problems and other criminogenic risk factors leading to a reduction in recidivism among the referred population. For this reason, this program requires contractor experience with judiciallyinvolved populations and adherence to an evidence-based, cognitive-behavioral, manualized, substance abuse curriculum. Experience in addressing substance abuse issues, criminal thinking errors, and familiarity with the drug-court model are essential components of this program. This program requires extensive collaboration, documentation, and communication between the contactor, DCCSCD, Community Supervision Officers (CSOs) and the Courts regarding attendance, treatment planning, progress reports, and aggregate data. The contractor for this program must be able to provide the required outpatient treatment services with appropriately licensed counselors at their facility in accordance with applicable CJAD standards and state and federal privacy laws. Contractor must be able to enroll and qualify a minimum of sixty-percent (60%) of referred individuals for IOP treatment through third-party funding sources. Contractor facilities must be accessible to public transportation in order to accommodate client indigence status. The contractor will be responsible for obtaining all necessary consents, releases and waivers to allow communication with DCCSCD and the courts. The contractor will also be responsible for all aspects of eligibility determination, enrollment, and billing through third parties. Only clients determined to be ineligible through alternative funding sources are eligible to be billed through this program. Under no circumstances shall contractor bill DCCSCD for any services provided to enrollees of any third party reimbursement entities. Responsibilities of Parties: In recognition of the public benefits to be derived from the implementation of the program the parties agree that their responsibilities shall be as follows: A. Dallas County CSCD Responsibilities: 1. DCCSCD will furnish the CONTRACTOR with the supervising officer s name, , business address, and phone number for all cases. 2. DCCSCD will furnish CONTRACTOR with copy of an evaluation and signed authorization to release information for all referred cases prior to client s initial intake appointment through CONTRACTOR. 3. DCCSCD will furnish CONTRACTOR with copy of the client s Conditions of Probation for all referred cases prior to client s initial intake appointment through CONTRACTOR. 4. DCCSCD will furnish CONTRACTOR with authorization number for clients referred to this program upon confirmation of court order. 5. DCCSCD will furnish CONTRACTOR with identifying information on all referred clients, including client name, ML number, and date of birth as well as court of jurisdiction having authority over the referred client. B. CONTRACTOR Responsibilities: 1. CONTRACTOR shall utilize an evidence-based cognitive-behavioral curriculum which addresses both substance abuse and criminal conduct/criminal thinking. 2. CONTRACTOR will provide treatment services at a facility accessible to public transportation. 3. CONTRACTOR will utilize the CATS evaluation in conducting the intake assessment prior to the onset of treatment. Any deviations in diagnosis/recommendations from those which are indicated in the CATS evaluation that are made by the treatment facility will be clinically justified in clinical documentation. 4. CONTRACTOR will limit group counseling sessions to a minimum of three participants and a maximum of 16 participants. 7

8 5. At the onset of treatment, CONTRACTOR will make clear the limits of confidentiality in relation to ongoing communication with DCCSCD, the CSO, and the court. Documentation of informed consent will be signed by the participant. This informed consent will make clear the participant understanding of the treatment facility s ongoing communication with CSCD regarding the participant s progress in treatment, as well as any significant disclosures that must be made to CSCD or other authorities. 6. CONTRACTOR will provide three (3) 2-hour IOP Group counseling sessions per week for a total of 18 sessions. 7. In addition to group sessions, CONTRACTOR will provide one (1) one hour individual session per month OR one (1) one hour family session per month during the course of treatment. CONTRACTOR may provide any combination of individual of family counseling during the course of treatment; however, the total number of individual and family sessions may not exceed one (1) per month. 8. CONTRACTOR will provide weekly written progress reports to client s CSO. Evidence of substance use, current or ongoing criminal behavior, or violations of probation conditions will be disclosed to the CSO within one (1) business day. CSO s will be notified within one (1) business day of a participant s no show to treatment. 9. CONTRACTOR will provide weekly written progress reports to client s CSO. Evidence of substance use, current or ongoing criminal behavior, or violations of probation conditions will be disclosed to the CSO within one (1) business day. CSO s will be notified within one (1) business day of a participant s failure to show for treatment. 10. CONTRACTOR will provide notifications of discharges from treatment (successful or unsuccessful) to CSOs within one (1) business day. A full discharge summary will be completed for successful and unsuccessful discharges and provided to CSO within 14 days of discharge. 11. CONTRACTOR will respond to all CSCD/CATS requests for any additional information within one (1) business day. 12. CONTRACTOR must maintain group and individual counseling session logs with client signatures, including date of service, topic discussed, client participation, and counselor signature, for all billed services. CONTRACTOR must provide copies of all counseling service logs to CSCD upon request and maintain original logs in client files available for CSCD audit. 13. CONTRACTOR must maintain client treatment files and make them available for audit by CSCD. Client treatment files should include group and individual counseling logs, progress notes, treatment plans signed by clients, client receipt of group rules, all consents, all waivers, all financial eligibility documents and any other documents signed by referred clients. 14. CONTRACTOR must provide drug screens to clients in treatment on at least a monthly basis and communicate results to DCCSCD within one (1) business day of receiving results. C. Fees and Rates : The contractors will be required to show proof that clients served were not eligible for funding of treatment through private insurance or ValueOptions/NorthSTAR reimbursements prior to billing DCCSCD. The reimbursement rate for these services will be based per hour (60 minutes) of direct client service. Please quote your cost in the following terms : Rate per Group treatment hour :. Rate per Individual/Family treatment hour :. 8

9 D. Responses should include copies of CONTRACTOR s : 1. organizational standard operating procedures. 2. organizational chart for proposing agency. 3. evidence of criminal background checks on all staff. 4. group rules including attendance policies. 5. waivers and releases. 6. consents. 7. financial eligibility documents. 8. all financial agreements signed by clients. 9. any additional documents to be signed by clients. 10. summary and description of curriculum and materials to be used. 11. overview of treatment progression including phases and step-down criteria. 12. proposed method(s) and reports for tracking clients and client data. 13. certificate of occupancy. 14. general and professional liability insurance coverage. For Statistical Gathering Purposes Only: Please indicate to Dallas County whether the principal company owner is a: (Please Check One) [ ] Dallas County Tax Payer [ ] Other County Tax Payer (Specify): Is your company certified through an agency other than North Central Texas Regional Certification Agency (NCTRCA)? (Example: Statewide Historically Underutilized Business (HUB) Program, MBE, WBE, DBE, SBA, SBA, Veteran, 8(a)) Yes No If yes, please provide state the agency name and the applicable certification number below: Certifying Agency Name: Registration or Certification Number: Expiration Date: Please indicate the manner in which you were notified of this solicitation: [ ] Daily Commercial Record [ ] Dallas County Website [ ] Letter from Dallas County Purchasing Department [ ] Other: specify: Bidders are required to indicate whether they have the required products on hand at the time of the bid or whether they will be required to obtain such upon award. Please indicate by checking the appropriate box: [ ] I/We do have the products in stock [ ] I/We will be required to obtain the products upon award of bid The attached documents shall be submitted with bid documents: 1. Dallas County Insurance Requirement Affidavit 2. Affidavit (if applicable) Thank You 9

10 Specify the name, telephone number and address (if any) of the account representative who will be handling this account: ACCOUNT REPRESENTATIVE: TELEPHONE NUMBER: ADDRESS: CITY: ST. ZIP: FEDERAL TAX ID NO. 10

11 DALLAS COUNTY INSURANCE REQUIREMENT AFFIDAVIT THIS FORM IS NOT A SUBSTITUTE FOR THE REQUIRED POLICY AND/OR STATE APPROVED CERTIFICATE OF INSURANCE FORM To Be Completed By Insurance Agent/Broker and Bidder I, the undersigned Agent/Broker, reviewed the insurance requirement contained in this bid document. If the Bidder shown below is awarded this contract by Dallas County, I will be able to, within ten (10) days after contract award and prior to commencement of services, meet all of the insurance requirements in this bid. Insurance Coverage Reviewed: Agent s Name: Agency Name: Address: City/State/Zip: Telephone No: Fax No: Bidder s Name and Company: Project/Bid No. and Title: ( ) ( ) By submitting a bid and signing below I affirm the following: I am aware of all costs to provide the required insurance, will do so pending contract award, and will have my insurance agent provide this information to Dallas County, meeting all requirements within ten days of notification of award. If the above ten day requirement is not met, Dallas County reserves the right to cancel the contract for non-performance. If you have any questions concerning these requirements, please contact the Dallas County Human Resource / Civil Service s Risk Manager at Insurance Agent/Broker Signature: Date: Bidder s Signature: Date: 11

12 WAIVER OF WORKERS' COMPENSATION INSURANCE AFFIDAVIT STATE OF TEXAS COUNTY OF DALLAS BEFORE ME, the undersigned authority personally appeared, individually and doing business as, who after being by me first duly sworn, deposed and stated as follows: 1. My name is appearing herein individually and as president and sole owner of. I am over 21 years of age, of sound mind, authorized and fully competent to make this affidavit. I have never been convicted of a felony or misdemeanor involving moral turpitude. I have personal knowledge of the facts and representations stated for the reasons stated herein, and such facts and representations are true and correct. 2. My name is. I am president and sole owner of located at. Dallas County issued Solicitation No. (hereinafter Bid/RFP ). Bid/RFP provisions required the successful contractor to maintain Workers Compensation Insurance Coverage meeting the requirements and coverage amounts as established by the Texas Workers Compensation Act, Title 5, Subtitle A, Texas Labor Code. I do not maintain Workers Compensation Insurance as required by the proposed bid. I am ineligible for purchasing Workers Compensation Insurance as required by the proposed bid in that I do not meet the minimum requirements to purchase such insurance for the following reasons:. Further affiant sayeth not. Name Company SWORN TO AND SUBSCRIBED TO BEFORE ME, on this day of, 20. Commission Expires Notary Public in and for the State of Texas 12

13 DALLAS COUNTY MINORITY/WOMEN OWNED BUSINESS ENTERPRISE DISADVANTAGEDD BUSINESS ENTERPRISE AND HISTORICALLY UNDERUTILIZED BUSINESS PROGRAM SPECIFICATIONS Patrece Richardson, Minority Business Officer REVISED 04/

14 MINORITY/WOMAN OWNED BUSINESS ENTERPRISE (M/WBE) DISADVANTAGEDD BUSINESS ENTERPRISE (DBE) AND HISTORICALLY UNDERUTILIZED BUSINESS (HUB) SPECIFICATIONS For Bids/RFPs I. POLICY STATEMENT Dallas County is wholly committed to developing, establishing, maintaining, and enhancing minority involvement in the total procurement process. It is the policy of Dallas County to involve qualified HUB and minority/women-owned businesses to the greatest extent feasible in the County's procurement of goods, equipment, services, and construction projects. The County, its contractors, their suppliers and subcontractors, and vendors of goods, equipment services, and professional services shall not discriminate on the basis of race, color, religion, national origin, handicap, or sex in the award and/or performance of contracts. However, competition and quality of work remains the ultimate "yardstick" in contractor, subcontractor, vendor, service, professional service, and supplier utilization. All vendors, suppliers, professionals, and contractors doing business or anticipating doing business with Dallas County shall support, encourage, and implement affirmative steps toward our common goal of establishing equal opportunity for all citizens of Dallas County. II. REQUIREMENT OF ALL BIDDERS/PROPOSERS: Each firm responding to this solicitation shall be required to submit with their bid/proposal information regarding minority/women business and HUB business participation in this project. This would include: Check upon completion (forms attached): 1. Compliance with Dallas County's Good Faith Effort Policy 2. MBE/WBE/DBE and HUB Participation Report Form 3. A Letter of Assurance A or Letter of Assurance B 4. MBE/WBE/DBE and HUB Identification 5. EEO-1 Form (To be submitted by the prime and any sub with 20% or more of the contract). 6. Dallas County MBE/WBE/DBE and HUB Payment Report. Note In the event that the awarded vendor is authorized to subcontract and commits effort to utilize minority and/or women-owned businesses as subcontractors, the name, address and telephone number of the actual subcontractor(s) with actual dollar awards to these subcontractors must be submitted to the Purchasing Department within five (5) working days after bids are opened. Once work commences, the awarded vendor (prime contractor) must submit an M/WBE and/or HUB subcontractor status payment report (attached) with each payment invoice before payments will be authorized for release. REVISED 04/

15 1. GOOD FAITH EFFORT Prior to an award, all bidders/proposers will be required to document a "Good Faith Effort" to secure minority/women-owned and/or HUB businesses as subcontractors/sub-consultants/suppliers. In the case of some construction projects, this documentation may be submitted after award of the contract, for those subcontract areas occurring later in the construction process. However, if the successful bidder/proposer does not document a "Good Faith Effort in securing minority/women-owned businesses, a representative of the company must appear before the Dallas County Commissioners Court and explain the situation and answer any questions raised by the Court. Fulfillment of the "good faith effort" can be accomplished by: 1. Attendance of pre-bid/pre-proposal conference, as scheduled by the County. 2. Efforts to follow-up initial solicitation of interest by contacting minority/women-owned firms to determine with certainty whether these firms are interested. 3. Efforts made to select portions of the work proposed to be performed by minority/women-owned firms in order to increase the likelihood of achieving participation (including, where appropriate, breakdown of subcontracts into economically feasible units to facilitate participation). 4. Documenting each minority/woman-owned firm contacted the conclusion or decision regarding inclusion and reasons for the conclusions. 5. Efforts to assist the minority/women-owned firms contacted that needed assistance in obtaining bonding, lines of credit or insurance. 6. Efforts that demonstrate that the contractor effectively used the services of available community organizations, contractor's groups, local, state and federal agencies, small businesses, minority/women business assistance offices and other organizations that provide assistance and placement of minority/woman-owned businesses. Company Name: Printed Name: Title: Signed: Date: REVISED 04/

16 2. MBE/WBE/DBE AND HUB PARTICIPATION REPORT* SOLICITATION/PROJECT NUMBER SOLICITATION/PROJECT TITLE Total Amount of Your Bid/Proposal $ (The amount should equal the total amount as shown on the bid sheet) List all proposed MBE/WBE/DBE/HUB subcontractors/sub-consultants/material suppliers that will be used in the performance of this contract and attach a copy of their current and valid certification document. Deletion of firms must be approved by Dallas County prior to finalization. 1. Sub-Contractor/Consultant/Material Supplier Name: Contact Name and Phone Number: Certification Classification: MBE WBE DBE HUB Certification Agency: Certification Number: Dollar Amount: $ Percentage % of Contract: % Description of Services/Work**: 2. Sub-Contractor/Consultant/Material Supplier Name: Contact Name and Phone Number: Certification Classification: MBE WBE DBE HUB Certification Agency: Certification Number: Dollar Amount: $ Percentage % of Contract: % Description of Services/Work: 3. Sub-Contractor/Consultant/Material Supplier Name: Contact Name and Phone Number: Certification Classification: MBE WBE DBE HUB Certification Agency: Certification Number: Dollar Amount: $ Percentage % of Contract: % Description of Services/Work**: 4. Sub-Contractor/Consultant/Material Supplier Name: Contact Name and Phone Number: Certification Classification: MBE WBE DBE HUB Certification Agency: Certification Number: Dollar Amount: $ Percentage % of Contract: % Description of Services/Work**: *Dallas County recognizes certifications from the following government entities and/or agencies: ** Must correspond with specific goods or services North Central Texas Regional Certification Agency (NCTRCA) outlined RFP/BID, specify section and page number DFW Minority Supplier Development Council (D/FW MSDC) The Women s Business Council Southwest (WBCS) State of Texas Historically Underutilized Business (TX HUB) Texas Unified Certification Program (TUCP) Texas Department of Transportation (TXDOT) Disadvantaged Business Enterprise (DBE) Program DOT PROJECTS ONLY No MBE/WBE/DBE s or HUBs will be utilized in the performance of this contract. Please explain and/or provide justification: COMPLETE THIS PORTION OF THE FORM WITH DATA ON YOUR COMPANY. Company Name Address: Phone No: Printed Name of Preparer: Preparer Signature Title: Date REVISED 04/

17 3. LETTERS OF ASSURANCE Letter of Assurance "A" The undersigned bidder/proposer hereby assures that our firm will meet or exceed submitted MBE//WBE/DBE/HUB goals and shall demonstrate and document a Good Faith Effort (GFE) to comply with the Dallas County s Minority and Woman-Owned Business Enterprise and HUB Involvement Policy in subcontract/subconsultant awards. The undersigned further agrees that any deviation from the initial goals will be done so only with the concurrence of Dallas County. Name of Company Signature Title (Officer of firm) Date (Complete this section only if you re planning to use the services of an MBE//WBE/DBE/HUB certified vendor) Or Letter of Assurance "B" The undersigned bidder/proposer hereby certifies that our firm will perform the contract: with our own work forces, and submit information sufficient to demonstrate that it is your normal business practice to do so. Or without the services of MBE//WBE/DBE/HUB subcontractors/sub-consultants. The undersigned further submits GFE documented attempt(s). Name of Company Signature Title (Officer of firm) Date (Complete this section only if you re not planning to use the services of MBE//WBE/DBE/HUB certified vendor) NOTE: Each bidder/proposer will be required to sign one of the above letters of assurance which should be returned with proposal. ============================================================================ 4. PRIME CONTRACTOR MBE/WBE/DBE AND/OR HUB IDENTIFICATION* Is your company a Minority Owned Business Enterprise (MBE)? - Yes - No If yes, attach a copy of current and valid certification document Certification Number: Expiration Date: Name of Certification Agency or Entity: Is your company a Woman Owned Business Enterprise (WBE)? - Yes - No If yes, attach a copy of current and valid certification document Certification Number: Expiration Date: Is your company a Historically Underutilized Business? - Yes - No If yes, attach a copy of current and valid certification document Certification Number: Expiration Date: Name of Certification Agency or Entity: Is your company a Disadvantaged Business Enterprise (DBE) DOT PROJECTS ONLY? - Yes - No If yes, attach a copy of current and valid certification document Certification Number: Expiration Date: Name of Certification Agency or Entity: Dallas County recognizes certifications from the following government entities and/or agencies: North Central Texas Regional Certification Agency (NCTRCA) DFW Minority Supplier Development Council (D/FW MSDC) The Women s Business Council Southwest (WBCS) State of Texas Historically Underutilized Business (TX HUB) Texas Unified Certification Program (TUCP) Texas Department of Transportation (TXDOT) Disadvantaged Business Enterprise (DBE) Program DOT PROJECTS ONLY REVISED 04/

18 5. EEO-1 Form (To be submitted by the prime and any sub with 20% or more of the contract). NAME OF FIRM: Job Categories 5. Section D- EMPLOYMENT DATA Employment at this establishment- Report all permanent full and part-time employees including apprentices and on-the-job trainees unless specifically excluded as set forth in the instructions. Enter the appropriate figures on all lines and in all columns. Blank spaces will be considered as zeros. Hispanic or Latino Male Female White Black or African American Native Hawaiian or Other Pacific Islander Male Number of Employees (Report employees in only one category) Race/Ethnicity Not-Hispanic or Latino Asian American Indian or Alaska Native Two or more races White Black or African American Native Hawaiian or Other Pacific Islander A B C D E F G H I J K L M N O Executive/Senior Level officials and Managers 1.1 First/Mid-Level Officials and Managers 1.2 Professionals 2 Technicians 3 Sales Workers 4 Administrative Support Workers 5 Craft Workers 6 Operatives 7 Laborers and Helpers 8 Service Workers 9 TOTAL 10 PREVIOUS YEAR TOTAL Date(s) of payroll period used: (Omit on the Consolidated Report.) Section E-ESTABLISHMENT INFORMATION (Omit on the Consolidated Report). What is the major activity of this establishment? (Be specific, i.e., manufacturing steel casings, retail grocer, wholesale plumbing supplies, title insurance, etc. Include the specific type of product or type of service provided, as well as the principal business or industrial activity.) Section F- REMARKS-Use this item to give any identification data appearing on the last EEO-1 report which differs from that given above, explain major changes in composition of reporting units and other pertinent information Section G- CERTIFICATION Check One 1 All reports are accurate and were prepared in accordance with the instructions. (Check on Consolidated Report only.) 2 This report is accurate and was prepared in accordance with the instructions. Name of Certifying Official Title Signature Date Name of person to contact regarding this report Title Address (Number and Street) City and State Zip Code Telephone No. (including area code and extension) address Female Asian American Indian or Alaska Native Two or more races All reports and information obtained from individual reports will be kept confidential as required by Section 709(e) of Title VII. WILLFULLY FALSE STATEMENTS ON THIS REPORT ARE PUNISHABLE BY LAW, U.S CODE, TITLE 18, SECTION 1001 Description of Race and Ethnic Identification and Job Categories are / Appendix 4. Race and Ethnic Identification / and Appendix 5. Description of Job Categories REVISED 04/ TOTAL COL. A-N 18

19 6. DALLAS COUNTY MBE/WBE/DBE AND/OR HUB PAYMENT AND COMPLIANCE REPORT SOLICITATION/PROJECT NUMBER Work Order Date: SOLICITATION/PROJECT TITLE Job Number: Prime/General Contractor Name: The following information and supporting documentation indicates the payment amounts to the MBE/WBE/DBE/HUB subcontractors/subconsultants/material suppliers for the solicitation/project listed above. Deletion of firms must be approved by Dallas County prior to finalization. 1. MBE/WBE/DBE/HUB Sub-Contractor/Consultant/Material Supplier Name: Amount of Invoice: $ Planned Participation Dollar Amount: $ Planned Percentage % of Contract: % Invoice Number and Invoice Date: Total Payment to Date: $ Percentage % of Contract to Date: % 2. MBE/WBE/DBE/HUB Sub-Contractor/Consultant/Material Supplier Name: Amount of Invoice: $ Planned Participation Dollar Amount: $ Planned Percentage % of Contract: % Invoice Number and Invoice Date: Total Payment to Date: $ Percentage % of Contract to Date: % 3. MBE/WBE/DBE/HUB Sub-Contractor/Consultant/Material Supplier Name: Amount of Invoice: $ Planned Participation Dollar Amount: $ Planned Percentage % of Contract: % Invoice Number and Invoice Date: Total Payment to Date: $ Percentage % of Contract to Date: % 4. MBE/WBE/DBE/HUB Sub-Contractor/Consultant/Material Supplier Name: Amount of Invoice: $ Planned Participation Dollar Amount: $ Invoice Number and Invoice Date: Total Payment to Date: $ Planned Percentage % of Contract: % Percentage % of Contract to Date: % Note: This form must be completed and submitted with each payment request. Any (significant) deviation from planned should include attached explanation Return/Submit/Send Form To: Dallas County Minority/Woman Owned Business Office 509 Main Street, 6 th Floor, Ste. 613, Dallas, Texas or (office) (fax) Patrece.Richardson@dallascounty.org or Rosa.Rodriguez@dallascounty.org ===================================================================================================================== To the best of my knowledge, I certify that the payment information on this form is true and accurate Printed Name of Prime/General Contractor Signature Date Authorized Representative Reviewed by: Dallas County Project Manager Date REVISED 04/

20 20

21 21

22 22

23 23

24 24