Fillable CITY OF PASADENA EMERGENCY SOLUTIONS GRANTS (ESG) Application (City of Pasadena, Texas)

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CITY OF PASADENA EMERGENCY SOLUTIONS GRANTS (ESG) Application (City of Pasadena, Texas)

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CITY OF PASADENA
EMERGENCY SOLUTIONS GRANTS (ESG)
Application for PRIOR YEAR FUNDS
Applications Due: Thursday, April 2, 2020 at 4:00 p.m. CST
NO LATE APPLICATIONS WILL BE ACCEPTED
Applications may be either mailed or hand delivered to:
Office of the City Secretary
1149 Ellsworth Drive, 2
nd
Floor
Pasadena, Texas 77506
Any application received after the above stated date and time will be returned unopened.
Your application will not be evaluated if all the submission requirements are not met and
the documentation is not attached.
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I. TERMS AND CONDITIONS 3
II. APPLICATION INSTRUCTIONS 7
III. OTHER REQUIREMENTS 10
IV. EVALUATION CRITERIA 11
V. SAMPLE EVALUATION FORM 12
VI. APPLICATION FOR FUNDING 15
VII. SUBMISSION CHECKLIST 30
VIII. APPLICATION SUBMISSION LABEL 31
IX. CONFLICT OF INTEREST 32
X. INDEMNITY CLAUSE 33
XI. NON-COLLUSION AFFIDAVIT (MUST BE NOTARIZED) 34
XII. CERTIFICATE OF NON-DEBARMENT (MUST BE NOTARIZED) 35
XIII. SOLICITATION QUESTIONNAIRE 36
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I. Terms and Conditions
This application does not commit the City of Pasadena (City) to award a contract or to pay any costs incurred as a
result of preparing such a response. The City reserves the right to accept or reject any and all applications received
in response to this request, to negotiate with all qualified applicants or to cancel in part, or in its entirety, this
application if it is in the best interest of the City. The City may choose to proceed with any or all portions of this
application at its sole discretion. These instructions are standard for all contracts for commodities or services issued
through the City. General Requirements apply to all advertised bids/proposals/applications; however, these may be
superseded, whole or in part, by the SPECIAL CONDITIONS OR OTHER DATA CONTAINED HEREIN.
READ THIS ENTIRE DOCUMENT CAREFULLY. FOLLOW ALL INSTRUCTIONS. YOU ARE RESPONSIBLE FOR
FULFILLING ALL REQUIREMENTS AND SPECIFICATIONS. BE SURE YOU UNDERSTAND THEM.
1. CHANGES IN SCOPE OF WORK
The City may request changes in the scope of work to be performed. Such changes, including increase or
decrease in compensation must be mutually agreed upon and incorporated by written amendment to the
agreement.
2. ANTI-LOBBYING PROVISION
During the period between the publication date and the contract award, applicants, including their agents and
representatives, shall not directly discuss or promote their application with any member of the Pasadena City
Council, Community Development Advisory Board or City Staff except in the course of city-sponsored inquiries,
briefings, interviews or presentation, unless requested by the City. This provision is not meant to preclude
respondents from discussing other matters with City Council members, Community Development Advisory
Board members or City Staff. This policy is intended to create a level playing field for all potential applicants,
assure that contract decisions are made in public and to protect the integrity of the application process.
Violation of this provision may result in rejection of the applicant’s application.
3. POTENTIAL CONFLICTS OF INTEREST
An outside consultant or contractor is prohibited from submitting an application for services on a City of
Pasadena project of which the consultant or contractor was a designer or other previous contributor, or was
an affiliate, subsidiary, joint venture or was in any other manner associated by ownership to any party that
was a designer or other previous contributor. If such a consultant or contractor submits a prohibited
application, that application shall be disqualified on the basis of conflict of interest, no matter when the conflict
is discovered by the City.
4. APPLICABLE LAW AND VENUE
Any agreement resulting from this application shall be construed according to the laws of the State of Texas.
The City and Agency’s agree that the venue for any legal action under this agreement shall be the Harris County,
Texas. In the event that any action is brought under any agreement resulting from the application in Federal
Court, the venue for such action shall be in the Federal Judicial District of Harris County, Texas.
5. IMMIGRATION REFORM and CONTROL ACT (IRCA)
The Immigration Reform and Control Act (IRCA), also Simpson-Mazzoli Act (Pub.L. 99-603, 100 Stat. 3359,
signed by President Ronald Reagan on November 6, 1986) is an Act of Congress which reformed United States
immigration law. The Act made it illegal to knowingly hire or recruit illegal immigrants (immigrants who do
not possess lawful work authorization), required employers to attest to their employees' immigration status,
and granted amnesty to certain illegal immigrants who entered the United States before January 1, 1982 and
had resided there continuously. The Act also granted a path towards legalization to certain agricultural
seasonal workers and immigrants who had been continuously and illegally present in the United States since
January 1, 1982.
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6. APPLICATION FORM COMPLETION
Unless otherwise specified, respondents must use the application form provided. Forms shall be completed
and submitted to the City Secretary’s Office. The contract will be binding only when signed by the City of
Pasadena, funds are certified by the City Controller, as applicable, and a Purchase Order issued.
7. SCANNED OR RE-TYPED RESPONSE
If in its application response, applicant either electronically scans, re-types, or in some way reproduces the
City’s published application, then in event of any conflict between the terms and provisions of the City’s
published application, or any portion thereof, and the terms and provisions of the application response made
by, the City’s specifications as published shall control. Furthermore, if an alteration of any kind to the City’s
published specifications is only discovered after the contract is executed and is or is not being performed; the
contract is subject to immediate cancellation.
8. APPLICATION RETURNS including ALTERNATE APPLICATIONS
Applicants shall submit six (6) unbound copies with “ORIGINAL” signatures in a sealed envelope or package of
comparable size. Please cut out and affix the application Label found on the “Application Submission
Label” section to the outermost mailing envelope (UPS, USPS, FEDEX, etc.) of your application to ensure
proper delivery!
Applicants must return all applications to the following location by the date and time specified:
City of Pasadena
City Secretary’s Office
1149 Ellsworth Drive, 2
nd
Floor
Pasadena, Texas 77506
Late applications will not be accepted, and will be returned to applicant unopened.
9. AWARD OF CONTRACT
The City anticipates entering into a contract to be most advantageous to the City. The respondent understands
that this application does not constitute an agreement or a contract with the City. An official contract or
agreement is not binding until applications are reviewed and accepted by the City and a written agreement or
contract is approved by both the City and the successful applicant. The City Council must award the contract
and the Mayor, or other person authorized by the Mayor, must sign the contract before it becomes binding on
the City or the bidders. Department heads are NOT authorized to sign agreements for the City.
10. PROTESTS
10.1. All protests regarding the solicitation process must be submitted in written form to the Community
Development Manager within five (5) working days following the submission of the application. This
includes all protests relating to legal advertisements, deadlines, application submittals, and all other
related procedures under the Local Government Code, as well as any protests relating to alleged
improprieties or ambiguities in the specifications contained herein or in the contract documents.
10.2. Post-award protests must be submitted in written form to the Community Development Manager
within five (5) working days after award and must specify the grounds upon which the protest is based.
A valid protest shall;
10.2.1. Come from an actual respondent for the contract, and
10.2.2. Who claim to be the rightful awardee. That is, the protest is not valid if filed by a respondent who
cannot show they would be awarded the contract if their protest were accepted.
10.3. The Community Development Manager, having authority to make the final determination, will respond
within ten (10) working days to each substantive issue raised in the protest. Allowances for
reconsiderations shall be made only if data becomes available that was not previously known, or if there
has been an error of law or regulation.
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11. INDEPENDENT CONTRACTOR
It is expressly understood and agreed by both parties hereto that the City is contracting with the successful
applicant as independent contractor/subrecipient. The parties hereto understand and agree that the City shall
not be liable for any claims which may be asserted by any third party occurring in connection with the services
to be performed by the successful applicant under this contract and that the successful applicant has no
authority to bind the City.
12. INSURANCE
If required, specific insurance provisions will be included in the application process. A copy of an insurance
certificate must be submitted within ten (10) days from the date of the request made by the Community
Development Department. The successful applicant will be required to maintain, at all times during
performance of the contract, the insurance detailed in bid/proposal specifications. Failure to provide this
document may result in disqualification of the application.
13. WAIVER OF SUBROGATION
Applicant and applicant’s insurance carrier waive any and all rights whatsoever with regard to subrogation
against City of Pasadena as an indirect party to any suit arising out of personal or property damages resulting
from respondent’s performance under this agreement.
14. TERMINATION
The City reserves the right to terminate the contract for default if applicant breaches any of the terms therein,
including warranties of the applicant or if the applicant becomes insolvent or commits acts of bankruptcy.
Such right of termination is in addition to and not in lieu of any other remedies which the City may have in law
or equity. Default may be construed as, but not limited to, failure to deliver the proper goods and/or services
within the proper amount of time, and/or to properly perform any and all services required to the City’s
satisfaction and/or to meet all other obligations and requirements.
15. TERMINATION-NOTICE
Either party may cancel the contract at any time after award. The City shall be required to give the applicant
notice thirty (30) days prior to the date of cancellation of the contract. The applicant shall be required to give
the City written notice sixty (60) days prior to the date of cancellation of the contract. The City may terminate
the contract without cause upon thirty (30) days written notice.
16. INDEMNITY
CONTRACTOR/SUBRECIPIENT covenants and agrees to FULLY INDEMNIFY and HOLD HARMLESS, the
CITY and elected officials, employees, officers, directors, and representatives of the CITY, individually
or collectively, from and against any and all costs, claims, liens, damages losses, expenses, fees, fines,
penalties, proceedings, actions, demands, causes of action, liability and suits of any kind and nature,
including but not limited to, personal injury or death and property damage, made upon the CITY,
directly or indirectly arising out of resulting from or related to bid activities under this bid, including
any acts or omissions of CONTRACTOR/SUBRECIPIENT any agent, officer, director, representative,
employee, consultant or subcontractor of CONTRACTOR, and their respective officers, agents,
employees, directors and representatives while in the exercise or performance of the rights or duties
under this CONTRACT, all without, however, waiving any governmental immunity available to the CITY
under Texas Law and without waiving any defenses of the parties under Texas Law. The provisions of
this INDEMNIFICATION are solely for the benefit of the parties hereto and not intended to create or
grant any rights, contractual or otherwise, to any other person or entity. CONTRACTOR/SUBRECIPIENT
shall promptly advise the CITY in writing of any claim or demand against the CITY or
CONTRACTOR/SUBRECIPIENT known to CONTRACTOR/SUBRECIPIENT related to or arising out of
CONTRACTOR/SUBRECIPIENT’S activities under this CONTRACT and shall see to the investigation and
defense of such claim or demand at CONTRACTOR/SUBRECIPIENT’S cost. The CITY shall have the right,
at its option and at its own expense, to participate in such defense without relieving CONTRACTOR of
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any of its obligations under this paragraph. It is the EXPRESS INTENT of the parties to this contract, that
the INDEMNITY provided for in this section, is an INDEMNITY extended by
CONTRACTOR/SUBRECIPIENT to INDEMNIFY, PROTECT and HOLD HARMLESS the CITY from
consequences of the CITY’S OWN NEGLIGENCE, provided however, that the INDEMNITY provided for in
this section SHALL APPLY only when the NEGLIGENT ACT of the CITY is a CONTRIBUTORY CAUSE of the
resultant injury, death, or damage, and shall have no application when the negligent act of the CITY is
the sole cause of the resultant injury, death, or damage. CONTRACTOR/SUBRECIPIENT further AGREES
TO DEFEND, AT ITS OWN EXPENSE and ON BEHALF OF THE CITY AND IN THE NAME OF THE CITY, any
claim or litigation brought against the CITY and its elected officials, employees, officers, directors and
representatives, in connection with any such injury, death, or damage for which this INDEMNITY shall
apply, as set forth above.
16.1. PATENTS/COPYRIGHTS
The successful applicant agrees to indemnify and hold the City harmless from any claim involving
patent infringement or copyrights on goods supplied.
17. TAXES
The City is exempt from all federal excise, state and local taxes unless otherwise stated in this document. The
City claims exemption from all sales and/or use taxes under Texas Tax Code §151.309, as amended. Texas
Limited Sales Tax Exemption Certificates will be furnished upon written request to the City’s Purchasing
Department.
18. ASSIGNMENT
The successful applicant shall not sell, assign, transfer or convey this contract in whole or in part, without the
prior written consent of the City of Pasadena Community Development Department. Any such assignment or
transfer shall not release applicant from all contractual obligations.
19. CONTRACT RENEWALS
Renewals may be made ONLY by written agreement between the City and the applicant.
20. HOUSE BILL 914 DISCLOSURE OF CERTAIN RELATIONSHIPS
The Texas Ethics Commission adopted Form CIQ (Conflict of Interest Questionnaire) pursuant to H.B. 914.
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 pertinent information in the Questionnaire
Form CIQ.
The questionnaire is to be filed in accordance with Chapter 176, Local Government Code by a person who has
a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person
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 person becomes aware of facts that require the statement to
be filed. See Section 176.006, Local Government Code. A person commits an offense if the person knowingly
violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
The CIQ Form can be located at http://www.ethics.state.tx.us/forms/CIQ.pdf
21. CERTIFICATE OF INTERESTED PARTIES
The Texas Ethics Commission adopted Form 1295 (Certificate of Interested Parties) pursuant to H.B. 1295.
Effective September 1, 2015, Chapter 2252 of the Texas Government Code requires that a business entity (any
vendor or person) doing business with a local government entity may not enter into a contract unless the
business entity has first submitted a completed Certificate of Interested Parties Form 1295 to the government
entity. The 1295 Form can be located at: https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm
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II. Application Instructions
The City of Pasadena receives an Emergency Solutions Grants (ESG) annually from the U.S. Department of Housing
and Urban Development (HUD) to fund activities and programs that assist individuals and families experiencing
homelessness and/or at-risk of homelessness. This application is specifically for Prior Year Funds and therefore
is limited in the types of activities eligible for funding.
Each year the City uses a competitive application process to make a portion of the ESG funds available for eligible
activities. The City of Pasadena’s Community Development Department is soliciting applications for the use of ESG
funds for emergency shelter, homelessness prevention, street outreach, HMIS and rapid re-housing activities.
Eligible agencies and non-profit organizations are invited to submit applications to fund ESG activities.
There is a statutory and regulatory limitation on the amount of ESG funds which may be used for Emergency Shelter
and Street Outreach activities. These activities may not exceed 60% of the annual ESG allocation.
ESG Program History
The Emergency Shelter Grant (ESG) was amended by the “Homeless Emergency Assistance and Rapid Transition to
Housing” (HEARTH) Act of 2009 to become the Emergency Solutions Grants (ESG) Program. The HEARTH Act
amends and reauthorizes the McKinney-Vento Homeless Assistance Act of 1987. The primary changes include a
greater emphasis on homelessness prevention, the addition of rapid re-housing, the regulatory requirements for
Homeless Management Information System (HMIS) use, increased emphasis on performance, and a requirement for
greater coordination and collaboration between the recipient and the Continuum of Care.
While the prior ESG Program had a greater emphasis on homeless assistance, the HEARTH regulations limit the
funding for homeless assistance and remove the limitations on funding for homelessness prevention and rapid re-
housing. Additionally, entry of information related to services provided to homeless individuals and families into
the Homeless Management Information System (HMIS) managed and operated by the Coalition for the Homeless of
Houston/Harris County is a required component for ESG. The regulations implementing the ESG Program are found
at 24 CFR Part 576.
Note: The City and subrecipients are responsible for ensuring that funds are expended efficiently and expediently
with the greatest degree of transparency and accountability as possible. One hundred percent (100%) of grant funds
must be expended within the time of performance outlined within the grant award agreement or funds will subject
to recapture. The City reserves the right to award funds at a lesser or higher amount than requested.
ESG Program
The ESG program provides funding to:
1. Engage homeless individuals and families living on the street;
2. Improve the number and quality of emergency shelters for homeless individuals and families;
3. Help operate these shelters;
4. Provide essential services to shelter residents;
5. Rapidly re-house homeless individuals and families; and
6. Prevent families and individuals from becoming homeless.
Beneficiary Eligibility
The minimum eligibility criteria for ESG beneficiaries are as follows:
For essential services related to street outreach, beneficiaries must meet the criteria under paragraph (1)(i)
of the “homeless” definition under § 576.2.
Emergency Shelter, beneficiaries must meet the “homeless” definition in 24 CFR 576.2.
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For essential services related to emergency shelter, beneficiaries must be “homeless” and staying in an
emergency shelter (which could include a day shelter).
For homelessness prevention assistance, beneficiaries must meet the requirements described in 24 CFR
576.103.
For rapid re-housing assistance, beneficiaries must meet requirements described in 24 CFR 576.104.
Further eligibility criteria may be established at the local level in accordance with 24 CFR 576.400(e).
Program Participant Eligibility
At a minimum, an eligible program participant must meet the following criteria:
1. Any individual or family provided with ESG financial assistance must have at least an initial consultation with
a case manager or other authorized representative who can determine the appropriate type of assistance to
meet their needs. HUD encourages communities to have a process in place to refer persons ineligible for ESG
to the appropriate resources or service provider that can assist them.
2. The household must be at or below 30 percent of Area Median Income (AMI). The City of Pasadena will use
HUD’s income eligibility standards for ESG.
3. The household must be either homeless or at risk of losing its housing and meet both of the following
circumstances: (1) no appropriate subsequent housing options have been identified; AND (2) the household
lacks the financial resources and support networks needed to obtain immediate housing or remain in its
existing housing.
Match Requirements
Non-profit agencies or local governments must match ESG funds at minimum of 100% from non-ESG sources.
Please note that funds used to match a previous ESG activity may not be used to match a subsequent grant award.
For the specific match requirements, refer to HUD Regulations at 24 CFR 576.201
Subrecipient agencies may use any of the following as sources of match:
1. Cash match
2. Value or fair rental value of any donated material or building
3. Value of any lease on a building
4. Salaries paid to staff to carry out the project
HMIS Requirements
Participation in a Homeless Management Information System (HMIS) is a federal ESG requirement.
Exception: Agencies whose primary mission is domestic violence victim services cannot participate in HMIS but must
use a comparable database that produces unduplicated, aggregate reports instead.
Houston/Harris County’s HMIS system is managed by the Coalition for the Homeless of Houston/Harris County. The
Coalition provides training on data entry and reporting.
Administrative Costs
Subrecipients will not be awarded ESG funds for the payment of administrative costs related to the planning of and
execution of ESG activities. ESG funds however may be used for case management. Selected projects must address
goals related to street outreach, emergency shelter, homelessness prevention and rapid re-housing that qualify as
eligible activities under the ESG guidelines. To effectively address these issues, the City encourages its prospective
partners to develop innovative programs that truly reflect the desires and needs of the community. As your entity
prepares its application, we strongly encourage you to engage the community to establish partnerships and support
networks. While Pasadena Community Development staff is unable to complete this application for you, feel free to
contact our office for general technical assistance.
Note: The City reserves the right to reallocate funding at any time in order to meet federal commitment or timeliness
requirements or to achieve other purposes consistent with the Consolidated Plan or the legislative intent of ESG.
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ESG Eligible Activities
All households and persons served must meet the U.S. Department of Housing and Urban Development definition of
homelessness (24 CFR 576.2) to be eligible. ESG funds may be used for eligible activities intentionally and specifically
focused on housing. Eligible activities must fall within the parameters of the following five (5) components:
1) Street Outreach (24 CFR 576.101) NOT ELIGIBLIBE UNDER THIS APPLICATION FOR PRIOR YEAR
FUNDS includes essential services necessary to reach out to homeless individuals including, but not limited
to:
Engagement;
Case management;
Emergency health and mental health services;
Transportation; and
Services for special populations (homeless youth, homeless persons with HIV/AIDS, etc.).
2) Emergency Shelter (24 CFR 576.102) NOT ELIGIBLIBE UNDER THIS APPLICATION FOR PRIOR YEAR
FUNDS includes essential services to homeless individuals in emergency shelters and direct support for
shelters. Allowable activities include, but are not limited to:
Case management;
Child care, education, employment, and life skills services;
Health, mental health, and substance abuse services;
Transportation;
Services for special populations; and
Shelter activities may include renovation, and/or operations (e.g. maintenance, utilities, furniture, food,
hotel/motel vouchers where no appropriate emergency shelters are available for a family household or
individual household that is homeless, etc.).
3) Homeless Prevention (24 CFR 576.103) includes services such as housing relocation and stabilization
services, and short/medium-term rental assistance. Allowable activities include, but are not limited to:
Short-term rental assistance for up to three (3) months;
Medium-Term rental assistance;
Payment of rental arrears;
Housing stability case management services;
Financial assistance costs; and
Housing search and placement necessary to assist participants locate, obtain, and retain permanent
housing;
4) Rapid Re-Housing (24 CFR 576.104) services are designed to help a homeless individual or family move
as quickly as possible into permanent housing and achieve stability. Allowable activities include, but are not
limited to:
Medium-term rental assistance from three (3) months up to twenty-four (24) months;
Payment of rental arrears;
Housing stability case management services;
Financial assistance costs; and
Housing search and placement necessary to assist participants locate, obtain, and retain permanent
housing;
5) HMIS (24 CFR 576.104) NOT ELIGIBLIBE UNDER THIS APPLICATION FOR PRIOR YEAR FUNDS As
required, Recipients/Subrecipients receiving ESG assistance must collect and report data on the use of the
funds awarded and persons served with this assistance in the Homeless Management Information System
(HMIS).
It is imperative that applicants anticipate and plan for the methods that will be used to determine and
document the eligibility of the beneficiaries serve through the ESG funded activity. Failure to adequately
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document client data may result in ineligibility of the activity, repayment of expended ESG funds and
cancellation of any monies awarded.
III. Other Requirements:
Faith Based Agencies: Faith based agencies are eligible to apply. HUD issued a final rule amendment allowing faith-
based agencies to compete for ESG funding on the same basis as other non-profits, however, ESG funds cannot be
used to support worship or religious instruction. Religious activities must be offered separately from the ESG
supported activity. Faith based agencies may not use direct ESG funds to support inherently religious activities such
as worship or religious instruction. Faith based agencies that participate in the ESG program shall not discriminate
against a program beneficiary on the basis of religion or religious belief. (Reference: CPD Notice 04-10)
Active Governing Body: Governance of the agency shall be vested in a responsible and active voluntary board,
which meets to establish and enforce policies. The Board shall be structured to be representative of the community
it serves. Per 24 CFR 576.405 (a) subrecipients must provide for the participation of not less than one homeless
individual or family on the board of directors.
Personnel: The agency must provide demonstration of adequate administration of the program to ensure delivery
of eligible services.
Non-Discrimination: Each agency receiving funds from the City is required to conduct its business in compliance
with the non-discrimination requirements of the City, State and Federal governments, as applicable. Equal
Opportunity in Employment policies are required.
DUNS Number: Each agency is required to have a DUNS (Data Universal Numbering System) number generated
from Dun & Bradstreet. If your agency does not have a DUNS number, one may be obtained free of charge for the
purpose of the application for federal funding. The website link to Dun & Bradstreet’s federal contract DUNS request
service is http://fedgov.dnb.com/webform. Regular business DUNS numbers require a fee.
WWW.SAM.GOV: The use of the DUNS (Data Universal Numbering System) number has been expanded to require
all applicant and grantee organizations to maintain an active registration in the System for Award Management
(SAM) Central Contractor Registry (CCR) database. The website link to the System for Award Management (SAM) is
SAM.GOV.
Accounting: Each agency shall maintain accounting records which are in accordance with Generally Accepted
Accounting Principles and auditing practices, as described in the Uniform Administrative Requirements, Cost
Principles and Audit Requirements for federal Awards (2 CFR 200). The final guidance at 2 CFR 200 supersedes and
streamlines requirements from OMB Circulars A-21, A-87, A-110, and A-122, Circulars A-89, A-102, A-133, and the
guidance in Circular A-50 on Single Audit Act follow-up. Agencies may be required to submit evidence of the
accounting systems to the City of Pasadena for approval prior to funds being awarded or disbursed.
Insurance: Once an agency’s project has been approved, at the time of contract signing, the agency must provide
evidence of insurance, including, but not limited to, multi-peril property and liability, medical, workers’
compensation, automobile liability, and other coverage as deemed necessary by the City Attorney, (with an
indemnification and hold harmless acceptable to the City of Pasadena). All certificates and endorsements are to be
received and approved by the City of Pasadena prior to commencement for the project.
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IV. Evaluation Criteria
Because the activities subject to funding by this application are specific in nature, the evaluation criteria must also
be specific to each activity type as outlined below. Minimum eligibility criteria for all applications are:
a. Nonprofit 501(c)(3) status for at least one (1) full year, or
b. Two (2) full years of operating experience under another non-profit entity, or
c. For-profit entity proposing to use funds for an eligible activity.
d. Demonstration of successful experience in undertaking comparable programs/projects.
e. Production and completion of projects previously awarded funds by the City of Pasadena.
*The form on the following page is a sample of evaluation criteria used for review and
scoring of applications. It is an example and should not be completed by your agency.
**Please note that applicants who have previously received ESG funding from the City will also be
evaluated based on their past performance.
Past performance will include but not be limited to:
attainment of objectives in a timely manner
expenditure of funds at a reasonable rate
timely submission of client data reports
adherence to the Scope of Services
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V. Sample Evaluation Form
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VI. APPLICATION FOR FUNDING
[THIS PAGE INTENTIONALLY LEFT BLANK]
NEXT PAGE IS PAGE ONE OF APPLICATION
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COVER SHEET
ESG Application for PRIOR YEAR Funds
FILL IN NAME OF YOUR ORGANIZATION IN SECTION BELOW:
ALL APPLICATIONS MUST BE TYPED AND SUBMITTED TO:
City of Pasadena
Office of the City Secretary
1149 Ellsworth Drive, 2nd Floor
Pasadena, Texas 77502
APPLICATION DUE: Thursday, April 2, 2020 at 4:00 pm
NO LATE APPLICATIONS WILL BE ACCEPTED
Signature of Applicant Title Date
- I have read & executed the CONFLICT OF INTEREST DISCLOSURE FORM in this application.
- I have THOUROUGHLY reviewed the 2020 APPLICATION WORKSHOP POWERPOINT
- I have read & understand the application instructions prior to submitting this Application.
- I have read & signed the Terms and Conditions Section of this Application.
17
ESG Application for PRIOR YEAR Funds
Organization Name:
Proposed Program Name:
DUNS Number:
Tax Identification Number:
Registered with
SAM.GOV
Organization’s Physical Address:
Organization’s Mailing Address:
Phone:
Fax:
Email:
Web Address:
Authorized Organization Official Signatory:
Phone:
Email:
*Primary Contact:
Phone:
Email:
* Alternate Contact:
Phone:
Email:
*Both the primary and alternate contact (provided above) will serve as intermediaries between the agency and the City of Pasadena Community
Development Department. Therefore, the primary and alternate contact shall be responsible for the distribution of information, provided by the
City of Pasadena Community Development Department, within the agency.
Type of Organization:
☐ Non Profit ☐ City Department ☐ Faith Based Organization ☐ Other: _____________________________
Homeless Participation Requirement.
Has at least one (1) board member experienced homelessness or is currently homeless?
☐ YES
☐ NO
Proposed ESG Component
(choose one):
☐ Street Outreach ☐ Emergency Shelter ☐ Homeless Prevention ☐ HMIS
☐ Rapid Re-Housing
Eligible Activity Type for selected ESG Component: ** Rental Assistance can be project-based or tenant-based
Street Outreach
24 CFR 576.101
Emergency Shelter
24 CFR 576.102
Homeless Prevention
24 CFR 576.103
HMIS
24 CFR 576.107
Rapid Re-Housing
24 CFR 576.104
☐ Essential Services
☐ Essential Services
☐ Renovation
☐ Shelter Operations
☐ URA Assistance
☐ Rental
Assistance**
☐ Housing
Relocation &
Stabilization Services
☐ HMIS
☐ Rental Assistance**
☐ Housing Relocation
& Stabilization
Services
Program Funding
1) Requested Amount of ESG Funds
2) Other Funding Sources
3) Total Program Cost *
4) Percentage of ESG funds toward Total Program Cost **
*Total Program Cost: (Line 1 + Line 2 = Line 3)
** Percentage of City of Pasadena funds towards program/project cost: (Line 1 ÷ Line 3 = Line 4)
18
Project/ Program Delivery Description
Provide a complete description of the proposed activity to be undertaken with federal funds including what products
or services are to be performed, where they are to be provided, for whom they are to be provided and how they are
to be provided.
*Attach the answers to this question on a separate piece of paper if it does not fit here –Attachment A - Program Description/Need
Project/Program Need
What unmet community need(s) will your project address? How did you determine that this need(s) exists? How
will your project address this need(s)? Include relevant statistics provided by the organization such as number of
referral calls, number of clients on waiting lists and time on waiting lists. Describe how you will meet priority
needs of homeless individuals or those most at risk of homelessness in Pasadena.
*Attach the answer to this question on a separate piece of paper if it does not fit here- Attachment A –Program Description/Need
Target Population
Please identify the primary beneficiaries your program will serve. Please check () all that apply:
Chronically Homeless
Elderly
Unaccompanied Youth
Veterans
Victims of Domestic Violence
Other (Specify): ____________________________________
Chronic Substance Abuse
Persons with HIV/AIDS
Other Disabled
19
Levels of Accomplishment – Goals and Performance Measures
Total number of person’s anticipated to be assisted by project/program:
Number of unduplicated clients expected to benefit from project/program:
Description of Services Provide a description of the services that will be provided.
EXAMPLE: Program will provide counseling services to abused children.
Units of Service Provide a definition of Units of Service - How will your organization determine the amount of
services rendered?
EXAMPLE: One unit of service is equal to 1 hour of counseling services.
One unit of service is equal to :
Project Site Information
Owner:
Contact Person:
Title:
Phone Number:
E-mail Address:
If agency owns property, date acquired:
If agency leases property, date the lease expires:
Employment/Client Participation
Does your organization currently notify the public that your agency does not discriminate
based on race, color, religion, gender, sexual orientation, national origin, age or disabilities
in hiring practices or provision of services?
Yes
No
If No, is your agency is willing to adopt this practice?
Yes
No
Accessibility for Physically Disabled
Will the completed project meet ADA standards for accessibility by the disabled?
Yes
No
N/A
If no, please describe accessibility problems and how you intend to correct them, including funding and
timetable:
20
Organization Capacity/ Additional Information
Please check all that have been included with your application (Attachment B):
☐ Organizational Chart ☐ Proof of Tax Exempt Status ☐ List of Board of Directors
☐ Articles of Incorporation ☐ Current Year Budget
How many years has your organization been in business?
Has your organization received ESG funding from the City of Pasadena in the past two years?
Yes
No
If yes, please provide a brief summary of the activity / amount funded:
Has your agency participated in this type of activity in the past?
Yes
No
In the space below describe your agency's past 5 years of experience with ESG or other federal grant programs.
Include number of years working with federal grants and the type/amount of each grant received:
(list individually)
Year Amount Type of Grant
Will any other federal grants be used to financially assist the program that you are currently
applying for? If yes, please list the name of the grant(s), how much and the name of the
organization that is providing the grant.
Yes
No
Does your organization currently or within the last five years have any litigation that is
pending or has been resolved?
Yes
No
If yes, please attach a summary of the litigation and its status; including any outstanding judgements
Has your organization filed a petition for bankruptcy or has a petition for bankruptcy been
filed against your organization?
Yes
No
If yes, please attach an explanation that includes the current status.
What level of financial review does your organization obtain from an independent source? Select from the
following options:
☐ Single Audit
☐ Reviewed Financial Statement
☐ No Independent Review
☐ Audited Financial Statements
☐ Compiled Financial Statements
☐ Other:___________________________________________________
Will the proposed project/program sustain if requested funds are not awarded?
Yes
No
21
1. What is the mission of your agency?
2. How long has your agency been in existence in its current form?
3. If Agency is a non-profit, how long has the Agency had its 501 (c) (3) status?
4. How many years has the Agency conducted the project/program for which it is requesting funding?
5. List all other programs managed by the Agency.
6. Does your organization use HMIS or a comparable system? Yes No
*Attach the answers to these questions on a separate piece of paper if they do not fit here. Attachment B – Organization
Information
22
Scope of Work Attachment – C Scope of Work
Please attach a statement of work / scope of services narrative that details the service activities the program will
undertake to achieve the program objectives. The following shall be included:
Service activity plan of action for each service activity to be provided (e.g. prevention, rapid re-housing, street
outreach, basic shelter);
Coordination with other service providers;
Use of the Homeless Management Information System (HMIS) to track client information;
Program specific procedures and guidelines.
Describe your service delivery plans including:
o Hours of operation
o Intake system
o Outreach plan
Define how client eligibility will be determined and documented.
Provide a timeline for project/program execution and completion.
Give the program goals:
o Units of Service (quantify the assistance and/or service program participants will receive)
o Number of unduplicated clients you expect to serve
Do not give an overview of your agency – Be project/program specific
Must be submitted as a separate document labeled Attachment C – Scope of Work.
THIS DOCUMENT SHOULD BE NO MORE THAN 3 PAGES.
23
Project / Program Team
Identify the name of the responsible party, job description and the experience of each staff member that will be
involved in the administration of this activity. Personnel identified after the application are subject to review. List
only those who will be working with ESG funds.
Staff Member
Job Description and Experience
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
24
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
25
Please indicate which administrative systems you currently utilize:
Please check all that apply:
Formal personnel system with written procedures
Staff salary tracking system by funding source
Audit system incorporating formal written accounting procedures
Recordkeeping system that tracks each funding source separately
Formal written cash management practices that includes proper security measures
Hard copy files and computer records systems with security and back-up in place
Internal monitoring/evaluation system that follows written procedures
Client eligibility verification
Client demographic data collection and reporting system
Procurement policy governed by formal written procedures
Conflict of interest policies
Client grievance policies
Annual fundraising/revenue generation
26
Organization Board of Directors (City Departments – List City Council Members)
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
27
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
28
Financial Capacity & Budget Attachment D – Additional Budget Information
Complete the budget charts below. Prepare and attach a brief budget narrative explaining the total program budget,
the line items listed on the budget form and how will the amount be matched. Provide an explanation for each of the
line item expenses.
What is the amount of your current Annual Operating Budget?
Agency Financial System (choose one):
Cash Basis
Accrual Basis
Fiscal Year starts:
Fiscal Year Ends:
Project/Program Budget (ESG FUNDS REQUESTED ONLY)
Please explain how each expense is related to project delivery and indicate the total cost of each line
item.
ELIGIBLE ACTIVITY
Homelessness
Prevention
Rapid Re-
Housing
Emergency
Shelter
Street
Outreach
Total Amount
Budgeted
Rental Assistance*
$
$
$
Housing Relocation &
Stabilization Services**
$
$
$
Essential Services
Renovation
Shelter Operations
Other Services
TOTAL
$
$
$
* Includes short and medium-term rent payments and up to 6 months of arrears
**Includes all other eligible forms of direct financial assistance under Prevention and Re-Housing, plus costs related to eligible services
Project/Program Budget – Personnel Costs
Please show all proposed staff positions funded with ESG funding that relate to the proposed activity. If multiple staff
members have the same position/title, list separately (ex. Case Manager 1, Case Manager 2).
Position Title
Current or
Proposed
Position
Annual
Salary
Annual Fringe
Benefits
Total Annual
Salary
Multiplied by %
of Time Spent on
ESG Program
Total Position
Costs Requested
from ESG
Ex: Case Manager
Current
$25,000
$5,000
$30,000
X 40%
$12,000
$
$
$
%
$
$
$
$
%
$
$
$
$
%
$
$
$
$
%
$
$
$
$
%
$
29
TOTAL PROJECT/PROGRAM BUDGET (INCLUDING ALL FUNDING SOURCES & MATCH)
Category Breakdown
ESG FUNDS
REQUESTED
Match Funds
Source of Match Funds
Total Funds
1. Personnel
Salaries
Personnel Subtotal
2. Financial Assistance
Short & Medium Term Rental
Assistance
Security Deposits
Utility Payments
Moving Costs
Other (Please specify)
Financial Assistance Subtotal
3. Other Costs Related to Housing Relocation and Stabilization Services
Housing Search /Placement
Other (Please specify)
Renovation
Services Subtotal
4. Shelter Operations
Maintenance
Rent
Security
Equipment
Insurance
Utilities
Other (Please specify):
Operations Subtotal
5.Essential Services
Activity (Specify):
Activity (Specify):
Activity (Specify):
Activity (Specify):
Essential Services Subtotal
HMIS
Total ESG Request
Total Other Funds
Grand Total
Note: Complete Budget Detail – Input personnel costs data in the table if staff costs are included in your application.
30
VII. SUBMISSION CHECKLIST
Item
Note
Applicant’s Initials
1.
Terms and Conditions (pgs. 2-6)
I acknowledge reading and understanding the
Terms and Conditions.
PLEASE REMEMBER:
2.
Applicants shall submit six (6) unbound copies with “ORIGINAL” signatures in a sealed envelope
or package of comparable size.
3.
Cut out and affix the Application Label to the outermost mailing envelope (UPS, USPS, FEDEX, etc.)
of your application found on page 31.
DID YOU REMEMBER TO:
4.
Fill out, sign and return the Community Development (ESG) Submission Checklist (pg. 30)
5.
Fill out, sign and return the application (pg. 16-29)
6.
Fill out, sign and return the Conflict of Interest (pg. 32)
7.
Fill out, sign and return the Indemnity Clause (pg. 33)
8.
Fill out and return the Non-Collusion Affidavit. Must be Notarized. (pg. 34)
9.
Fill out and return the Contractor’s Certification of Non-Debarment. Must be Notarized. (pgs. 35)
10.
Fill out and return the Solicitation Questionnaire. (pg. 36)
ATTACHMENTS:
Attachment A – Project Description / Need (pg. 18)
Attachment B – Organizational Capacity and Experience (pg. 20)
Attachment C – Statement of Work / Scope of Services (pg. 22)
Attachment D – Additional Budget Information / Budget Narrative (pg. 28-29)
Attachment E – WWW.SAM.GOV Proof of Registration – The use of the DUNS (Data Universal Numbering
System) number has been expanded to require all applicant and recipients organizations to obtain a DUNS number and
maintain an active registration in the System for Award Management (SAM) Central Contractor Registry (CCR) database.
The website link to the System for Award Management (SAM) is WWW.SAM.GOV.
Attachment F – Conflict of Interest Questionaire Form (if applicable)
Attachment G – Proof of 501(C) Status (Nonprofit Applicants Only)
**Note: Appendix A is contingent upon the approval of the submitted application. Pursuant to the requirements of House Bill 1295, 84th
Legislative Session, any contract approved by Council is contingent upon the business entity's completion of the required Form 1295,
Certificate of Interested Parties.
I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND THAT IT
CONTAINS NO FALSIFICATIONS, MISREPRESENTATIONS, INTENTIONAL OMISSIONS, OR CONCEALMENT OF
MATERIAL FACTS. I FURTHER CERTIFY THAT NO CONTRACTS HAVE BEEN AWARDED, FUNDS COMMITTED,
OR CONSTRUCTION BEGUN ON THE PROPOSED PROGRAM AND THAT NONE WILL BE DONE PRIOR TO
ISSUANCE OF A RELEASE OF FUNDS BY THE CITY OF PASADENA.
SIGNATURE OF AUTHORIZED PERSON LISTED ABOVE
DATE
PRINT NAME
TITLE
31
VIII. APPLICATION SUBMISSION LABEL
LATE APPLICATIONS WILL NOT BE ACCEPTED
Please cut out and affix the application label below to the outermost mailing
envelope (UPS, USPS, FEDEX, etc.) of your submission to ensure proper delivery!
Cut along dotted line.
SEALED BID/PROPOSAL/QUALIFICATIONS
PROGRAM: Emergency Solutions Grants (ESG)
DESCRIPTION: PRIOR YEAR FUNDS APPLICAITON
DUE DATE: THURSDAY, April 2, 2020
DUE TIME: NO LATER THAN 4:00 P.M. CST
COMPANY NAME:
32
IX. CONFLICT OF INTEREST
All Applicants
No employee, officer, or agent shall participate in the selection, award, or administration of a contract supported by
federal funds if real or apparent conflict of interest would be involved. Such a conflict would arise when an employee,
officer, or agent, any member of his or her immediate family, his or her partner, or an organization which employs
or about to employ any of the parties indicated herein, has a financial or other interest in the firm selection for an
award.
The ESG regulations at 24 CFR 576.404 provide that no person who is an employee, agent, consultant, officer, or
elected official or appointed official of the recipient or subrecipients that are receiving ESG funds and (1) who
exercises or has exercised any functions or responsibilities with respect to activities assisted with ESG funds; or (2)
who is in a position to participate in a decision-making process or gain inside information with regard to these
activities, may obtain a financial interest from a ESG-assisted activity, or have any interest 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 or for one (1) year thereafter.
□ I certify that no conflict of interest exists between the City of Pasadena and ____________________________________.
Name of Subrecipient Agency
□ I certify that no conflict of interest exists between the City of Pasadena’s consultant and ____________________________________.
Name of Subrecipient Agency
□ I certify that no conflict of interest exists between the City of Pasadena and any subcontractors of
____________________________________.
Name of Subrecipient Agency
IF THERE IS A CONFLICT, COMPLETE THE FOLLOWING:
□ I certify that a conflict of interest does exist between the City of Pasadena and ____________________________________.
Name of Subrecipient Agency
□ I certify that a conflict of interest does exist between the City of Pasadena’s consultant and ____________________________________.
Name of Subrecipient Agency
□ I certify that a conflict of interest does exist between the City of Pasadena and any subcontractors of
____________________________________.
Name of Subrecipient Agency
Describe the nature of the conflict of interest below. Please identify the individual, employment, and the conflict
or potential conflict and their affiliation with your organization:
______________________________________________ ____________________
Signature Date
______________________________________________________________________________
Print Name and Title
33
X. INDEMNITY CLAUSE
THE CONTRACTOR SHALL DEFEND, INDEMNIFY AND SAVE HARMLESS
THE CITY AND ITS OFFICERS, AGENTS AND EMPLOYEES FROM
AND
AGAINST ANY AND ALL CLAIMS, DEMANDS, LIABILITIES, PENALTIES, DAMAGES, EXPENSES AND JUDGMENTS OF ANY NATURE AND
HOWEVER CAUSED, ARISING OUT OF OR RELATING TO THE
CONTRACTOR AND ITS AGENTS, SERVANTS OR
EMPLOYEES OPERATIONS IN THE CONCESSION AND CATERING SERVICES
PERFORMED BY CONTRACTOR
UNDER THIS
CONTRACT WITHIN THE CITY, INCLUDING THOSE
CLAIMS, DEMANDS, PENALTIES, DAMAGES, EXPENSES AND JUDGMENTS
WHICH
INVOLVE OR MAY INVOLVE THE ACTUAL OR ALLEGED JOINT NEGLIGENCE OF:
(i)
THE CONTRACTOR OR ANY OF ITS EMPLOYEES, AGENTS, SERVANTS OR EMPLOYEES; AND
(ii)
THE CITY, ITS OFFICERS, AGENTS, OR EMPLOYEES
IT IS THE EXPRESSED INTENTION OF BOTH THE CITY AND THE
CONTRACTOR THAT THE INDEMNITY PROVIDED FOR IN THIS
SECTION
IS INDEMNITY BY THE CONTRACTOR TO INDEMNIFY AND PROTECT THE CITY FROM THE CONSEQUENCES OF THE NEGLIGENCE
OF THE
CITY, ITS OFFICERS, AGENTS OR EMPLOYEES WHERE SUCH
NEGLIGENCE IS A CONCURRING CAUSE OF INJURY, LOSS,
DEATH OR
DAMAGE. FURTHERMORE, IT IS THE EXPRESSED INTENTION OF BOTH
THE CITY AND THE CONTRACTOR THAT THE
INDEMNITY PROVIDED
FOR IN THIS SECTION SHALL HAVE NO APPLICATION TO ANY CLAIMS,
LOSS, DAMAGE, CAUSE OF ACTION, SUIT
OR LIABILITY WHERE THE
INJURY, DEATH OR DAMAGE RESULTS FROM THE NEGLIGENCE OF THE CITY UNMIXED WITH THE FAULT
OF THE CONTRACTOR OR ANY OF ITS EMPLOYEES. FOR PURPOSES OF THIS INDEMNIFICATION PROVISION, ACTS AND/OR OMISSION OF
THE CONTRACTOR'S OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES SHALL BE CONSIDERED THE ACTS AND
OMISSIONS OF THE
CONTRACTOR.
Company/ Name of Agency
Mailing Address (PO Box or street)
City, State, and Zip Code
Name of Authorized Representative
Signature Title
Telephone # Fax #
34
XI. NON-COLLUSION AFFIDAVIT (MUST BE NOTARIZED)
State of (State)
County of (County) §.
Being first duly sworn, deposes and says that:
He/She is the (Owner, Partner, Officer, Representative or Agent) of
(Company), the party that has submitted the attached
Proposal;
He/she is fully informed respecting the preparation and contents of the attached Proposal and of all pertinent
circumstances respecting such Proposal;
Such application is genuine and is not a collusive or sham application;
Neither the said applicant nor any of its officers, partners, owners, agents, representatives, employees or parties in
interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or indirectly, with
any other Proposer, firm, or person to submit a collusive or sham Proposal in connection with the Work for which
the attached Proposal has been submitted; or to refrain from bidding in connection with such Work; or have in any
manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any
Proposer, firm, or person to fix the price or prices in the attached Proposal or of any other Proposer, or to fix any
overhead, profit, or cost elements of the Proposal price or the Proposal price of any other Proposer, or to secure
through any collusion, conspiracy, connivance, or unlawful agreement any advantage against (Recipient), or any
person interested in the proposed Work;
The price or prices quoted in the attached Proposal are fair and proper and are not tainted by any collusion,
conspiracy, connivance, or unlawful agreement on the part of the Proposer or any other of its agents, representatives,
owners, employees or parties in interest, including this affiant.
Authorized Representative’s Signature Company Name
Representative’s Name Representative’s Title
On this the _____ day of _______ , 20 , before me, the undersigned Notary Public of the State of Texas,
personally appeared the individual whose name is subscribed to within the instrument, and he/she/they
acknowledge that he/she/they executed it.
WITNESS my hand and official seal.
NOTARY PUBLIC
SEAL OF OFFICE: ______________________________________________________
(Name of Notary Public: Print, Stamp, or Type as Commissioned)
35
XII. CERTIFICATE OF NON-DEBARMENT (MUST BE NOTARIZED)
DATE:
NAME/ADDRESS OF APPLICANT ENTITY:
APPLICANT NAME:
CITY OF PASADENA
COMMUNITY DEVELOPMENT DEPARTMENT
P.O. BOX 672
PASADENA, TX 77501-0672
2020 funding application for ESG
(I) (We) certify that no individual, firm, partnership or association which is hereby bidding on the above-named project
is designated as not being debarred from contracting on federally-funded projects or as an ineligible contractor by the
Controller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5
(29 CFR, Part 5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (10 U.S.C. 276u-2(a).
LEGAL NAME AND BUSINESS ADDRESS OF THE APPLICANT:
THE APPLICANT IS:
A SINGLE PROPRIETORSHIP
A CORPORATION ORGANIZED IN THE STATE OF:
A PARTNERSHIP
OTHER ORGANIZATION (DESCRIBE):
APPLICANT’S FEDERAL ID (DUNS) NUMBER:
____ - _______ - _______
NAME, TITLE AND ADDRESS OF THE OWNER, PARTNERS OR OFFICERS OF THE APPLICANT:
NAME
TITLE
ADDRESS
Name of Applicant:
Authorized Representative Signature:
Name and Title:
STATE OF TEXAS §
COUNTY OF HARRIS §
BEFORE ME, the undersigned authority, on this day personally appeared ___________________________, know to me to be
the person and officer whose name is subscribed to the foregoing instrument, and acknowledged to me that he executed the
same for the purposes and consideration herein expressed and in the capacity therein stated as the act and deed of said
_______________________________.
GIVE UNDER MY HAND AND SEAL OF OFFICE this the ________day of ____________________, A.D., 20_______.
NOTARY PUBLIC AND FOR THE STATE OF TEXAS
Name: __________________________________________
WARNING
U.S. Criminal Code, Section 1010, Title18, U.S.C., provides in part: “Whoever, Makes, passes, utters, or published any statement, knowing the same
to be false …. Shall be fined not more than $5,000 or Imprisoned not more than two years, or both.”
36
XIII. SOLICITATION QUESTIONNAIRE
The City of Pasadena constantly strives to improve competitive bidding. In order to facilitate these improvements,
we would like to know how you were informed that this application and how you may have received a copy of the
document.
How did you learn of this funding opportunity?
Direct Contact with Community Development Department
City of Pasadena Website www.pasadenatx.gov
Newspaper or trade publication
Chamber of Commerce
Other Means: Describe
How did you obtain your copy of the application document?
Direct Contact with Community Development Dept.
Via Email Via Fax In Person
City of Pasadena Website www.pasadenatx.gov
Notification service
Other Means: Describe
37
Example: Certificate of Interested Parties
Pursuant to the requirements of House Bill 1295, 84th Legislative Session, any contract approved by Council is contingent
upon the business entity's completion of the required Form 1295, Certificate of Interested Parties
.
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
FORM CIQ
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the
vendor meets requirements under Section 176.006(a).
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.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
Date Received
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 No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
Yes No
7
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).
Signature of vendor doing business with the governmental entity
Date
Name of vendor who has a business relationship with local governmental entity.
1
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.)
2
3
Name of local government officer about whom the information is being disclosed.
Name of Officer
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
CIQ as necessary.
4
6
5
Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
A complete copy of Chapter 176 of the Local Government Code may be 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 § 176.001(1-a): "Business relationship" means a connection between two or more parties
based on commercial activity of one of the parties. The term does not include a connection based on:
(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(B) a transaction conducted at a price and subject to terms available to the public; or
(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and
that is subject to regular examination by, and reporting to, that agency.
Local Government Code § 176.003(a)(2)(A) and (B):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
***
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2,500 during the 12-month period
preceding the date that the officer becomes aware that
(i) a contract between the local governmental entity and vendor has been executed;
or
(ii) the local governmental entity is considering entering into a contract with the
vendor;
(B) has given to the local government officer or a family member of the officer one or more gifts
that have an aggregate value of more than $100 in the 12-month period preceding the date the
officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed; or
(ii) the local governmental entity is considering entering into a contract with the vendor.
Local Government Code § 176.006(a) and (a-1)
(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local governmental entity and:
(1) has an employment or other business relationship with a local government officer of that local
governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);
(2) has given a local government officer of that local governmental entity, or a family member of the
officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any
gift described by Section 176.003(a-1); or
(3) has a family relationship with a local government officer of that local governmental entity.
(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator
not later than the seventh business day after the later of:
(1) the date that the vendor:
(A) begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(B) submits to the local governmental entity an application, response to a request for proposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity; or
(2) the date the vendor becomes aware:
(A) of an employment or other business relationship with a local government officer, or a
family member of the officer, described by Subsection (a);
(B) that the vendor has given one or more gifts described by Subsection (a); or
(C) of a family relationship with a local government officer.
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CITY OF PASADENA EMERGENCY SOLUTIONS GRANTS (ESG) Application (City of Pasadena, Texas)

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Completed 25 February 2021

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