Water Distribution Repair and Improvement Program

EXHIBIT III

City of Houston Ownership Information Form

Rev. 12/23/2019

The City of Houston Ownership Information Form is used to gather information to comply with:

The City of Houston Contractor Ownership Disclosure Ordinance ();

The City of Houston Fair Campaign Ordinance (); and,

The State of Texas Statement of Residency Requirements ().

Please complete the form, in its entirety, and submit it with the Official Bid or Proposal Form. Except as noted below regarding the Statement of Residency, failure to provide this information may be just cause for rejection of your bid or proposal.

Notice of Affirmative Acceptance of the City of Houston Fair Campaign Ordinance

By submitting a bid or proposal to the City of Houston for a Contract in excess of $50,000 or for which a request is presented to City Council for approval, all respondents agree to comply with the Chapter 18 of the Code of Ordinances.

Further, pursuant to Section 18-36 of the Code of Ordinances, it shall be unlawful either for any person who submits a bid or proposal to contribute or offer any contribution to a candidate or for any candidate to solicit or accept any contribution from such person for a period commencing at the time of posting of the City Council Meeting Agenda including an item for the award of the Contract and ending upon the 30th day after the award of the Contract by City Council.

Instructions

Please type or legibly print in dark ink responses. Individuals and entities shall disclose their full, legal names (not initials) and all required corporate letters ("Inc", "LLP", etc.).

If a firm is operating under an assumed name, the following format is recommended: Corporate/Legal Name DBA Assumed Name.

Full addresses are required, including street types ("St", "Rd", etc.) and unit number.

Individuals or entities with 10% or more ownership of the corporation, partnership, or joint venture (including persons who own 100%) are required to be disclosed with their full name and full address. All officers and directors are also required to be disclosed with their full name and full address.

City of Houston Ownership Information Form

Rev. 12/23/2019

Project and Bid/Proposal Preparer Information

Project or Matter Being Bid:

Bidder's complete firm/company business information

Name:

Business Address [No./Street]

City / State / Zip Code

Telephone Number

Bidder's email address

Email Address:

Statement of Residency

(THE STATEMENT OF rESIDENCY PORTION OF THis dOCUMENT IS NOT APPLICABLE IF THE SOLICITATION INDICATES FEDERAL FUNDS WILL BE USED)

TEX. GOV'T CODE 2252.001, (4) defines a "Resident bidder" as a bidder whose principal place of business* is in this state, and includes a contractor whose ultimate parent company or majority owner has its principal place of business in this state.

TEX. GOV'T CODE 2252.001 (3) defines a "Nonresident bidder" as a bidder who is not a resident in this state.

* Principal Place of Business in Texas means that the business entity:

has at least one permanent office located within the State of Texas, from which business activities other than submitting bids to governmental agencies are conducted and from which the bid is submitted; and

has at least one employee who works in the Texas office.

Based on the definitions above, your business is a:

If you are a Nonresident Bidder, does your home state have a statute giving preference to resident bidders? If so, you must attach a copy of the statute to this Document.

A copy of the State of statute is attached.

NOTE: The State of residency of a bidder is not used in the decision-making criteria for the award of contracts for projects receiving federal funding, whether in whole or in part.

City of Houston Ownership Information Form

Rev. 12/23/2019

Contracting Entity Organizational Entity Type

LISTING OF ADDRESSES

List all current and prior addresses where the bidder does/has done business or owns property (real estate and/or business personal property) in the city of Houston ("Houston") in the past 3 years from the date of submittal of this form. If within the past 3 years from the date of submitting this form, the bidder does not and has not done business and has not or does not own property (real estate and/or business personal property) in Houston, please state "None" on the first line below.

Address

Address

Address

Attach additional sheets as needed.

City of Houston Ownership Information Form

Rev. 12/23/2019

Listing of Officers

List all Officers of the entity, regardless of the amount of ownership (if none state "None")

Name

Officer Address

Name

Officer Address

Name

Officer Address

Name

Officer Address

Name

Officer Address

Name

Officer Address

Listing of Directors OR MEMBERS

List all Directors of the entity, regardless of the amount of ownership (if none state "None")

Name

Director or Member Address

Name

Director or Member Address

Name

Director or Member Address

Name

Director or Member Address

Name

Director or Member Address

City of Houston Ownership Information Form

Rev. 12/23/2019

Disclosure of ownership (or non-profit officers)

Bidders are required to disclose all owners of 10% or more of the Contracting Entity. For non-profit entities, please provide the complete information for the President, Vice-President, Secretary, and Treasurer.

In all cases, use full names, local business and residence addresses and telephone numbers. Do not use post office boxes for any address. Inclusion of e-mail addresses is optional, but recommended.

Attach additional sheets as needed.

Contracting Entity:

Name:

Business Address [No./Street]

City / State / Zip Code

Telephone Number

Email Address:

Disclosure of ownership (or non-profit officers) continued.

Owner(s) of 10% or More (IF NONE, STATE "NONE."):

Name:

Business Address [No./Street]

City / State / Zip Code

Telephone Number

Email Address:

Residence Address [No./Street]

City / State / Zip Code

Owner(s) of 10% or More (IF NONE, STATE "NONE."):

Name:

Business Address [No./Street]

City / State / Zip Code

Telephone Number

Email Address:

Residence Address [No./Street]

City / State / Zip Code

Attach additional sheets as needed.

City of Houston Ownership Information Form

Rev. 12/23/2019

OptionaL: Tax AppeaL Information

If the firm/company or an owner/officer is actively protesting, challenging, or appealing the accuracy and/or amount of taxes levied with a tax appraisal district, please provide the following information:

Status of Appeal [Describe]:

If an appeal of taxes has been filed on behalf of your company, please include a copy of the official form receipted by the appropriate agency.

required: unsworn declaration

I certify that I am duly authorized to submit this form on behalf of the firm, that I am associated with the firm in the capacity noted below, and that I have personal knowledge of the accuracy of the information provided herein. I affirm that all the information contained herein is true and correct to the best of my knowledge. I understand that failure to submit accurate information with my submission may result in my submission being considered non-responsive and non-responsible.

Preparer's Signature Date

Printed name

Title

NOTE: This form constitutes a governmental record, as defined by Section 37.01 of the Texas Penal Code. Submission of a false government record and falsification of a governmental record are crimes, punishable as provided in Section 37.10 of the Texas Penal Code.