HomeMy WebLinkAboutPR 24760: APPROVAL OF AMENDMENT NO. 1 HEALTHY TEXAS MOTHERS & BABIES COMMUNITY COALITION GRANT (TEXAS DEPARTMENT OF STATE HEALTH SERVICES) City of
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INTEROFFICE MEMORANDUM
Date: January 23, 2026
To: The Honorable Mayor and City Council
Through: Ronald Burton, CPM, City Manager
From: Christina B. Patteson, MS, RD, LD, WIC Director
Judith A. Smith, RN, BSN, Director of Health Services
RE: Approval of Amendment No. 1 —Healthy Texas Mothers & Babies Community
Coalition Grant (Texas Department of State Health Services)
Background:
Jefferson County has been designated as a high infant mortality county. Participation in this
grant program allows the City,through its Health Department and established local partnerships,
to address disparities in birth outcomes and maternal and infant health through coordinated
public health strategies.
On March 18, 2025, the City Council approved a grant contract between the City of Port Arthur
and the Texas Department of State Health Services ("DSHS") for participation in the Healthy
Texas Mothers & Babies Community Coalition Grant pursuant to Resolution No. 25-103. The
original contract provided $75,000.00 in funding to support evidence-based, community-driven
initiatives to reduce maternal and infant mortality.
The Texas Department of State Health Services has approved additional funding in the amount
of$85,000.00 for Fiscal Year 2027, increasing the total contract amount to an amount not to
exceed $160,000.00, with no cash match required by the City.
Budget Impact:
Total payments received from this contract will be $85,000 through August 31, 2027. These
funds will cover the operation of the program: salaries, fringe, travel, and supplies.
Proposed amendment:
DSHS has approved Amendment No. 1 to the grant contract, which proposes the following
material changes:
1. Increase in Funding
o Adds $85,000.00 in grant funds for Fiscal Year 2027
o Increases the total contract amount to not to exceed $160,000.00
o No cash match is required from the City
2. Scope of Work
"Remember,we are here to serve the Citizens of Port Arthur"
P.O. Box 1089 X Port Arthur,Texas 77641-1089 X 409.983.8101 X FAX 409.982.6743
City of
tent rthur
o Supplements the grant project scope to include additional authorized services to
be provided by the City during FY 2027
3. Reporting Requirements
o Updates and supplements the reporting requirements applicable to the grant for
FY 2027
4. Contract Term Extension
o Extends the contract term for an additional one-year period,with a new
expiration date of August 31, 2027,unless earlier terminated or renewed in
accordance with the contract
Recommendation:
It is recommended that the City Council approve P.R. No. 24760, Amendment No. 1, between
the Texas Department of State Health Services and the City of Port Arthur for the Texas Healthy
Mothers and Babies Community Coalition grant.
"Remember,we are here to serve the Citizens of Port Arthur"
P.O.Box 1089 X Port Arthur,Texas 77641-1089 X 409.983.8101 X FAX 409.982.6743
P. R. No. 24760
01/23/2026-js- tnr
RESOLUTION NO.
A RESOLUTION APPROVING AMENDMENT NO. 1 TO THE
CONTRACT BETWEEN THE TEXAS DEPARTMENT OF STATE
HEALTH SERVICES AND THE CITY OF PORT ARTHUR FOR
THE HEALTHY TEXAS MOTHERS & BABIES COMMUNITY
COALITION GRANT; INCREASING THE INITIAL FUNDING OF
$75,000 BY AN ADDITIONAL $85,000.00 FOR A TOTAL
CONTRACT AMOUNT NOT TO EXCEED $160,000.00;
AMENDING THE SCOPE OF WORK AND REPORTING
REQUIREMENTS; EXTENDING THE CONTRACT TERM
THROUGH AUGUST 31, 2027. NO CASH MATCH REQUIRED.
WHEREAS, the Healthy Texas Mothers & Babies Initiative was established to assist
Texas communities in reducing maternal and infant mortality through evidence-based,
community-driven interventions involving local stakeholders, healthcare providers, and insurers;
and
WHEREAS, Jefferson County has been designated as a high infant mortality county, and
participation in this grant program will assist in reducing disparities in birth outcomes and
maternal and infant mortality while improving long-term public health and reducing healthcare
costs; and
WHEREAS, the City of Port Arthur Health Department utilizes established local
partnerships to implement participatory programming models designed to address maternal and
infant health disparities within the community; and
WHEREAS, the City Council approved the original grant contract with the Texas
Department of State Health Services on March 18, 2025, pursuant to Resolution No. 25-103, in
the amount of$75,000.00; and
WHEREAS, the Texas Department of State Health Services has approved additional
funding in the amount of$85,000.00 for Fiscal Year 2027, increasing the total contract amount
to an amount not to exceed $160,000.00, with no cash match required by the City; and
WHEREAS, the parties desire to amend the contract to (i) increase funding, (ii)
supplement the scope of work for authorized services to be provided by the City during Fiscal
Year 2027, (iii) supplement the reporting requirements applicable to the grant, and (iv) extend
the contract term for an additional one-year period through August 31, 2027, unless earlier
terminated or renewed in accordance with the contract.
P. R. No. 24760
01/23/2026-js- tnr
NOW THEREFORE BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF PORT ARTHUR, TEXAS:
Section 1. That the facts and opinions are true and correct.
Section 2. That the City Council finds it to be in the best interest of the City of Port
Arthur to approve Amendment No. 1 to the contract between the Texas Department of State
Health Services and the City of Port Arthur for the Healthy Texas Mothers & Babies Community
Coalition Grant.
Section 3. That Amendment No.1 authorizes the acceptance of additional funding in
the amount of $85,000.00 for Fiscal Year 2027, increasing the total contract amount to an
amount not to exceed $160,000.00, with no cash match required by the City.
Section 4. That the City Manager and the Director of the City of Port Arthur Health
Department are hereby authorized to execute Amendment No. 1 to the contract, substantially in
the form attached hereto as Exhibit "A."
Section 5. That a copy of the caption of this Resolution be spread upon the Minutes
of the City Council.
READ, ADOPTED, AND APPROVED, this day of , 2026 at
a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following Vote:
AYES:May or:
Councilmembers:
NOES:
Mayor, Charlotte M. Moses
ATTEST:
Sherri Bellard, City Secretary
P. R. No. 24760
01/23/2026-js
APPROVED AS TO FORM:
Roxann Pais Cotroneo, City Attorney
APPROVED AS TO FUNDS:
/3/A
Lynda sw 1, MA, ICMA-CM Finance Director
APPROVE 1 I i ; 1 ►' o'ISTRATION:
Ron Burton, �� ity Manager Jud. Smith, R.N. BSN, Director of Health
P. R. No. 24760
01/23/2026-js
EXHIBIT "A"
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SIGNATURE DOCUMENT FOR
DEPARTMENT OF STATE HEALTH SERVICES GRANT AGREEMENT,
CONTRACT No.HHS001564200001
AMENDMENT No.1
The TEXAS DEPARTMENT OF STATE HEALTH SERVICES("DSHS" or "System Agency")
and CITY OF PORT ARTHUR("Grantee"),collectively the"Parties,"to that certain Healthy
Texas Mothers and Babies ("HTMB") community coalition contract effective September
1, 2025, and denominated HHSC Contract No. HHS001564200001 ("Grant Agreement"
or"Contract"), now desire to amend the Contract.
WHEREAS, the Parties desire to extend the term of the Contract for an additional one-year
period;
WHEREAS, the Parties desire to add funds to the Contract for authorized services to be
provided by Grantee in State Fiscal Year 2027 ("FY2027") and amend the Budget
accordingly;
WHEREAS, the Parties desire to supplement the reporting requirements table for reports to
be submitted by Grantee in FY2027;
WHEREAS, the Parties desire to supplement the Scope of Grant Project for authorized
services to be provided by Grantee in FY2027;
WHEREAS, the Parties desire to update the Contract Affirmations; and
WHEREAS, System Agency desires to revise certain terms for compliance with applicable
state law, federal law, and System Agency policy.
Now,THEREFORE, the Parties amend and modify the Contract as follows:
1. SECTION III, DURATION, of the Contract is amended to reflect a revised termination
date of August 31, 2027, unless renewed or terminated earlier pursuant to the terms
and conditions of the Contract.
2. SECTION V, BUDGET AND INDIRECT COST RATE, of the Contract is amended to add
funds in the amount of$85,000.00 for services delivered by Grantee in FY2027. The
total not-to-exceed amount of this Contract is increased to $160,000.00. All
expenditures incurred during FY2027 must be within the Contract period and in
accordance with ATTACHMENT B-1,BUDGET.
3. SECTION VI, REPORTING REQUIREMENTS,of the Contract is supplemented to add the
reporting requirements table for FY2027 as follows:
DSHS Contract No.HHS001564200001
Amendment No. 1 Page 1 of 4
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REPORT FREQUENCY DUE DATE
Finalized Work Plan One-time September 30,2026
Annual Program Once per state fiscal year August 31,2027
Performance Report
Financial Status Reports The last business day of the month March 31,2027
(FSRs)—Biannual following the end of the second state
fiscal quarter AND forty-five (45) September 30,2027
calendar days following the end of the
final state fiscal quarter of the project
period
Invoices/Requests for The last business day of the month October 30,2026
Reimbursement—Monthly following the month in which expenses November 30,2026
were incurred AND thirty(30)calendar December 31,2026
days following the expiration date of the January 29,2027
Grant Agreement. February 26,2027
March 31,2027
April 30,2027
May 31,2027
June 30,2027
July 30,2027
August 31,2027
September 30,2027
Property Inventory Report Once per state fiscal year October 15,2027
(Form GC-11)—Annual
4. ATTACHMENT A, SCOPE OF GRANT PROJECT (FY2026), of the Contract is
supplemented to add ATTACHMENT A-1, SCOPE OF GRANT PROJECT (FY 2027),
which is attached to this Amendment No. 1 and incorporated and made part of the
Contract for all purposes.
5. ATTACHMENT B, BUDGET (FY2026), of the Contract is deleted in its entirety and
replaced with ATTACHMENT B-1,BUDGET, which is attached to this Amendment No.
1 and incorporated and made part of the Contract for all purposes.
6. ATTACHMENT C, HHS CONTRACT AFFIRMATIONS,VERSION 2.5, of the Contract is
deleted in its entirety and replaced with ATTACHMENT C-1, HHS CONTRACT
AFFIRMATIONS,VERSION 2.8,EFFECTIVE DECEMBER 2025,which is attached to this
Amendment No. 1 and incorporated and made part of the Contract for all purposes.
7. ATTACHMENT I, FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT
(FFATA)CERTIFICATION FORM,of the Contract is supplemented with ATTACHMENT
DSHS Contract No.HHS001564200001
Amendment No. 1 Page 2 of 4
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I-1, FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA)
CERTIFICATION FORM for FY2027, which is attached to this Amendment No. 1 and
incorporated and made part of the Contract for all purposes.
8. This Amendment is effective immediately upon execution by the last party to sign
below. Operations and funding for Fiscal Year 2027 begin on September 1,
2026. Except as modified by this Amendment, all existing terms of the Contract,
including the current Statement of Work, shall remain in full force and effect until and
unless modified by written agreement of the Parties.
9. Except as modified by this Amendment No. 1, all terms and conditions of the Contract,
shall remain in full force and effect.
10.Any further revisions to the Contract shall be by written agreement of the Parties.
11. Each Party represents and warrants that the person executing this Amendment No. 1 on
its behalf has full power and authority to enter into this Amendment No. 1.
SIGNATURE PAGE FOLLOWS
DSHS Contract No.HHS001564200001
Amendment No. 1 Page 3 of 4
Docusign Envelope ID:775C0A82-DA94-4727-AB84-BE5089F26816
SIGNATURE PAGE FOR SYSTEM AGENCY GRANT AGREEMENT
CONTRACT No.HHS001564200001
TEXAS DEPARTMENT OF STATE HEALTH CITY OF PORT ARTHUR
SERVICES
Signature
Name: Name:
Title: Title:
Date of Signature: Date of Signature:
THE FOLLOWING DOCUMENTS ARE ATTACHED AND INCORPORATED AND MADE PART
OF THE CONTRACT FOR ALL PURPOSES:
ATTACHMENT A-1 SCOPE OF GRANT PROJECT(FY2027)
ATTACHMENT B-1 BUDGET(FY2027)
ATTACHMENT C-1 HHS CONTRACT AFFIRMATIONS,VERSION 2.8,
EFFECTIVE DECEMBER 2025
ATTACHMENT I-I FISCAL FEDERAL FUNDING ACCOUNTABILITY AND
TRANSPARENCY ACT(FFATA)CERTIFICATION FORM
DSHS Contract No.HHS001564200001
Amendment No. 1 Page 4 of 4
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ATTACHMENT A-1
SCOPE OF GRANT PROJECT (FY2027)
1. GRANTEE RESPONSIBILITIES
Grantee will:
A. Coordinate a Healthy Texas Mothers and Babies Community Coalition (HTMB CC)
initiative and collaborate with community partners and stakeholders to strengthen
local capacity and community partnerships to implement evidence-based
interventions to improve perinatal and infant health outcomes and reduce disparities
in infant mortality rates toward achievement of Healthy People 2030 goals.
B. Meet the standards and definitions of a community coalition, as described in the
Prevention Institute's "Developing Effective Coalitions: An Eight Step Guide,"
located at the following URL:
https://www.preventioninstitute.org/publications/developing-effective-coalitions-
an-eight-step-guide.
C. Coordinate quarterly HTMB CC meetings with DSHS, coalition member
organizations, community members, and other stakeholders to provide a forum to
discuss data,current and emerging perinatal and infant health priorities,and strategies.
D. Coordinate HTMB CC stakeholder and member participation in webinars, trainings,
collaborative learning forums, and other events.
E. Offer activities that strengthen and expand community partnerships by recruiting and
engaging members, developing and defining member roles, and expanding and
strengthening coordination and collaboration among partners.
F. Engage HTMB CC membership that is representative of the community(i.e., service
organizations, local WIC clinics, health systems, faith based, minority community
representatives, local government, school districts, and/or university research
partners).
G. Develop sustainable activities and initiatives using best practice recommendations,
tools, and resources.
H. Participate in project planning, sharing,and status meetings(virtual or in person)with
System Agency as scheduled. Schedule meetings approximately on a monthly basis,
and as needed or requested. During status meetings, communicate HTMB CC needs
for technical assistance,perinatal and infant health and safety subject matter expertise,
and support with training, sustainability, and capacity building.
I. Attend quarterly calls with other HTMB CCs to share programmatic activities.
J. Use public health data, project metrics, needs assessment information, strategic
planning, and community stakeholder appraisal to develop and refine an Annual
Report by:
1. Coordinating activities and achievement of metrics with partners, stakeholders,
System Agency, and community members;
2. Establishing and tracking process and outcomes metrics; and
3. Activating HTMB CC members and stakeholders in implementation efforts to
mobilize community, region, and statewide involvement, address challenges,
identify and share lessons learned, and the collective impact within the
community, region, and statewide.
DSHS Contract No.HHS001564200001
Amendment No. 1,Attachment A-1 Page 1 of 4
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K. Submit to System Agency the following documents or other reports in the formats
requested by System Agency:
1. A finalized Work Plan that outlines the Grantee's planned approach to comply
with this Contract, including planned implementation and communication
strategies. System Agency must provide written approval of the Work Plan prior
to implementation.Throughout the fiscal year,Grantee must seek System Agency
approval for any communications or marketing activities that are not included in
the approved Work Plan. Grantee must submit the Work Plan by August 31,2026,
to the following email addresses: cdsbna,dshs.texas.gov; and
InfantHealthAdshs.texas.gov.
2. Grantee will use data,project indicators, needs assessment information, strategic
planning, and community stakeholder appraisal to develop and refine its written
HTMB CC Work Plan that identifies and justifies:
a. The HTMB CCs mission and vision;
b. Activities that address perinatal and infant health and mortality, with the
infant defined herein as babies from zero (0) to one (1) year of age, as the
target population and identify baseline data used to develop necessary
interventions;
c. Locally appropriate evidence-based and/or evidence-informed infant
mortality and disparity reduction interventions for implementation;
d. A sustainability domain,from the list below,that aligns with each Work Plan
objective:
1. Environmental Support;
2. Funding Stability;
3. Partnerships;
4. Organizational Capacity;
5. Program Evaluation;
6. Program Adaptation;
7. Communications; and
8. Strategic Planning;
e. Roles and responsibilities of all HTMB CC members and partners;
f. Resources needed and resources to be leveraged for Work Plan
implementation;
g. Communication plans to support coalition and community events, and build
community awareness regarding perinatal and infant health and safety topics,
or other emerging infant health topics. Communication plans must identify
proposed communication channels, such as social media marketing, digital,
audiovisual and print materials, or other advertising channels that align with
System Agency's HTMB framework and focus; and
h. Evaluation and sustainability measures and milestones implemented.
3. An Annual Program Performance Report, including a description of the
implementation of strategies and activities, progress towards metrics, and the
challenges identified by unmet metrics established in the Work Plan during the
DSHS Contract No.HHS001564200001
Amendment No. 1,Attachment A-1 Page 2 of 4
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project period(September 1,2026,through August 31,2027).Grantee must submit
the Annual Program Performance Report by September 30,2027,to the following
email addresses: cdsb@dshs.texas.gov; and InfantHealth@dshs.texas.gov.
4. Biannual Financial Status Reports (FSR) to be submitted to cdsb@,dshs.texas.gov
and to FSRGrants@,dshs.texas.gov by the dates below for FY2027:
Period Covered Due Date
September 1, 2026 -February 28, 2027 March 31, 2027
March 1, 2026 -August 31, 2027 September 30, 2027
L. Maintain an inventory of equipment, supplies defined as "Controlled Assets" (see
definition in form titled, "DSHS Contractor's Property Inventory Report (Form GC-
11)," link below), and real property. Grantee must submit an annual cumulative report
of the above stated items on the Form GC-11, located at the following URL:
https://www.dshs.texas.gov/contractor-forms. Grantee submits the Form GC-11, via
email, to FSOequipAdshs.texas.gov, with a copy to the System Agency Contract
Representative identified in SECTION VII, CONTRACT REPRESENTATIVES, of this
Contract,no later than October 15th of each calendar year.
M. DSHS-approved budget may be revised by Grantee in accordance with the following
requirements:
1. For any transfer between budget categories, Grantee shall provide Notification of
transfer between budget categories by submission of a revised Categorical Budget
Form to the DSHS Contract Representative, highlighting the areas affected by the
budget transfer and written justification for the transfer request. After DSHS
review, the designated DSHS Contract Representative will provide notification of
acceptance or rejection to Grantee by email.
2. For transfer of funds between direct budget categories, other than the"`Equipment'
and `Indirect Cost' categories,for less than or equal to cumulative twenty-five(25)
percent of the total value of the respective Contract budget period, Grantee shall
submit timely written notification to DSHS Contract Representative using the
Revised Budget Form and request DSHS approval. If approved, DSHS Contract
Representative will provide notification of acceptance to Grantee by email, upon
receipt of which, the revised budget will be incorporated into the Contract.
3. For transfer of funds between direct budget categories, other than the `Equipment'
and `Indirect Cost' categories, that cumulatively exceeds twenty five (25) percent
of the total value of the respective Contract budget period, Grantee shall submit
timely written notification to DSHS Contract Representative using the Revised
Budget Form and request DSHS approval. If the revision is approved, the budget
revision is not authorized and the funds cannot be utilized until an amendment is
executed by the Parties.
4. Any transfer between budget categories that includes `Equipment' and/or `Indirect
Costs' categories must be incorporated by amendment.Grantee shall submit timely
written notification to DSHS Contract Representative using the Revised Budget
Form and request DSHS approval. If the revision is approved, the budget revision
DSHS Contract No.HHS001564200001
Amendment No. 1,Attachment A-1 Page 3 of 4
Docusign Envelope ID:775C0A82-DA94-4727-AB84-BE5089F26816
is not authorized and the funds cannot be utilized until an amendment is executed
by the Parties.
2. PERFORMANCE MEASURES
System Agency will monitor the Grantee's performance of the requirements in this
Scope of Grant Project and compliance with the terms and conditions of the Grant
Agreement.
3. INVOICE AND PAYMENT
A. Grantee shall request monthly payments by the last business day of the month following
the month in which expenses were incurred by submitting the State of Texas Purchase
Vouchers (using Form B-13) currently located at
https://www.dshs.texas.gov/contractor-forms. Grantee shall submit Form B-13, and
any supporting documentation as follows:
i. If by email, then send electronically to: invoicesAdshs.state.tx.us,
CMSinvoices@a,dshs.texas.gov, and InfantHealth@dshs.texas.gov.
ii. If by mail,then send to:
Department of State Health Services
Claims Processing Unit, MC 1940
1100 West 49th Street
Austin, Texas 78714
iii. If by fax, then send to: (512)458-7442
B. Grantee will be paid on a cost reimbursement basis in accordance with the budget for
the corresponding budget period under this Grant Agreement.
C. Grantee shall electronically submit a final close-out invoice(using Form B-13 and with
supporting documentation) no later than thirty(30) calendar days following the end of
the State Fiscal Year 2027. Vouchers received more than thirty(30)days following the
end of the fiscal year are subject to denial of payment.
DSHS Contract No.HHS001564200001
Amendment No. 1,Attachment A-1 Page 4 of 4
Docusign Envelope ID:775C0A82-DA94-4727-AB84-BE5089F26816
ATTACHMENT B-1
BUDGET (FY2027)
CATEGORIES FY2026 FY2027 Total Amount
PERSONNEL $48,740.00 $50,446.00 $99,186.00
FRINGE BENEFITS $21,202.00 $21,944.00 $43,146.00
TRAVEL $1,025.00 $5,600.00 $6,625.00
EQUIPMENT $0.00 $0.00 $0.00
SUPPLIES $500.00 $300.00 $800.00
CONTRACTUAL $0.00 $3,240.00 $3,240.00
OTHER $3,533.00 $3,470.00 $7,003.00
TOTAL DIRECT $75,000.00 $85,000.00 $160,000.00
COSTS
INDIRECT COSTS $0.00 $0.00 $0.00
TOTAL (DIRECT
COSTS AND S75,000.00 $85,000.00 S160,000.00
INDIRECT COSTS)
DSHS Contract No.HHS001564200001
Amendment No. 1,Attachment B-1 Page 1 of 1
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HEALTH AND HUMAN SERVICES
Contract Number HHS001564200001
Exhibit C-1 CONTRACT AFFIRMATIONS
For purposes of these Contract Affirmations, HHS includes both the Health and Human Services
Commission(HHSC) and the Department of State Health Services (DSHS). System Agency
refers to HHSC, DSHS, or both, that will be a party to this Contract. These Contract
Affirmations apply to all Contractors and Grantees (referred to as "Contractor")regardless of
their business form(e.g., individual,partnership, corporation).
By entering into this Contract, Contractor affirms, without exception,understands, and agrees to
comply with the following items through the life of the Contract:
1. Contractor represents and warrants that these Contract Affirmations apply to Contractor
and all of Contractor's principals, officers, directors, shareholders,partners, owners,
agents, employees, subcontractors, independent contractors, and any other representatives
who may provide services under,who have a financial interest in, or otherwise are
interested in this Contract and any related Solicitation.
2. Complete and Accurate Information
Contractor represents and warrants that all statements and information provided to HHS
are current, complete, and accurate. This includes all statements and information in this
Contract and any related Solicitation Response.
3. Public Information Act
Contractor understands that HHS will comply with the Texas Public Information Act
(Chapter 552 of the Texas Government Code) as interpreted by judicial rulings and
opinions of the Attorney General of the State of Texas. Information, documentation, and
other material prepared and submitted in connection with this Contract or any related
Solicitation may be subject to public disclosure pursuant to the Texas Public Information
Act. In accordance with Section 2252.907 of the Texas Government Code,Contractor is
required to make any information created or exchanged with the State pursuant to the
Contract, and not otherwise excepted from disclosure under the Texas Public Information
Act, available in a format that is accessible by the public at no additional charge to the
State.
4. Contracting Information Requirements
Contractor represents and warrants that it will comply with the requirements of Section
552.372(a)of the Texas Government Code. Except as provided by Section 552.374(c) of
the Texas Government Code,the requirements of Subchapter J(Additional Provisions
Related to Contracting Information), Chapter 552 of the Government Code, may apply to
the Contract and the Contractor agrees that the Contract can be terminated if the
Contractor knowingly or intentionally fails to comply with a requirement of that
subchapter.
Health and Human Services
Contract Affirmations v.2.8
Effective December 2025
Page 1 of 14
Docusign Envelope ID:775C0A82-DA94-4727-AB84-BE5089F26816
5. Assignment
A. Contractor shall not assign its rights under the Contract or delegate the performance
of its duties under the Contract without prior written approval from System Agency.
Any attempted assignment in violation of this provision is void and without effect.
B. Contractor understands and agrees the System Agency may in one or more
transactions assign,pledge, or transfer the Contract. Upon receipt of System
Agency's notice of assignment, pledge, or transfer, Contractor shall cooperate with
System Agency in giving effect to such assignment,pledge, or transfer, at no cost to
System Agency or to the recipient entity.
6. Terms and Conditions
Contractor accepts the Solicitation terms and conditions unless specifically noted by
exceptions advanced in the form and manner directed in the Solicitation, if any,under
which this Contract was awarded. Contractor agrees that all exceptions to the Solicitation,
as well as terms and conditions advanced by Contractor that differ in any manner from
HHS' terms and conditions, if any, are rejected unless expressly accepted by System
Agency in writing.
7. HHS Right to Use
Contractor agrees that HHS has the right to use,produce, and distribute copies of and to
disclose to HHS employees, agents, and contractors and other governmental entities all or
part of this Contract or any related Solicitation Response as HHS deems necessary to
complete the procurement process or comply with state or federal laws.
8. Release from Liability
Contractor generally releases from liability and waives all claims against any party
providing information about the Contractor at the request of System Agency.
9. Dealings with Public Servants
Contractor has not given, has not offered to give, and does not intend to give at any time
hereafter any economic opportunity, future employment, gift, loan, gratuity, special
discount,trip, favor, or service to a public servant in connection with this Contract or any
related Solicitation, or related Solicitation Response.
10. Financial Participation Prohibited
Under Section 2155.004, Texas Government Code (relating to financial participation in
preparing solicitations), Contractor certifies that the individual or business entity named
in this Contract and any related Solicitation Response is not ineligible to receive this
Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
11. Prior Disaster Relief Contract Violation
Under Sections 2155.006 and 2261.053 of the Texas Government Code (relating to
convictions and penalties regarding Hurricane Rita, Hurricane Katrina, and other
disasters), the Contractor certifies that the individual or business entity named in this
Contract and any related Solicitation Response is not ineligible to receive this Contract
Health and Human Services
Contract Affirmations v.2.8
Effective December 2025
Page 2 of 14
Docusign Envelope ID:775C0A82-DA94-4727-AB84-BE5089F26816
and acknowledges that this Contract may be terminated and payment withheld if this
certification is inaccurate.
12. Child Support Obligation
Under Section 231.006(d) of the Texas Family Code regarding child support, Contractor
certifies that the individual or business entity named in this Contract and any related
Solicitation Response is not ineligible to receive the specified payment and acknowledges
that the Contract may be terminated and payment may be withheld if this certification is
inaccurate. If the certification is shown to be false, Contractor may be liable for
additional costs and damages set out in 231.006(f).
13. Suspension and Debarment
Contractor certifies that it and its principals are not suspended or debarred from doing
business with the state or federal government as listed on the State of Texas Debarred
Vendor List maintained by the Texas Comptroller of Public Accounts and the System for
Award Management(SAM)maintained by the General Services Administration. This
certification is made pursuant to the regulations implementing Executive Order 12549
and Executive Order 12689, Debarment and Suspension, 2 C.F.R. Part 376, and any
relevant regulations promulgated by the Department or Agency funding this project. This
provision shall be included in its entirety in Contractor's subcontracts, if any, if payment
in whole or in part is from federal funds.
14. Excluded Parties
Contractor certifies that it is not listed in the prohibited vendors list authorized by
Executive Order 13224, "Blocking Property and Prohibiting Transactions with Persons
Who Commit, Threaten to Commit, or Support Terrorism,"published by the United
States Department of the Treasury, Office of Foreign Assets Control.'
15. Foreign Terrorist Organizations
Contractor represents and warrants that it is not engaged in business with Iran, Sudan, or
a foreign terrorist organization, as prohibited by Section 2252.152 of the Texas
Government Code.
16. Executive Head of a State Agency
In accordance with Section 669.003 of the Texas Government Code,relating to
contracting with the executive head of a state agency, Contractor certifies that it is not(1)
the executive head of an HHS agency, (2) a person who at any time during the four years
before the date of this Contract was the executive head of an HHS agency, or(3) a person
who employs a current or former executive head of an HHS agency.
17. Human Trafficking Prohibition
Under Section 2155.0061 of the Texas Government Code, Contractor certifies that the
individual or business entity named in this Contract is not ineligible to receive this
Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
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18. Franchise Tax Status
Contractor represents and warrants that it is not currently delinquent in the payment of
any franchise taxes owed the State of Texas under Chapter 171 of the Texas Tax Code.
19. Debts and Delinquencies
Contractor agrees that any payments due under this Contract shall be applied towards any
debt or delinquency that is owed to the State of Texas.
20. Lobbying Prohibition
Contractor represents and warrants that payments to Contractor and Contractor's receipt
of appropriated or other funds under this Contract or any related Solicitation are not
prohibited by Sections 556.005, 556.0055, or 556.008 of the Texas Government Code
(relating to use of appropriated money or state funds to employ or pay lobbyists, lobbying
expenses, or influence legislation).
21. Buy Texas
Contractor agrees to comply with Section 2155.4441 of the Texas Government Code,
requiring the purchase of products and materials produced in the State of Texas in
performing service contracts.
22. Disaster Recovery Plan
Contractor agrees that upon request of System Agency, Contractor shall provide copies of
its most recent business continuity and disaster recovery plans.
23. Computer Equipment Recycling Program
If this Contract is for the purchase or lease of computer equipment,then Contractor
certifies that it is in compliance with Subchapter Y, Chapter 361 of the Texas Health and
Safety Code related to the Computer Equipment Recycling Program and the Texas
Commission on Environmental Quality rules in 30 TAC Chapter 328.
24. Television Equipment Recycling Program
If this Contract is for the purchase or lease of covered television equipment, then
Contractor certifies that it is compliance with Subchapter Z, Chapter 361 of the Texas
Health and Safety Code related to the Television Equipment Recycling Program.
25. Cybersecurity Training
A. Contractor represents and warrants that it will comply with the requirements of
Section 2063.104 of the Texas Government Code relating to cybersecurity training
and required verification of completion of the training program.
B. Contractor represents and warrants that if Contractor or Subcontractors, officers, or
employees of Contractor have access to any state computer system or database,the
Contractor, Subcontractors, officers, and employees of Contractor shall complete
cybersecurity training pursuant to and in accordance with Government Code, Section
2063.104.
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26. Restricted Employment for Certain State Personnel
Contractor acknowledges that, pursuant to Section 572.069 of the Texas Government
Code, a former state officer or employee of a state agency who during the period of state
service or employment participated on behalf of a state agency in a procurement or
contract negotiation involving Contractor may not accept employment from Contractor
before the second anniversary of the date the Contract is signed or the procurement is
terminated or withdrawn.
27. No Conflicts of Interest
A. Contractor represents and warrants that it has no actual or potential conflicts of
interest in providing the requested goods or services to System Agency under this
Contract or any related Solicitation and that Contractor's provision of the requested
goods and/or services under this Contract and any related Solicitation will not
constitute an actual or potential conflict of interest or reasonably create an appearance
of impropriety.
B. Contractor agrees that, if after execution of the Contract, Contractor discovers or is
made aware of a Conflict of Interest, Contractor will immediately and fully disclose
such interest in writing to System Agency. In addition, Contractor will promptly and
fully disclose any relationship that might be perceived or represented as a conflict
after its discovery by Contractor or by System Agency as a potential conflict. System
Agency reserves the right to make a final determination regarding the existence of
Conflicts of Interest, and Contractor agrees to abide by System Agency's decision.
28. Fraud,Waste,and Abuse
Contractor understands that HHS does not tolerate any type of fraud, waste, or abuse.
Violations of law, agency policies, or standards of ethical conduct will be investigated,
and appropriate actions will be taken. Pursuant to Texas Government Code, Section
321.022, if the administrative head of a department or entity that is subject to audit by the
state auditor has reasonable cause to believe that money received from the state by the
department or entity or by a client or contractor of the department or entity may have
been lost, misappropriated, or misused, or that other fraudulent or unlawful conduct has
occurred in relation to the operation of the department or entity,the administrative head
shall report the reason and basis for the belief to the Texas State Auditor's Office (SAO).
All employees or contractors who have reasonable cause to believe that fraud,waste, or
abuse has occurred(including misconduct by any HHS employee, Grantee officer, agent,
employee, or subcontractor that would constitute fraud,waste, or abuse) are required to
immediately report the questioned activity to the Health and Human Services
Commission's Office of Inspector General. Contractor agrees to comply with all
applicable laws, rules,regulations, and System Agency policies regarding fraud,waste,
and abuse including,but not limited to, HHS Circular C-027.
A report to the SAO must be made through one of the following avenues:
• SAO Toll Free Hotline: 1-800-TX-AUDIT
• SAO website: http://sao.fraud.state.tx.us/
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All reports made to the OIG must be made through one of the following avenues:
• OIG Toll Free Hotline 1-800-436-6184
• OIG Website: ReportTexasFraud.com
• Internal Affairs Email: InternalAffairsReferral@hhsc.state.tx.us
• OIG Hotline Email: OIGFraudHotline@hhsc.state.tx.us.
• OIG Mailing Address: Office of Inspector General
Attn: Fraud Hotline
MC 1300
P.O. Box 85200
Austin, Texas 78708-5200
29. Antitrust
The undersigned affirms under penalty of perjury of the laws of the State of Texas that:
A. in connection with this Contract and any related Solicitation Response,neither I nor
any representative of the Contractor has violated any provision of the Texas Free
Enterprise and Antitrust Act,Tex. Bus. & Comm. Code Chapter 15;
B. in connection with this Contract and any related Solicitation Response,neither I nor
any representative of the Contractor has violated any federal antitrust law; and
C. neither I nor any representative of the Contractor has directly or indirectly
communicated any of the contents of this Contract and any related Solicitation
Response to a competitor of the Contractor or any other company, corporation, firm,
partnership or individual engaged in the same line of business as the Contractor.
30. Legal and Regulatory Actions
Contractor represents and warrants that it is not aware of and has received no notice of
any court or governmental agency proceeding, investigation, or other action pending or
threatened against Contractor or any of the individuals or entities included in numbered
paragraph 1 of these Contract Affirmations within the five (5) calendar years immediately
preceding execution of this Contract or the submission of any related Solicitation
Response that would or could impair Contractor's performance under this Contract,relate
to the contracted or similar goods or services, or otherwise be relevant to System
Agency's consideration of entering into this Contract. If Contractor is unable to make the
preceding representation and warranty,then Contractor instead represents and warrants
that it has provided to System Agency a complete, detailed disclosure of any such court
or governmental agency proceeding, investigation, or other action that would or could
impair Contractor's performance under this Contract, relate to the contracted or similar
goods or services,or otherwise be relevant to System Agency's consideration of entering
into this Contract. In addition, Contractor acknowledges this is a continuing disclosure
requirement. Contractor represents and warrants that Contractor shall notify System
Agency in writing within five(5)business days of any changes to the representations or
warranties in this clause and understands that failure to so timely update System Agency
shall constitute breach of contract and may result in immediate contract termination.
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31. No Felony Criminal Convictions
Contractor represents that neither Contractor nor any of its employees, agents, or
representatives, including any subcontractors and employees, agents,or representative of
such subcontractors,have been convicted of a felony criminal offense or that if such a
conviction has occurred Contractor has fully advised System Agency in writing of the
facts and circumstances surrounding the convictions.
32. Unfair Business Practices
Contractor represents and warrants that it has not been the subject of allegations of
Deceptive Trade Practices violations under Chapter 17 of the Texas Business and
Commerce Code, or allegations of any unfair business practice in any administrative
hearing or court suit and that Contractor has not been found to be liable for such practices
in such proceedings. Contractor certifies that it has no officers who have served as
officers of other entities who have been the subject of allegations of Deceptive Trade
Practices violations or allegations of any unfair business practices in an administrative
hearing or court suit and that such officers have not been found to be liable for such
practices in such proceedings.
33. Entities that Boycott Israel
Contractor represents and warrants that(1)it does not, and shall not for the duration of
the Contract,boycott Israel or(2)the verification required by Section 2271.002 of the
Texas Government Code does not apply to the Contract. If circumstances relevant to this
provision change during the course of the Contract, Contractor shall promptly notify
System Agency.
34. E-Verify
Contractor certifies that for contracts for services, Contractor shall utilize the U.S.
Department of Homeland Security's E-Verify system during the term of this Contract to
determine the eligibility of:
1. all persons employed by Contractor to perform duties within Texas; and
2. all persons, including subcontractors, assigned by Contractor to perform work
pursuant to this Contract within the United States of America.
35. Former Agency Employees—Certain Contracts
If this Contract is an employment contract, a professional services contract under Chapter
2254 of the Texas Government Code, or a consulting services contract under Chapter
2254 of the Texas Government Code, in accordance with Section 2252.901 of the Texas
Government Code, Contractor represents and warrants that neither Contractor nor any of
Contractor's employees including, but not limited to,those authorized to provide services
under the Contract,were former employees of an HHS Agency during the twelve(12)
month period immediately prior to the date of the execution of the Contract.
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36. Disclosure of Prior State Employment—Consulting Services
If this Contract is for consulting services,
A. In accordance with Section 2254.033 of the Texas Government Code, a Contractor
providing consulting services who has been employed by, or employs an individual
who has been employed by, System Agency or another State of Texas agency at any
time during the two years preceding the submission of Contractor's offer to provide
services must disclose the following information in its offer to provide services.
Contractor hereby certifies that this information was provided and remains true,
correct, and complete:
1. Name of individual(s)(Contractor or employee(s));
2. Status;
3. The nature of the previous employment with HHSC or the other State of Texas
agency;
4. The date the employment was terminated and the reason for the termination; and
5. The annual rate of compensation for the employment at the time of its
termination.
B. If no information was provided in response to Section A above, Contractor certifies
that neither Contractor nor any individual employed by Contractor was employed by
System Agency or any other State of Texas agency at any time during the two years
preceding the submission of Contractor's offer to provide services.
37. Abortion Funding Limitation
Contractor understands, acknowledges, and agrees that,pursuant to Article IX of the
General Appropriations Act(the Act), to the extent allowed by federal and state law,
money appropriated by the Texas Legislature may not be distributed to any individual or
entity that, during the period for which funds are appropriated under the Act:
1. performs an abortion procedure that is not reimbursable under the state's Medicaid
program;
2. is commonly owned, managed, or controlled by an entity that performs an abortion
procedure that is not reimbursable under the state's Medicaid program; or
3. is a franchise or affiliate of an entity that performs an abortion procedure that is not
reimbursable under the state's Medicaid program.
The provision does not apply to a hospital licensed under Chapter 241, Health and Safety
Code, or an office exempt under Section 245.004(a)(2), Health and Safety Code.
Contractor represents and warrants that it is not ineligible, nor will it be ineligible during
the term of this Contract, to receive appropriated funding pursuant to Article IX.
38. Funding Eligibility
Contractor understands, acknowledges, and agrees that,pursuant to Chapter 2273 of the
Texas Government Code, except as exempted under that Chapter,HHSC cannot(1)
contract with(a) an abortion provider or an affiliate of an abortion provider; or(b) an
abortion assistance entity for the purpose of providing an abortion or abortion assistance;
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or(2)contract or appropriate or spend money to provide any person logistical support for
the express purpose of assisting a woman with procuring an abortion or the services of an
abortion provider. Respondent certifies that it is not ineligible to contract with System
Agency under the terms of Chapter 2273 of the Texas Government Code and certifies
that the contract is not a taxpayer resource transaction, appropriation, or expenditure of
money prohibited by Chapter 2273 of the Texas Government Code.
39. Gender Transitioning and Gender Reassignment Procedures and Treatments for
Certain Children—Prohibited Use of Public Money; Prohibited State Health Plan
Reimbursement.
Contractor understands, acknowledges, and agrees that,pursuant to Section 161.704 of
the Texas Health and Safety Code(eff. Sept. 1, 2023),public money may not directly or
indirectly be used, granted,paid, or distributed to any health care provider, medical
school,hospital, physician, or any other entity, organization, or individual that provides
or facilitates the provision of a procedure or treatment to a child that is prohibited under
Section 161.702 of the Texas Health and Safety Code. Contractor also understands,
acknowledges, and agrees that, pursuant to Section 161.705 of the Texas Health and
Safety Code (eff. Sept. 1, 2023), HHSC may not provide Medicaid reimbursement and
the child health plan program established under Chapter 62 may not provide
reimbursement to a physician or health care provider for provision of a procedure or
treatment to a child that is prohibited under Section 161.702 of the Texas Health and
Safety Code. Contractor certifies that it is not ineligible to contract with System Agency
under the terms of Chapter 161, Subchapter Y, of the Texas Health and Safety Code.
40. Prohibition on Certain Telecommunications and Video Surveillance Services or
Equipment(2 CFR 200.216)
Contractor certifies that the individual or business entity named in this Response or
Contract is not ineligible to receive the specified Contract or funding pursuant to 2 CFR
200.216.
41. COVID-19 Vaccine Passports
Pursuant to Texas Health and Safety Code, Section 161.0085(c), Contractor certifies that
it does not require its customers to provide any documentation certifying the customer's
COVID-19 vaccination or post-transmission recovery on entry to,to gain access to, or to
receive service from the Contractor's business. Contractor acknowledges that such a
vaccine or recovery requirement would make Contractor ineligible for a state-funded
contract.
42. Entities that Boycott Energy Companies
Pursuant to Section 2276.002 of the Texas Government Code (relating to prohibition on
contracts with companies boycotting certain energy companies), Contractor represents
and warrants that: (1) it does not, and will not for the duration of the Contract,boycott
energy companies or(2) the verification required by Section 2276.002 of the Texas
Government Code does not apply to the Contract. If circumstances relevant to this
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provision change during the course of the Contract, Contractor shall promptly notify
System Agency.
43. Entities that Discriminate Against Firearm and Ammunition Industries
In accordance with Senate Bill 19, Acts 2021, 87th Leg., R.S.,pursuant to Section
2274.002 of the Texas Government Code (relating to prohibition on contracts with
companies that discriminate against firearm and ammunition industries), Contractor
verifies that: (1) it does not, and will not for the duration of the Contract,have a practice,
policy, guidance, or directive that discriminates against a firearm entity or firearm trade
association or(2)the verification required by Section 2274.002 of the Texas Government
Code does not apply to the Contract. If circumstances relevant to this provision change
during the course of the Contract, Contractor shall promptly notify System Agency.
44. Security Controls for State Agency Data
In accordance with Senate Bill 475,Acts 2021, 87th Leg.,R.S., pursuant to Texas
Government Code, Section 2054.138, Contractor understands, acknowledges, and agrees
that if,pursuant to this Contract, Contractor is or will be authorized to access, transmit,
use, or store data for System Agency, Contractor is required to meet the security controls
the System Agency determines are proportionate with System Agency's risk under the
Contract based on the sensitivity of System Agency's data and that Contractor must
periodically provide to System Agency evidence that Contractor meets the security
controls required under the Contract.
45. Cloud Computing State Risk and Authorization Management Program (TX-RAMP)
Pursuant to Texas Government Code, Section 2063.408, Contractor acknowledges and
agrees that, if providing cloud computing services for System Agency, Contractor must
comply with the requirements of the state risk and authorization management program
and that System Agency may not enter or renew a contract with Contractor to purchase
cloud computing services for the agency that are subject to the state risk and
authorization management program unless Contractor demonstrates compliance with
program requirements. If providing cloud computing services for System Agency that are
subject to the state risk and authorization management program, Contractor certifies it
will maintain program compliance and certification throughout the term of the Contract.
46. Contract for Professional Services of Physicians,Optometrists, and Registered
Nurses
In accordance with Senate Bill 799,Acts 2021, 87th Leg., R.S., if Texas Government
Code, Section 2254.008(a)(2)is applicable to this Contract, Contractor affirms that it
possesses the necessary occupational licenses and experience.
47. Foreign-Owned Companies in Connection with Critical Infrastructure
If Texas Government Code, Section 2275.0102(a)(1) (relating to prohibition on contracts
with certain foreign-owned companies in connection with critical infrastructure) is
applicable to this Contract,pursuant to Government Code Section 2275.0102, Contractor
certifies that neither it nor its parent company, nor any affiliate of Contractor or its parent
company, is: (1) majority owned or controlled by citizens or governmental entities of
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China, Iran,North Korea, Russia, or any other country designated by the Governor under
Government Code Section 2275.0103 or(2)headquartered in any of those countries.
48. Critical Infrastructure Subcontracts
For purposes of this Paragraph, the designated countries are China, Iran,North Korea,
Russia, and any countries lawfully designated by the Governor as a threat to critical
infrastructure. Pursuant to Section 117.002 of the Business and Commerce Code,
Contractor shall not enter into a subcontract that will provide direct or remote access to or
control of critical infrastructure, as defined by Section 117.001 of the Texas Business and
Commerce Code, in this state, other than access specifically allowed for product warranty
and support purposes to any subcontractor unless (i)neither the subcontractor nor its
parent company,nor any affiliate of the subcontractor or its parent company, is majority
owned or controlled by citizens or governmental entities of a designated country; and (ii)
neither the subcontractor nor its parent company, nor any affiliate of the subcontractor or
its parent company, is headquartered in a designated country. Contractor will notify the
System Agency before entering into any subcontract that will provide direct or remote
access to or control of critical infrastructure, as defined by Section 117.001 of the Texas
Business & Commerce Code, in this state.
49. Enforcement of Certain Federal Firearms Laws Prohibited
In accordance with House Bill 957, Acts 2021, 87th Leg., R.S., if Texas Government
Code, Section 2.101 is applicable to Contractor, Contractor certifies that it is not
ineligible to receive state grant funds pursuant to Texas Government Code, Section
2.103.
50. Prohibition on Abortions
Contractor understands, acknowledges, and agrees that,pursuant to Article II of the
General Appropriations Act, (1)no funds shall be used to pay the direct or indirect costs
(including marketing, overhead,rent,phones, and utilities) of abortion procedures
provided by contractors of HHSC; and(2)no funds appropriated for Medicaid Family
Planning, Healthy Texas Women Program, or the Family Planning Program shall be
distributed to individuals or entities that perform elective abortion procedures or that
contract with or provide funds to individuals or entities for the performance of elective
abortion procedures. Contractor represents and warrants that it is not ineligible, nor will it
be ineligible during the term of this Contract, to receive appropriated funding pursuant to
Article II.
51. Hardening of State Government
Pursuant to Executive Order GA-48, relating to hardening of state government, issued
November 19,2024, Contractor certifies it is not and, if applicable, any of its holding
companies or subsidiaries is not:
a. Listed in Section 889 of the 2019 National Defense Authorization Act(NDAA);
or
b. Listed in Section 1260H of the 2021 NDAA; or
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C. Owned by the government of a country on the U.S. Department of Commerce's
foreign adversaries list under 15 C.F.R. § 791.4; or
d. Controlled by any governing or regulatory body located in a country on the U.S.
Department of Commerce's foreign adversaries list under 15 C.F.R. § 791.4.
52. Artificial Intelligence Disclosure.
Contractor certifies that it has disclosed in writing to System Agency each artificial
intelligence system it may use to complete any deliverable or a portion of any deliverable
under the Contract. "Artificial intelligence system"means a machine-based system that
for explicit or implicit objectives infers from provided information a method to generate
outputs, such as predictions, content,recommendations, or decisions, to influence a
physical or virtual environment with varying levels of autonomy and adaptiveness after
deployment. Contractor promises not to use an artificial intelligence system to perform
the Contract without the prior written consent of System Agency.
53. Surveillance,Intimidation, and Related Acts.
Contractor certifies that it(and its subcontractors)have not, and if awarded a contract,
will not, either directly or indirectly through a third party, engage in surveillance
targeting or engage in an act of intimidation, coercion, extortion, undue influence, or
other similar conduct intended to influence, silence, or retaliate against:
(1) a member of the state legislature or person employed to support the state
legislature in any capacity;
(2) a family member of a person described by(1);
(3) a state agency employee; or
(4) an individual making a complaint or raising concerns regarding state
agency operations or contracting.
Contractor certifies that it and its subcontractors have not, and if awarded a contract will
not, either directly or indirectly through a third party,use private or confidential
information to manipulate or influence a state contracting decision or proceeding.
Contractor acknowledges that it, its executives and directors, and other associated entities
and individuals could be terminated,barred from state contracts, and penalized up to $2
million for a violation of Government Code, Section 2261.302.
54. False Representation
Contractor understands, acknowledges, and agrees that any false representation or any
failure to comply with a representation,warranty, or certification made by Contractor is
subject to all civil and criminal consequences provided at law or in equity including,but
not limited to, immediate termination of this Contract.
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55. False Statements
Contractor represents and warrants that all statements and information prepared and
submitted by Contractor in this Contract and any related Solicitation Response are
current, complete,true, and accurate. Contractor acknowledges any false statement or
material misrepresentation made by Contractor during the performance of this Contract
or any related Solicitation is a material breach of contract and may void this Contract.
Further, Contractor understands, acknowledges, and agrees that any false representation
or any failure to comply with a representation,warranty, or certification made by
Contractor is subject to all civil and criminal consequences provided at law or in equity
including, but not limited to, immediate termination of this Contract.
56. Permits and License
Contractor represents and warrants that it will comply with all applicable laws and
maintain all permits and licenses required by applicable city, county, state, and federal
rules, regulations, statutes, codes, and other laws that pertain to this Contract.
57. Equal Employment Opportunity
Contractor represents and warrants its compliance with all applicable duly enacted state
and federal laws governing equal employment opportunities.
58. Federal Occupational Safety and Health Law
Contractor represents and warrants that all articles and services shall meet or exceed the
safety standards established and promulgated under the Federal Occupational Safety and
Health Act of 1970, as amended(29 U.S.C. Chapter 15).
59. Signature Authority
Contractor represents and warrants that the individual signing this Contract Affirmations
document is authorized to sign on behalf of Contractor and to bind the Contractor.
Signature Page Follows
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Authorized representative on behalf of Contractor must complete and sign the following:
Legal Name of Contractor
Assumed Business Name of Contractor,if applicable(d/b/a or `doing business as')
Texas County(s)for Assumed Business Name(d/b/a or `doing business as')
Attach Assumed Name Certificate(s)filed with the Texas Secretary of State and Assumed
Name Certificate(s),if any, for each Texas County Where Assumed Name Certificate(s) has
been filed.
Signature of Authorized Representative Date Signed
Printed Name of Authorized Representative Title of Authorized Representative
First, Middle Name or Initial, and Last Name
Physical Street Address City, State, Zip Code
Mailing Address,if different City, State, Zip Code
Phone Number Fax Number
Email Address DUNS Number
Federal Employer Identification Number Texas Identification Number(TIN)
Texas Franchise Tax Number Texas Secretary of State Filing
Number
SAM.gov Unique Entity Identifier(UEI)
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e' '��� TEXAS
'*,�, Texas Department of State
� HealthandHuman
��: ' Services Health Services
Attachment I-1
Fiscal Federal Funding Accountability and
Transparency Act (FFATA)
The certifications enumerated below represent material facts upon which DSHS relies when
reporting information to the federal government required under federal law. If the Department
later determines that the Contractor knowingly rendered an erroneous certification, DSHS may
pursue all available remedies in accordance with Texas and U.S. law. Signor further agrees that
it will provide immediate written notice to DSHS if at any time Signor learns that any of the
certifications provided for below were erroneous when submitted or have since become
erroneous by reason of changed circumstances. If the Signor cannot certify all of the
statements contained in this section, Signor must provide written notice to DSHS
detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: FFATA Contact: (Name, Email and Phone Number):
Primary Address of Contractor: Zip Code: 9-digits required www.usas.com
Unique Entity ID (UEI): This number replaces the DUNS State of Texas Comptroller Vendor Identification Number
www.sam.gov (VIN) - 14 digits:
Printed Name of Authorized Representative: Signature of Authorized Representative
Title of Authorized Representative Date Signed
1
Department of State Health Services Form 4734—April 2022
Contract Management Section
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Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative (Signor) of the Contractor, I hereby certify that the
statements made by me in this certification form are true, complete, and correct to the best of
my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax
year? Yes No
If your answer is "Yes", skip questions "A", "B", and "C" and finish the certification. If your answer is "No",
answer questions "A" and "B".
A. Certification Regarding % of Annual Gross from Federal Awards.
Did your organization receive 80% or more of its annual gross revenue from federal awards during the
preceding fiscal year? Yes E No
B. Certification Regarding Amount of Annual Gross from Federal Awards.
Did your organization receive $25 million or more in annual gross revenues from federal awards in the
preceding fiscal year? Yes No pi
If your answer is "Yes" to both question "A" and "B", you must answer question "C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the certification.
C. Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the senior executives in your
business or organization (including parent organization, all branches, and all affiliates worldwide) through
periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C.
78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Yes No
If your answer is "Yes" to this question, where can this information be accessed?
If your answer is "No" to this question, you must provide the names and total compensation of
the top five highly compensated officers below.
Provide compensation information here:
2
Department of State Health Services Form 4734-April 2022
Contract Management Section
0 docusign
Certificate Of Completion
Envelope Id:775C0A82-DA94-4727-AB84-BE5089F26816 Status:Sent
Subject:Please Docusign:HHS001564200001 FY27 HTB-Port Arthur Al.pdf
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Ronald Burton Sent: 1/9/2026 4 29 01 PM
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Judith A.Smith COPIED Sent: 1/9/2026 4:29:00 PM
judith.smith@portarthurtx.gov Viewed: 1/12/2026 9:38:38 AM
Director of Health Services
City of Port Arthur
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