HomeMy WebLinkAboutPR 24842: APPROVING CONTRACT AMENDMENT NO. 2 BETWEEN DEPARTMENT OF STATE HEALTH SERVICES AND COPA TO RECEIVE GRANT FUNDS TO EXTEND THE HEART AND STROKE PREVENTION PROGRAM City of%
ort rthu�
Texas
www.PortArthurTx.gov
INTEROFFICE MEMORANDUM
Date: April 21, 2026
To: The Honorable Mayor and City Council
Through: Ron Burton, CPM, City Manager
From: (Judith Smith, Director of Health Services)
RE: (P. R# 24842 )Authorization to approve Contract Amendment No. 2 between the
Department of State Health Services and the City of Port Arthur to receive grant funds
to extend the Heart and Stroke Prevention Program. No City Match required.
Introduction:
The intent of this Agenda Item is to seek the City Council's approval to amend the Contract
Agreement between the Department of State Health Services and the City of Port Arthur to extend the
Heart and Stroke Innovative Program.
Background: The Department of State Health Services received funding for local health departments
with communities at high risk for heart disease and strokes. The health department applied for grant
funds and received funding to set up a program to help the community focus on preventive measures
related to heart disease and strokes.
Budget Impact: Council approved the Grant Agreement per Res.No. 24-252 on 06/04/2024 for a total
not to exceed $170,000, and approved Res. No. 25-265 on 06/17/2025 for a total not to exceed
265,000, now the Department of State Health Services is amending the contract and adding $96,000
for FY 2027. The total grant award will not exceed $361,000, with$96,000 being awarded for FY
2027. The Grant will expire August 31, 2027.No city match is required.
"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
Recommendation:
It is recommended that the City Council approve P.R. No.24842, Contract Amendment No. 2 between
the Department of State Health Services and the City of Port Arthur to extend the Heart and Stroke
Prevention Innovative Program.
"Remember. He are here to sere the(
P.O.Box 1089 X Port Arthur.Texas 77641-1089 X 409.983.8101 X FAX 409,982.6743
P.R. No. 24842
04/21/2026-js
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER
TO EXECUTE CONTRACT AMENDMENT NO.
2 BETWEEN THE DEPARTMENT OF STATE
HEALTH SERVICES AND THE CITY OF PORT
ARTHUR TO CONTINUE THE HEART AND STROKE
PREVENTION INNOVATIVE PROGRAM BY REVISING
THE CONTRACT TERMINATION DATE TO AUGUST
31, 2027, AND INCLUDING AN ADDITIONAL
FUNDING AWARD OF $96,000.00 FOR FY 2027, FOR A
TOTAL GRANT AWARD NOT TO EXCEED $361,000.00,
WITH NO CITY MATCH REQUIRED.
WHEREAS, the Department of State Health Services provides financial assistance to the
City of Port Arthur to support and supplement the delivery of public health services. This grant has
enabled the Port Arthur Health Department to implement a Heart and Stroke prevention program
and engage in activities aimed at high-risk populations for heart disease and strokes; and,
WHEREAS, pursuant to Resolution 24-252, the Council approved the grant agreement
with the Department of State Health Services for the implementation of a Heart and Stroke
Prevention Innovative Program, and pursuant to Resolution 25-265, the Council approved
Amendment No. 1 extending the contract to August 31, 2026; and,
WHEREAS, the Department of State Health Services has issued Amendment No. 2
Extension,which modifies the contract to allocate an additional$96,000.00 for the fiscal year 2027,
resulting in a total not to exceed $361,000.00, with no matching funds required and extends the
contract terminate date to August 31, 2027.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF PORT
ARTHUR, TEXAS:
SECTION 1. That the facts and preamble are true and correct.
P.R. No. 24842
04/21/2026-js
SECTION 2. That the City Council of the City of Port Arthur hereby authorizes the City
Manager and Director of Health Services to execute said amended agreement, in substantially the
same from, attached hereto as Exhibit"A".
SECTION 3. 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 May A.D., 2026, at a
Regular Meeting of the City Council of the City of Port Arthur, Texas, by the following vote:
AYES:
•
Mayor:
Councilmembers:
•
NOES:
CITY OF PORT ARTHUR:
Charlotte M. Moses, Mayor
ATTEST:
Sherri Bellard,
City Secretary
APPROVED AS TO FORM:
Roxann Pais Cotroneo,
City Attorney
P.R. No. 24842
04/21/2026-js
APPROVE FOR A ILI 1 FUNDS:
�� 1r
Lynda oswell, M.A., ICMA-CM
Director of Finance
APPROVE OR ADMINISTRATION:
Ronald Burto , C M
City Man r
Autt
JuceA. Smith,RN, BSN
Director of Health Services
P.R. No. 24842
04/21/2026-js
EXHIBIT "A"
(Contract Amendment No. 2)
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT No.HHS001446300004
AMENDMENT No.2
EXTENSION
The DEPARTMENT OF STATE HEALTH SERVICES("System Agency" or"DSHS") and THE CITY
OF PORT ARTHUR ("Grantee"), who are collectively referred to herein as the "Parties," to that
certain Heart Disease and Stroke Prevention Innovation Program Contract effective June 17,2024
and denominated DSHS Contract No. HHS001446300004 ("Contract"or"Grant Agreement"), as
amended, now desire to further amend the Contract.
WHEREAS, System Agency desires to exercise its option to extend the term of the Contract for
an additional one-year period;
WHEREAS, System Agency desires to add funds to the Contract for authorized services to be
provided by Grantee in State Fiscal Year("FY") 2027 and revise the Budget accordingly;
WHEREAS,the Parties desire to supplement the Statement of Work for FY 2027;
WHEREAS,the Parties desire to update certain Contract terms and conditions; and
WHEREAS, the Parties desire to update the Fiscal Federal Funding Accountability and
Transparency Act(FFATA) Certification Form.
Now,THEREFORE, the Parties hereby amend and modify the Contract as follows:
1. SECTION III of the Contract, DURATION, is hereby amended to reflect a revised
termination date of August 31,2027.
2. SECTION V of the Contract, BUDGET AND INDIRECT COST RATE, is hereby amended to
add funding in the amount of$96,000.00 for authorized services to be provided by Grantee
in FY 2027. The section is revised to read as follows:
The total amount of this Grant Agreement will not exceed THREE HUNDRED SIXTY-
ONE THOUSAND DOLLARS ($361,000.00). Grantee is not required to provide
matching funds.
The total not-to-exceed amount includes the following:
Total Federal Funds: $361,000.00
Total State Funds: $0.00
All expenditures under the Grant Agreement will be in accordance with
ATTACHMENT B-2,FY2027 BUDGET.
1
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
If the System Agency approves or acknowledges an updated indirect cost rate, the
Grant Agreement will be amended to incorporate an updated rate (and the new
indirect cost rate letter, if applicable) and the budget revised accordingly.
3. SECTION VI of the Contract, REPORTING REQUIREMENTS, is revised to read as follows:
Grantee shall submit reports in accordance with the requirements and reporting
schedules of the applicable State Fiscal Year Statement of Work attachment and in
compliance with all other applicable terms and conditions of the Grant Agreement. All
invoices and reporting requirements survive the expiration or termination of this Grant
Agreement.
4. ATTACHMENT A-1 of the Contract, FY2026 STATEMENT OF WORK, is hereby
supplemented with the addition of ATTACHMENT A-2, FY2027 STATEMENT OF WORK
for Grantee FY 2027 services,which is attached to this Amendment and incorporated into
and made part of the Contract for all purposes.
5. ATTACHMENT B-1 of the Contract, REVISED BUDGET, is hereby deleted in its entirety
and replaced with ATTACHMENT B-2, FY2027 BUDGET, which is attached to this
Amendment and incorporated into and made part of the Contract for all purposes.
6. ATTACHMENT C-1 of the Contract, HHS CONTRACT AFFIRMATIONS V. 2.5, is hereby
deleted in its entirety and replaced with ATTACHMENT C-2,CONTRACT AFFIRMATIONS
V. 2.9, which is attached to this Amendment to be completed by Grantee, after which it
will be incorporated into and made part of the Contract for all purposes.
7. ATTACHMENT H-1 of the Contract, FFATA CERTIFICATION FORM, is hereby
supplemented with the addition of ATTACHMENT H-2,FFATA CERTIFICATION FORM,
which is attached to this Amendment to be completed by Grantee, after which it will be
incorporated and made part of the Contract for all purposes.
8. This Amendment No. 2 shall be effective as of the date last signed below. Operations and
funding for State Fiscal Year 2027 begin September 1, 2026.
9. Except as amended and modified by this Amendment No. 2, all terms and conditions of
the Contract, as amended, 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 on its behalf
has full power and authority to enter into this Amendment.
SIGNATURE PAGE FOLLOWS
2
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
SIGNATURE PAGE FOR AMENDMENT No.2
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT No.HHS001446300004
DEPARTMENT OF STATE HEALTH SERVICES THE CITY OF PORT ARTHUR
By: By:
Name: Name:
Title: Title:
Date of Signature: Date of Signature:
THE FOLLOWING ATTACHMENTS ARE ATTACHED AND INCORPORATED AS PART OF THE
CONTRACT:
ATTACHMENT A-2 FY2027 STATEMENT OF WORK
ATTACHMENT B-2 FY2027 BUDGET
ATTACHMENT C-2 CONTRACT AFFIRMATIONS V.2.9
ATTACHMENT H-2 FFATA CERTIFICATION FORM
3
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
ATTACHMENT A-2
FY2027 STATEMENT OF WORK
I. GRANTEE RESPONSIBILITIES
A. Grantee will ensure the following activities are completed.Develop and implement a work
plan that addresses and accomplishes activities as outlined below.
1. Health systems with executed memorandums of agreement (MOAs) or equivalent
forms of documentation identified by the University of Texas Health Science Center
at Houston and serve the populations of focus within Jefferson County by conducting
the following:
a. Evaluate and improve the plan to create and recruit partners for the
multidisciplinary care coordinated network in collaboration with the Texas
Cardiovascular Disease Learning Collaborative (LC) with the use of the
Community Health Assessment (CHA) reports and patient feedback gathered
by the grantee and UTHealth Houston, using the PCH Institute Model as a
potential framework.
b. The coordinated network shall continue to monitor and expand the database of
community-based resources developed from Community Health Assessment
(CHA)data to address social supports and services of the populations of focus
and use data collected on usage of the database from Y3 to inform evaluation
of the database and employment of Plan-Do-Study-
Act (PDSA) quality improvement measurements as necessary with feedback
from the LC.
c. Utilize data collected to evaluate the coordinated networks on the social
supports and services of the populations of focus to identify and recruit
partners that address the social needs and social supports of populations of
focus. Sustain the database of community-based resources and partners and
develop communication strategies to increase community awareness of
available resources.
2. Continue to address gaps in community-clinical linkages that address populations of
focus' social supports and services by conducting the following:
a. Evaluate and refine the implementation plan to connect populations of focus
to identified lifestyle change programs (LCPs) for hypertension and/or high
blood cholesterol through bi-directional/multi-directional referral systems and
coordination of efforts among local health departments and academic
stakeholders.
b. Strengthen coordination and communication with referral system partners to
connect populations of focus to LCPs and the effectiveness of LCPs to address
hypertension and/or high blood cholesterol in populations of focus by
expanding outreach and developing strategies to sustain referrals and
enrollment in LCPs.
c. Update and maintain referral systems and coordination of efforts based on
feedback and findings.
4
Docusign Envelope ID:BFF14C16-0FCD-4OEB-BAE8-95D6C3AD19F0
3. Health systems with executed memorandums of agreement (MOAs) or equivalent
forms of documentation identified by the University of Texas Health Science Center
at Houston and serve the populations of focus within Jefferson County by conducting
community asset mapping of self-measure blood pressure (SMBP) monitoring and
clinical support resources and programs by conducting the following:
a. Evaluate the implementation plan to connect the populations of focus to SMBP
monitoring programs with the use of clinical support resources with existing
healthcare providers or create new SMBP monitoring programs at clinical sites
that serve the populations of focus.
b. Collect and monitor data to track progress,participation in SMBP monitoring
programs,address any challenges, and provide ongoing technical assistance to
evaluate and improve the implementation plan.
c. Enhance and update the SMBP programs based on results of monitoring
utilizing partner feedback and identify opportunities for expansion, address
identified gaps and develop sustainability strategies for ongoing community
and clinical support.
B. Additional Requirements:
1. Participate in, at minimum,monthly conference calls with Texas Department of State
Health Services (DSHS) staff to provide updates on activities and technical assistance
related to heart disease and stroke.
2. Participate in the Texas Cardiovascular Disease Learning Collaborative.
3. Participate in partner meetings.
4. Submit to DSHS for feedback and approval, prior to dissemination, all publications,
resources, and data collection tools (e.g., surveys) created for this project.
5. Submit written progress reports that provide updates for activities and the short-term
and intermediate measures using templates developed by DSHS. Reports shall be
submitted to cardio@dshs.texas.gov on required dates.
a. Progress reports shall be submitted in accordance with the reporting periods
in the table below.
Deliverables Reporting Period FY26 Due Dates
1. Progress Report IV
2. Performance Measures July 1, 2026—September 29, October 6, 2026
Report IV 2026
Deliverables Reporting Period FY27 Due Dates
Updates to Sustainability
September 30, 2026
Plan
1. Progress Report I October 1, 2026— January 7, 2027
2. Performance Measures December 31,2026
5
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
Report I
1. Progress Report II January 1, 2027—
2. Performance March 31, 2027 April 7, 2027
Measures Report II
1. Progress Report III April 1,2027—
2. Performance June 30, 2027 July 7, 2027
Measures Re ort III
Work Plan Year 5 August 31, 2027
6. Submit the Financial Status Report(FSR-269A)biannually as outlined below. Grantee
shall email the Financial Status Report(FSR-269A)to the following email address
FSRgrantsAdshs.texas.gov.
Period Covered Due Date
September 1, 2026—February 28, 2027 March 31, 2027
March 1, 2027—August 31, 2027 September 29, 2027
7. Maintain an inventory of equipment, supplies defined as Controlled Assets, and real
property. Submit an annual cumulative report of the equipment and other property on
HHS System Agency Grantee's Property Inventory Report to the designated DSHS
Contract Manager and fsoequip@dshs.texas.gov by email not later than October 15 of
each year. Controlled Assets include firearms, regardless of the acquisition cost, and
the following assets with an acquisition cost of $500.00 or more, but less than
$5,000.00: desktop and laptop computers (including notebooks, tablets and similar
devices), non-portable printers and copiers, emergency management equipment,
communication devices and systems, medical and laboratory equipment, and media
equipment. Controlled Assets are considered Supplies.
8. Provide written notification of budget transfers by submission of a revised Categorical
Budget Form to the designated DSHS Contract Manager, highlighting the areas
affected by the budget transfer. Grantee is advised as follows:
a. Transferring funds between budget categories, other than the equipment and
indirect cost categories, is allowable, but cannot exceed 25% of the total
Contract value during a Contract budget period. If the budget transfer(s)
exceeds 25% of the total Contract value, alone or cumulatively, a formal
Contract amendment is required; and
b. After review, the designated DSHS Contract Manager shall provide
notification of acceptance to Grantee via email, upon receipt of which, the
revised budget shall be incorporated into the Contract if amendment is not
required. Otherwise, the revised funding allocation is not effective until an
amendment incorporating the changes is executed.
6
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
ATTACHMENT B-2
FY2027 BUDGET
CATEGORIES FY24 FY25 FY26 FY27 TOTAL
PERSONNEL $0.00 $0.00 $0.00 $0.00 $0.00
FRINGE BENEFITS $0.00 $0.00 $0.00 $0.00 $0.00
TRAVEL $0.00 $0.00 $0.00 $0.00 $0.00
EQUIPMENT $0.00 $0.00 $0.00 $0.00 $0.00
SUPPLIES $33,300.00 $11,470.00 $946.00 $219.00 $45,935.00
CONTRACTUAL $46,700.00 $69,780.00 $92,804.00 $95,781.00 $305,065.00
OTHER $5,000.00 $3,750.00 $1,250.00 $0.00 $10,000.00
TOTAL DIRECT $85,000.00 $85,000.00 $95,000.00 $96,000.00 $361,000.00
COSTS
INDIRECT COSTS $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL $85,000.00 $85,000.00 $95,000.00 $96,000.00 $361,000.00
7
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
HEALTH AND HUMAN SERVICES
Contract Number HHS001446300004
Attachment C-2 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.2.9
Effective March 2026
Page 1 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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.2.9
Effective March 2026
Page 2 of 14
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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(0.
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 3 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 4 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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/
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 5 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 6 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 7 of 14
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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;
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 8 of 14
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 9 of 14
Docusign Envelope ID: BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 10 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 11 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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 a continuing obligation to disclose 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 certifies that it is in compliance
with all applicable laws and regulations regarding the use of artificial intelligence
systems.
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 12 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 13 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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)
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 14 of 14
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
TEXAS
Health and Human Texas Department of State
-4 — Services I Health Services
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.usos.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
Docusign Envelope ID:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0
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 or anization have a gross income, from all sources, of less than $300,000 in your previous tax
year? Yes I1 No n
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 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 n
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:BFF14C16-0FCD-40EB-BAE8-95D6C3AD19F0 Status:Sent
Subject:Please Docusign:HHS001446300004 CoPA HDSP INV A2.pdf
Source Envelope:
Document Pages:23 Signatures:0 Envelope Originator:
Certificate Pages:2 Initials:0 CMS Internal Routing Mailbox
AutoNav:Enabled 11493 Sunset Hills Road
Envelopeld Stamping:Enabled #100
Time Zone:(UTC-06:00)Central Time(US&Canada) Reston,VA 20190
CMS.InternalRouting@dshs.texas.gov
IP Address: 167.137.1.7
Record Tracking
Status:Original Holder:CMS Internal Routing Mailbox Location:DocuSign
4/16/2026 9:03:29 AM CMS.InternalRouting@dshs.texas.gov
Signer Events Signature Timestamp
Ron Burton Sent:4/16/2026 9:11:13 AM
ron.burton@portarthurtx.gov
City Manager
City of Port Arthur
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Susana Garcia
Susana.Garcia@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Patty Melchior
Patty.Melchior@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Manda Hall
manda.hall@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Carbon Copy Events Status Timestamp
Judith A.Smith COPIED Sent:4/16/2026 9:11:12 AM
judith.smith@portarthurtx.gov Viewed:4/16/2026 9:18:11 AM
Director of Health Services
City of Port Arthur
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Matthew Welter
Matthew.Welter@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
CMS Internal Routing Mailbox
CMS.InternalRouting@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 4/16/2026 9:11:12 AM
Payment Events Status Timestamps