HomeMy WebLinkAboutPR 24990: AMENDMENT NO. 2 TO THE TUBERCULOSIS PREVENTION AND CONTROL er r -
( t.y Ci"
ort rthu
7ricr�
www.PortArthurTx.gov
INTEROFFICE MEMORANDUM
Date: May 29, 2026
To: The Honorable Mayor and City Council
Through: Ron Burton, CMP, City Manager
From: Judith A. Smith, RN, BSN, Director of Health Services
RE: Authorization to approve Amendment No. 2 of the State and Federal TB award
between The Department of State Health Services and the City of Port Arthur to
provide TB services in South Jefferson County. The Contract is effective on
September 1, 2026, through August 31, 2027. This Contract requires a 20%
Match.
Introduction:
The Texas Department of State Health Services (DSHS) has provided federal and state funding
to the City of Port Arthur since 2015 to support tuberculosis (TB) prevention and control
activities conducted by the Port Arthur Health Department. These funds assist the City in
providing essential TB screening, treatment, monitoring, outreach, and education services to
residents of South Jefferson County, including individuals and populations at increased risk of
developing tuberculosis.
The proposed Amendment No. 2 renews the existing Tuberculosis Prevention and Control
Contract for the period of September 1, 2026, through August 31, 2027. The amendment
provides funding in an amount not to exceed $64,217.00, consisting of a federal share of
$17,660.00 and a state share of $35,854.00. The City is required to provide a cash match of
$10,703.00, consisting of a federal match of$3,532.00 and a state match of$7,171.00.
Upon approval of Amendment No. 2, the cumulative contract amount between DSHS and the
City of Port Arthur will increase to an amount not to exceed $192,649.00. Funding provided
through this amendment will support a portion of personnel costs, travel expenses, and other
program-related expenditures necessary for the continued operation of the Tuberculosis
Prevention and Control Program.
Budget Impact: The total award will not exceed $192,649.00. The Federal award will not
exceed $21,192.00. The State award will not exceed $43,025.00. The combined total of the
City's cash match is $10,703.00.
Recommendation: It is recommended that the Council approve P.R. No. 24990, the contract
between the Department of State Health Services and the City of Port Arthur for TB services
for the period September 1, 2026, through August 31, 2027.
"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. 24990
05/29/2026-js-tnr
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE EXECUTION OF AMENDMENT
NO. 2 TO THE TUBERCULOSIS PREVENTION AND CONTROL
CONTRACT BETWEEN THE TEXAS DEPARTMENT OF STATE
HEALTH SERVICES AND THE CITY OF PORT ARTHUR; ACCEPTING
FEDERAL AND STATE FUNDING IN AN AMOUNT NOT TO EXCEED
$64,217.00; AUTHORIZING THE REQUIRED CITY MATCH IN THE
AMOUNT OF $10,703.00; STARTING SEPTEMBER 1, 2026, AND WILL
TERMINATE AUGUST 31, 2027. FUNDING IS AVAILABLE IN
ACCOUNT 101-23-061-5111-00-50-000 PROJECT HG27TB
WHEREAS, the Texas Department of State Health Services ("DSHS") has provided
federal and state funding to the City of Port Arthur since 2015 for the administration of
tuberculosis ("TB") prevention and control services, including outreach activities directed toward
individuals and populations at risk of developing tuberculosis; and
WHEREAS, the City of Port Arthur Health Department utilizes such funding to provide
essential TB prevention, screening, treatment, monitoring, education, and outreach services to
residents of South Jefferson County; and
WHEREAS, pursuant to Resolution No. 24-222, the City Council approved the original
contract between DSHS and the City of Port Arthur for the provision of tuberculosis prevention
and control services; and
WHEREAS, pursuant to Resolution No. 25-288, the City Council approved Amendment
No. 1 to said contract; and
WHEREAS, DSHS has offered Amendment No. 2 to the contract for the funding period
beginning September 1, 2026, and ending August 31, 2027, providing additional funding in an
amount not to exceed $64,217.00, consisting of:
• Federal funding in an amount not to exceed $17,660.00, requiring a City cash match of
$3,532.00, for a total federal program amount of$21,192.00; and
• State funding in an amount not to exceed $35,854.00, requiring a City cash match of
$7,171.00, for a total state program amount of$43,025.00; and
WHEREAS, the combined City cash match required under Amendment No. 2 is
$10,703.00; and
WHEREAS, the funding provided through Amendment No. 2 will support a portion of
personnel costs, travel expenses, and other program-related expenditures necessary to continue
P.R. No. 24990
05/29/2026-js-tnr
tuberculosis prevention and control services within the City of Port Arthur Health Department;
and
WHEREAS, the City Council finds that acceptance of Amendment No. 2 and the
associated funding is in the best interests of the citizens of Port Arthur and will enhance the
City's ability to protect public health and provide essential tuberculosis prevention and control
services.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF PORT ARTHUR,TEXAS:
Section 1. That the facts and opinions in the preamble are true and correct.
Section 2. The City Council hereby accepts and approves Amendment No. 2 to the
Tuberculosis Prevention and Control Contract between the Texas Department of State Health
Services and the City of Port Arthur for the contract period commencing September 1, 2026, and
terminating August 31, 2027, thereby increasing the total contract amount to an amount not to
exceed$192,649.00.
Section 3. The City Council hereby accepts federal and state funding under Amendment
No. 2 in an amount not to exceed $64,217.00, consisting of a federal share of$17,660.00, a state
share of$35,854.00, and authorizes the City's required cash match in the amount of$10,703.00.
Funding is available in Account 101-23-061-5111-00-50-000 PROJECT HG27TB.
Section 4. The City Council further authorizes the City Manager and the Director of
Health Services to execute Amendment No. 2 and any related documents necessary to carry out
the purposes of this Resolution, in substantially the same form as 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 A.D.,
at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the following
Vote: AYES: Mayor:
Councilmembers:
NOES:
P.R.No. 224990
05/29/2026-js
Charlotte M. Moses, Mayor
ATTEST:
Christe Whitley Ned, TRMC, City Secretary
APPROV •
t 7
Roxann Pais Cotroneo, City Attorney
APPROVED FO NISTRATION:
u d /t .Airnat
Ron Burton, CPM Judi A. Smith, RN,BSN
City Manager Director of Health Services
APPR I VED AS TO AVAILABILITY OF FUNDS:
dr4i1 tda AVZ7
yn:. Boswell, M.A., ICMA-CM
Director of Finance
EXHIBIT "A"
r
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT No. HHS001437400024
AMENDMENT NO. 2
The DEPARTMENT OF STATE HEALTH SERVICES ("System Agency" or "DSHS") and PORT
ARTHUR(CITY OF) HEALTH DEPARTMENT ("Grantee"), who are collectively referred to herein
as the "Parties," to that certain Contract to provide federal and state funding for Tuberculosis
Prevention and Control services, effective September 1, 2024, and denominated DSHS Contract
No. HHS001437400024("Contract"), as amended,now desire to further amend the Contract.
WHEREAS, DSHS desires to exercise its option to extend the Contract for an additional one-year
term for State Fiscal Year 2027, representing the second of four (4) one-year extension options
("Second Extension Period");
WHEREAS,DSHS desires to add funds to the Contract for the Second Extension Period and revise
the Budget accordingly;
WHEREAS, DSHS desires to update the Statement of Work to update the reporting requirements
and Contract Affirmations to comply with applicable law and DSHS policy; and
WHEREAS, Grantee agrees to complete the annual Fiscal Federal Funding Accountability and
Transparency Act("FFATA") Certification form.
Now,THEREFORE,the Parties amend and modify the Contract as follows:
1. ARTICLE III, CONTRACT PERIOD AND RENEWAL, of the Contract is amended to reflect an
expiration date of August 31, 2027.
2. ARTICLE IV,CONTRACT AMOUNT AND PAYMENT FOR SERVICES,of the Contract is amended
to add funding in the amount of$64,217.00 for the Second Extension Period.
3. ARTICLE V, CONTRACT AMOUNT AND PAYMENT FOR SERVICES, of the Contract is deleted
and replaced as follows:
V. CONTRACT AMOUNT AND PAYMENT FOR SERVICES
The total amount of this Contract will not exceed$192,649.00. The total for FY27 amount
includes the following:
a. Federal funds in the amount of$21,192.00,comprised of System Agency's Federal
share of$17,660.00 and Grantee's required Federal match amount of$3,532.00;
and
DSHS Contract No.HHS001437400024 Page 1 of 4
Amendment No.2
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
b. State funds in the amount of 43,025.00, comprised of System Agency's State share
of$35,854.00 and Grantee's required State match amount of$7,171.00.
All expenditures under the Contract shall be in accordance with ATTACHMENT B-2,FY27
REVISED BUDGET.
4. ARTICLE VI,ADDITIONAL GRANT INFORMATION, of the Contract is supplemented with the
updated grant information as follows:
Federal Award Identification Number(FAIN): NU52PS910284
A. Assistance Listings Title,Number,and Dollar Amount: Tuberculosis Elimination and
Laboratory Cooperative Agreement—Prevention& Control, 93.116, $7,646,132.00
B. Federal Award Date: 08/18/2025
C. Federal Award Period: 01/01/2025 — 12/31/2029
D. Name of Federal Awarding Agency: Centers for Disease Control and Prevention
E. Federal Award Project Description: Tuberculosis Elimination and Laboratory
Cooperative Agreement—Prevention and Control
F. Awarding Official Contact Information: Mrs. Shanica Railey
G. Total Amount of Federal Funds Awarded to System Agency: $7,646,132.00
H. Amount of Funds Awarded to Grantee: $80,910.00
I. Identification of Whether the Award is for Research and Development: No
5. ATTACHMENT A-1,FY26 STATEMENT OF WORK,of the Contract is deleted in its entirety and
replaced with ATTACHMENT A-2, REVISED STATEMENT OF WORK(FY25-FY27), which is
attached to this Amendment and incorporated and made part of the Contract for all purposes.
6. ATTACHMENT B-1,FY26 BUDGET,of the Contract is deleted in its entirety and replaced with
ATTACHMENT B-2, REVISED BUDGET (FY25-FY27), which is attached to this Amendment
and incorporated and made part of the Contract for all purposes.
7. ATTACHMENT D-1,CONTRACT AFFIRMATIONS V.2.5(NOVEMBER 2024), of the Contract is
deleted in its entirety and replaced with ATTACHMENT D-2,CONTRACT AFFIRMATIONS V.2.9
(MARCH 2026), which is attached to this Amendment and incorporated and made part of the
Contract for all purposes.
8. ATTACHMENT G-2, FFATA CERTIFICATION FORM, is attached to this Amendment and
incorporated into and made part of the Contract for all purposes. Grantee is required to
complete the Certification Form to meet the Federal requirements.
9. This Amendment No. 2 shall be effective as of the date last signed below. Operations and
funding for Fiscal Year 2027 begin on September 1, 2026. Except as amended and modified
by this Amendment, all terms and conditions of the Contract, as previously 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 individual executing this Amendment No. 2 on its
respective behalf has full power and authority to enter into this Amendment No. 2.
DSHS Contract No.HHS001437400024 Page 2 of 4
Amendment No.2
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
SIGNATURE PAGE FOLLOWS
DSHS Contract No.HHS001437400024 Page 3 of 4
Amendment No.2
Pr
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
SIGNATURE PAGE FOR AMENDMENT NO.2
DSHS CONTRACT No.HHS001437400024
DEPARTMENT OF STATE HEALTH SERVICES PORT ARTHUR(CITY OF)HEALTH
DEPARTMENT
By: By:
Name: Name:
Title: Title:
Date of Signature: Date of Signature :
DSHS Contract No.HHS001437400024 Page 4 of 4
Amendment No.2
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
ATTACHMENT A-2
REVISED STATEMENT OF WORK(FY25-FY27)
FY25 STATEMENT OF WORK
I. Grantee Responsibilities
Grantee will:
A. Establish parameters in which local health departments (LHDs) receiving state funds will
deliver services to maintain an effective infrastructure that promotes consistent public
health practices for the health and well-being of Texans.
B. Comply with all applicable federal and state statutes and regulations, policies, and
guidelines, as revised.
C. Comply with the most current version of the DSHS Tuberculosis Work Plan that is
currently available online and can be accessed at:
https://www.dshs.texas.gov/disease/tb/programs.shtm#workplan.
D. Provide matching funds of no less than 20% of the total budget reflected in the Contract.
E. Provide match at the required percentage or DSHS may withhold payments, use
administrative offsets, or request a refund from Grantee until such time as the required
match ratio is met.No federal or other grant funds can be used as part of meeting the match
requirement.
F. Ensure no DSHS funds or matching funds are used for:
1. Entertainment, or
2. Sectarian worship, instruction, or proselytization.
G. Not lapse more than 1% of the total funded amount on both state and federal funds of the
Contract. During the term of this Contract, DSHS reserves the right to decrease funding
amounts as a result of the Grantee's budgetary shortfalls and/or due to the Grantee lapsing
more than 1% of total funds.
H. Maintain and adjust the spending plan throughout the Contract term to avoid lapsing funds.
I. Maintain staffing levels to meet required activities of the Contract and to ensure all funds
in the personnel category are expended.
J. Agree to read the Texas Grant Management Standards (TxGMS), which is currently
available online and can be accessed at: https://comptroller.texas.gov/purchasing/grant-
management/, and work with DSHS staff regarding the management of funds received
under this Contract.
DSHS Contract No.HHS001437400024 Page 1 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
P
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
K. Enter all collected TB information into the DSHS-designated state TB information system,
including all data fields on the Report of Verified Case of Tuberculosis (TB340), any
laboratory results received locally, and any additional clinical information, according to
documented timelines and specifications. Data entered into DSHS data systems will be
considered submitted to DSHS.
II. Federal Requirements
Grantee will use federal funds under this Contract to support any of the following core TB
control front-line activities:
1. Directly observed therapy(DOT);
2. Outpatient services (tuberculin skin testing, chest radiography,medical evaluation,
treatment);
3. Class B immigrant evaluation and treatment;
4. Contact Investigation, evaluation and treatment;
5. Cohort Review;
6. Surveillance;
7. Reporting;
8. Data analyses;
9. Cluster investigations;
10. Provider education and training; and
11. Patient incentives.
Grantee will ensure no federal funds or matching funds are used for:
1. Medication purchases
2. Inpatient clinical care (hospitalization services or clinical services)
3. Entertainment
4. Furniture
5. Equipment
6. Sectarian worship, instruction, or proselytization
III.Performance Measures
DSHS will monitor the Grantee's performance of the requirements set forth within the
Statement of Work(Attachment A)and compliance with the Contract's terms and conditions.
If Grantee fails to meet any of the performance measures, Grantee will respond to any finding
in a written narrative explaining the barriers and the plan to address those barriers. This
requirement does not excuse any violation of this Contract, nor does it limit DSHS as to any
options available under the Contract regarding breach.
IV.Invoice and Payment
A. Grantee will request payments using the State of Texas Purchase Voucher (FormB-13)
located at http://www.dshs.texas.gov/grants/forms/b13form.doc. The voucher and any
supporting documentation will be mailed or submitted by fax or electronic mail to the
address/number below.
DSHS Contract No.HHS001437400024 Page 2 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
*'V,O'nfi9 nr1 'i «cnC x wrmisr;n cr :;az r A
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Department of State Health Services
Claims Processing Unit, MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, TX 78714-9347
FAX: (512)458-7442
EMAIL: invoices(a dshs.texas.gov and CMSinvoicesna,dshs.texas.gov
B. Grantee will be paid on a cost reimbursement basis and in accordance with the Budget in
Attachment B of this Contract.
C. Support documents must align with the approved budget in all cost categories.
D. Grantee must submit final Financial Status Report (FSR) and final reimbursement or
payment request no later than thirty (30) calendar days following the end of the Contract
term.
V. Programmatic Reporting Requirements
Report Name Frequency Period Begin Period End Due Date
Annual Progress Report Annually Sept. 1, 2024 August 31, 2025 April 1, 2025
Financial Status Report Biannually Sept. 1, 2024 Feb. 28, 2025 March 31, 2025
(FSR)
FSR Biannually March 1, 2025 August 31, 2025 September 30, 2025
Final Quarter-Match Annually June 1, 2025 August 31, 2025 September 30,2025
Reimbursement/
Certification Form
("Form B-13A")
Cohort Review Periods and Submission Schedule
Cohort period cases counted in: Are reviewed and reported by:
First quarter(Jan 1 —Mar 31) current year Mar 31 of the following year
Second quarter(Apr 1 —Jun 30) current year Jun 30 of the following year
Third quarter(Jul 1 —Sep 30) current year Sep 30 of the following year
Fourth quarter(Oct 1 —Dec 31)current year Dec 31 of the following year
Submission Instructions:
Annual Report: Submit program reports to the TB Reporting Mailbox:
TBContractReportingAdshs.texas.gov
DSHS Contract No.HHS001437400024 Page 3 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
11,
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Financial Reports(FSRs,B-13s,and B-13A)
Department of State Health Services
Claims Processing Unit, MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, Texas 78714-9347
Fax: (512)458-7442
Email: invoices@,dshs.texas.gov and CMSinvoices@,dshs.texas.gov
(Remainder of Page Intentionally Left Blank)
DSHS Contract No.HHS001437400024 Page 4 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID: B3DDB159-B8DC-82C4-838E-54A4C2750453
FY26 STATEMENT OF WORK
I. Grantee Responsibilities
Grantee will:
A. Establish parameters in which local health departments (LHDs) receiving state funds will
deliver services to maintain an effective infrastructure that promotes consistent public
health practices for the health and well-being of Texans.
B. Comply with all applicable federal and state statutes and regulations, policies, and
guidelines, as revised.
C. Comply with the most current version of the DSHS Tuberculosis Work Plan that is
available online and can be accessed at:
https://www.dshs.texas.gov/disease/tb/programs.shtm#workplan.
D. Provide matching funds of no less than 20% of the total budget reflected in the Contract.
E. Provide match at the required percentage or DSHS may withhold payments, use
administrative offsets, or request a refund from Grantee until such time as the required
match ratio is met.No federal or other grant funds can be used as part of meeting the match
requirement.
F. Ensure no DSHS funds or matching funds are used for:
1. Entertainment, or
2. Sectarian worship, instruction, or proselytization.
G. Not lapse more than 1% of the total funded amount on both state and federal funds of the
Contract. During the term of this Contract, DSHS reserves the right to decrease funding
amounts as a result of the Grantee's budgetary shortfalls and/or due to the Grantee lapsing
more than 1% of total funds.
H. Maintain and adjust the spending plan throughout the Contract term to avoid lapsing funds.
I. Maintain staffing levels to meet required activities of the Contract and to ensure all funds
in the personnel category are expended.
J. Agree to read the Texas Grant Management Standards (TxGMS), which is currently
available online and can be accessed at: https://comptroller.texas.gov/purchasing/grant-
management/, and work with DSHS staff regarding the management of funds received
under this Contract.
K. Enter all collected TB information into the DSHS-designated state TB information system,
including all data fields on the Report of Verified Case of Tuberculosis (TB340), any
laboratory results received locally, and any additional clinical information, according to
documented timelines and specifications. Data entered into DSHS data systems will be
DSHS Contract No.HHS001437400024 Page 5 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
considered submitted to DSHS.
II. Federal Requirements
Grantee will use federal funds under this Contract to support any of the following core TB
control front-line activities:
1. Directly Observed Therapy(DOT);
2. Outpatient services (tuberculin skin testing, chest radiography, medical evaluation,
treatment);
3. Class B immigrant evaluation and treatment;
4. Contact Investigation, evaluation and treatment;
5. Cohort Review;
6. Active Surveillance;
7. Timely reporting in NEDSS;
8. Data analyses;
9. Cluster investigations;
10. Provider education and training; and
11. Patient incentives.
Grantee will ensure no federal funds or matching funds are used for:
1. Medication purchases
2. Inpatient clinical care(hospitalization services or clinical services)
3. Entertainment
4. Furniture
5. Equipment
6. Sectarian worship, instruction, or proselytization
III.Performance Measures
DSHS will monitor the Grantee's performance of the requirements set forth within the
Statement of Work (Attachment A-1) and compliance with the Contract's terms and
conditions.
If Grantee fails to meet any of the performance measures, Grantee will respond to any finding
in a written narrative explaining the barriers and the plan to address those barriers. This
requirement does not excuse any violation of this Contract, nor does it limit DSHS as to any
options available under the Contract regarding breach.
IV.Invoice and Payment
A. Grantee will request payments using the State of Texas Purchase Voucher (FormB-13)
located at http://www.dshs.texas.gov/grants/forms/bl3form.doc. The voucher and any
supporting documentation will be mailed or submitted by fax or electronic mail to the
address/number below.
Department of State Health Services
Claims Processing Unit,MC 1940
1100 West 49th Street
P.O. Box 149347
DSHS Contract No.HHS001437400024 Page 6 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Austin, TX 78714-9347
FAX: (512)458-7442
EMAIL: invoices(a,dshs.texas.gov and CMSinvoices( dshs.texas.gov
B. Grantee will be paid on a cost reimbursement basis and in accordance with the Budget in
Attachment B-1 of this Contract.
C. Grantee will maintain all documentation that substantiates invoices and make that
documentation available to System Agency upon request. In the event a cost reimbursed
under the Contract is later determined to be unallowable, the Grantee will reimburse
System Agency for that cost. Support documents must align with the approved budget in
all cost categories.
D. Invoices must be submitted monthly to prevent delays in subsequent months. If Grantee
does not incur expenses for a month, Grantee is still required to submit a timely "zero
dollar"invoice. Grantee must submit a final close-out invoice no later than thirty(30)days
following the end of the State Fiscal Year. Invoices received more than thirty (30) days
following the end of the State Fiscal Year are subject to denial of payment.
E. Grantee must submit final Financial Status Report (FSR) and final reimbursement or
payment request no later than thirty (30) calendar days following the end of the Contract
term.
V. Reporting Requirements
Report Name Frequency Period Begin Period End Due Date
Annual Progress Report Annually Sept. 1, 2025 Aug. 31, 2026 April 1, 2026
Financial Status Report Biannually Sept. 1, 2025 Feb. 28, 2026 March 31,
(FSR) 2026
Final FSR Biannually March 1, 2026 Aug. 31, 2026 Sept. 30, 2026
Final Quarter-Match Annually June 1,2026 Aug. 31, 2026 Sept. 30, 2026
Reimbursement/
Certification Form
("Form B-13A")
Contractor's Property Annually Sept. 1,2025 Aug. 31,2026 Oct. 15, 2026
Inventory Report(GC-
11)
These forms can be found at Contractor Forms I Texas DSHS
https://www.dshs.texas.2ov/contractor-forms
Submission Instructions:
Annual Report: Submit program reports to the TB Reporting Mailbox:
TBContractReporting(a,dshs.texas.gov
DSHS Contract No.HHS001437400024 Page 7 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Financial Reports (FSRs,B-13s,and B-13A)
Department of State Health Services
Claims Processing Unit, MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, Texas 78714-9347
Fax: (512)458-7442
Email: invoices@dshs.texas.gov and CMSinvoices@dshs.texas.gov
Contractor Property Inventory Report(GC-11)
Submit to DSHS Fiscal Support and Oversight Email: FSOequip@,dshs.texas.gov
(Remainder of Page Intentionally Left Blank)
DSHS Contract No.HHS001437400024 Page 8 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
FISCAL YEAR 2027
I. Grantee Responsibilities
A. Grantee shall establish parameters in which local health departments(LHDs)receiving
state funds will deliver services to maintain an effective infrastructure that promotes
consistent public health practices for the health and well-being of Texans.
B. Grantee shall comply with all applicable federal and state statutes and regulations,
policies, and guidelines.
C. Grantee shall comply with the most current version of the DSHS Tuberculosis Manual
that is available online and can be accessed at: TB Funded Programs I Texas DSHS.
D. Grantee shall provide matching funds of no less than twenty percent(20%)of the total
budget reflected in the Contract.
E. Grantee shall provide match at the required percentage or DSHS may withhold
payments, use administrative offsets, or request a refund from Grantee until such time
as the required match ratio is met. No federal or other grant funds can be used as part
of meeting the match requirement.
F. Grantee shall ensure no DSHS funds or matching funds are used for:
1. Entertainment, or
2. Sectarian worship, instruction, or proselytization.
G. Grantee shall not lapse more than one percent(1%)of the total funded amount on both
state and federal funds of the Contract.During the term of this Contract,DSHS reserves
the right to decrease funding amounts because of Grantee's budgetary shortfalls and/or
due to Grantee lapsing more than one percent(1%) of total funds.
H. Grantee shall maintain and adjust the spending plan throughout the Contract term to
avoid lapsing funds.
I. Grantee shall maintain a Class D pharmacy license as issued by the Texas Board of
Pharmacy.
J. Grantee shall provide advance notification of all proposed budget transfers across
budget categories by submitting the following to the DSHS Contract Representative:
(1)a Budget Change Request form,as provided by DSHS;and(2)a revised categorical
budget highlighting the areas affected by the budget transfer. After reviewing the
proposed budget transfer(s), the DSHS Contract Representative will provide written
notification of DSHS' determination. If approved by DSHS and:
1. The budget transfer request involves revisions to the "Equipment" or "Indirect
Cost" categories, the revised funding allocation is not authorized unless and until
an amendment incorporating the budget revisions is effectuated.
DSHS Contract No.HHS001437400024 Page 9 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
2. The budget transfer request does not involve revisions to the "Equipment" or
"Indirect Cost"categories and:(a)is less than or equal to twenty-five percent(25%)
of the total value of the budget period, DSHS Contract Representative will notify
Grantee of acceptance to Grantee by email; or (b) if the transfer is more than
twenty-five percent (25%) of the total value of the budget period, the revised
funding allocation is not authorized unless and until an amendment incorporating
the budget revisions is effectuated.
K. Grantee shall maintain staffing levels to meet required activities of the Contract and to
ensure all funds in the personnel category are expended.
L. Grantee shall enter all collected TB information into the DSHS-designated state TB
information system, including all data fields on the Report of Verified Case of
Tuberculosis (TB340), any laboratory results received locally, and any additional
clinical information, according to documented timelines and specifications in the TB
manual. Data entered into DSHS data systems will be considered submitted to DSHS.
II. Federal Requirements
A. Grantee will use federal funds under this Contract to support any of the following core
TB control front-line activities:
1. Directly Observed Therapy(DOT);
2. Outpatient services (tuberculin skin testing, chest radiography, medical evaluation,
treatment);
3. Class B immigrant evaluation and treatment;
4. Contact investigation, evaluation and treatment;
5. Cohort review;
6. Active surveillance;
7. Timely reporting in the National Electronic Disease Surveillance System(NEDSS);
8. Data analyses;
9. Cluster investigations;
10. Provider education and training; and
11. Patient incentives.
Grantee will ensure no federal funds or matching funds are used for:
1. Medication purchases
2. Inpatient clinical care (hospitalization services or clinical services)
3. Entertainment
4. Furniture
5. Equipment
6. Sectarian worship, instruction, or proselytization
III. DSHS Monitoring
DSHS will monitor the Grantee's performance of the requirements in this ATTACHMENT
A-2, REVISED STATEMENT OF WORK and compliance with the Contract's terms and
conditions.
DSHS Contract No.HHS001437400024 Page 10 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
IV. Invoice and Payment
A. Grantee will request payments using the State of Texas Purchase Voucher(Form B-13)
located at http://www.dshs.texas.gov/grants/forms/b13form.doc. The voucher and any
supporting documentation will be mailed or submitted by.fax or electronic mail to the
address/number below.
Department of State Health Services
Claims Processing Unit,MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, TX 78714-9347
FAX: (512)458-7442
EMAIL: invoices@dshs.texas.gov and CMSinvoices@dshs.texas.gov
B. Grantee will be paid on a cost reimbursement basis and in accordance with
ATTACHMENT B-2,REVISED BUDGET in of this Contract.
C. Grantee shall maintain all documentation that substantiates invoices and make that
documentation available to System Agency upon request. In the event a cost
reimbursed under the Contract is later determined to be unallowable,the Grantee must
reimburse System Agency for that cost. Support documents must align with the
approved budget in all cost categories.
D. Invoices must be submitted monthly to prevent delays in subsequent months.If Grantee
does not incur expenses for a month, Grantee is still required to submit a timely"zero
dollar" invoice. Grantee must submit a final close-out invoice no later than thirty(30)
calendar days following the end of the State Fiscal Year. Invoices received more than
thirty(30)calendar days following the end of the State Fiscal Year are subject to denial
of payment.
E. Grantee must submit a final Financial Status Report(FSR)and final reimbursement or
payment request no later than thirty (30) calendar days following the end of the
Contract term.
V. Reporting Requirements
A. Grantee must submit the following programmatic reports to comply with the DSHS
Tuberculosis Manual that can be accessed at TB Funded Programs I Texas DSHSand
listed below:
DSHS Contract No.HHS001437400024 Page 11 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Epidemiology Reporting
Report Name Reporting Requirement
Weekly Report of New Report TB deaths, TB cases in children under 5 years of
Concerning TB Events age, and drug-resistant tuberculosis (DR-TB) to the TB
Unit, TBEpi@u,dshs.texas.gov the following Friday using
the DSHS Weekly Report of New Concerning
Tuberculosis Events form. A report must be submitted
even if there are no concerning events to report.
TB Incident Reports Report concerning contact investigations and/or large-
scale screenings to the TB Unit TBEpi(a,dshs.texas.gov
within 48 hours of meeting the criteria for an incident
report. Attach 12-12104 or 12-12063 to the patient record
in NEDSS.
Travel Restriction For patients that are candidates for a Do Not Board and
(DNB/LO) Requests Public Health Lookout (DNB/LO), submit the 12-12065
(Do Not Board/Public Health Lookout Consultation
Request)to the TB Unit at TBEpiAdshs.texas.gov.
Reporting False- Report false-positive investigations to the TB Unit at
Positive Investigations TBEpi4 dshs.texas.gov.
Surveillance Reporting
Reporting in NEDSS(Suspected/Confirmed TB Case Information)
• All persons evaluated for TB Create a Tuberculosis (2020 Report of Verified
disease and started treatment Case of Tuberculosis (RVCT)) investigation in
• All persons evaluated for TB NEDSS within three (3) business days of
infection and started treatment notification unless the investigation was already
• Persons named as a contact created by an electronic laboratory report(ELR).
particularly high and medium risk
contacts
Disposition Suspects Obtain and enter the initial TB intake
information into NEDSS within seven (7) days
of notification for all suspected TB cases started
on an anti-TB medication regimen. Within the
90-day period,all diagnostic tests for TB should
be completed and a disposition entered in
NEDSS.
Updates Enter all updates to the investigation in NEDSS
as soon as the information is available, not to
exceed ten(10)working days after information
is obtained.
Completion of Treatment Treatment and case outcome information
should be entered in NEDSS for all cases as
soon as treatment is complete or treatment
information is available, not to exceed seven(7)
days from therapy stop date.
DSHS Contract No.HHS001437400024 Page 12 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
••'I , .. .. ! .mom:.-m. .-r'.aim nr. m••a mnrrgn ._. .....
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Data Quality Reports Review data quality reports and make
appropriate updates to the NEDSS investigation
by the deadlines provided at the time the reports
are distributed.
Reporting in NEDSS(Contact Investigation Information)
Contact Investigation Information Enter initial contact investigation information
within fifteen (15) working days of the
suspected or confirmed TB case being
identified.
Contact Evaluation Information Enter contact evaluation information within ten
(10) working days of initiating the evaluation.
Enter relevant information including but not
limited to TB and Latent TB Infection (LTBI)
history, initial symptom screening results, TB
screening tests (i.e., tuberculin skin test or
interferon gamma results assay) results, and
chest imaging.
Updates Enter all updates to the investigation in NEDSS
as soon as the information is available, not to
exceed ten (10)working days after information
is obtained.
Disposition Contacts After contact evaluation is complete, assign an
American Thoracic Society(ATS) classification
in NEDSS. The ATS classification should be
updated within five (5) working days from
when a clinical diagnosis is made. If unable to
complete a full evaluation, document outcomes
in the NEDSS investigation.
Data Quality Reports Review data quality reports and make
appropriate updates to the NEDSS investigation
by the deadlines provided at the time the reports
are distributed.
B. Grantee shall comply with the following contractual reporting requirements:
Contractual Reporting
Report Name Frequency Period Begin Period End Due Date
Annual Progress Annually Sept. 1,2026 Aug. 31, 2027 April 1,2027
Report
Financial Status Biannually Sept. 1, 2026 Feb. 28, 2027 March 31, 2027
Report(FSR)
Final FSR Biannually March 1, 2027 Aug. 31,2027 Sept. 30, 2027
Final Quarter- Annually June 1, 2027 Aug. 31, 2027 Sept. 30, 2027
Match
Reimbursement/
DSHS Contract No.HHS001437400024 Page 13 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Pr
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Certification Form
("Form B-13A")
Contractor's Annually Sept. 1, 2026 Aug. 31, 2027 Oct. 15, 2027
Property Inventory
Report(GC-11)
These forms can be found at Contractor Forms I Texas DSHS
https://www.dshs.texas.gov/contractor-forms
Submission Instructions:
Annual Report: Submit program reports to the TB Reporting Mailbox:
TBContractReporting@dshs.texas.gov
Financial Reports (FSRs,B-13s, and B-13A)
Department of State Health Services
Claims Processing Unit,MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, Texas 78714-9347
Fax: (512)458-7442
Email: invoicesadshs.texas.gov and CMSinvoices( dshs.texas.gov
Contractor Property Inventory Report(GC-11)
Submit to DSHS Fiscal Support and Oversight Email: FSOequip a,dshs.texas.gov
(Remainder of Page Intentionally Left Blank)
DSHS Contract No.HHS001437400024 Page 14 of 14
Attachment A-2,Revised Statement of Work(FY25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
ATTACHMENT B-2
REVISED BUDGET(FY25-FY27)
Budget FY27
Budget Category DSHS Funds Cash Match Category Total
Personnel $35,666.00 $7,133.00 $42,799.00
Fringe Benefits $14,267.00 $2,854.00 $17,121.00
Travel $1,235.00 $78.00 $1,313.00
Equipment $0.00 $0.00 $0.00
Supplies $1,866.00 $638.00 $2,504.00
Contractual $0.00 $0.00 $0.00
Other $480.00 $0.00 $480.00
Total Direct $53,514.00 $10,703.00 $64,217.00
Indirect Charges $0.00 $0.00 $0.00
Total $53,514.00 $10,703.00 $64,217.00
Budget FY26
Budget Category DSHS Funds Cash Match Category Total
Personnel $37,360.00 $1,106.00 $38,466.00
Fringe Benefits $15,318.00 $453.00 $15,771.00
Travel $420.00 $350.00 $770.00
Equipment $0.00 $0.00 $0.00
Supplies $416.00 $8,181.00 $8,597.00
Contractual $0.00 $0.00 $0.00
Other $0.00 $612.00 $612.00
Total Direct Costs $53,514.00 $10,702.00 $64,216.00
Indirect Costs $0.00 $0.00 $0.00
Totals: $53,514.00 $10,702.00 $64,216.00
DSHS Contract No.HHS001437400024 Page 1 of 2
Attachment B-2,Revised Budget(FY 25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
Budget FY25
Budget Category DSHS Funds Cash Match Category Total
Personnel $37,509.00 $1,103.00 $38,612.00
Fringe Benefits $15,257.00 $441.00 $15,698.00
Travel $402.00 $402.00 $804.00
Equipment $0.00 $0.00 $0.00
Supplies $346.00 $8,132.00 $8,478.00
Contractual $0.00 $0.00 $0.00
Other $0.00 $624.00 $624.00
Total Direct Costs $53,514.00 $10,702.00 $64,216.00
Indirect Costs $0.00 $0.00 $0.00
Totals: $53,514.00 $10,702.00 $64,216.00
DSHS Contract No.HHS001437400024 Page 2 of 2
Attachment B-2,Revised Budget(FY 25-FY27)
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
HEALTH AND HUMAN SERVICES
Contract Number HHS001437400024
Exhibit D2 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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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.
Health and Human Services
Contract Affirmations v.2.9
Effective March 2026
Page 3 of 14
4 ...,•.:!rT,fl,, ,._FF'Ra.r.,w.a�•:rni*^..sw ..vr.x.,n5,_.&, .:!r.!r-=+-....w..,... ..F ,- y pg«._. .,, v _ ...
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
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
I
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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: B3DDB159-B8DC-82C4-838E-54A4C2750453
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
IFF
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
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
PF
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
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: B3DDB159-B8DC-82C4-838E-54A4C2750453
Authorized representative on behalf of Contractor must complete and sign the following:
Judith Smith
Legal Name of Contractor
City of Port Arthur
Assumed Business Name of Contractor, if applicable(d/b/a or `doing business as')
City of Port Arthur
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.
CSigned by.
ilia& a. SKA61 t5SNj May 18, 2026
GBAB50^AEDlQ.7t
Signature of Authorized Representative Date Signed
Judith A. Smith, BSN, RN Director of Health Services
Printed Name of Authorized Representative Title of Authorized Representative
First,Middle Name or Initial, and Last Name
5860 9th Avenue Port Arthur, TX,77642
Physical Street Address City, State, Zip Code
5860 9th Avnue Port Arthur, TX,77642
Mailing Address, if different City, State,Zip Code
(409) 983-8832 (409) 983-8832
Phone Number Fax Number
judith.smithl.ortarthurtx.giv 13734909
Email Address DUNS Number
17460018550-011 74-6001885
Federal Employer Identification Number Texas Identification Number(TIN)
1-74-6001855-0 17460018850-11
Texas Franchise Tax Number Texas Secretary of State Filing
Number
EMVNEFW21014
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:B3DDB159-B8DC-82C4-838E-54A4C2750453
TEXAS Health and Texas Department of State`V
Services 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):
City of Port Arthur Lynda Boswell, lynda.boswelll.ortarthurtx.gov (409) 983-8186
Primary Address of Contractor: Zip Code: 9-digits required www.usps.com
5860 9th Avenue, Port Arthur, TX, 77642 77642-8609
Unique Entity ID (UEI):This number replaces the DUNS State of Texas Comptroller Vendor Identification Number
www.sam.ciov (VIN) - 14 digits:
EMVNEFW2KN4 17460018550-011
Printed Name of Authorized Representative: Signature of Authorized Representative
Judith A. Smith, BSN, RN "—Signed by:
3I414 a. 5wxif(L, 15sw, I2N
'-F84B504AED30471.
Title of Authorized Representative Date Signed
Director of Health Services May 18, 2026
1
Department of State Health Services Form 4734—April 2022
Contract Management Section
Docusign Envelope ID:B3DDB159-B8DC-82C4-838E-54A4C2750453
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 NoEl
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 n
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 0 No Q
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 n No n
If your answer is "Yes" to this question, where can this information be accessed?
Through open records request
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:
N/A
2
Department of State Health Services Form 4734-April 2022
Contract Management Section
0 docusign
Certificate Of Completion
Envelope Id:B3DDB159-B8DC-82C4-838E-54A4C2750453 Status:Sent
Subject:Please Docusign:HHS001437400024 -A-2-Port Arthur Health Department -TB Combo
Source Envelope:
Document Pages:36 Signatures:2 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: 167.137.1.8
Record Tracking
Status:Original Holder:CMS Internal Routing Mailbox Location: DocuSign
5/14/2026 9:05:52 AM CMS.InternalRouting@dshs.texas.gov
Signer Events Signature Timestamp
Judith A.Smith,BSN,RN E—�Signed by, Sent:5/14/2026 9:22:15 AM
judith.smith@portarthurtx.gov .A4a• Sa+tiu.t MN) INN Viewed:5/18/2026 9:34:01 AM
�FB413504AED30471
Director of Health Services Signed:5/18/2026 9:43:13 AM
City of Port Arthur
Security Level:Email,Account Authentication
Signature Adoption:Pre-selected Style
(None) Using IP Address:71.40.211.219
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Ron Burton Sent:5/18/2026 9:43:15 AM
ron.burton@portarthurtx.gov
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
Christy Havel Burton
christy.havelburton@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
Gabby Lara COPIED Sent:5/14/2026 9:22:14 AM
Gabby.Lara@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Giselle Statham
giselle.statham@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 5/14/2026 9:22:14 AM
Envelope Updated Security Checked 5/14/2026 11:59:04 AM
Payment Events Status Timestamps
d
•