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<br />111(/ <br /> <br />-... -~~ foonft .7'32 <br />11 ~ 88rW:88 . NONGOVëRNMENT A!.. CONTRACTOR CERTIFICATION 0d0ò8r ,~ <br /> <br /> <br />\8 . ccncßtlon of the Texas Dep8rtment'Of Human SeMces '. (DHS) 8uthority to expend funda, the FY.1 ¡go..1 i91 state appropriations <br />tct (S.B. 222, 71st Legislature, Regular SessIon, 1S89) requl,... DRS to notffy the l.egisiatfv8 Budget Beard (L.BB) and the Governor.$ <br />)fflce 30 days in advance of ~.h.-cting with organizations In which. fonnef' bean:! member Ot'~yee (whose last day of duty <br />na on or after September 1, 1S87) has any ownet'Ship Of control, Of who is an employee or consultant of auch organizatJon. The <br />'..BS orthe Govemor's Offtc::e may dlsappnMt of expenditures for such ......uh..cts. AJ8o, T8X8S Revised CMI St8tutes, Artide 5547-202, <br />~on 2.45 prohibits for one year after employment fonner DHS employees In pay grades equivalent to OC" above pay grade 17, <br />3tep 1, from helping (for pay) another entity obtain a contract with DHS In an area fer which the fonner employee was directly con- <br />:emed Of had 8dmfn1stratfve responaIbUtty. AddItionally, DHS has 8dopted stan<1ards for contrac:ting with contractOf$ anodated <br />fIrith current or fonner employees and board members, and their relatives. -- <br /> <br />~JI patemfaJ noc~.:mr.:Øõìll ~~... foe any type of contr8Ct must complete this certification. The contract, if awarded, may <br />3e tenninated for cause if <br /> <br />(1) corrtractor knowingly provides Incorrect information In Its certification; or <br />(2) contractor uses a subteriuge, such as . subcontnlct anangement, to 8V~d the application of state laws or DHS rules. <br /> <br />I. Does the potential contractor have as an officer, director, empk)yee, consultant, or <br />owner (in part or whole) a person (a) who is now a DHS employee or DHS board member, <br />or (b) who was a former DHS board member or former DHS employee and whose last <br />day of duty with DHS was on or after September 1, 19871 ........................................:...... D Ves 0 No <br /> <br /> <br />2. Does the potential contractor have as an officer, director, employee, consultant, or owner <br />(in part or whole) a person who is related in the following manner (a) to a current DHS <br />employee or DHS board member, or (b) to a former DHS employee or DHS'board member . <br />whose last day of service was on or after September 1,19871 ......................... ... ............ ....DVes DNo <br /> <br />A. Wife E. Brother I. Stepdaughter M. Spouse's Sister <br />B. Husband F. Sister J. Stepson N. Spouse's Brother <br />C. Father G. Son K. Mother~n-Iaw <br />D. Mother H. Daughter L. Father-in-law ~ <br /> <br /> <br />IF QUESTION 1 OR 2 IS CHECKED "VES," VOU MUST COMP1.ETE FORM 4732-A <br /> <br /> <br /> <br />¡ CERTIACA TION <br /> <br />¡ I certify that the information above Is complete, true and correct to the best of my knowledge. I understand that lack of <br />: fr." true and complete disdosure may be grounds for withholding payment for delivered services and may cause contract <br />! tl ination. <br />I 1 <br />Ire of PotentIal Non-governmental Contractor ., Contract No. I Social Security No. or VtN I <br /> <br /> <br /> <br />~ ~ Pnnt or Type Name I <br />- / . 12/14/93 Larry D. Gilley <br />sognalure-LXnonzed Repr..~!Ve Oate <br /> <br /> <br /> <br />~his form is not applicable because the City of San Marcos <br />1S a governmental entity. <br />