CONTRACT BY AND BETWEEN FORT BEND INDEPENDENT SCHOOL DISTRICT AND SHILOH TREATMENT CENTER, INC. June 5, 2018 to July 27, 2013 (29 days) AMOUNT: $9,713.14 CLIENT (STUDENT): This contract and agreement is entered into by and between Fort Bend independent School District, hereinafter called "School District?, and Shiloh Treatment Center lnc., hereinafter called ?Contractor", for the purpose of providing services to one handicapped person who is a resident of the State of Texas and meets age eligibility according to IDEA regulations. The Contractor will provide the specialized facilities and personnel necessary to furnish all services covered by this contract. During the contract period, if the Contractor becomes unable to or fails to provide specialized facilities or personnel necessary under this contract, the School District may withhold payment to Contractor until Contractor does provide the required facilities or personnel. The School District and the Contractor agree and understand that the parent(s) or guardian(s) of this student have voluntarily given their permission for this student to receive the following Indicated services provided by this contract agreement. A. Day School B. Educational Services 0. Related Services (where specified) The School District will pay to the Contractor for its complete and satisfactory performance of this contract for all services covered by this contract. This sum shall be payable in installments in the amount specified in each billing. Shiloh will continue the regular rate through any transition, or shortened day agreements. The School District will maintain the eligibility folder. The School District will compile and send to the Contractor copies of the following items, on a routine basis: ARD notice of ARD individual transition plan comprehensive individual assessment reintegration plan notice of assessments current current contract, properly executed nave anew CONTRACT BY 8; BETWEEN HOUSTON INDEPENDENT SCHOOL DISTRICT AND TREATMENT CENTER, INC. The local district is responsible for overseeing implementation of the and provides annual reevaluation of appropriateness of the instructional arrangement. The Contractor will maintain records and accounts to assure a proper accounting to the School District of all monies, state and federal, applicable to this contract. The Contractor will compile and furnish to the School District any reports that the School District requires to comply with applicable laws, rules, and regulations of the State of Texas and the Texas State Board of Education and any other evaluative information the School District requires. The term of this contract shall begin on June 5, 2018, and end not later than July 27, 2018. The contract may be terminated by mutual agreement of the parties once it has been determined that such is the proper course of action based upon an Admission, Review, and Dismissal Committee meeting. Should Shiloh Non Public School lose the approval status with the Texas Education Agency the current contract may be terminated. Additionally, should said student become medically fragile or it is determined that they are under the influence of illegal drugs or drugs not prescribed by an attending physician said student will be subject to immediate discharge in accordance with local, federal or state laws. in the event that the contract is terminated prior to the date specified above, fees and charges shall be prewrated to the date of discharge plus thirty days. The facility provides all services specified in the contract with the school istrict(s) without charge to the parents, surrogates, guardians, or adult student. This instrument constitutes the entire agreement by and between the parties for the purpose of accomplishing the results and objectives herein contained and as stated in the Admission, Review, and Dismissal Committee report, and any alteration thereof, or addition, or deletion, shall be by addendum hereto in writing and executed by the parties. The Contractor agrees that funds will be utilized in accordance with the attached cost analysis sheet. Payments should be sent to the following address: Shiloh Treatment Center, inc. P.O. Box 84469 Pearland, TX 77584-0011 Notices required by this agreement shall be made in writing and delivered to the parties to and at: "Contractor" Shiloh Treatment Center, inc. Attn: Brenda Gardner - Valdes 3926 Bahler Avenue Manvel, TX 77578 CONTRACT BY 8; BETWEEN HOUSTON INDEPENDENT SCHOOL DISTRICT AND SHILOH TREATMENT CENTER, INC. ?School District" Fort Bend Independent School District Attn: Dr. Deena Hill Office of Special Education 16431 Ste 300 Fort Bend, TX 77479 Notwithstanding any provisions or conditions in this contract to the contrary, this contract in all its particulars is subject to and governed by all Texas State Laws and Texas State Board of Education Policies, and any recourse to judicial action under this contract shall be in the courts of the State of Texas to the exclusion of all other courts. AC TED and APPROVED on behalf of Shiloh Treatment Center, Inc. this the of ?(A/Mes. .2018. i BY: If? biw- Chief Operating Officer ACCEPTED and APPROVED on behalf of Fort Bend Independent School District this the day of 2018. BY: 39., Wop?V Superintendent, Fort Bend ISD TITLE: CONTRACT BY 8: BETWEEN HOUSTON INDEPENDENT SCHOOL DISTRICT AND SHILOH TREATMENT CENTER, INC. SHILOH TREATMENT CENTER, INC. COST ANALYSIS June 5, 2018 to July 27, 2018 (29 days) DISTRICT: Fort Bend Independent School District SERVICES Daily Weekly Totals Education Services $26.66 $773.14 Behavior Therapy Related Services Individual Therapy Group Therapy Physical Therapy Occupational Therapy Speech LRE Transition Therapy School Health Services $120.00 $240.00 Services Residential Services Day Programming $300.00 $8,700.00 Extended Day Services Respite 24 Hours Contract Total $9,713.14 in services approved by the ARE) committee couid result in changes to the payment. An addendum will be submitted should this occur. Exhibit EDGAR CERTIFICATIONS ADDENDUM FOR CONTRACT FUNDED BY U.S. FEDERAL GRANT The following certi?cations and provisions are required and apply when Fort Bend independent School District expands federal funds for any contract resulting from this procurement process. Accordingly, the parties agree that the following terms and conditions apply to the Contract between the District and Shiloh Treatment Center, inc. in all situations where Vendor has been paid or will be paid with federal funds: REQUIRED CONTRACT PROVISIONS FOR NON-FEDERAL ENTITY CONTRACTS UNDER FEDERAL AWARDS APPENDIX ll T0 2 CFR PART 200 (A) Contracts for more than the simplified acquisition threshold currently set at $150,000, which is the inflation adjusted amount determined by the Civilian Agency Acquisition Council and the Defense Acquisition Regulations Council (Councils) as authorized by 41 U.S.C. 1908, must address administrative, contractual, or legal remedies in instances where contractors violate or breach contract terms, and provide for such sanctions and penalties as appropriate. Pursuant to Federal Rule (A) above, when FBISD expands federal funds, FBISD reserves all rights and privileges under the applicable laws and regulations with respect to this procurement in theEveT of breach of contract by either party. Does Vendor agree? YES Initials of Authorized Representative of Vendor (B) Termination for cause and for convenience by the grantee or subgrantee including the manner by which it will be effected . and the basis for settlement. {All contracts in excess of $10,000) Pursuant to Federal Rule (B) above, when expands federal iunds, reserves the right to immediately terminate any agreement in excess of $10,000 resulting from this procurement process in the event of a breach or default of the agreement by Vendor in the event Vendor fails to: (1) meet schedules, deadlines, andlor delivery dates within the time speci?ed in the procurement solicitation, contract. andior a purchase order; (2) make any payments owed; or otherwise perform in accordance with the contract andlor the procurement solicitation. also reserves the right to terminate the contract immediately, with written notice to vendor, for convenience, if believes, in its sole discretion that it is in the best interest of to do so. Vendor will be compensated for Work performed and accepted and goods accepted by FBISD as of the termination date if the contract is terminated for convenience of An award under this procurement process is not exclusive and reserves the right to purchase goods and set-trimmer Vendors when it is in best interest. Does Vendor agree? YES initials of Authorized Representative of Vendor (C) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all contracts that meet the definition of ?federally assisted construction contract? in 41 CFR Part ?ll-1.3 must include the equal opportunity clause provided under 41 CFR in accordance with Executive Order 11246, ?Equal Employment Opportunity? (30 FR 12319, 12935, 3 CFR Part, 19644965 Comp, p. 339), as amended by Executive Order 11375, ?Amending Executive Order 11246 Relating to Equal Employment Opportunity," and implementing regulations at 41 CFR part 60, ?Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor." Pursuant to Federal Rule (O) above, when FBISD expands federal funds on any federally assisted construction contract, the equal opportunity clause is incorporated by reference herein. Does Vendor agree to abide by the above? YES initials oi Authorized Representative of Vendor (D) Davis-Bacon Act, as amended (40 0.8.0. 3141-3148). When required by Federal program legislation, all prime construction contracts in excess or $2,000 awarded by non-Federal entities must include a provision for compliance with the Davis-Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations {29 CFR Part 5, ?Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction?). in accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor. in addition, contractors must be required to pay wages not less than once a week. The non-Federal entity must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The non-Federal entity must report all suspected or reported violations to the Federal 5 awarding agency. The contracts must also include a provision for compliance with the Copeland ?Anti-Kickback" Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3, ?Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States?). The Act provides that each contractor or subrecipient must be prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The non- Federal entity must report all suspected or reported violations to the Federal awarding agency. Pursuant to Federal Rule (D) above, when FSISD expands federal funds during the term of an award for all contracts and subgranis for construction or repair, Vendor will be in compliance with a a?elioable Davis-Bacon Act provisions. Does Vendor agree? YES I Initials of Authorized Representative of Vendor (E) Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3700). Where applicable, all contracts awarded by the non- Federal entity in excess of $100,000 that involve the employment of mechanics or laborers must include a provision for compliance with 40 U.S.C. 3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must be required to compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided that the worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that no laborer or mechanic must be required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or contracts for transportation ortrensmission of intelligence. Pursuant to Federal Rule (E) above, when expands federal funds, Vendor certi?es that Vendor will be in compliance with all applicable provisions of the Contract Work Hours and Safety Standards Act during the term of an award for all contracts by BISD resulting from this procurement process. Does Vendor agree? YES Initials of Authorized Representative of Vendor (F) Rights to inventions Made Under a Contract or Agreement. if the Federal award meets the definition of "funding agreement" under 37 CFR ?401.2 and the recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit organization regarding the substitution of parties, assignment or performance of experimental, developmental, or research work under that ?funding agreement," the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements,? and any implementing regulations issued by the awarding agency, Pursuant to Federal Rule (F) above, when federal funds are expanded by Vendor certi?es that during the term of an award for all contracts by resulting from this procurement process. Vendor agrees to comply with all applicable requirements as referenced in Federal Rule (F) above. Does Vendor agree? YES bi) initieis of Authorized Representative of Vendor (G) Clean Air Act (42 U.S.C. Federal Water Pollution Control Act (33 U.S.C. 1251-4387), as amended? Contracts and subgrants of amounts in excess of $i50,090 must contain a provision that requires the non-Federal award to agree to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 13.3.0. idiot-7671(1) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251? 1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA). Pursuant to Federal Rule (G) above, when federal funds are expanded by FBISD. Vendor that during the term of an award for all contracts by FBISD resulting from this procurement pros as, Vendor agrees to comply with all applicable requirements as referenced in Federal Rule (G) above. Does Vendor agree? YES initials of Authorized Representative of Vendor (H) Debarment and Suspension (Executive Orders 12549 and contract award (see 2 CFR 180.220) must not be made to parties listed on the government wide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp, p. 189) and 12609 (3 CFR part1989 Comp, p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended, or 6 otherwise excluded by agencies, as well as parties declared Ineligible under statutory or regulatory authority other than Executive Order 12549. Pursuant to Federal Rule (H) above, when federal funds are expended by Vendor certi?es that during the term of an award for all contracts by resulting from this procurement process, Vendor certi?es that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, rvoluntariiy excluded from participation by any federal department or agency. Does Vendor agree? YES I09 initials of Authorized Representative of Vendor Anti-Lobbying Amendment (31 1.1.8.8. that apply or bid for an award exceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer orempioyee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 0.3.6. 1352. Each tier must also disclose any lobbying with nonnFederai funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the hon- Federat award. . Pursuant to Federal Rule above, when federal lands are expanded by Vendor certi?es that during the term and after the awarded term at an award for all contracts by FBISD resulting from this procurement process, the vendor certi?es that it is in compliance with all applicable provisions of the Amendment (31 0.3.0. 1352). The undersigned further certi?es that: a) No Federal appropriated funds have been paid or will be paid for on behalf of the undersigned, to any person for influencing or attempting to in?uence an of?cer or employee of any agency, a Member of Congress, an officer or employee oi congress, or an employee of a Member of Congress in connection with the awarding of a Federal contract, the making of a Federal grant, the making Federal loan. the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or modi?cation of a Federal contract, grant, loan. or cooperative agreement. b) it any funds other than Federal appropriated funds have been paid or will be paid to any person for in?uencing or attempting to in?uence an of?cer or employee of any agency, a Member of Congress, an of?cer or employee of congress, or an employee of a Member of Congress in connection with this Federal grant or cooperative agreement, the undersigned shall complete and submit Standard ?Disclosure Form to Report Lobbying?, in accordance with its instructions. c) The undersigned shall require that the language of this codi?cation be included in the award documents for all covered sub-awards exceeding $100,000 in Federal funds at all ppropriate tiers and that all subrectpients shali certify and disclose accordingly. Does Vendor agree? YES initials of Authorized Representative of Vendor RECORD RETENTION FOR CONTRACTS FEDERAL FUNDS When federal funds are expanded by for any contract resulting from this procurement process, Vendor certi?es that it will comply with the record retention requirements detailed in 2 CFR 200.333. Vendor further certi?es that it will retain all records as required by 2 CFR 200.333 fora period of three years after grantees or subgrantees submit final expenditure reports or quarterly or annual ?nancial reports, as applicable, and all other pending matters are closed. Does Vendor agree? YES ?5 initials of Authorized Representative of Vendor CERTIFICATION OF COMPLIANCE WITH THE ENERGY POLICY AND CONSERVATION ACT When FBISD expands federal funds for any contract resulting from this procurement process, Vendor certi?es that it will comply with the mandatory standards and policies relating to energy efficiency which are contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (42 0.8.0. 6321 et Part 18). Does Vendor agree? YES initials of Authorized Representative of Vendor CERTIFICATION OF EQUAL EMPLOYMENT STATEMENT 7 it is the policy of FBISD not to discriminate on the basis of racel coior, national origin, gender. English pro?ciency or handicapping conditions in its programs. Vendor agrees not to discriminate against any employee or applicant for employment to be emptoyed in the performance at this Contract, with respect to hire, tenure, terms. conditions and priviteges of employment, or a matter directly or indirectly related to employment, because of age (except where based on a bona ?de occupational quali?cation), sex (except where based on a bone tide occupational quali?cation) or race, coior, religion. national origin, or ancestry. Vendor further agrees that every subcontract entered into for the performance of this Contract shalt contain a provision requiring nondiscrimination in employment herein specified, binding upon each subcontractor. Breach of this covenant maybe regarded ear/anpt?tiai breach of the Contract. I Does Vendor agree? YES initials of Authorized Representative of Vendor CERTIFICATION OF COMPLIANCE BUY AMERICA PROVISIONS FBISD has a preference for domestic and products for supplies acquired for use in the United States when spending federal funds (purchases that are made with non-federal funds or grants are excluded from the Buy America Act). Vendor certi?es that it is in compliance with all applicable provisions of the Buy America Act. Does Vendor agree? YES Initials of Authorized Representative of Vendor CERTIFICATION OF ACCESS TO RECORDS -- 2 C.F.R. 200.336 Vendor agrees that the District?s inspector General or any of their duly authorized representatives shall have access to any books, documents, papers and records of Vendor that are directly pertinent to Vendor?s discharge at its obligations under the Contract for the purpose of making audits, examinations. eXcerpts, and transcriptions. The right also includes timely and reasonabie access to Vendor's personnel for the purpose of interview and discussion rotating to such document in 1 Does Vendor agree? YES initials of Authorized Representative of Vendor CERTIFICATION OF APPLICABILITY TO SUBCONTRACTRS Vendor agrees that all contracts it awards pursuant to the Contract shall be boo foregoing terms and conditions. Does Vendor agree? YES initials of Authorized Representative of Vendor VENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS, AND IT IS FURTHER ACKNOWLEDGED THAT VENDOR CERTIFIES COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, AS SPECIFICALLY NOTED ABOVE. Vendor's Name: x" IAI Lit IA Address, City, State. and Zip Code: 3 (I 9?6? 6 VI 7797?( Phone Number: 381 if? 0 Fax Number: 9?37 5?7 ?X0$m Printed Name and Title of Authorized Representative: 6 UCL. I OI 3 CO 0 Email Address: I . Signature of Authorized Represgniative: (it; {5/61 I7 as: o/q/rr? Confidential Student Information Agreement Exhibit to Specialized Services Agreement . Between Shiloh Treatment Center, inc., and the Fort Bend Independent School District (in behalf of Shiloh Treatment Center, inc. (?Contractor?), I acknowledge that in the course of our work for the Fort Bend Independent School District (?School District?), Contractor may have access to individual student information. The Confidential Student information Agreement sets forth Contractor's work for the District in providing specialized services for students with disabilities, related to mental health and behavior problems to serve the District?s educational needs. The work to be performed by Contractor is work performed as independent contractors of the District. Consequently, for purposes of the work to be performed for the District, Contractor is a "school official? as the term is used in FL (Local). Therefore, Contractor has a legitimate educational Interest in the student information provided for the use in supporting the District?s educational needs. As such, Contractor?s access to individual student information is permitted under the Family Educational Rights and Privacy Act of 1974 (FERPA) and its implementing federal regulations found in I 34 CFR Part 99. Contractor agrees and understands that information concerning any individual student is to be held in strictest confidence and assures that procedures are in place for monitoring and protecting confidentiality of student information, including, but not limited to, tracking access by assigned passwords. All media that contain individual student records arid Contractor records that contain individual student records will be kept in a secure area at the District. Each Contractor representative that will access the individual student records must agree to protect student confidentiality by signing the attached ?Access Agreement.? In addition, Contractor agrees that any data sets or output reports that its representatives may generate with individual student data are confidential. Contractor will not disclose to any unauthorized person any data sets or reports with individual student data which is obtained or devised. Contractor agrees to be responsible?for any computer transactions performed as a result of access authorized by use of passwordis). Contractor agrees to destroy the data when it is no longer needed for purposes of the work for which Contractor has contracted to perform for the District. Contractor understands that any unauthorized disclosure of confidential student information is illegal as provided in FERPA and its implementing regulations. FERPA is specifically incorporated into the Texas Public Information Act as an exception to records which are subject to disclosures to the public (Texas Government Code, Chapter 552). . Ljhil Treatment Center, inc. Signed By: mc?k Title: ACocl . .. . . Printed Name: i; 2?16?dc5 id Date: (Dr 7 i EXHIBIT ACCESS AGREEMENT Under the terms of the Agreement between Shiloh Treatment Center, inc. ("Contractor?) and the Fort Bend Independent School District (?School District?), 1 am requesting access to confidential student Information. i understand that any unauthorized disclosure of confidential student information is illegal as provided in the Family Educational Rights and Privacy Act of 1974 (FERPA) and in the' implementing federal regulations found at 34 CFR, Part 99. I understand that any personal characteristics of a student that could make the student?s identity traceable are protected. In addition, I understand that any data sets or output reports that I may generate using confidential data are to be protected. 1 will not distribute to any unauthorized person any data sets or reports that i have access to or may generate using confidential data. I will not disclose any data analysis or report to any party without the consent of the District. I understand that lam responsible for any telephone or computer transactions performed as a result of access authorized by u'se of aiso understand that failure to observe these restrictions is prohibited by Texas Goyernrnent Code {$552352 and FERPA. Signed By: 3/02/14 Jaw (jaw/5% ?29 9' Title: CO L) . Printed Name: bed {19% U01 [Chip 10 EXHIBIT Contractor Certi?cation De?nitions Covered employees: Employees who have or will have continuing duties related to the service to be performed at the District and have or will have direct contact with students. The District will he the ?nal arbiter of what constitutes direct contact with students. Disqualijying criminal history: Any conviction or other criminal history information designated by the District, or one of the following offenses, if at the time of the offense, the victim was under 18 or enrolled in a public school: a felony offense under Title 5, Texas Penal Code; an offense for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; or an equivalent offense under federal law or the laws of another state. On behalf of Shiloh Treatment Center, Inc. (?Contractor?), I certify that [check one]: Contractor has no employees; Contractor provides services to the District as an individual and has or will have direct contact with students. Contractor certi?es that Contractor does not have a disqualifying criminal history. 0r None of Contractor?s employees are covered employees, as de?ned above. If this box is checked, I further certify that Contractor has taken precautions or imposed conditions to ensure that Contractor?s employees will not become covered employees. Contractor will maintain these precautions or conditions throughout the time the contracted services are provided. 02? Some or all of Contractor?s employee are covered employees. If this box is checked, I thither certify that: 1. Contractor has obtained all required criminal history record information regarding its covered employees. None of the covered employees has a disqualifying criminal history. 2. If Contractor receives information that a covered employee subsequently has a disqualifying criminal history, Contractor will immediately remove the covered employee from contract - duties and notify the District in writing within 3 business days. 3. Upon request, Contractor will provide the District with the name and any other requested information of covered employees so that the District may obtain criminal history record information on the covered employees. 4. If the District objects to the assignment of a covered employee on the basis of the covered employee?s criminal history record information, Contractor agrees to discontinue using the covered employee to provide services at the District. yepresenta ?o7gar ing this certi?cation may be grounds for contract termination. . '0 We Date /?N?c?nwc?n{pliance 11 EXHIBIT CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 1491, Both Leg.. Regular Session. OFFICE USE ONLY This questionnaire is being tited in accordance with Chapter 176, Local Government Code by a person who has a business relationship as defined by Section with a local Received governmental entity and the person meets requirements under Section By law this questionnaire must be filed with the records administrator of the locat governmental entity not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person commits an offense if the person knowingiy vioiates Section 176.006, Local Government Code. An offense under this section is a Class misdemeanor. Name of person who has a bueiness relationship with local gove)mentai entity. Elsi [Wk Wectbmewiw sexier Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you ?le an updated completed questionnaire with the appropriate tiling authority not later than the 7th business day after the date the originally fiied questionnaire becomes incomplete or inaccurate.) _l Ii Name of local government officerwith whom filer has employment or business relationship. Name of Of?cer This section (item 3 including subparts A, B, D) must be completed for each of?cer with whom the ?ier has an emptoyment or other business relationship as de?ned by Section Local Government Code. Attach additional pages to this Form 010 as necessary. A. is the toast government officer named in this section receiving or likely to receive taxable income, other than investment income, from the ?ier of the questionnaire? Yes El No E3. is the iiler of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government of?cer named in this section AND the taxable income is not received from the tonal governmental entity? Yes El No C, is the titer of this questionnaire emptoyed by a Corporation or other business entity with respect to which the local government officer serves as an of?cer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each employment or business reiaticnship with the iocal government of?cer named in this section. 5% ?ea/K; . ??gj 363/ 7 a" Signatur??offl?erson doing ElsinEsE?witiQhe 12 EXHIBIT FELONY CONVICTION NOTICE I, the undersigned Contractor or agent for the ?rm named above, certify that the information concerning noti?cation of felony convictions has been reviewed by me and the following information furnished is true to the best of my knowledge. The Contractor must complete the following information in accordance with state law. Please .9in only one: A. My ?rm is a publicly?held corporation, therefore, this repo1ting requirement is not applicable. Signature of Contractor Date OR B. My ?rm is nor 01371;: by ax?? Signature of Contractor: 4: or - Men convicted of a elony. 5 Date: gar/7: OR C. My ?rm is owned or operated by the following individual(s) who hasfhave been convicted of a felony. Name of Felon(s): Date: (attach additional Sheet ifnecassary) Details of Conviction(s): (attach additional sheet ifnecessary) Signature of Contractor: Date: 13 EXHIBIT SUSPENSION AND DEBARMENT CERTIFICATION Federal Law (A?l 02 Cominon Rule and OMB Circular prohibits non-federal entities from contracting with or making subawards under covered transactions to parties that are suspended or debarred or whose principals are suspended or debarred. Covered transactions include procurement contracts for goods or services equal to or in excess of $25,000 and all nonproeurement transactions subawards to subrecipients). Contractors receiving individual awards of $25,000 or more and all subrecipients must certify that their organization and its principals are not suspended or debarred by a federal agency. Before an award of $25,000 or more can be made to your ?rm, you must certify that your organization and its principals are not snap ended or debarred by a federal agency. I, the undersigned agent for the ?rm named below, certify that neither this ?rm nor its principals are suspended or debarred by a federal agency. SHEOH TREATMENT CENEER: .: 7 I Signature of Company Of?cial: 1/001 4/51: Date Signed: 7 I Printed name of company of?cial signing above: 6 (Cit?f 14 Relationships with Foreign Entities During the 85th Legislative Session (2017), the State of Texas enacted two additional requirements affecting all government contracts for goods and services. Ail government contracts for goods and services signed after September 1, 2017 must include required provisions from HB 89 (Certification Regarding lsrael), and language to implement SB 252 (Verification Regarding Terrorist Organizations]. Therefore, in compliance with HB 89 and SB 252 of the 85th Texas Legislative Session, Contractor agrees that: in accordance with Texas Government Code Chapter 2252, Subchapter F, Contractor certifies that it is not a company identified on the Texas Comptroller?s list of companies known to have contracts with, or provide supplies or services to, the Government of iran, the Government of Sudan, or a foreign organization designated as a Foreign Terrorist Organization by the US. Secretary of State. Contractor further certifies and verifies that, pursuant to Texas Government Code Chapter 2270, neither Contractor, nor any affiliate, subsidiary, or parent company of Contractor, if any (the "Contractor Companies?), boycotts Israel, and Contractor agrees that Contractor and Contractor Companies will not boycott israel during the term of Agreement with Fort Bend Name of Vendor (?Contractor?) 37969 66bltl?V We Mame/(716 7767? Mailing Address City State bra/mew oi UWU Coo "?th red by UK Title ,4MJja, ?a Signature Date Revised Dept. of Legai Services A ACOR CERTIFICATE OF LIABILITY INSURANCE SHILTRE-O1 ANNBERGFELD DATE 03I27I2018 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THEISSUING INSURERIS), AUTHORIZED IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy?es} must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in of such endorsemen?s). PRODUCER CT ?0 FEES. em: (210) 646-9870 1 F235. ?014210) 646-8418 San Antonio, TX 78218 EEHDQFIIESS: AFFORDING COVERAGE II American Insurance Company 33138 INSURED Mutual Insurance Com oanv 22945 Shiloh Treatment Center Inc. and Investments Inc. INSURERC: PHD. BOX 84469 INSURER D: Pearland, TX 77584 INSURER e: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TIE TYPE or INSURANCE I?sn?' POLICY NUMBER LIMITS A it? COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 I CLAIMS-MADE OCCUR 09i'26i'2017 oeizsizoi 8 50,0 00 MED EXP (Any one person} 5?000 PERSONAL INJURY ?000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE a 3?000?000 POLICY Iggf L00 PRODUCTS - COMPIOP AGO 1'000'000 OTHER: 3 AUTOMOBILE LIABILITY f5 ANY AUTO BODILY INJURY {Per person} OWNED SCHEDULED AUTOS ONLY AUTOS BODILY (Per accident) RED NON. ED ROPERTY DAMAGE A TOS ONLY AUTO FPer accident) 5 UMBRELLA LiAe OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION WORKERS COMPENSATION PER OTH- AND LIABILITY I 1 I STATUTE I ER ANY PROPRIETORIPARTNERIEXECUTIVE D3I14I2013 03? 4? 2019 EL EACH ACCIDENT 1.000.000 PFFICE IA 1 000 000 ?an? I E.L. DISEASE - EA EMPLOYEE lfges. describe under 1 000 000 SCRIPTION OF OPERATIONS beiow EL. DISEASE - POLICY LIMIT 5 i i A Professionat Liab. 09I26I2017 UQIZBIZOI 8 Per CIaim 1,000,000 DESCRIPTION OF OPERATIONS LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, ma be attached If more space regulred} . See attached Additional Insured Endorsement on the General Liability, Endorsemen 3. A Waiver of Subrogation is included on the Worker's Compensation. CERTIFICATE HOLDER CANCELLATION Fort Bend independent School District 16431 Lexington Blvd. Sugar Land, TX ?479 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (201 SIDS) ?1983?2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LANDMARK AMERICAN INSURANCE COMPANY This Endorsement Changes The Policy. Please Read It Carefully BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modi?es insurance provided underthe following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM - CLAIMS MADE AND REPORTED SCHEDULE Name of Person or Organization: Blanket when required by written contract. Any person or organization towhorn or to which you are obligated by virtue of a written contract or by the issuance or existence of a written permit, to provide insurance such as is afforded by this policy. A. SECTION ll - WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown on the SCHEDULE, but only with respect to liability for ?bodily injury?, ?properly damage? or ?personal and advertising injury" caused. in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insured, the following additional exclusions apply: This insurance does not apply to ?bodily injury? or ?property damage? occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of ?your work" out ofwhich the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part ofthe same project. This endorsement effective 9/26/2017 forms part of Policy Number issued to TREATMENT CENTER Endorsement No; 03 by Landmark American Insurance Company CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 1 Complete Nos. 1 4 and 8 if there are interested parties. OFFICE USE ONLY Complete Nosthere are no interested parties. CERTIFICATION OF FILING 1 Name of business entity tiling form, and the city, state and country of the business entity?s place Certificate Number: of bueiness. Shiloh Treatment Center Manvel, TX United States Bate Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 05(0412013 being filed. Fort Bend independent School District Date 3 Provide the identi?cation number used by the governmental entity or state agency to track or identity the contract. and provide a description at the services, goods. or other property to be provided under the contract. Speciei Education Services Nature of interest (cheek applicable) Controlling Intermediary Name of interested Party City. State? Country (place of business) Hiit. Clay Manvei. TX United States 5 Check only it there is NO Interested Party. 3 UNSWORN DECLARATION My name is 6 media I) (street) My address is 6a It ier i declare under oe aity of perjury that the foregoing is true and correct. 1 . and my date of birth is 09TX. 7757a it ?rth-trite (city) (state) (zip code) (country) County. State of if ,on the 5 day of.) MM (2018 . Executed in 3&0 . am ?we? th LAURA JAMIESON 3 ID #125539433 My Commission Expires 6? Jenuew12.2022 . . If"; Signature agent of contiacting bueiness entity (Declarant) Forms provided by Texas Ethics Commission Version V1.0.5523