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Job No.: 12/0309 Attachment a

TAX FORM/DEBT/ RESIDENCE CERTIFICATION

(for Advertised Projects)

Taxpayer Identification Number (T.I.N.):

Company Name submitting Bid/Proposal:

Mailing Address:

Are you registered to do business in the State of Texas? Yes No

If you are an individual, list the names and addresses of any partnership of which you are a general partner or any

assumed name(s) under which you operate your business

I. Property: List all taxable property in Harris County owned by you or above partnerships as well as any d/b/a

names. (Use a second sheet of paper if necessary.)

Harris County Tax Acct. No.* Property address or location**

* This is the property account identification number assigned by the Harris County Appraisal District.

** For real property, specify the property address or legal description. For business personal property, specify the

address where the property is located. For example, office equipment will normally be at your office, but inventory

may be stored at a warehouse or other location.

II. Harris County Debt - Do you owe any debts to Harris County (taxes on properties listed in I above, tickets,

fines, tolls, court judgments, etc.)?

Yes No If yes, attach a separate page explaining the debt.

III. Residence Certification - Pursuant to Texas Government Code §2252.001 et seq., as amended, Harris County

requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the

awarding of governmental contracts; pertinent provisions of §2252.001 are stated below:

(3) "Nonresident bidder" refers to a person who is not a resident.

(4) "Resident bidder" refers to a person whose principal place of business is in this state, including a

contractor whose ultimate parent company or majority owner has its principal place of business in

this state.

I certify that is a Resident Bidder of Texas as defined in Government Code

[Company Name]

§2252.001.

I certify that is a Nonresident Bidder as defined in Government Code

[Company Name]

§2252.001 and our principal place of business is .

[City and State]

Revised 11/09

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