HomeMy WebLinkAboutResolution - 2021-R0323 - Amendment No. 1 Contract 14220 with Benchmark Business Solutions 8.24.21Resolution No. 2021-R0323
Item No. 7.32
August 24, 2021
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and
on behalf of the City of Lubbock, Amendment No. 1 to Service Contract No. 14220 for
Workcentre printers and consumable supplies, by and between the City of Lubbock and
Benchmark Business Solutions of Lubbock, Texas, and related documents. Said Amendment is
attached hereto and incorporated in this resolution as if fully set forth herein and shall be
included in the minutes of the City Council.
Passed by the City Council on
AT EST:
. A I
Rebecca Garza, City Secretary
APPROVED AS TO CONTENT:
"fto_
Brooke Witcher, Assistant City Manager
APPROVED AS TO FORM:
-y
August 24, 2021
DANIEL M. POPE, MAYOR
RES.Amendment No. 1, Contract 14220-Benchmark Business Solutions
8.10.21
Resolution No. 2021-RO323
Amendment I Contract 14220
TIP'S Contract 180103
Contract Term
Monitoring Software
Electronic Invoicing
Smart Center
Analyst Serv.ces
Auto Quote
Special Provisions:
Benchmark
A Visual Edge Technology Company
Maintenance Agreement
Benchmark Business Solutions
BenchmarkYourOffice.com
Phone: (800) 378-9179
Fax: (800) 640-5514
New Equipment
[CUSTOMER (hereinafter referred to as "You" or "Your') DATE] 8/6/2021I
City of Lubbock
See Equipment Schedule
PO BOX 2000
1314 Ave K. Lubbock, TX 79457
Lubbock, TX 79457
Agreement Summary:
Lubbock
Lubbock
Device Model
Monthly
service Base
Amount
Serial
Number
',/known
Install Adress
'if different from above
Monthly Image
Allowance
Contract Usage Per
Image Charge
Plus Tax
B&W
COLOR
B&W
COLOR
C8155
$0.0059
$0 0483
C8145
$0.0059
$0 0483
B8155
$0.0059
TOTAL CONSOLIDATED MONTHLY IMAGE ALLOWANCE AND CONTRACT USAGE PER IMAGE CHARGES
(IF CONSOLIDATED)
Agreement Options
Billing Frequency Monthly
LEASE
YES/$0
YES
NO
YES
Included: All Travel, Parts and Labor (including drums, PM kits, toner and developer), Access to the Benchmark
Smart Center
Not Included: Paper, Staples, Exterior Plastic, and Glass
"Installation of monitoring software is required for all print devices as specified In the full terms and
conditions. Failure to provide access to monitoring software, will result in a $10 monthly admin fee per device
for manual meter collection. - , please understand that all service, supplies and meter reads
will be a manual process requiring input from you the customer -
"Base Charges are billed in Advance and Overage is billed in Arrears
—Billing payment period is monthly unless otherwise indicated
"'$10 per device Includes: Set up of print drivers on new computers, install network scanning on server, install
Scan -To -PC software, setup scan to email, setup fax & LAN fax, setup equipment accounting.
**When monitoring software alerts Benchmark that new equipment has been installed a specialist will
automatically send you a quote to add the device to a service agreement.
Agreement p 1688942 - see equipment schedule for locations
wH.—ULUNUTION5 RHIN IEU ON THIS PAGE, THE REVERSE SIDE, ATTACHED EQUIPMENT.IST, ANY APPLICABLE ADDENDUMS, ALL OF WHICH PERTAIN TO THIS
AGREEMENT AND WHICH YOU ACXNO,WNGE HAVING READ. TH:S AGREEMENT IS NOT BIND NG UNTIL ACCEPT-D BY US. YOU CERTIFY ALL ACTIONS REQUIRED TO AUTHORIZE EXECUTION OF THIS
AGREEMENT, INCLUDING YOUR AUT RITY, AVE BEEN FULFILLED
JSTOMER: (As Stated Above)
By. X August 24, 2021
Date Acceptft
Signature VXNIEL M. POPE, -MA
ATTESY k APPROV 'D AS TO FO
Rebecca ecretary
R n broke, si tant City Attorney
AS TO CONTENT:
James Brown —,Chief Information Officer
Powered by SUPPLEMENT
VISUAL
EDGEMASTER AGREEMENT NO. APPLICATION NO. CONTRACT/SUPPLEMENT NITO.
1406485-000 1688942
CUSTOMER. OR -
FULL LEGAL NAME: Lubbock, City of
ADDRESS:1314 Avenue K Lubbock, TX 79401
REFERS TO THE AGREEMENT BETWEEN YOU AND US IDENTIFIED IN OUR RECORDS BY THE MASTER AGREEMENT NO. AROVF
DESCRIPTIONOF
•I IIPMENT ADD-ED OR AMENDED
® SEE ATTACHED EQUIPMENT OR GROUP BILLING SCHEDULE
MAKE, MODEL NUMBER, INCLUDED ACCESSORIES &
AMENDED SERIAL NO.
NOT
FINANCED
UNDER THIS
AGREEMENT
BEGINNING METER
READING
MONTHLY IMAGE
ALLOWANCE
EXCESS PER IMAGE
CHARGE PLUS TAX
B&W
7OLOR
B&W
COLOR
B&W
COLOR
❑
❑
❑
❑
❑
❑
❑
TOTAL CONSOLIDATED MONTHLY IMAGE ALLOWANCE AND EXCESS PER IMAGE CHARGES
• WIVOvuunl w ALLUVV w,ta ANU tAL t55 rtH IMAGt AMUUN I 5HUWN ABOVE (CHECK ONE): LJ APPLY TO EQUIPMENT LISTED UNDER THIS SUPPLEMENT ONLY ® APPLY
TO EQUIPMENT LISTED UNDER THIS SUPPLEMENT TOGETHER WITH EQUIPMENT LISTED ON THE MASTER AGREEMENT AND ANY APPLICABLE SUPPLEMENT(S), OR ❑ ARE NOT
LISTED, BECAUSE IMAGES ON THE LISTED EQUIPMENT WILL COUNT TOWARDS THE EXISTING CONSOLIDATED ALLOWANCES AND EXCESS UNDER THE MASTER AGREEMENT OR
APPLICABLE SUPPLEMENT(S)
IF THE AMENDED BOX IS CHECKED NEXT TO. A) INDIVIDUAL ITEM(S) OF EQUIPMENT AND/OR B) THE TOTAL CONSOLIDATED AMOUNTS, THE ALLOWANCE AND EXCESS PER IMAGE
CHARGES ARE MODIFIED ONLY TO THE EXTENT NOTED ABOVE,
EQUIPMENT LOCATION: See the attached a UI ment schedule for locations METER FREQUENCY: Monthl
DESCRIPTION OF •UIPMENT REMOVED
CUSTOMER ENDING METER READING
MAKE, MODEL NUMBER, INCLUDED ACCESSORIES & SERIAL NO. OWNED B&W COLOR
PAYMENT tCHECK ONE OPTION)
® MONTHLY BASE PAYMENT AMOUNT*; $9,510.00 (INCLUDES AMOUNTS DUE UNDER THIS SUPPLEMENT ONLY) ('PLUS TAX)
❑ TOTAL CONSOLIDATED MONTHLY BASE PAYMENT AMOUNT': $ (INCLUDES AMOUNTS DUE UNDER THIS SUPPLEMENT, THE MASTER
AGREEMENT, AND ANY OTHER APPLICABLE SUPPLEMENTIS) DURING THE TF RM THFRFnF%
❑ TERM: THE END OF THE TERM OF THIS SUPPLEMENT IS THE END OF TERM OF THE MASTt R AGREEMENT (COTERMINOUS)
® TERM IN MONTHS: 117 (APPLIES TO THIS SUPPLEMENT ONLY)
If this Supplement relates to Equipment not subject to the Master Agreement (i.e., additional Equipment), this Supplement, together with the preprinted terms of the Master Agreement
(as amended), constitutes an agreement between you and us with respect to the Equipment referenced herein, separate and distinct from the Master Agreement You agree to be
bound by the terms of this Supplement, which includes the preprinted terms of the Master Agreement (as amended) and agree this Supplement shall commence on the date of our
acceptance. The parties agree that this Supplement and any related documents hereto may be authenticated by electronic means. The parties agree that the anginal hereof for
enforcement and perfection purposes, and the sole "record" constituting "chattel paper" under the UCC, is the paper copy hereof bearing (i) the original or a copy of either your manual
signature or an electronically applied indication of your intent to enter into this Supplement, and (ii) our original manual signature. You agree not to raise as a defense to the
enforcement of this Supplement or any related documents that you executed or authenticated such documents by electronic or digital means or that you used facsimile or other
electronic means to transmit your signature on such documents. Notwithstanding anything to the contrary herein, we reserve the right to require you to sign this Supplement or any
related documents hereto manually. If any provision in this Supplement conflicts with a provision in the Master Agreement, the provision in this Supplement shall control
If this Supplement relates to Equipment subject to the Master Agreement (i.e. replaced or removed Equipment and/or payment modifications), the Master Agreement shall be modified
or supplemented as set forth above as of the date we accept this Supplement. Except as specifically modified by this Supplement, all other terms and conditions of the Master
Agreement (as amended) remain in full force and effect.
Benchmark Business Solutions
OWNER SIGNATURE PRINT NAME & TITLE DATE
UNCONDITIONAL
The undersigned, jointly and severally if more than one, unconditionally guarantee(s) that the Customer will timely perform all ob' gations under the above Supplement. The undersigned also we ve(s) any notification if the
Customer is in default and consent(s) to any extensions or modifications granted to the Customer. In the event of default, the undersigned vri!i immediately pay all sums due under the terms of the Supplement without requiring
us or our assignee to proceed against Customer or any other party or exercise any rights in the Equipment. The undersigned authorizes us or our assignee to obtain credit bureau reports for cred t and col edon purposes and
to share them with our aW aces and agents Within 30 days after our request, you will deliver all requested information (including tax returns) which we deem reasonably necessary to determine your current financial condition
and faithful performance of the terms hereof THE UNDERSIGNED, AS TO THIS GUARANTY, AGREE(S) TO THE DESIGNATED FORUM AND CONSENT(S) TO PERSONAL JURISDICTION, VENUE, AND CHOICE OF
LAW AS STATED IN THE MASTER AGREEMENT, AGREE(S) TO PAY ALL COSTS AND EXPENSES, INCLUDING ATTORNEY FEES, INCURRED BY US OR OUR ASSIGNEE RELATED TO THIS GUARANTY AND
THE SUPPLEMENT, WAIVE(S) A JURY TRIAL AND TRANSFER OF VENUE.
SIGNATURE: X INDIVIDUAL: DATE
SIGNATURE: X INDIVIDUAL: DATE-
VET-SW-VUP0306A 0221
Powered by
VISUAL
E'DG E
'T
EQUIPMENT SCHEDULE
AGREEMENT NO.: 1688942
DESCRIPTIOA OF •
NOT
FINANCED
UNDERTHIS
MAKE, MODEL NUMBER & INCLUDED ACCESSORIES SERIAL NO. AGREEMENT
BEGINNING METER
READING
MONTHLY IMAGE
ALLOWANCE
EXCESS PER IMAGE
CHARGE PLUS TAX
I B&W
I COLOR
B&W
COLOR
B&W
COLOR
B8155 —Animal Services ❑
1
.0059
3323 SE Loop 289 Lubbock, TX 79401 ❑
C8155 — Silent Wings Museum ❑
.0059
.0483
6202 North 1-27 Lubbock, TX 79415 ❑
C8155 — LP&L Business Center ❑
.0059
.0483
1301 Broadway Lubbock, TX 79401 ❑
C8155 — LP&L Business Center ❑
.0059
.0483
1301 Broadway Lubbock, TX 79401 ❑
C8155 — LP&L Business Center ❑
.0059
.0483
1301 Broadway Lubbock, TX 79401 ❑
C8145 — East Police Sub -Station ❑
.0059
.0483
1901 East 191h Street Lubbock, TX 79401 ❑
C8145 — East Police Sub -Station ❑
.0059
.0483
1901 East 19" Street Lubbock, TX 79401 ❑
C8145 — East Police Sub -Station ❑
.0059
.0483
1901 East 191 Street Lubbock, TX 79401 ❑
C8145 — North Police Sub -Station ❑
.0059
.0483
5910 Erskine Street Lubbock, TX 79416 ❑
C8145 — North Police Sub -Station ❑
.0059
.0483
5910 Erskine Street Lubbock, TX 79416 ❑
C8145 — North Police Sub -Station ❑
.0059
.0483
5910 Erskine Street Lubbock, TX 79416 ❑
C8145 — South Police Sub -Station ❑
.0059
.0483
14005 Indiana Avenue Lubbock, TX 79423 ❑
C8145 — South Police Sub -Station ❑
.0059
.0483
14005 Indiana Avenue Lubbock, TX 79423 ❑
C8145 — South Police Sub -Station ❑
1
.0059
.0483
14005 Indiana Avenue Lubbock, TX 79423 ❑
TOTAL CONSOLIDATED MONTHLY IMAGE ALLOWANCE AND EXCESS PER IMAGE CHARGES IF CONSOLIDATED
The undersigned acknowledges having received a copy of this
indication of your intent to agree to the terms set forth herein, sF
of I X
VETSW-VUP0305A-0221 PAGE 1 OF 1
this document containing your original or facsimile signature, or other
DANIEL M. POPE, MAYOR August 24, 2021
GENERALTERMS Maintenance Terms & Conditions
1. De nito ns. T e words "you" and "your' mean the legal entity identified in "Customer Information" fields above, and "we," "us" and "our" mean Benchmark Business
Solutions, Inc. "Device(s)" means the items identified in "Equipment" above and in any attached Equipment Schedules, or future Addendums. "Base" rates refer to
static monthly charges for service. "Allowance" means the number of copies included in the Base charge. "Useage Per Image Charge" means the applicable prints or
copies made in excess of any stated allowance.
2. Payments and Late Payments. You agree to pay us the full amount due for all Base charges, Usage charges, and billable service or supply charges by the due date listed
on the Invoice. If any amount payable to us is not paid when due, you will be subject to interruption of covered services and a late charge up to three (3) percent of the
overdue balance. Billing disputes must be submitted to us no later than the due date listed on the invoice to avoid late charges or service interruption. ACH or Credit
Card draft payment method may be required for certain coverage plans or contract terms.
3. Renewal. We may annually increase both the Base rate and Overage rates by amounts determined at our discretion, but not to exceed IS% of the then current payment
and/or rate in each year.
4. Term. The term of this agreement will be based on the length selected above or based on the length of active lease agreements, whichever is longer. Minimum term
requirements may vary based on equipment lease agreements and selected coverage plans. Commencement date and coverage will begin on the date of new
equipment installation or ten (business days) from the date of confirmed monitored status, whichever is later.
S. Covered Equipment. Services selected above will be provided to those devices listed under Equipment.
6. Cancellation Notice. We maintain responsibility covered under customer selected services for the full term of this agreement until either party provides written notice
of cancellation with 60-days' notice. If your agreement term is based on an active equipment lease agreement, all lease terms and conditions must be met before
cancellation requests are accepted. If we elect to cancel this agreement, written notice will be sent to the contact and address listed above.
7. Liability. The parties agree that we will not be liable for any consequential damages of any nature caused to the business or property of Owner of Equipment
("Company") by any failure, defect, or malfunction of equipment to be maintained by us.
8. WARRANTY. NOTWITHSTANDING ANYTHING IN THIS AGREEMENT TO THE CONTRARY, WE WARRANT (A) THAT ALL PERSONNEL PERFORMING SERVICES HEREUNDER BY
OR ON BEHALF OF US WILL HAVE APPROPRIATE TRAINING AND EXPERIENCE AND (B) ALL EQUIPMENT 15 IN ACCORDANCE WITH INDUSTRY STANDARDS, AND ALL
SUPPLIES AND MATERIALS ARE OF GOOD QUALITY. WITHOUT LIMITING THE GENERALITY OF THE FOREGOING (AND WITHOUT LIMITING ANY OBLIGATION OF US TO
MAKE REPAIRS UNDER THIS AGREEMENT), YOU EXPRESSLY AGREE AND ACKNOWLEDGE THAT IN NO EVENT SHALL ANY MANUFACTURER'S WARRANTY, INCLUDING BUT
NOT LIMITED TO ANY IMPLIED WARRANTY OF MERCHANTABILITY, AND FITNESS FOR A PARTICULAR PURPOSE, BE DEEMED GIVEN BY OR OTHERWISE TRANSFERRED OR
APPLIED TO US.
9. EQUIPMENT WARRANTY DISCLAIMER. WE HAVE MADE NO AFFIRMATION OF FACT OR PROMISE RELATING TO THE GOODS AND SERVICES BEING PROVIDED THAT HAS
BECOME ANY BASIS OF THIS BARGAIN. FUTHER, WE HAVE MADE NO AFFIRMATION OF FACT OR PROMISE RELATING TO THE GOODS OR SERVICES BEING PROVIDED
THAT HAS CREATED OR AMOUNTED TO AN EXPRESS WARRANTY THAT THE GOODS WOULD CONFORM TO ANY SUCH AFFIRMATION OR PROMISE. WE DISCLAIM ANY
WARRANTY OF MERCHANTABILITY WITH RESPECT TO THE GOODS OR SERVICES PROVIDED BY THIS AGREEMENT. WE DISCLAIM ANY WARRANTY OF FITNESS FOR ANY
PARTICULAR PURPOSES WHATSOEVER WITH RESPECT TO THE GOODS OR SERVICES BEING PROVIDED UNDER THIS AGREEMENT. COMPANY AGREES THAT WE SHALL
NOT BE LIABLE FOR DAMAGES RESULTING FROM AN ALLEGED BREACH OF THIS AGREEMENT BEYOND THE COST OF ONE YEARS SERVICE AND MAINTENANCE UNDER
THIS AGREEMENT.
20. GOVERNING LAW, CONSENT TO JURISDICTION AND VENUE OF LITIGATION. THIS AGREEMENT AND EACH SCHEDULE SHALL BE GOVERNED BY THE LAWS OF THE STATE
OF TEXAS. YOU AGREE THAT ANY DISPUTE ARISING UNDER OR RELATED TO THIS AGREEMENT WILL BE ADJUDICATED IN THE FEDERAL OR STATE COURT LOCATED IN
LUBBOCK COUNTY TEXAS. YOU HEREBY CONSENT TO PERSONAL JURISDICTION AND VENUE IN THAT COURT AND WAIVE ANY RIGHT TO TRANSFER VENUE. EACH PARTY
WAIVES ANY RIGHT TO A TRIAL BY JURY.
BREAK/FIX SERVICE TERMS
1. We agree to maintain all equipment listed, in a normal operating condition. All costs for Labor, Parts, Travel and Service will be borne by us, subject to the terms of this
agreement and based on specific plan options selected. Non -covered charges for labor, parts, or travel will be billed at the then current rates.
2. All necessary parts will be replaced, at no additional cost, provided the cost of those parts does not exceed the total value of the equipment. If the cost of necessary
parts exceeds the total value of the equipment, we will notify you with suggested replacement options. Replacement cost is your responsibility. If the replacement is
purchased from us, a trade-in credit may be offered toward the cost of a new device.
3. We will not be responsible for maintenance in the event of: Damage caused by Accident, Misuse, Act of God, Line Voltage Problems, Neglect or Failure To Follow Factory
Operating Instructions, or if maintenance or repairs are performed by anyone other than our personnel. It also ceases if competitive supplies are used, or if the damage
occurs as a result of your abuse or improper handling of the device or supplies.
4. All equipment will be serviced upon your request, during our normal business hours (8 a.m. to 5 p.m. local time, except weekends and holidays). Request for service
outside our normal business hours will be provided on a best effort basis and, if available, will be billed at overtime rates plus travel.
5. We, at our discretion, may authorize our approved maintenance subcontractors or approved service providers to perform maintenance and repairs to the Devices
Devices located outside our local service areas will require subcontractor coverage for any onsite service needed.
TONER AND SUPPLY TERMS
1. All cost for toner and ink consumables, and standard shipping will be borne by us for all devices covered by this agreement and actively reporting through the
Monitoring Software. We agree to supply you with all toner and ink consumables required to operate the Devices. We agree to provide auto supply replenishment for
those devices using Monitoring Software. You must purchase staples and paper separately.
2. All toner and ink consumables provided as a part of this agreement in the standard course of business or as Safety Stock shall at all times remain our property. You may
use the toner and ink consumables pursuant to the terms of this Agreement, but you shall not have any ownership rights in or to the toner or ink consumables. You
shall promptly return to us all unused items supplied by us under this agreement. You shall not be charged for any toner or ink consumables in use upon the expiration
or termination of this Agreement. Any items not returned shall be billed by us to you at the then current cartridge retail purchase price.
3. Auto supply replenishment is scheduled based on individual device performance, coverage, and usage, and may vary. Waste Toner Containers are not available for auto
shipment. Other certain items may not be eligible for auto shipment based on device model and supply item type. Covered items not eligible for auto shipment will be
provided at no additional cost, but must be requested by you as needed to allow for standard shipping time. Additional requests for toner and ink consumables will be
subject to approval based on current usage and shipment history. Any customer request for additional items will be considered Safety Stock unless otherwise
approved. Flat rate overnight shipping amounts can be quoted at the time of order.
4. Cost -per -image and cartridge pricing is based on an industry -standard 5% page coverage model. Toner and ink consumables ordered or requested based on excessive
page coverage may be subject to a mid-term cost -per -image escalation or billing for additional cartridges.
S. Any defective toner or ink consumable items provided to you by us must be reported and returned to us within 30 days of receiving a replacement item. If defective
item is not returned, the replacement item may be billed at then current retail price. Standard shipping for defective items and replacements will be covered by us.
METER READING REQUIREMENTS
Mont ly meter readings are required for each covered device.
1. Meter collection. Those devices reporting through Monitoring Software will be collected by us. Devices not reporting for any reason will require your submission until
monitoring is restored.
2. Estimated Meters. Estimated meters are based on historical volume usage. If historical volume usage is unavailable, a minimum estimation of 50 mono impressions will
be applied. If estimated meters are issued for three (3) consecutive billing cycles, you may become subject to invoicing monthly data collection fees and prevailing
hourly billable rate for labor and travel to collect accurate meter readings.
3. Meter Adjustments. Any billing issued based on estimated meters are not eligible for billing adjustments, but will not be responsible for additional overage charges until
current meters exceed billed meters. Additional estimations will cease until such time that the current meters exceed previously billed estimates, as long as accurate
meters are being submitted monthly.
MONITORING SOFTWARE. Monitoring Software is involved, You grant Permission to Install and Maintain.
1. Customer Refusal or on -Response. Customers refusing these Monitoring Software terms or not -responding to our requests for installations or updates may disqualify
printing devices from certain coverage, delay existing services, or become subject to invoicing monthly data collection fees and prevailing hourly billable rate for labor
to collect meter readings.
2. Device Changes. You agree to notify us in writing of any contact person or location changes regarding covered devices. You assume responsibility for estimated meter
readings, delayed service and supply fulfillment in the case of device changes not reported.
ANALYST CONSULTING & SMART CENTER ANALYST SERVICES
1. I Ana yst Consu tmg services are included in the pure ase of a printing device from us, our trained and certified employees will work with your IT personnel (if
applicable) to setup all covered equipment and software, according to machine configuration, following equipment delivery for the first ninety (90) days following
installation. Following the completion of those 90 days or in the case that Analyst services were not included in the Purchase Agreement, you will be responsible to
complete the work yourselves or agree to pay us to provide the work at standard billable rates.
2. Smart Center Analyst Services are considered separate and apart from Break/Fix technical services
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
lofl
Complete Nos. 1- 4 and 6 if there are interested parties.
OFFICE USE ONLY
Complete Nos.1, 2, 3, 5, and 6 if there are no interested parties.
CERTIFICATION OF FILING
Certificate Number:
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2021-793098
Visual Edge, Inc. DBA Benchmark Business Solutions
Lubbock, TX United States
Date Filed:
08/20/2021
2
Name of governmental entity or state agency that is a party tot the contract for which the form is
being filed.
City of Lubbock
Date Acknowledged:
08/20/2021
3
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
14220
Copier and Printer Services
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
5
Check only if there is NO Interested Parry.
X
6
UNSWORN DECLARATION
My name is and my date of birth is
My address is ,
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of . 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc