HomeMy WebLinkAboutResolution - 2022-R0022 - PO 31063554 with Altec Industries, Inc.Resolution No. 2022-R0022
Item No. 7.32
January 11, 2022
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, Purchase Order 31063554, as per Sourcewell Contract
#012418-ALT, for a 50' Aerial Bucket Truck for Lubbock Fire and Rescue, by and between the
City of Lubbock and Altec Industries, Inc. of Odessa, Texas, and related documents. Said
Purchase Order 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 January 11, 2022
DANIEL M. POPE, MAYOR
ATTEST:
f P
-WJA ¢_ )C
Rebe a Garza, City Seer"
APPROVED AS TO CONTENT:
Erik Rejino, Assistant City Manager
APPROVED AS TO FORM:
Ryan ro e, Assistant City Attorney
RESTO 31063554 Altec Industries, Inc.
12.23.21
AIA,,` City of
Lubbock
TEXAS
PURCHASE ORDER
TO: ALTEC INDUSTRIES INC
13107 W 1-20 E
ODESSA TX 79766
Page - 1
Date - 12/14/2021
Order Number 31063554 000 OP
Branch/Plant
SHIP TO: CITY OF LUBBOCK
FLEET SERVICES
206 MUNICIPAL DRIVE
LUBBOCK TX 79404
INVOICE TO: CITY OF LUBBOCK
ACCOUNTS PAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 BY:
*,ltAll,,ectorof Purchasing & Contract Management
Ordered 12/14/2021 Freight
Requested 4/10/2024 Taken By K MORGAN
Delivery PER N DODSON REQ 58206 SOURCEWELL CONTRCT 012418-ALT /PUR 16331
Ifyou have any questions about this order, please contact Natalie Dodson at 806-775-2374 or via email at
NDodson@mylubbock.us
Description/Supplier Item Ordered Unit Cost LIM Extension Request Date
Articulating Telescopic Aerial Device 1.000 189,416.0000 EA 189,416.00 4/10/2024
Insulated w/ Options
Total Order
Terms NET DUE ON RECEIPT
E gwe,TamLq§LVL$ i I' a
189,416.00
3526
Commercial General Liability, per occurrence- $1,000,000
Automotive Liability- Combined Single limit for Any Auto -
General Aggregate.
$1,000,000
Products-Comp/Op AGG
Personal & Adv. Injury
Cargo - 1,000,000
Contractual Liability
Med Exp (Any one Person)
Worker's Compensation Amounts- $500,000 or Employer's
Liability. Copies of endorsements are required.
City of Lubbock is named as an additional insured on a primary and non-contributory basis with a waiver of subrogation in favor of the
City of Lubbock on liability coverages. To include products of completed operations endorsements. Waiver of subrogation provided on
the workers' compensation.
This pulchase order encumbers funds in the amount of $189,416.00 awarded to Altec Industries, Inc. of Odessa, TX,
on January 11 2022. The following is incorporated into and made part of this purchase order by reference: Quote dated
December 5, 2021, from Altec Industries, Inc. of Odessa, TX, and Sourcewell Contract 012418-ALT:
Resolution # 2022-R0022
CITY OF LUBBOCK
Daniel M. Pope, Mayor
ATTEST:
'w'u" X�
Rebec a Garza, City Secretary
Rev. 9/2021
Seller and Buyer agree as
follows:
PURCHASE ORDER
TERMS AND CONDITIONS
IMPORTANT: READ CAREFULLY
STANDARD TERMS AND CONDITIONS
CITY OF LUBBOCK, TX
1. SELLER TO PACKAGE GOODS. Seller will package goods in accordance with good commercial practice.
Each shipping container shall be clearly and permanently marked as follows (a) Seller's name and address,
(b) Consignee's name, address and purchase order or purchase release number and the supply agreement number
if applicable, (c) Container number and total number of containers, e.g. box I of 4 boxes, and (d) the number
of the container bearing the packing slip. Seller shall bear cost of packaging unless otherwise provided. Goods
shall be suitably packed to secure lowest transportation costs and to conform with requirements of common
carriers and any applicable specifications. Buyer's count or weight shall be final and conclusive on shipments
not accompanied by packing lists.
2. SHIPMENT UNDER RESERVATION PROHIBITED. Seller is not authorized to ship the goods under
reservation and no tender of a bill of lading will operate as a tender of goods.
3. TITLE AND RISK OF LOSS. The title and risk of loss of the goods shall not pass to Buyer until Buyer
actually receives and takes possession of the goods at the point or points of delivery.
4. NO REPLACEMENT OF DEFECTIVE TENDER Every tender of delivery of goods must fully comply
with all provisions of this contract as to time of delivery, quality and the like. If a tender is made which does
not fully conform, this shall constitute a breach and Seller shall not have the right to substitute a conforming
tender, provided, where the time for performance has not yet expired, the Seller may reasonably notify Buyer
of his intention to cure and may then make a conforming tender within the contract time but not afterward.
5. INVOICES & PAYMENTS. a. S e 11 e r shall submit separate invoices, in duplicate, one each purchase
order or purchase release after each delivery. Invoices shall indicate the purchase order or purchase release
number and the supply agreement number if applicable. Invoices shall be itemized and transportation charges,
if any, shall be listed separately. A copy of the bill of lading, and the freight waybill when applicable, should
be attached to the invoice. Mail To: Accounts Payable, City of Lubbock, P. 0. Box 2000. Lubbock, Texas
79457. Payment shall not be due until the above instruments are submitted after delivery.
6. GRATUITIES. The Buyer may, by written notice to the Seller, cancel this contract without liability to
Seller if it is determined by Buyer that gratuities, in the form of entertainment, gifts or otherwise, were offered
or given by the Seiler, or any agent or representative of the Seller, to any officer or employee of the City of
Lubbock with a view to securing a contract or securing favorable treatment with respect to the awarding or
amending, or the making of any determinations with respect to the performing of such a contract. In the event
this contract is canceled by Buyer pursuant to this provision, Buyer shall be entitled, in addition to any other
rights and remedies, to recover or withhold the amount of the cost incurred by Seller in providingsuch gratuities.
7. SPECIAL TOOLS & TEST EQUIPMENT. If the price stated on the face hereof includes the cost of any
special tooling or special test equipment fabricated or required by Seller for the purpose of filling this order,
such special tooling equipment and any process sheets related thereto shall become the property of the Buyer
and to the extent feasible shall be identified by the Seller as such.
8. WARRANTY -PRICE. a. The price to be paid by the Buyer shall be that contained in Seller's bid
which Seller warrants to be no higher than Seller's current process on orders by others for products of the kind
and specification covered by this agreement for similar quantities under similar of like conditions and methods
of purchase. In the event Seller breaches this warranty, the prices of the items shall be reduced to the
Seller's current prices on orders by others, or in the alternative. Buyer may cancel this contract without
liability to Seller for breach or Seller's actual expense. b. The Seller warrants that no person or selling agency
has been employed or retained to solicit or secure this contract upon an agreement or understanding for
commission, percentage, brokerage, or contingent fee excepting bona fide employees of bona fide established
commercial or selling agencies maintained by the Seller for the purpose of securing business. For breach of
vitiation of this warranty the Buyer shall have the right in addition to any other right of rights to cancel this
contract without liability and to deduct from the contract price, or otherwise recover without liability and to
deduct from the contract price, or otherwise recover the full amount of such commission, percentage, brokerage
or contingent fee.
9. WARRANTY -PRODUCT. Seller shall not limit or exclude any implied warranties and any attempt to do
so shall render this contract voidable at the option of the Buyer. Seller warrants that the goods furnished will
conform to the specification, drawings, and descriptions listed in the bid invitation, and to the samples) furnished
by the Seller, if any. In the event of a conflict or between the specifications, drawings, and descriptions, the
specifications shall govern. Notwithstanding any provisions contained in the contractual agreement, the Seller
represents and warrants fault -free performance and fault -free result in the processing date and date related data
(including, but not limited to calculating, comparing and sequencing) of all hardware, software and firmware
products delivered and services provided under this Contract, individually or in combination, as the case may
be from the effective date of this Contract. The obligations contained herein apply to products and services
provided by the Seller, its sub- Seller or any third party involved in the creation or development of the products
and services to be delivered to the City of Lubbock under this Contract. Failure to comply with any of the
obligations contained herein, may result in the City of Lubbock availing itself of any of its rights under the
law and under this Contract including, but not limited to, its right pertaining to termination or default. The
warranties contained herein are separate and discrete from any other warranties specified in this Contract,
and are not subject to any disclaimer of warranty, implied or expressed, or limitation of the Seller's liability
which may be specified in this Contract, its appendices, its schedules, its annexes or any document incorporated
in this Contract by reference.
10. SAFETY WARRANTY. Seller warrants that the product sold to the Buyer shall conform to the standards
promulgated by the U. S. Department of Labor under the Occupational Safety and Health Act of 1970. In the
event the product does not conform to OSHA standards, Buyer may return the product for correction or
replacement at the Seller's expense. In the event Seller fails to make the appropriate correction within a
reasonable time, correction made by Buyer will be at the Seller's expense.
11. NO WARRANTY BY BUYER AGAINST INFRINGEMENTS. As part of this contract for sale Seller
agrees to ascertain whether goods manufactured in accordance with the specifications attached to this agreement
will give rise to the rightful claim of any third person by way of infringement of the like. Buyer makes no
warranty that the production of goods according to the specification will not give rise to such a claim, and in no
event shall Buyer be liable to Seller for indemnification in the event that Seller is sued on the grounds of
infringement of the like. If Seller is of the opinion that an infringement or the like will result, he will notify the
Buyer to this effect in writing within two weeks after the signing of this agreement. If Buyer does not receive
notice and is subsequently held liable for the infringement or the like, Seller will save Buyer harmless. If
Seller in good faith ascertains the production of the goods in accordance with the specifications will result in
infringement or the like, the contract shall be null and void.
12. NON APPROPRIATION. All ftmds for payment by the City under this contract are subject to the
availability of an annual appropriation for this purpose by the City. In the event of nonappropriation of funds
by the City Council of the City of Lubbock for the goods or services provided under the contract, the City will
terminate the contract, without termination charge or other liability, on the last day of the then -current fiscal
year or when the appropriation made for the then -current year for the goods or services covered by this contract
is spent, whichever event occurs first. If at any time funds are not appropriated for the continuance of this
contract, cancellation shall be accepted by the Seller on thirty (30) days prior written notice, but failure to give
such notice shall be of no effect and the City shall not be obligated under this contract beyond the date of
termination.
13. RIGHT OF INSPECTION. Buyer shall have the right to inspect the goods at delivery before accepting
them.
14. CANCELLATION. Buyer shall have the right to cancel for default all or any part of the undelivered
portion of this order if Seller breaches any of the terms hereof including warranties of Seller or if the Seller
becomes insolvent or commits acts of bankruptcy. Such right of cancellation is in addition to and not in
lieu of any other remedies which Buyer may have in law or equity.
1 S. TERMINATION. The performance of work under this order may be terminated in whole, or in part by the
Buyer in accordance with this provision. Termination of work hereunder shall be effected by the delivery
of the Seller of a "Notice of Termination' specifying the extent to which performance of work under the
order is terminated and the date upon which such termination becomes effective. Such right or termination is
in addition to and not in lieu of the rights of Buyer set forth in Clause 14, herein.
16. FORCE MAJEURE. Neither party shall be held responsible for losses, resulting if the fulfillment
of any terms of provisions of this contract is delayed or prevented by any cause not within the control of the
party whose performance is interfered with, and which by the exercise of reasonable diligence said party is
unable to prevent.
17. ASSIGNMENT -DELEGATION. No right or interest in this contract shall be assigned or delegation of
any obligation made by Seller without the written permission of the Buyer. Any attempted assignment or
delegation by Seller shall be wholly void and totally ineffective for all purpose unless made in conformity with
this paragraph.
18. WAIVER No claim or right arising out of a breach of this contract can be discharged in whole or in part
by a waiver or renunciation of the claim or right unless the waiver or renunciation is supported by
consideration and is in writing signed by the aggrieved parry.
19. INTERPRETATION -PAROLE EVIDENCE This writing, plus any specifications for bids and
performance provided by Buyer in its advertisement for bids, and any other documents provided by
Seller as part of his bid, is intended by the parties as a final expression of their agreement and intended also
as a complete and exclusive statement of the terms of their agreement. Whenever a term defined by the
Uniform Commercial Code is used in this agreement, the definition contained in the Code is to control.
20. APPLICABLE LAW. This agreement shall be governed by the Uniform Commercial Code. Wherever
the temm "Uniform Commercial Code" is used, it shall be construed as meaning the Uniform Commercial
Code as adopted in the State of Texas as effective and in force on the date of this agreement.
21. RIGHT TO ASSURANCE. Whenever one parry to this contract in good faith has reason to question
the other party's intent to perform he may demand that the other party give written assurance of his intent to
perform. In the event that a demand is made and no assurance is given within five (5) days, the demanding
party may treat this failure as an anticipatory repudiation of the contract.
22. INDEMNIFICATION. Seller shall indemnify, keep and save harmless the Buyer, its agents, officials and
employees, against all injuries, deaths, loss, damages, claims, patent claims, suits, liabilities, judgments, costs
and expenses, which may in anywise accrue against the Buyer in consequence of the granting of this Contract
or which may anywise result therefrom, whether or not it shall be alleged or determined that the act was
caused through negligence or omission of the Seller or its employees, or of the subSeller or assignee or its
employees, if any, and the Seller shall, at his own expense, appear, defend and pay all charges of attorneys
and all costs and other expenses arising therefrom of incurred in connection therewith, and, if any judgment
shall be rendered against the Buyer in any such action, the Seller shall, at its own expenses, satisfy and
discharge the same Seller expressly understands and agrees that any bond required by this contract, or
otherwise provided by Seller, shall in no way limit the responsibility to indemnify, keep and save harmless
and defend the Buyer as herein provided.
23. TIME. It is hereby expressly agreed and understood that time is of the essence for the performance of
this contract, and failure by contract to meet the time specifications of this agreement will cause Seller to
be in default of this agreement.
24. MBE. Tate City of Lubbock hereby notifies all bidders that in regard to any contract entered into
pursuant to this request, minority and women business enterprises will be afforded equal opportunities to
submit bids in response to this invitation and will not be discriminated against on the grounds of race, color,
sex or natural origin in consideration for an award.
25. NON -ARBITRATION. The City reserves the right to exercise any right or remedy to it by law, contract,
equity, or otherwise, including without limitation, the right to seek any and all forms of relief in a court of
competent jurisdiction. Further, die City shall not be subject to any arbitration process prior to exercising
its unrestricted right to seek judicial remedy. The remedies set forth herein are cumulative and not exclusive,
and may be exercised concurrently. To the extent of any conflict between this provision and another provision
in, or related to, this document, this provision shall control.
26. RIGHT TO AUDIT. At any time during the term of the contract, or thereafter, the City, or a duly
authorized audit representative of the City or the State of Texas, at its expense and at reasonable times,
reserves the right to audit Contractors records and books relevant to all services provided to the City under
this Contract. In the event such an audit by the City reveals any errors or overpayments by the City,
Contractor shall refund the City the full amount of such overpayments within thirty (30) days of such
audit findings. or the City, at its option, reserves the right to deduct such amounts owing the City from any
payments due Contractor.
27. ASSIGNING OR SUBLETTING THE CONTRACT. The Contractor shall not assignor sublet the contract,
or any portion of the contract, without written consent front the Director of Purchasing and Contract
Management. Should consent be given, the Contractor shall insure the Subcontractor or shall provide proof on
insurance from the Subcontractor that complies with all contract Insurance requirements.
29. HOUSE BILL 1295 DISCLOSURE OF INTERESTED PARTIES. House Bill 1295, adopted by the 84th
Legislature, created §2252.908, Texas Government Code. Section 2252.908 requires a business entity entering
into certain contracts with a governmental entity or state agency to file with the governmental entity or state
agency a disclosure of interested parties at the time the business entity submits the signed contract to die
govemmental entity or state agency. Instructions for completing Form 1295 are available at:
hSlp://www ci lubbock tx,us/deoartmental-websites/deoartments/p r ine/vendor-information
30. CONTRACTOR ACKNOWLEDGES, by supplying any Goods or Services that the Contractor has read,
fully understands, and will be in full compliance with all terms and conditions and the descriptive material
contained herein and any additional associated documents and Amendments. The City disclaims any terms and
conditions provided by the Contractor unless agreed upon in writing by the parties. In the event of conflict
between these terms and conditions and any terms and conditions provided by the Contractor, the terms and
conditions provided herein shall prevail. The terms and conditions provided herein are the final terms agreed
upon by the parties, and any prior conflicting terms shall be of no force or effect.
31. TEXAS GOVERNMENT CODE, CHAPTER 2252. The undersigned representative of the undersigned
company or business, being an adult over the age of eighteen (18) years of age, pursuant to Texas Government
Code, Chapter 2252, Section 2252.152, certify that the company named above is not listed on the website of
the Comptroller of the State of Texas concerning the listing of companies that are identified under Section
806.051. Section $07.051 or Section 2253.153. I further certify that should the above -named company enter
into a contract that is on said listing of companies on the website of the Comptroller of the State of Texas, which
do business with Iran, Sudan or any Foreign Terrorist Organization, I will immediately notify the City of
Lubbock Purchasing and Contract Department.
32. TEXAS GOVERNMENT CODE, CHAPTER 2270 This section applies only to a contract that: (1) is
between a governmental entity and a company with 10 or more full-time employees; and (2) has a value of
$100.000 or more that is to be paid wholly or partly from public funds of the governmental entity. (b) A
governmental entity may not enter into a contract with a company for goods or services unless the contract
contains a written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott
Israel during the term of the contract.
33. TEXAS PUBLIC INFORMATION ACT. The requirements of Subchapter J, Chapter 552, Goverment
Code, may apply to this contract and the contractor or vendor agrees that the contract can be terminated if the
contractor or vendor knowingly or intentionally fails to comply with a requirement of that subchapter. To the
extent Subchapter J. Chapter 552, Government Code applies to this agreement, Pursuant to Section 552.301(c)
of the Texas Government Code; the City of Lubbock has designated the following email address for which
public information requests may be made by an entailed request. Please send this request to this email address
for it to be processed: orrriiimvlubbock.us.
REV. 9/2021
Quote Number:
Alec.
Opportunity Number:
All Industries, Inc.
Sourcewell Contract #: 012418-ALT
Date:
Quoted for: City of Lubbock
Customer Contact:
Phone: / Email:
Phone: / Email: 919-880-1437 /lorl.woods@altec.com
Altec Account Manager: Chad Sprague 505-301-1421 chad.sprague@altec.com
Sourcewell
REFERENCE ALTEC MODEL Price
AT41M lArticulating Telescopic Aerial Device with Material Handling Insulated 4V---T $163 854
A. SOURCEWELL OPTIONS ON CONTRACT Unit
1
AT41 M-U548M
Articulating telescopic Aerial Device with Material Handling (insulating lower arm)
with 48' boom boom height AT48M
$6,343
2
AT41 M-AWD
All Wheel Drive
$5,606
3
4
Al. SOURCEWELL OPTIONS ON CONTRACT General
11
PSWI2
PURE SINE WAVE INVERTER.2400 Watts Continuous. GFCI Outlet at Rear.
$3,610
2
RL
COMPARTMENT LIGHTS in Body Compartments - Rope LED It 84/Compartment)
$1,288
3
SPOT3
FOUR 4 POINT STROBE SYSTEM LED
$701
4
SPOT6
Remote Spot Light, LED, Permanent Mount, With Wireless Dash Mounted Controls
$887
5
VRC
12 Volt Receptacle Cigarette Lighter Style), Weatherproof
$348
6
VCAM
Backup Camera System
$1,092
7
TBE
ELECTRIC TRAILER BRAKE CONTROLLER. Controls Trailers with Electric Brakes,
Wired to 7-WayPlugNext to Pintle Hook
$275
8
FSC
Li ht Duty SUPER CAB
$2,461
SOURCEWELL OPTIONS TOTAL: 1 $186,465
1B 1 OPEN MARKET ITEMS /CucMmar Renuecledl
1
UNIT
Platform Elevator 24" WC Preferred Customer Discount
$249
2
UNIT & HYDRAULIC ACC
$0
3
BODY
$0
4
BODY & CHASSIS ACC
$0
5
ELECTRICAL
$0
6
FINISHING
$0
7
CHASSIS
$0
8
OTHER
$0
OPEN MARKET OPTIONS TOTAL: -$249
SUB -TOTAL FOR UNITIBODYICHASSIS: $186,216
Delivery to Customer: $3,200
TOTAL FOR UNITIBODYICHASSIS: $189,416
"Pricing valid for 45 days —
NOTES
PAINT COLOR: White to match chassis, unless otherwise specified
WARRANTY: Standard Altec Warranty for Aerials and Derricks - One (1) year parts warranty One (1) year labor warranty Ninety (90)
days warranty for travel charges (Mobile Service) Limited Lifetime Structural Warranty. Chassis to include standard warranty, per the
manufacturer.
TO ORDER: To order, please contact the Altec Account Manager listed above.
CHASSIS: Per Altec Commercial Standard
DELIVERY: No later than 790.820_days ARO, FOB Customer Location
TERMS: Net 30 days
BEST VALUE: Altec boasts the following "Best Value" features: Altec ISO Grip Controls for Extra Protection, Only Lifetime Warranty
on Structural Components in Industry, Largest Service Network in Industry (Domestic and Overseas), Altec SENTRY Web/CD Based
Training, Dedicated/Direct Gov't Sales Manager, In -Service Training with Every Order.
TRADE-IN: Please ask your Altec Account Manager for more information
BUILD LOCATION: Creedmoor, NC
Sourcewell (formerly NJPA) Quote Template 12-5-2021 - Model Year 2024
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.
2021-833783
Altec Industries, Inc.
Birmingham, AL United States
Date Filed:
12/16/2021
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:
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.
012418-aft
Public Utility Equipment with Related Accessories and Supplies
4
Nature of interest
Name of Interested Party
City, State, Country (place of business)
(check applicable)
Controlling
Intermediary
5
Check only if there is NO Interested Party.
X
6
UNSWORN DECLARATION
Riley Browne
My name is and my date of birth Is
33 Inverness Center Parkway Birmin ham AlMy address is g , _ 35242 � USA
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Shelby Alabama
Executed in County, State of , on the 2$_ day of December 2p 21
(month) (year)
opK+N ked W: Rby Brovw�
two
Riley Brown -:A0,:_ Indus
; �;
Signature of authorized agent of contracting business entity
(Declarant)
rorrns proviueu oy i exas tmics commission www.etnics.state.tx.us Version V1.1.191b5cdc
CERTIFICATE OF INTERESTED PARTIES
FORM 129rJ
1of1
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:
2021-833783
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Altec Industries, Inc.
Birmingham, AL United States
Date Filed:
12/16/2021
2
Name of governmental entity or state agency that is a parry to the contract for which the form is
being filed.
112/28/2021
City of Lubbock
Date Acknowledged:
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.
012418-aft
Public Utility Equipment with Related Accessories and Supplies
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 Party. 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)
r'-UlI11, NiwiuCU Uy I Cxas =uiIL;s %.vrnrrnssian www.etnics.siaie.oc.us Version V1.1.191b5cdc