HomeMy WebLinkAboutResolution - 2022-R0143 - PO 10025153 with Advanced Security Technologies 3.22.22Resolution No. 2022-RO143
Item No. 7.31
March 22, 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 fo
and on behalf of the City of Lubbock, Purchase Order No. 10025153 for the purchase of Modul
Vehicle Barrier System with Trailer, by and between the City of Lubbock and Advanced Securi
Technologies, LLC, and related documents. Said Purchase Order is attached hereto an(
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
ATTEST:
Reb ca Garza, City Secret
APPROVED AS TO CONTENT:
Police
APPROVED AS TO FORM:
Jd5fartiell, Assistant City Attorney
March 22, 2022
DANIEL M. POPE, MAYOR
vw:ccdocs/RES.Advanced Security Tech-PurchaseOrd
March 11, 2022
City of
PURCHASE ORDER
Lubbock
TEXAS
ADVANCED SECURITY TECHNOLO IE ,LLC
TO: 47 TRAUTWEIN CRESCENT SHIP TO:
CLOSTER NJ 07624-2935
Page - 1
Date - 3/11/2022
Order Number 10025153 000 OP
Branch/Plant 5735
CITY OF LUBBOCK
POLICE DEPARTMENT
916 TEXAS AVENUE
LUBBOCK TX 79401
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 4BY:Y'o
Marta A area, Director of Purchasing & Contract Management
Ordered 3/11/2022 Freight
Requested 5/31/2022 Taken By
Delivery PER L PEDERSON, REQ 58614
SOLE SOURCE
SBALLANCE
If you have any questions, please contact Lisa Pederson: LPederson@mylubbock.com or 806-775-2765
Description/Supplier Item Ordered Unit Cost UM Extension Request Date
48 MVB3X Capaciy Fully Loaded 1.000 122,946.0000 EA 122,946.00 5/31/2022
ASM-4848- 320208-20B
Trailer System
Total Order
Terms NET 30
122,946.00
This purchase order encumbers funds in the amount of $248,800.00 awarded to Advanced Security Technologies LLC
of Closter, NJ, on March 22nd , 2022. The following is incorporated into and made part of this purchase order by
reference: Quote dated January 20, 2022, from Advanced Security Technologies LLC of Closter, NJ, and Sole Source for this product.
Resolution # 2022-RO 143
CITY OF L OCK ATTEST:
Daniel M. Pope, Mayor Rebe ca Garza, City Sec-retatkJ
Rev. 9/2021
PURCHASE ORDER
Seller and Buyer agree as
follows:
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) Containernumber and total number of containers, e.g box 1 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
tamers and any applicable specifications Buyer's count or weight shall be final and conclusive on shipments
not accompanied by packing lists
2 SHIPhIENT 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 I I 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 Seller, 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 of 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 othenvise 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 sample(s) 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 Sellers 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 funds 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
) ear 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 thirt) (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.
15 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 terns 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 parry 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 conformitywith
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 party
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. Whereever
the term "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 party 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 h®E The 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, the 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 maybe 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 Contractor's 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 from 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 909, 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 the
governmental entity or state agency Instructions for completing Forth 1295 are available at
hap Avw%v 6 lubbock.ucnformation
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 (I8) 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 807 051 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 1, Chapter 552, Government
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 Goverment 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 on irr ylILh L...us
REV 9/2021
M 7�
Bringing Advanced Technologies to the Security World
January 20, 2022
Nathan White
Assistant Chief Tel: 806-775-2759
Lubbock Police Department Email: mwhite@mvlubbock.us
916 Texas Ave.
Lubbock, TX
REFERENCE: Modular Vehicle Barrier 3X System -Price Quotation — 48 Unit Trailer
Dear Assistant Chief White,
It was a pleasure speaking with you regarding the Mifram Modular Vehicle Barrier System. Per our
conversation, please find additional product information on the Mifram Modular Vehicle Barrier 3X
System. Advanced Security Technologies LLC (AST) is the US distributer and sales arm for the Mifram
product line. AST also manufactures dedicated US made transport trailers that can be used as a shard
asset to transport the equipment to different events. After the event, the equipment is loaded back into
the dedicated trailer that will be used as storage.
A. System Advantaees:
1. One person to install
2. One person to dismantle at the end of the event
3. One minute for each section to be connected
4. Quick access in case of an emergency
5. System can be used as an active gate
6. Assembled without the need of any tools
7. Folds for easy carrying
8. Easy to store
9. Zero maintenance
10. Complete modular system. System can be as short or long as the event requires.
B. Mobile Vehicle Barrier Vehicle Barrier Specification:
1. Barriers must be certified to ASTM-F2656-15.
2. Barriers must be certified to ASTM/PAS 68 & IWA standards.
3. Barrier System must be modular and adaptable to any road width.
4. Spacing between barriers must be 21".
5. Each complete MV63X unit must weigh less than 55 lbs.
www.adsectec.com
6. Each unit dimensions: L-46.5", W^21", H-32".
7. Tools shall not be required. System is to be assembled with pins.
8. Barriers must have the ability to be folded for transportation.
9. Property tag labelling service must be made available as part of this package.
10. MVB3X units must have the option to pivot and transition into an operational gate.
11. MVB3X units must have the option of slide wheels.
12. MVB3X pivoting section shall be modular (meaning user can decide how many sections to open).
13. Barriers must be capable of quick deployment (less than a minute to deploy a single unit).
14. Barriers must be able to be deployed by one person.
15. Bottom edges of the barriers shall be protected by aluminum covers (for pedestrian safety).
16. Barrier System shall have the ability to be deployed from the road and up to sidewalk in one
continuous line.
17. MVB3X units shall have multi -terrain capability.
18. MVB3X units shall not require any maintenance.
19. Magnetic sequential lights shall attach to MVB3X units.
C. MVB3X Transport Trailer Specification:
1. The Trailer shall be made in the United States and comply with US DOT regulations
2. The Trailer must be NEW/unused
3. Trailer to include drip rails
4. Trailer can hold up to 48MVB3X units + Pivots
5. 48-unit trailer will have 4 doors on each side
6. Trailer shall be 16 feet long
7. Trailer shall be 101.5" wide
8. Tandem axel
9. 10,000/14,000 lb hauling capacity
10. Electric brakes
11. LED lighting
12. 15,000 lb Safety chain
13. 2 5/16" hitch
14. Spare wheel + Tire ST225/75/1112 (6 Lug)
15. All containment steel shall be powder coated
16. MVB3X barriers can be loaded/stored from both sides
17. Each MVB3X unit has its own dedicated slot for safe transport
18. Each MVB3X is locked in place for transport with secondary retainment system
19. Each MVB3X tray shall have UHMH
20. Unit shall have Stainless Steel latches & hinges
21. Zinc coated steel rivets
22. Zinc coated nuts & bolts
23. Dedicated space for pivot units
24. Each door has locks for safe storage. All keyed alike.
25. Single/double extra storage compartments shall be provided on the trailer (one in the front of
the trailer and an additional unit in the back of the trailer). Each compartment shall be 24" tall x
35" deep x 96" wide.
www.adsectec.com I www.vehicle-barriers.com 2
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26. Trailer shall black color
D. Pricine Information
48 X MVB3X Unit Trailer — Provides approximately 6 lanes of Coverage per Trailer
System Number
Description
Unit Price
AST3X-48/48-320208-20B
48 MVB3X Capacity Fully Loaded Trailer System
$122,946
Freight
F.O.B. Destination
Included
AST Services
Equipment Training (Fee Waived)
Included
MV1B3X New Generation MVB
Unit Price
QTY
Extended
MVB3X unit
$1,455
48
$69,840
Pivot system
$594
24
$14,256
Slide Wheels - fixed
$435
2
$870
Slide Wheels - rotating
$435
6
$2,610
Large Storage/Shipping Box
$1,287
3
$3,861
[RECHARGEABLE] Set of 10 ICS Sequential Flares
(Orange Side LED/Red Top LED) - Orange Plastic
$650
2
$1,300
Single Lane Banner
$875
1
$875
One-time On -site Product Training (fee waived)
$1,200
1
$ -
Freight
$925
1
$925
Transport Options
Unit Price
QTY
Extended
Trailer for up to 48 x MVB3X units plus pivots. Trailer
will have 4 door on each side. Each section will be two
rows of 3 sections tall
$25,509
1
$25,509
Shipping of Trailer to your site
$2,900
1
$2,900
MVB-3X
Total
$122,946
48 x MVB3X Unit Trailer with 4 doors on each side
www.adsectec.com I www.vehicle-barriers.com
F� �1;1- ' - i t-
E. Note:
1. Property tag labelling service must be made available as part of this package. If desired,
property tags and other adhesive labelling can be applied to each MVB3X Unit prior to delivery
at no additional charge. Property tags and other adhesive labels must be supplied by the end
user.
2. Number of pivots and sequential flares can be modified based on operational requirements.
3. Number of pivots are an estimate.
F. Terms & Conditions:
1. F.O.B — Destination. Shipping has been included in the above price.
2. Taxes are not included. Should any taxes are levied they will be paid for by the purchaser.
3. Delivery: 8-10 weeks ARO — depending on material availability.
4. Payment terms — 50% down payment 50 % net 30.
5. Prices are valid for 60 days.
6. Purchase of equipment is subject to Advanced Security Technologies LLC standard terms and
conditions.
Please do not hesitate to contact me should you require additional information.
Sincerely,
Yaron Getter
Principal & Co -Founder
Advanced Security Technologies LLC
Mobile: (917) 561-13441 vgetter@adsectec.com
www.adsectec.com I www.vehicle-barriers.com 4
CERTIFICATE OF INTERESTED PARTIES FORM 2295
loft
Complete Nos. 1- a and 6 if there are interested parties.
OFFICE USE ONLY
Complete Nos.1, 2, 3, 5, and 6 if there are no Interested parties.
12022-861766
CERTIFICATION OF RUNG
Certificate Number:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Advanced Security Technologies LLC
CLOSTER. NJ United States
Date Flied:
2 Name of governmental entity or state agency that Is a party to the contract for which the form Is
03/16/2022
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.
10025153
Modular Vehicle Barrier System
Nature of interest
4 Name of Interested Party
City, State, Country (place of business)
(check applicable)
Controlling
Intermediary
DiSalvo, Sal
Manalapan, NJ United States
X
Getter, Yaron
CLOSTER, NJ United States
X
5 Check only If there is NO Interested Party. ❑
6 UNSWORN DECLARATIONr
.
M name is & ron � t 16- and my date of birth is
y
J /� L
I rSch2! C10S✓J � er �, Cx62 y
My address is 4� TracerwP,fl -
(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 vi.1.19100coc