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HomeMy WebLinkAboutResolution - 2018-R0048 - Lutheran Social Services - 01/25/2018Resolution No. 2018-R0048 Item No. 6.37 January 25, 2018 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, Community Development Funding Contract 13908, and all related documents, between the City of Lubbock and Lutheran Social Services of the South, for funding allocation from the Comprehensive Energy Assistance Program to provide utility assistance to qualified low-income persons and families. Said Contract 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 25, 2018 DANIEL M. POPE, MAYOR ATTEST: Reb cca Garza, City Secret APPROVED AS TO CONTENT: ---g /)Jzj�' Bil e n, Ass' ant City Manager APPROVED AS TO FORM: Justin.Xuitt,4ssist�nt City Attorney ccdocs/RES. Contract 13908 — Lutheran Social Services of the South — 2018 CEAP Allocation January 8, 2018 Resolution No. 2018-R0048 COMPREHENSIVE ENERGY ASSISTANCE PROGRAM This Comprehensive Energy Assistance Program (the "Agreement") is made by and between the City of Lubbock, a State of Texas home rule municipal corporation (the "City") and Lutheran Social Services of the South, Inc., a State of Texas non-profit organization (the "Contractor"), (each a "Parry," and collectively the "Parties") acting by and through the Parties' representative officers and officials, and is by the Parties on January 25, 2018 (the "Effective Date"). RECITALS WHEREAS, the City is obligated to do and perform certain services in its administration of the Comprehensive Energy Assistance Program (the "CEAP"); and WHEREAS, the Contractor operates a non-profit center offering services to low-income individuals in Lubbock County, Texas (the "Services"); and WHEREAS, the City finds that the Services benefit citizens of Lubbock County and constitute a valuable public service; and WHEREAS, the City finds that the Services are the predominate purpose of this Agreement; and WHEREAS, the Contractor and the Services have been found to meet the criteria for funding under a request for proposals issued by the City; and WHEREAS, the continuing supervision by the City and State together with statutory and contractual requirements provide sufficient assurance that the public purpose is accomplished and an audit provides sufficient protection of the handling of public money; and WHEREAS, the City finds that the Contractor has the special expertise, knowledge, and experience necessary for the performance of this Agreement and that the City will receive adequate consideration in the form of substantial public benefit; and WHEREAS, the City desires to enter into this Agreement with the Contractor to snake available operating assistance for the City's Utility Assistance and Household Crisis Program (the "Program"); and NOW, THEREFORE, THE PARTIES, FOR GOOD AND VALUABLE CONSIDERATION, AGREE AS FOLLOWS: AGREEMENT Article 1. SCOPE OF SERVICE A. The City's Responsibilities 1. The City agrees to award the Contractor funding from the CEAP in an amount not to exceed nine hundred twelve thousand four hundred ninety-two dollars ($912,492) in return for Contractor performing the Services of the Program (the "Funding"). 2. The City's awarding of the Funding under this Agreement is contingent upon the City's receipt of adequate funds to meet the City's liabilities under this Agreement. If adequate funds are not made available to the City so that it cannot award the Funding, then the City shall notify the Contractor in writing within a reasonable time after such fact is CEAP Agreement —City of Lubbock & Lutheran Social Services-2018 Page 1 determined, the City shall terminate this Agreement, and the City will not be directly or indirectly liable for failure to award the Funding to the Contractor under this Agreement. 3. The Funding shall be disbursed in the amounts and at the time the fiends are disbursed to the City by the State of Texas. The City is not responsible for any amounts not distributed by the State of Texas. Any Community Services Block Grant (the "CSBG") funds applicable to this Agreement shall be disbursed in the amount and at the time such funds are disbursed to the City by the State of Texas. 4. The City shall not be liable to the Contractor for any costs incurred by the Contractor which have been paid to the Contractor, which are subject to be paid to the Contractor, which have been reimbursed to the Contractor, or which are subject to reimbursement to the Contractor by any source other than the City or the Contractor. 5. The City shall not be liable for any costs incurred by the Contractor which are not allowable costs as set forth in this Agreement. 6. The City shall not be liable to the Contractor for any costs incurred by the Contractor or for any performances rendered by the Contractor which are not strictly in accordance with the terms of this Agreement. 7. The City shall not be liable to the Contractor for any costs incurred by the Contractor in the performance of this Agreement which have not been billed to the City by the Contractor within sixty (60) days following the termination of this Agreement. 8. The City shall not be liable for any costs incurred or performances rendered by the Contractor before the commencement or after termination of this Agreement. 9. The Funding will be limited to the following: a. For the sole purpose of the Contractor's Services for the Program; b. For the satisfaction of expenses incurred by the Contractor in its provision of Services for the Program; and c. For the benefit of lower -income families that reside in Lubbock County, Texas, and whose gross household income does not exceed one hundred and fifty percent (150%) of the most recent Poverty Income Guidelines issued by the U.S. Department of Health and Human Services. B. Contractor's Responsibilities 1. The Contractor agrees to the Funding solely for the purpose of the Program as it is performed at Neighborhood House, 1212 13th Street, Suite 102, Lubbock, Texas 79401. 2. The Contractor agrees to comply with all applicable uniform administrative requirements as described in the Lutheran Social Services Policy Manual; all generally accepted administrative requirements for the Texas State Government located at 1TAC5.141, et seq.; and, all federal administrative requirements located at 45CFR Part 96. 3. The Contractor agrees to carry out the Services contemplated under this Agreement in compliance with all State and Local laws and regulations. CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 2 4. The Contractor shall retain in its clients' files only those documents that are required to validate its clients' eligibility for the Program. Such documents may include forms of documentation of disability such as Social Security or a Supplemental Security Income statement. The Contractor shall not include documentation from a medical professional, such as a doctor's letter, in its clients' files. Article 2. TIME OF PERFORMANCE This Agreement shall commence January 1, 2018 and shall terminate December 31, 2018 (the "Term"). The Term may be extended on a year to year basis during the five (5) year roll-over cycle ending December 2018, provided funds are received from the Texas Department of Housing and Community Affairs (the "TDHCA"), and providing that the Contractor meets its obligations during the Term, subject to the approval of the City Council of the City. Article 3. BUDGET The Contractor will use the CEAP hinds awarded under this Agreement to administer the Program in the following manner: CEAP Utility Assistance $671,222 CEAP Household Crisis $120,000 CEAP Program Services Cost $121,270 Total CEAP funds awarded under this Agreement $912,492 Article 4. PAYMENT The City will pay up to nine hundred twelve thousand four hundred ninety-two dollars ($912,492) to the Contractor based upon the receipt of a request for funds and project expense summary for the Contractor's Services under the Project. The Contractor shall submit to the City invoices for items purchased in the Contractor's performance of the Services under the Project. The City shall determine the reasonableness of each purchase and shall not make a disbursement of any such payment until the City has reviewed and approved each purchase. The City may release up to ten percent (10%) of the funds to be used as start-up funding for the Contractor's Services under the Project. The Contractor will then bill the City monthly for expenses incurred by the Contractor during the prior month of Services performed under the Project. By December 31, 2017, the Contractor will have provided the City with the proper documentation to show how all funds were expended by the Contractor in its performance of Services under the Program, including the start-up costs. Article 5. NOTICES All communication required under this Agreement shall be directed to the following Party representatives: For the City: Piata Bryant City of Lubbock P. O. Box 2000 Lubbock, TX 79457 For the Contractor: Joy Loper Lutheran Social Services of the South, Inc. 1212 13th Street, Suite 102 Lubbock, TX 79401 CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 3 Article 6. SPECIAL CONDITIONS A. The Contractor will maintain adequate case management files on each client it assists, whether the case management is funded through the Funding or not, and whether the case management is provided by the Contractor or not. B. The Contractor will keep adequate documentation of the design of the Program, the implementation of the Program, and evaluation of Program design. C. The Contractor will keep documentation of its efforts to leverage CEAP funds with other programs to enhance the Services provided to its clients. D. The Contractor will keep documentation of its efforts to cooperate and collaborate with other service providers. Article 7. GENERAL CONDITIONS A. General Compliance 1. Contractor agrees to comply with all applicable federal, state, and local laws and regulations governing the Funding provided under this Agreement which were made available under the City's LEAP. 2. The Contractor shall administer the CEAP to eligible clients in accordance with TDHCA CEAP regulations, as out lined in Texas Administrative Code (TAC 10) regulations; the Low -Income Home Energy Assistance Act of 1981, as amended; 42 U.S.C. Sec. 8621 et seq.; the LIHEAP Act Public Law 97-35; the LIHEAP State Plan; and, sections 103 & 107 of the Contract Work Hours and Safety Standards Act (40 USC 327-330) as supplemented by Agency of labor regulations (29 CFR, Part 5). B. Labor Standards The Contractor agrees to comply with the requirements of the Secretary of Labor in accordance with the Copeland "Anti -Kickback" Act (40 U.S.0 276a-276a-5; 40 USC 327 and 40 USC 26c) and all other applicable Federal, state and local laws and regulations pertaining to the labor standards insofar as those acts apply to the performance of this Agreement. C. Right to Exercise The City reserves the right to exercise any right or remedy available 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 may be exercised concurrently. To the extent of any conflict between this provision and another provision in, or related to, this Agreement, the former shall control. D. Independent Contractor Nothing contained in this Agreement is intended to, or shall be construed in any manner, as creating or establishing the relationship of employer and employee between the Parties. The Contractor shall at all times remain an independent contractor with respect to the services to be performed under this Agreement. The City shall be exempt from payment of all Unemployment CEAP Agreement —City of Lubbock & Lutheran Social Services — 2018 Page 4 Compensation, FICA, retirement, life, medical insurance, and Worker's Compensation insurance as the Contractor is an independent contractor. E. Indemnity and Release 1. The Contractor shall indemnify and hold harmless, to the fullest extent permitted by law, the City, and the City's respective officers, employees, elected officials, and agents, from and against any and all losses, damages, claims, or liabilities, of any kind or nature, which arise directly or indirectly, or are related to, in any way, manner, or form, the activities contemplated hereunder, including, but not limited to, losses, damages, claims, or liabilities arising from or related to, in any way, manner, or form, the act or omission of third parties or the negligence or fault of the City, its respective officers, employees, elected officials, or agents. The Contractor further covenants and agrees to defend any suits or administrative proceedings brought against the City or the City's respective officers, employees, elected officials, or agents on account of any such claim, and to pay or discharge the full amount or obligation of any such claim incurred by, accruing to, or imposed on the City, or the City's respective officers, employees, elected officials, or agents, as applicable, resulting from such suits, claims, or administrative proceedings or any matter resulting from the settlement or resolution of said suits, claims, or administrative proceedings. Additionally, the Contractor shall pay to the City, all attorney's fees incurred by the Parties in enforcing the Contractor's indemnity in this section. 2. The City, and its respective officers, employees, elected officials, and agents shall not be liable, and the Contractor hereby releases the City, and its respective officers, employees, elected officials, and agents, for, from, and against any losses, damages, claims, or liabilities to the Contractor, on any theory of legal liability, including, but not limited to the negligence, of any type of degree or fault, of the City, arising from or related to, in any way, manner, or form, the unenforceability or voidance, for any reason, of all or part of this Agreement. 3. The indemnity and release provided herein shall survive the termination or voidance of this Agreement. F. Worker's Compensation The Contractor shall provide Worker's Compensation insurance coverage or other approved coverage for all employees involved in the performance of this Agreement. G. Insurance and Bonding Throughout the Term, the Contractor shall maintain liability insurance in the following minimum amounts: Type oflnsurance Minimum Liability Commercial General Liability $1,000,000 Limit Property Damage Liability $100,000 Each Occurrence H. City Recognition The Contractor shall insure the recognition of the role of the City's CEAP in providing funding through this Agreement. All activities, facilities, and items utilized pursuant to this Agreement CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 5 shall be prominently labeled as to a funding source. In addition, the Contractor will include a reference to the support provided herein in all publications made possible with funds made available under this Agreement. I. Amendments 1. The City or the Contractor may amend this Agreement at any time, provided that such amendment makes specific reference to this Agreement, is executed in writing, signed by a duly -authorized representative of both Parties, and approved by the City. Any such amendment shall not invalidate this Agreement, and shall neither relieve nor release the City or the Contractor from its obligations under this Agreement. 2. The City may, in its sole discretion, amend this Agreement to conform with federal, state, or local governmental guidelines, policies, and available funding amounts, or for other reasons. If any such amendment results in a change to the Funding, the scope of services, or the activities to be undertaken as part of this Agreement, then such amendment will be incorporated into this Agreement only by written amendment signed by both the City and the Contractor. J. Suspension or Termination 1. Either Party may terminate this Agreement at any time by giving written notice to the other Party of such termination, and by specifying the effective date thereof, at least thirty (30) days before the effective date of such termination. Partial termination of any portion of this Agreement may only be undertaken with the prior approval of the City. In the event of any termination of this Agreement for convenience, all finished or unfinished documents, data, studies, surveys, maps, models, photographs, reports, or other materials prepared by the Contractor under this Agreement shall, at the option of City, become the property of the City, and the Contractor shall be entitled to receive just and equitable compensation for any satisfactory work completed on such documents or materials prior to the termination. 2. The City may also suspend or terminate this Agreement, in whole or in part, if the Contractor materially fails to comply with any term of this Agreement, or with any of the rules, regulations, or provisions referred to herein. In such a circumstance, the City may declare the Contractor ineligible for any further participation in future City contracts, in addition to other remedies as provided by law. In the event there is probable cause to believe the Contractor is in noncompliance with any applicable rules or regulations, the City may withhold up to fifteen percent (15%) of the Funding until such time as the Contractor is found to be in compliance by the City or is otherwise adjudicated to be in compliance. 3. The City may also terminate this Agreement in the event of an emergency or disaster, whether an act of God, natural, or manmade, by giving twenty four (24) hour verbal notice to the Contractor. Any expenditure incurred prior to receiving such notice will be reimbursed; however, in no event shall the City pay for any expenses incurred after such notice of termination is given by the City. CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 6 K. Prevention of Waste, Fraud, and Abuse 1. The Contractor shall establish, maintain, and utilize systems and procedures to prevent, detect, and correct waste, fraud, and abuse in activities funded under this Agreement. The systems and procedures shall address possible waste, fraud, and abuse by the Contractor, its employees, recipients, vendors, and administrating agencies. The Contractor's internal control systems and all transactions and other significant events are to be clearly documented, and the documentation is to be readily available for monitoring by the City. 2. The Contractor shall give the City complete access to all of its records, employees, and agents for the purposes of any investigation of the funded programs. The Contractor shall immediately notify the City of any discovery of waste, fraud, or abuse. The Contractor shall fully cooperate with the City's efforts to detect, investigate, and prevent waste, fraud, and abuse in the Program. 3. The Contractor may not discriminate against any employee or other person who reports a violation of the terms of this Agreement or of any law or regulation to the City or to any appropriate law enforcement authority, if the report is made in good faith. L. Legal Remedies In any instance where the Contractor violates or breaches this Agreement, the City may apply administrative, contractual, or legal remedies. The City may suspend all activities under this Agreement temporarily pending either corrective action by the Contractor or a decision by the City to terminate this Agreement. M. Legal Authority 1. The Contractor represents that it possesses the practical ability and legal authority to enter into this Agreement, receive and manage funds authorized by this Agreement, and to perform the services the Contractor has obligated itself to perform under this Agreement. 2. The Contractor's signatory hereby warrants that he/she has been authorized by the Contractor to execute this Agreement on behalf of the Contractor and to bind the Contractor to this Agreement. Article 8. ADMINISTRATIVE REQUIREMENTS A. Financial Management 1. Accounting Standards: The Contractor agrees to comply with Attachment F of OMB Circular A-110 and agrees to adhere to the accounting principles and procedures required therein, utilize adequate internal controls, and maintain necessary source documentation for all costs incurred. 2. Cost Principles: The Contractor shall administer the Program in conformance with OMB Circulars A-122, "Cost Principles for Non -Profit Organizations", or 2 CFR Part 200 Cost Principles for Educational Institutions", as applicable, for all costs incurred whether charged on a direct or indirect basis. CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 7 B. Documentation and Record -Keeping 1. Record Keeping Requirements: The Contractor shall maintain fiscal and programmatic records and supporting documentation for all expenditures made under this Agreement in accordance with the UGMS and Section III, Common rule: State Uniform Administrative Requirements for Grants and Cooperative Agreements, Subpart C: Post Award Requirements, 18.42. For purposes of compliance, all associated documentation must be readily available, whether stored electronically or hard copy to justify compliance with program rules and regulations. 2. Open Records: The Contractor acknowledges that all information collected, assembled, or maintained by the Contractor pertaining to this Agreement is subject to the Texas Public Information Act, Chapter 552 of Texas Government Code and must provide citizens, public agencies, and other interested parties with reasonable access to all records pertaining to the Agreement subject to the Texas Public Information Act. 3. The Contractor shall give the HHS, the U.S. General Accounting Office, the Texas Comptroller, the State Auditor's Office, and the City, or any of their duly authorized representatives, access to and the right to examine and copy, on or off the premises of the Contractor, all records pertaining to this Agreement. Such right to access shall continue as long as the records are retained by the Contractor. The Contractor agrees to maintain such records in an accessible location for the greater of (a) four (4) years; (b) if notified by the City in writing, the date that the final audit is accepted with all audit issues resolved to the City's satisfaction; (c) if any litigation claim, negotiation, inspection, or other action has started before the expiration of the required retention period records must be retained until completion of the action and resolution of all issues which arise under it; or (d) a date consistent with any other period required by federal or state law or regulation. The Contractor agrees to cooperate with any examination conducted under this Agreement. Upon the termination of this Agreement, all of the Contractor's records shall become property of the City. C. Retention The Contractor shall retain all record pertinent to expenditures incurred under this Agreement for a period of five (5) years after the termination of all activities funded under this Agreement, or after the resolution of all State audit findings, whichever occurs later. D. Client Data The Contractor shall maintain client data demonstrating client eligibility for services provided. Such data shall include, but not be limited to: total number of information and referral calls received and broken down into subject categories for every call; specific information obtained through random screening of calls such as income level, gender, race, age, education -level, and household size. Such information shall be made available to the City for review by the tenth (1 Wh) day of every month. E. Audits and Inspections All Contractor records with respect to any matters covered by this Contract shall be made available to City, their designees or the State Government, at any time during normal business hours, as often as City or State deems necessary, to audit, examine, and make excerpts or transcripts of all relevant data, both financial and programmatic. Any deficiencies noted in audit CEAP Agreement — City of Lubbock & Lutheran Social Services —2018 Page 8 reports must be fully cleared by Contractor within thirty (30) days after receipt by the Contractor. Failure to comply with the above audit requirements will constitute a violation of this Contract and may result in the withholding of future payments. F. Operation and Financial Reports 1. Financial Record Reports: The Contractor agrees to submit to the City invoices for the services and approved costs of the Program by the tenth (loth) day of each month. 2. Operation Reports: The Contractor agrees to submit to the City a monthly activity report in accordance with instructions provided by the State. Article 9. PERSONNEL AND PARTICIPANT CONDITIONS A. Civil Rights 1. The Contractor agrees to comply and to require all subcontractors to comply with Title VI of the Civil Rights Act of 1964 as amended, Title VIII of the Civil Rights Act of 1968 as amended, Section 109 of Title I of the Housing and Community Development Act of 1974, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Executive Order 11063, and with Executive Order 11246 and the regulations issued under the order at 41 CFR Chapter 60. 2. No person shall on the ground of race, color, religion, sex, national origin, age, disability, political affiliation or belief be excluded from participation in, be denied the benefits of, be subjected to discrimination under, or be denied employment in the administration of or in connection with any program or activity funded in whole or in part with funds made available under this Agreement. B. Conduct 1. Prohibit Political Activity and Lobbying. The Contractor hereby certifies that: a. No Federal appropriated funds have been paid or will be paid, by or on behalf of it, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement; b. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, it will complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; c. It will require that the language of this certification be included in the award documents for all subawards at all tiers (including any subcontracts, subgrants, and CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 9 contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly: "None of the funds provided under this contract shall be used for influencing the outcome of any election, or the passage or defeat of any legislative measure. This prohibition shall not be construed to prevent any official or employee of Contractor from furnishing to any member of its governing body upon request, or to any other local or official not considered under law to be confidential information. Any action taken against an employee or official for supplying such information shall subject the person initiating the action to immediate dismissal from employment" d. No funds provided under this Agreement may be used directly or indirectly to hire employees or in any other way fund or support candidates for the legislative, executive, or judicial branches of government of Contractor, the State of Texas, or the government of the United States; and e. None of the funds provided under this Agreement shall be paid to any official or employee who violates any of the provisions of this section. 2. Con ict of Interest and Nepotism. a. The Contractor covenants that neither it nor any member of its governing body presently has any interest or shall acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance of this Agreement. The Contractor further covenants that in the performance of this Agreement no person having such interest shall be employed or appointed by the Contactor. b. No person: (1) Who is an employee, agent, consultant, officer, or official of the Contractor, and who exercises or has exercised any functions or responsibilities with respect to assisted contract activities; or, (2) Who is in a position to participate in a decision making process or gains inside information with regard to such activities, may obtain a personal or financial interest or benefit, direct or indirect, in any contract, subcontract, or agreement with respect thereto, or the proceeds there under, either for themselves or those with whom they have familiar or business ties, during their tenure. c. The Contractor's employees, officers, and agents shall neither solicit nor accept gratuities, favors, or anything of monetary value from subcontractors, or potential subcontractors. C. Air & Water The Contractor agrees to comply with the following requirements insofar as they apply to the performance of this Agreement: Clean Air Act, 42 U.S.C., 7401, et seq., Federal Water Pollution Control Act, as amended, 33 U.S.C. 1251, et seq., as amended, 1318 relating to inspection, monitoring, entry, reports, and information, as well as other requirements specified in said Section 114 and Section 308, and all regulations and guidelines issued thereunder. IN WITNESS HEREOF, THE PARTIES HAVE EXECUTED AND ENTER INTO THIS AGREEMENT ON THE EFFECTIVE DATE [Signature Page to Follow] CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 10 SIGNATURES THE CITY OF LUBBOCK: LUTHERAN SOCIAL SERVICES OF THE SOUTH, INC. DANIEL M. POPE, MAYOR Name (Signature) Dr. Kurt Senske Name (Printed) ATTEST: FED.I.D.# 74- 1109745 Reb teca Garza, City Secretar APPROVED AS TO CONTENT: vv� Karen Murfee, Community Dev opment Director APPROVED AS TO FORM: CEAP Agreement — City of Lubbock & Lutheran Social Services — 2018 Page 11 CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 1 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. 2018-303104 Lutheran Social Services of the South, Inc. Austin, TX United States Date Filed: 01/17/2018 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Lubbock Date Acknowledged: 01/22/2018 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. 13908 Social 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 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) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337 CERTIFICATE OF INTERESTED PARTIES FORM 1295 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: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2018-303104 Lutheran Social Services of the South, Inc. Austin, TX United States Date Filed: 01/17/2018 2 Name of governmental entity or state agency that is a party to 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. 13908 Social Services Nature of interest 4 Name of Interested Party City, State, Country (place of business) (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is Dr. Kurt Senske and my date of birth is My address is 8305 Cross Park Drive Austin TX , 78754 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Travis County, State of Texas on the 17&y of January 20 18 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.etnlcs.state.ix.us Versrun Vl.u.333/