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HomeMy WebLinkAboutResolution - 2018-R0179 - PO With Mity Lite Inc. - 05/24/2018Resolution No. 2018-RO179 Item No. 5.14 May 24, 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, Purchase Order No. 27600012 for the purchase of Folding Tables for the Civic Center as per ITB 18-14031-MA, by and between the City of Lubbock and Mity Lite Inc., of Orem, Utah, 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 May 24, 20 ( - " P-1:0� JEFF GRIFFITH, MAYOR PRO TEM ATTEST: '� I A Rebecca Garza, CiVy Secretary APPROVED AS TO CONTENT: / SC6*E v A Scott Snider, Assistant City Manager APPROVED AS TO FORM: R n Ycoke, ssistant City Attorney ccdocs/RES.PO 27600012.Folding Tables for the Civic Center 04.27.2018 City of ►► Lubb o ck TEXAS PURCHASE ORDER TO: MITY LITE INC 1301 WEST 400 NORTH OREM UT 84057 SHIP TO: Page - 1 Date - 4/26/2018 Order Number 27600012 000 OP CITY OF LUBBOCK P O BOX 2000 LUBBOCK TX 79457 INVOICE TO: CITY OF LUBBOCK ACCOUNTSPAYABLE P.O. BOX 2000 LUBBOCK, TX 79457 BY: 4i4,/ Marta Warez, birector of Purchasing & Contract Management Ordered 4/26/2018 Freight Requested 7/2/2018 Taken By F MONCADA Delivery M VILLAGRANA REQ 52101 ITB 18-14031-MA Description/Supplier Item Ordered Unit Cost UM Extension Request Date ABS Folding Tables 29"x8'x30in 110.000 171.8500 EA 18,903.50 7/2/2018 ABS Folding Tables 29"x6'x18in 110.000 141.9200 EA 15,611.20 7/2/2018 ABS Folding Tables 29"x60in 150.000 212.5400 EA 31,881.00 7/2/2018 circular Total Order Terms NET 30 66,395.70 This purchase order encumbers funds in the amount of $66,395.70 awarded to Mity Lite Inc. of Orem, UT, on May 24, , 2018. The following is incorporated into and made part of this purchase order by reference: ITB 18-14031-MA dated April 2, 2018 from Mity Lite Inc. of Orem, UT. Resolution # 2018-RO179 CITY OF LUBBOCK JEFF GRIFFITH, MAYOR PRO TEM ATTEST: Rebecca Garza, &ty Secretary 195 Seller and Buyer agree as follows: PURCHASE ORDER TERMS AND CONDITIONS IMPORTANT: READ CAREFULLY STANDARD TERMS AND CONDITIONS CITY OF LUBBOCK, TX L SELLER TO PACKAGE GGODS. Seller will package goods in accordance with goodcom.2eruial practice. Each shipping container shall be clearly and permanently marked as FoEows (a) Seller's name and advss. (b) Corsigaee's name, address and purchase order orpurchase release number and the supply agreeme .t nu:cber ifapplicable.(a) Container number and total number of containers, e.g. box I ofs boxes, and (d) the numbe of the container buaricg the packing slip. Selr shall lebear cost of packaging m:ss otherxise pros ie d Goods sha8 be suitably packed to sonic lowest timmportation costs and to cenfartn with requirements of common carriers and any applicable specifications. Buyer's court or wnghi shall be final and ceaclusiYe on shipments net accomparued by packing lists 2. SHIPMENT UNDER RFSFRVATIONI PROHIBITED Seller is cot authorized to ship the rood; 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 pessess:on of the goods at the poiet or points of de!isery. 4. NO REPLACEMENT OF DFFF.0 IVE TENDER Ecary tender of delver a of goods muse filly cu:stply with all provisions of :his coctract as to time of dahvay. quality and the like If a raiderrs made which doe. not fully conform. this shall consiitute a breach and Seller shall nor bare the right to substitute a coofo:minu leader, provide tL where the tune for perfor amce has not yet expired. the Seller may reasonably notify Buycr of his interstice to cure and may rFam make a Conforming tender u.thic the cuct:act ti.-ne but act ahervard 5. rNVOICES & PANMENTS. a. Seller shall suborn separate invoices, in duplicate, one each purchiisc order or purchase release aria each delivery Invoices shall indca:e the purchase order or purchase release numller and the supply agreement eimbcc if applicable, Invoices shall br aemized and marsponatian charges, if any. sha0 be (utcd separately A copy of the bill of lading, and the weight waybill when applicah:e, should be attached to the invoice Mail To Accounts Payable. City of Lubbock. P O Box 2000, Lubbock. Texas 79-57. Payment shall not be due until the above mslrvrmenis ire submitted after deliveiv fi GRATUITIES The Buyer may, by wmica notice to the Sella• cancel this contract wahe.( habday to Sella if it is detarrunt l by Buyer that gracaiaies. in the form of entaTainmcer, gills or o:hcrwise. were offered or given by the Seller, or any agent or representative or the Seller, to any officer or employee of the City of Lubbock with a view to seeming a court= or securing fatarabie n earmeat with respect to the awarding or amending, or the making of any determinations with respect to the performing of such a contract. In the rent Ibis contract is canceled by Brayer ptusuart to this provision. Buy= shall be entitled, in addition to any otha rights and ralo dim to recoveror withhold the ame= of the cost incurred by Seller in pmyiding such gramit:es 7. SPECIAL TOOLS & TEST EOUIPMEAT If the price stated on thr face hereof includes the cost of an, special tooling or special tat equipment fabricated or required by Scler for the purpose of fining this orda. such special tooting equipment and any process sheets related theeta shall become the property of the Buyer and to the extent feasible shall be identified by the Seller as such 8. W'.ARRA.N'TY-PRICE. a The price to be paid by the Buyer shall be that comaincd in Seller's bid which Seller warrants to be no higher than Sella's current process an orders by others for products of the ku:d and spc:ificatioo covered by this Waxoncat for similar quantities under similar of like conditions and methods of purchase. In the e+em Seller breaches this warranty. the prices of the items shall be reduced to the Seller's corona: prices on orders by others, or in the alternative. Buyer may cancel this contract without liability to Seiler for breach or Seller's actual asperse, b The Seller warrants that no person or selling agency bas been employed or retained to solicit or secure this contract upon an agreement or understanding Cr commission, percentage. brokerage, or contingent fee excepting bona fide employes of bona fide established ccrnrtsercial or selling agencies maintained by the Sella for the purpose of securing business. For breach of iicialion of This warramy the Buyer shall have the right in addition to any other tight of rights to eatceI this contract wahou, liability and to deduct from the contract price, or Otherwise recover without liability aril to deduct from the coutract price, or otherwise recoverthe full amount of well cornmssun, pet tentage. brokerage or contingent fee. 9 WARRANTY -PRODUCT Sella shall not limit or exclude any implied warranties and toy altcmpi to do so shall reading this contract voidable at the option of the Buyer Seller warrinits that the goods furnished will conform to the specif:cat ion, drawings, and descriptions listed in the bid in•; itarion. and to the samples) furnished by the Seller, if any. To doe event of a conflict or between the specificat:uns, drawings, and desaiprions, the specifications shall govern. Notwithstanding any provisions contained in the camranual agreeouat, the Sella represents and warrants fuck -bee performance and fault -free result in the processing date and date related data (including. but act limited to calculating. enmparing and segrrrncing) of all hardware, software and firmware products delivered and set%ices presided under this Contract, bidividuaW or in combination, u the Case may be from the effective date of this Contract. The obligations coutaiacd herein apply to products and sin ices provided by the Sella, its sub- Sella or any third parry involved m the creation or dcvelopmcn( of the products and services to be delivered to the City of Lubbock under ibis Contract Failure to comply with any of The obligations coma¢ed herein. may result in the City of Lubbock as ailing asc'f of any of its tights under the law and under this Contract including. but Out lustucd to. its right pertaining to temiinat:on or derauh. Thu , arras iu contained herein are separate and discrete from arty other warranties Specified in this Contract, and are not subject to any disclaimer or warranty, implied or expressed or limi:at:on of the Seller's liability which may be specified in this Contract, its appecdua, its schedules. its aanexa or any documai incorporated is ibis Contract by reference. 10 SAFM WARRANTY. Seiler warrants that the product sold to the Bayer shall conform 10 the standards promulgated by the U. S Department or Labor under the Occupational Safety and Health Act of 1970. In the meet the prndxt does not conform to OSHA Standards. Buyer may return the product for correction or replacement at the Seller's expense In the evert Seller fails to make the appropriate correction within a reasonable time, correction made by Buyer win be at the Sena's expense 11. NO WARRANTY BY BUYER AGArNST LNFMGE.MENTS As pan of this comrauT for We Sella agrees to ascertain whether goods maoufactmed in accordance with the specifications attached to this agreement will give rise to the rightful claim of toy third person by way of infringement of the Idle. Buyer makes no warranty that the production of goads according to the specaf cti ion will not give use to such a things. and irk no evxmt shall Buyer be liable to Sella for indemnification in the event that ScBer is sued an the grounds of iafringemcl of the like If Seier is of the opinion that an urkiage9cat or the lii:e will result, he will entity the Buyer tothA effer, in waving within two weeks after the signing oohs agreement. If Buyerdoes col receive notice and is subsequently held liable for the infringement or the like. Sena will save Buyer harmless IF Sella in good faith ascertains the production of the goods in a,cor ce with are spectficatons wal result m iafriagai or the like. The contract sisal: be nall and void . 12. NON APPROPRIATION' All funds for payment by the City Omda this eonrraa are subjwr to the availabday of an armual appropriation for the purpose by the Cny It the ,vent of ecoappropriauon of funds by the City Council of the City of Lubbock for the goods or services pre•: ided under the contract. The City will tarainate the contract withom termination charge or other liability, on the gait day of the, then -current fecal year or when the appropracion made for The tbea-cumeat year for the goods or services covered by this Contrite, is spent, whichever even occurs first. If at any time funds are not appropcialud for the contiruaace of tbs comma, cwce!latien shall be accepted by the Sella on Thirty (30) days prior written notice. but failure :o gist finch r�aicr -tell Lr of en r(rrd ..^toil rh:• C.1y A.tp rot I'.: rEF •a+ �,t n.: i..i h`'.: e roll a.; F: .I hbo .,re, 13. RIGHT OF INSPECTION. Buyer shall have the right to inspect the goods at delivery before accepting them 1,1 C',%NCELI ATl.'X: (%icy:: shall U.c t z .3;U to C:_ d L, ci ,-zAk portion of this order if Sella breaches any Of the turns haeul including waman:ies of Sella Or if the Seder hecnmes invrhvnr or plmmas artq of hanknmlcv Such rioter of raracIlatinn k in adrlbim in and not in Inv of any other :emedis which Buyer may have m law or equity. 15 TFILMINfATION. The perfarmanceof work under this order maybe terminated in whcic, Orin parr by the Buyer in accordance with ibis provision. Tammation of work bereunder shall be effected by the deli_,of the Seller of a "Notice of Termination" specifying the extent to lhlh per foTmaace of nark under the order is terminated and the date •upoe which such tmnination bccems effective Such right or termination is an addition to and not in lira of the rights of Buyer set forth in Clause 14, bercia. ifi FORCF 1.LAJEURE. Neither party shall be held responsible for losses, resulting hf the fulfill"; of any terns of provis;oas of this contract is delayed or prevented by any corer, not within the control of the perry whoa FerFomaace is intafaed with. and which by the exercise of reaac,nable diligence said party n unable to presort. 17, .ASSIGNMENT -DELEGATION, No right or m:exst in this contract shall be assigned or dekgation of any cblieatien made In Seller without the w—nu" permission of the Buyer. Any aCcn:pted :tssignm:m or de'ego'iea Sy Seller shatl be wholly 'vaid and Totally s:effecrive rot all purpose unless made in conform:ywah this parntraph 19 WAIVFR No claim or right rsirg nice OFa breach of this coctract can be discharged it: Abele Cr it, par, by a waiter or renunciat:an of the claim or right unless Lie umver or renunciation is supported by consufaation and is in writing signed by the aggrieved party. 19. INTERPRETATION -PAROLE EVIDENCE. This writing: plus any specifitcatiors for bids and perrommnue provided by Buyv in its advenitscmea: for bids, and any other docu Ounls provided by Sella as pan of his bid is intecdcd by (hc parties as a final upressioa of thou agreement and intended also as a complete and exclusive statmat of the terms of their agreement. Whenever a term defined by the Vniform Comraercial Code a used a this ai7"ment, the defiration cuatza:edin the Code is to Control. 20. APPLICABLF LAW. This aloeeaunt shall be gnvemcd by t^.c Uniform Commercial Cede Wharner the case -Uniform Commercial Code- is used, it Shan be construed as meaning the Uniform Commercui Code as adopted in the State of Texas m effecinc and to fcrte on the date orthis agreement. 21 RIGHT TO ASSURANCE. Whenn'er one party to this contract in good faith haq reason to question the other party's intent to perform he may demand that the other party grvc written assurance of has intent to perform. 10 tic event that a demand is made and no assurance is given within five (5) days. the demanding party may treat this failure as an amicipatory repudiation. of We cantrae.. 22 INDENLNIFTCATION. Sella shall indemnify, keep and save harmless the Buyer, its agents. officials and emp!oydo. again.,, all injuries, deaths loss. c! rO%Ves, claims, patent clabre, suits. liabilities, judgments, costs and exptves, which may in anywise aec,ic agamst the Buyer in consequence a£the granting of this Contract or which may anywise result tbcrefrom 'halter or not it shall be alleged or determined that the act was Caused through negliracc or emission of the Seller or its employers, or of the suhSella or assignee or its employees. if any; and the Sena shall at his nun expense, appear, defend and pay all charges of attorneys and all costs and other cxpens arising therefiom of incurred in connection therewith, and, if arty judgment shall be rendered against the Buyer in any such action. $r Sella shall. at itsown expenses, satisfy and discharge else same Sella expressly undr;vands and agrees that ry bond required by this comma, ar mhm risc prm iJud by Sella, shall is no way !lour The responsibility to indemnify, keep u save liaimlcss and defend the Butler as herein provided. 23. 71?IE•. It is herehy expressly agreed and understood that time is of the asture for the perfarmance of this contract, and failure by contract to meet the time specifications of this agreement will cause Seller to be in defanh ofihrs agreement. 24 MBF. The Cily or Lubbock hereby notifies all bidders :hut is regard to any contract entered into pursuant to this request. minority and women business enterprise will be afforded equal opportutities to snbmu bids in rspaase 10 this invitmion and will not be discriminated against on the grounds of race court sex or natural orirm m comideratiea for an award 25. NON -ARBITRATION. The Cny rsev,s the right to exercise any right or remedy to it by law, contract. equity, or otherwise. including without limitation. the right w seek any and all forms of relief in a court of compete It jurisdiction Further, the City shall not be subject to any arbitration process prior to exercising its unrestricted rightto seek judicial remedy The remedies ser forth herein are cumulative and not exclusive, and may be uacisal concurrently. To the extent of any conflict between this provision and mocha provision in, or related To, this document. this provision shall central 25. RIGHT TO AUDIT At any law during the Tank of the contract, or thereafter, the City, or a duly authorized audit representative of the City or the State of Text, at its expense and at reasonable times, resm•eq the right to audit Contractors records and books relevant W all services provided to the City coda this Contract. h: the n1oll such an audit by the City reveal any errors cr oveppaymenu by the City, Contractor shall refund the City the full amount of Bach overpayments within thin (30) days of such audit findings. or the City. at ns option. resrnxs the right :o deduct such amounts oiling the City from any Payments due Contractor 27- HOUSE BILL 2015- HU`aae Bid ''-015, signed by the Governor on June la, 2013 and effective an January L 2014, authorizes a penalty to be imposed on a pawn who Contracts for certain Stan ices wish a governmental entity and who fails to properly classify their workers. This applies to subcontractors as w•c0. Contractors and subcontractors who Fail to properly classify individuals performing work under a govemmeatal contract will be penalized $200 for each individual that has been misclasekfred (Texas Government Code Section 2155 001) 28 ASSIGNING OR SUBLETTLNG THE CONTRACT 1oc Cootractorshall not amign or sublet the contract, or any portion of the contract, xilbom written consent from the Dreelor of Purchasing and Contract Management Should corsem be given, the Contractor shall casino the Subcatractor or shall provide proof ct insurance from the Subcontractor that complies with all contract tasurance requzemenls 29. HOUSE. BILL 1295 DISCLOSURE OF INTERESTED PARTIES, Howe Bill 1295, adopted by the 84th LcOlaltut. created §22-52.90& Texas Govaamem Code. Setting M2.908 «Qu'ves a business eaity eaterug 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 tine the businras corny subunits the signed contract to the governmennal entity or state agency I= -liens for completing Form 1295 are available at (Slp:::w>,•w ci le6 ..rt ex „rdrrmni1h em41-w•ebsites•dens•,ahemtdpurcfin�+*�_ven�t?7 nfotmmion 30. CONTRACTOR ACKNOWLEDGES, by supplying any Goods or Services that the Contractor has rod. funv understands and will be in full compliance with all terms and conditions and the descriptive material contained herein and any additional associated dcoumeacs and Amendments The City disclaims arty terms and camdameq prcvidcd by Thu Contractor unless agreed upon in wnlmg by the parties. In the event Of Conflict hot%= these terms and cenditasns sad airy terms and conditions provided by the Contractor, the terror and conditions prnv ided herein shall prevail, The :ettas and conditions provided herin are the Final terms agreed upon by the parties. and any prior ctnflhaing terms shall be of ao force or effect 31 By nccalirc this pur,+:a. order, to Vendor rerifms that it d„eq not Boy cot Lrarl. and agrees that dnrine lLv Icuu rl Its flz.ciment If'n:dt�.h a.::,du .!dal ., i1j o: Irv:,n Iv....:,: •La it „ de!Snca in Tt'.;n lie, rtnnu•nh CcJ•_ Section SCN.01, a: mend:os City of Lubbock Bid ITB 18-14031-MA BID FORM Folding Tables for the Civic Center City of Lubbock, TX ITB No. 18-14031-MA In compliance with the Invitation to Bid 18-14031-MA, the undersigned Bidder having examined the Invitation to Bid and Specifications, and being familiar with the conditions to be met, hereby submits the following Bid for furnishing the material, equipment, labor and everything necessary for providing the items listed below and agrees to deliver said items at the locations and for the prices set forth on this form. A bid will be subject to being considered irregular and may be rejected if it shows omissions, alterations of form, conditional alternate bids, additions or alternates in lieu of the items specified, if the unit prices are obviously unbalanced (either in excess of or below reasonably expected values), or irregularities of any kind. The Invitation to Bid 18-14031-MA is by reference incorporated in this contract. The Bid Form must be completed in blue or black ink or by typewriter. ' ITEM DESCRIPTION QTY (+/-) U/M UNIT EXTENDED DELIVERY COST* COST Days ARO** 1. ABS Folding Tables — 29" x 8' x 30in, 110 EA $ rJ per specifications '. ABS Folding Tables — 29" x 6' x l 8in, 110 EA �� i� 2� `� cJ per specifications (.c(� ; • 3. ABS Folding Tables — 29" x 60 in. 150 EA Lj L•5 J' ©O i, circular, r specifications Total Cost $ *PRICE: F.O.B. Destination, Freight Pre -Paid and Allowed "Days After Receipt of Order (ARO) Unless otherwise specified herein, the City may award the bid either item -by —item or on an all -or -none basis for any item or group of items shown on the bid. PAYMENT TERMS AND DISCOUNTS -Bidder offers a prompt payment discount of __0_%, net—V calendar days. Discounts will not be considered in determining low bid. Unless otherwise indicated on the Bid Form, payment terms will be NET THIRTY DAYS. The City will pay the successful bidder within thirty days after the receipt of a correct invoice or after the date of acceptance, whichever event occurs later. Discounts for prompt payment requiring payment by the City within a stipulated number of days will be interpreted as applying within the stipulated number of calendar days after the date of receipt by the City of a correct invoice or after the date of acceptance that meets contract requirements, whichever event occurs later. Discounts for payment in less than ten days will not be considered. MOST FAVOURED PRICING: The Bidder certifies that the price quoted is not in excess of the lowest price charged anyone else, including its most favoured customer, for like quality and quantity of the products/services; does not include an element of profit on the sale in excess of that normally obtained by the Bidder on the sale of products/services of like quality and quantity; and does not include any provision for discounts to selling agents. If at any time during the contract period, the supplier should sell or offer for sale to any other customer, an equal or less quantity of similar contract products of like or better quality, at a lower net price(s) than provided herein, supplier agrees to notify the City and sell same product(s) at the lower price(s) on all deliveries made during the period in which such lower price(s) is effective. INTERLOCAL PURCHASING (optional): The City desires to make available to other local governmental entities of the State of Texas, by mutual agreement with the successful bidder, and properly authorized interlocal purchasing agreements as provided for by the interlocal Cooperation Act (Chapter 791, Government Code), the right to purchase the same services, at the prices quoted, for the period of this contract. Each bidder shall indicate on the Bid Form in the space provided below if he/she will honor Political Subdivision orders in addition to orders from the City of Lubbock. Should these other governmental entities decide to participate in this contract, would you (the bidder) agree that all terms, conditions, specifications, and pricing would apply? Other governmental entities that might have interests in this contract are Frenship Independent School District, Lubbock Housing Authority, Lubbock County, Lubbock County Hospital District, Lubbock Independent School District, South Plains Association of Governments, City of Texarkana, Texas Tech University, West Texas Municipal Power Agency, Lynn County, and City of Wolfforth. 3/23/2018 3:11 PM P 7 City of Lubbock Bid ITB 18-14031-MA YES NO •J • If you (the bidder) checked YES, the following will apply: • Governmental entities utilizing Interlocal Agreements for Cooperative Purchasing with the City of Lubbock will be eligible, but not obligated, to purchase materials/services under the contract(s) awarded as a result of this solicitation. All purchases by governmental entities other than the City of Lubbock will be billed directly to that governmental entity and paid by that governmental entity. City of Lubbock will not be responsible for another governmental entity's debts. Each governmental entity will order their own materials/service as needed. THIS BID IS SUBMITTED BY IAt�jgk a corporation organized under the laws of the State of MaV, , or a partnership consisting of of the City of 0 rtwl Firm: 1A IA-4 I.l+�• or individual trading as Address: 133' 1 W e&f LtCl) City: State: UT Zip CM d5-7 Bidder acknowledges receipt of the following addenda: Addenda No. Date Addenda No. Date Addenda No. Date M/WBE Firm: By Authorized Woman I I Black American Native American Hispanic American I I Asian Pacific Americas I Other (Specify) sign by hand Officer Name and Title: �'eT Scott Please Print Business Telephone Number bok - n'A - FAX: K©l - 'ZZH - (1 11 E-mail Address: n t`�i ( 1IY\ FOR CITY USE ONLY Bid Form Item Number(s) Awarded to Above Named Firm/Individual: Date of Award by City Council (for bids over $50, 000): Date P.O./Contract Issued: RETURN COMPLETED & SIGNED BID FORM ALONG WITH CITY OF LUBBOCK SPECIFICATIONS. LABEL THE OUTSIDE OF YOUR SEALED BID WITH THE ITB NUMBER, THE CLOSING DATE AND TIME, AND YOUR COMPANY NAME AND ADDRESS 3/23/2018 3:11 PM P. 8 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. 2018-357269 Mity Lite, Inc Orem, UT United States Date Filed: 05/22/2018 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: 05/22/2018 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. 2760012 Folding Tables 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 V1.0.5523 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. 2018-357269 Miry Lite, Inc Orem, UT United States Date Filed: 05/22/2018 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: g 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. 2760012 Folding Tables 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 % /� �itand my date of birth is My address is `J �%� 1/.Z �—f % /t� ���. (% Ir, ��1• (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in 1/ ih County, State of [, on the �L day of r� 20-1/-�- (month) (year) Signature of authori agent of co acting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us version v1.u.5bL3