HomeMy WebLinkAboutResolution - 2019-R0151 - Berryhill Sewer Service - 05/14/2019 Resolution No. 2019-RO 1 S 1
Item No. 6.3
May 14, 2019
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, Service Contract No. 14608 for Chemical Toilet
Rentals for Various Departments as per ITB 19-14608-RR, by and between the City of
Lubbock and Berryhill Sewer Service, Inc., of Lubbock, Texas, and related documents. 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 May 14, 2019
DANIEL M. POPE, MAYOR
ATTEST:
Re ecca Garza, City Secre ary
APPROVED AS TO CONTENT:
- 622�0
Blu ostelic , Chief Financial Officer
APPROVED AS TO FORM:
t.
MZ"IJ AV14'e
elli Leisure, Assistant City Attorney
ccdocs/RES.Service Contract 14608—Berryhill Sewer Svcs.
04.22.19
Resolution No. 2019-RO 151 Contract 14608
City of Lubbock,TX
Contract for
Chemical Toilet Rentals for Various Department
THIS CONTRACT made and entered into this 14th day of May , 2019, by and between the
City of Lubbock("City"), and Berryhill Sewer Service, Inc., ("Contractor").
WITNESSETH:
WHEREAS, the City of Lubbock duly advertised for bids for Chemical Toilet Rentals for
Various Departments and bids were received and duly opened as required by law; and
WHEREAS, after careful consideration of the bid submitted by Contractor, the City authorized
the execution, in the name of the City of Lubbock a contract with said Contractor covering the purchase
and delivery of the said Chemical Toilet Rentals for Various Departments.
NOW,THEREFORE, in consideration of the mutual agreement contained herein, as well as the
financial consideration hereinafter referred to, the parties hereby covenant and agree as follows:
1. In accordance with City's specifications and Contractor's bid,copies of which are attached hereto
and made part hereof, Contractor will deliver to the City, Chemical Toilet Rentals for Various
Departments and more specifically referred to as Items 1 through 11 on the bid submitted by the
Contractor or in the specifications attached hereto.
2. The City promises and agrees to employ, and does employ, the Contractor to cause to be done
the work provided for in this Contract and to complete and finish the same according to the
attached specifications, offer, and terms and conditions contained herein.
3. The contract shall be for a term of one year, with the option of four, one year extensions, said
date of term beginning upon fonnal approval. All stated annual quantities are approximations of
usage during the time period to be covered by pricing established by this bid. Actual usage may
be more or less. Order quantities will be determined by actual need. The City of Lubbock does
not guarantee any specific amount of compensation, volume, minimum, or maximum amount of
services under this bid and resulting contract. The Contractor must maintain the insurance
coverage required during the tenn of this contract including any extensions. It is the responsibility
of the Contractor to ensure that valid insurance is on file with the Purchasing and Contract
Management Department as required by contract or contract may be terminated for non-
compliance.
4. The rates may be adjusted upward or downward at this time at a percentage not to exceed the
effective change in the Consumer Price Index (CPI) or Product Price Index (PPI), whichever is
most appropriate for the specific contract for the previous 12-months. At the City's discretion,
the effective change rate shall be based on either the local or national index average rate for all
items. If agreement cannot be reached, the contract is terminated at the end of the current contact
period.
5. This contract shall remain in effect until the first of the following occurs: (1)the expiration date,
(2) perfonnance of services ordered, or (3) termination of by either party with a 30 day written
notice. The City of Lubbock reserves the right to award the canceled contract to the next lowest
and best bidder as it deems to be in the best interest of the city.
6. Contractor shall at all times be an independent contractor and not an agent or representative of
City with regard to performance of the Services. Contractor shall not represent that it is, or hold
itself out as, an agent or representative of City. In no event shall Contractor be authorized to
enter into any agreement or undertaking for or on behalf of City.
7. Insurance Requirements
SECTION A. Prior to the approval of this contract by the City, the Contractor shall furnish a completed Insurance
Certificate to the City, which shall be completed by an agent authorized to bind the named underwriter(s) to the
coverages, limits, and termination provisions shown thereon, and which shall furnish and contain all required
information referenced or indicated thereon. THE CITY SHALL HAVE NO DUTY TO PAY OR PERFORM UNDER
THIS CONTRACT UNTIL SUCH CERTIFICATE SHALL HAVE BEEN DELIVERED TO THE CITY.
SECTION B. The City reserves the right to review the insurance requirements of this section during the effective
period of the contract and to require adjustment of insurance coverages and their limits when deemed necessary and
prudent by the City based upon changes in statutory law, court decisions, or the claims history of the industry as well
as the Contractor.
SECTION C. Subject to the Contractor's right to maintain reasonable deductibles in such amounts as are approved by
the City, the Contractor shall obtain and maintain in full force and effect for the duration of this contract, and any
extension hereof,at Contractor's sole expense,insurance coverage written by companies approved by the State of Texas
and acceptable to the City, in the following type(s) and arnount(s):
TYPE OF INSURANCE COMBINED SINGLE LIMIT
GENERAL LIABILITY
® Commercial General Liability General Aggregate 5500.000
❑ Claims Made ® Occurrence Products-Comp/Op AGG X
❑ W/Heavy Equipment Personal&Adv. Injury X
❑ To Include Products of Complete Operation Endorsements Contractual Liability X
Fire Damage(Any one Fire)
Med Exp (Any one Person)
PROFESSIONAL LIABILITY
❑ General Aggregate
AUTOMOTIVE LIABILITY
® Any Auto ❑ All Owned Autos
❑ Scheduled Autos ❑ Hired Autos
❑ Non-Owned Autos Per Occurrence 5500.000
EXCESS LIABILITY
❑ Umbrella Form Each Occurrence
Aggregate
GARAGE LIABILITY
❑ Any Auto Auto Only- Each Accident
❑ _ Other than Auto Only:
Each Accident
Aggregate
❑ BUILDER'S RISK ❑ 100%of the Total Contract Price
❑ INSTALLATION FLOATER ❑ 100%of the Total Material Costs
❑ CARGO
® WORKERS COMPENSATION—STATUTORY AMOUNTS OR
OCCUPATIONAL MEDICAL AND DISABILITY
® EMPLOYERS' LIABILITY $500.000
OTHER:COPIES OF ENDOSEIVIENTS ARE REQUIRED
® City of Lubbock named as additional insured on Auto/General Liability on a primcay and non-contributory bases.
® To include products of completed operations erzdorserraertt.
® Waiver of subrogation in favor of the City of Lubbock on all coverages, except
IMPORTANT: POLICY ENDORSEMENTS
The Contractor will provide copies of the policies without expense, to the City and all endorsements thereto
and may make any reasonable request for deletion, revision, or modification of particular policy terms,
conditions, limitations, or exclusions (except where policy provisions are established by law or regulation
binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the
City, the Contractor shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall
pay the cost thereof. Any costs will be paid by the Contractor.
REQUIRED PROVISIONS
The Contractor agrees that with respect to the above required insurance, all insurance contracts and certificate(s)
of insurance will contain and state, in writing, on the certificate or its attachment, the following required
provisions:
a. Name the City of Lubbock and its officers, employees, and elected representatives as additional insureds,
(as the interest of each insured may appear) as to all applicable coverage;
b. Provide for 30 days notice to the City for cancellation, nonrenewal, or material change;
c. Provide for notice to the City at the address shown below by registered mail;
d. The Contractor agrees to waive subrogation against the City of Lubbock, its officers, employees, and
elected representatives for injuries, including death, property damage, or any other loss to the extent same
may be covered by the proceeds of insurance;
e. Provide that.all provisions of this contract concerning liability, duty, and standard of care together with
the indemnification provision, shall be underwritten by contractual liability coverage sufficient to include
such obligations within applicable policies.
NOTICES
The Contractor shall notify the City in the event of any change in coverage and shall give such notices not less
than 30 days prior the change, which notice must be accompanied by a replacement CERTIFICATE OF
INSURANCE.
All notices shall be given to the City at the following address:
Marta Alvarez, Director of Purchasing & Contract Management
City of Lubbock
1625 13"' Street, Room 204
Lubbock, Texas 79401
SECTION D. Approval, disapproval, or failure to act by the City regarding any insurance supplied by the
Contractor shall not relieve the Contractor of full responsibility or liability for damages and accidents as set forth
in the contract documents. Neither shall the bankruptcy, insolvency, or denial of liability by the insurance
company exonerate the Contractor from liability.
8. Neither the City nor the Contractor shall assign, transfer or encumber any rights, duties or
interests accruing from this Contract without the written consent of the other.
9. 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 document, this provision shall
control.
10. At any time during the tern 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 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.
11. 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 non-appropriation 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 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 tennination.
12. The Contractor shall not assign or 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.
13. 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 Ainendments. 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 teens and conditions and any ten-ns and
conditions provided by the Contractor, the terns and conditions provided herein shall prevail.
The terns and conditions provided herein are the final terms agreed upon by the parties, and any
prior conflicting terns shall be of no force or effect.
14. SB 252 prohibits the City from entering into a contract with a vendor that is identified by The
Comptroller as a company known to have contracts with or provide supplies or service with
Iran, Sudan or a foreign terrorist organization.
15. The Contractor warrants that it complies with Chapter 2270, Subtitle F, Title 10 of the Texas
Government Code by verifying that:
(1) The Contractor does not boycott Israel; and
(2) The Contractor will not boycott Israel during the term of the Agreement.
16. This Contract consists of the following documents set forth herein; Invitation to Bid No. 19-
14608-RR, Specifications, and the Bid Form.
-----INTENTIONALLY LEFT BLANK-----
IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed the day and
year first above written. Executed in triplicate.
CITY OF LUBBOCK CONTRACTOR
BY: :YJ,A.=,,f -2
Daniel M. Pope, Mayor Authorized Represenfative
ATTEST: 'Yh,
Print Name
Reb c Garza, City Seer ary
Address
APPROVED AS TO CONTENT:
City, State, Zip Code
Marta A varez, Director of Purchasing and
Contract Management
APPROVED AS TO FORM
KPLeiisurc, Assistant City Attorney
City of Lubbock,TX
ITB 19-14608-RR
Chemical Toilet Rentals for Various Department
Specifications
1. GENERAL:
1.1 The purpose of this invitation to bid is to set for a period of one year,firm pricing for the rental and servicing
of chemical toilets at various locations up to 25 miles outside the city limits of the City of Lubbock.The City
and Contractor may, upon written mutual consent, extend the contract for four additional one-year periods.
The rates may be adjusted upward or downward at this time at a percentage not to exceed the effective change
in the Consumer Price Index (CPI) or Product Price Index (PPI), whichever is most appropriate for the
specific contract for the previous 12-months.At the City's discretion,the effective change rate shall be based
on either the local or national index average rate for all items. If agreement cannot be reached, the contract
is terminated at the end of the current contract period. In order to assure adequate coverage, the City may
make multiple awards,selecting multiple vendors to provide the products desired, if multiple awards are in
the best interest of the City.A decision to make a multiple award of this Bid,however,is an option reserved
by the City,based on the needs of the City.
2. MINIMUM REQUIREMENTS:
2.1 All stated quantities are approximations of usage or consumption during the time period to be covered by
pricing established by this bid. Actual usage or consumption may be more or less. Order quantities and
time will be determined by actual need.Bidder shall provide delivery of chemical toilets rentals,cleaning
and moving services at various locations up to 25 miles outside the city limits of the City of Lubbock.
Contractor shall provide chemical toilets within twenty-four hours after receipt of order.The number of
units needed and the placement of the chemical toilets will be determined by the City of Lubbock.
2.2 Contractor shall provide professional staff experienced and qualified to provide rental and servicing of
chemical toilets. Contract shall provide all chemicals,water and supplies needed. The City shall provide
the electrical connection point and electricity for trailer units with electricity requirements for lights,air-
conditioning,and heating.
2.3 Rental rates shall include delivery,on-site cleaning and servicing of chemical toilets. The cleaning and
servicing of the chemical toilets will be as often as requested,generally either weekly or twice per week.
Cleaning consists of removing wastes,mopping with soap based chemicals,and refurnishing the unit with
the following: five gallons of fresh chemical for the tank,two rolls of toilet paper,and one deodorant
block. Chemical toilets shall be scheduled for cleaning on the same day or days of each week for consistent
cleaning.Additional cleanings due to weather are to be free of charge. Any additional on-site cleaning and
servicing will be determined by the City of Lubbock.
2.4 Contractor will be notified 24 hours in advance if chemical toilets need to be moved to a new location on
clean day.Move to new location will be free of charged. Contractor shall empty holding tanks once per
week, or as needed.
2.5 The City shall provide Contractor with name(s)of City representative(s)authorized to initiate orders and
provide locations for toilet placement. Placement shall be at a City facility,project site,or other locations
up to 25 miles outside the city limits of the City of Lubbock. At the City's option,the City may
designate locations for portable toilets to handle emergencies or natural disasters and Contractor
shall be provided with a list of such locations as it is made available. Contractor shall provide the City
with the name and emergency phone number of Contractor's representative responsible for handling service
requests during and after normal business hours and updating the purchasing department if information is
changed.
BID FORM
City of Lubbock, TX
Purchasing and Contract Management
Chemical Toilet Rentals for Various Departments
ITB No. 19-14608-RR
In compliance with the Invitation to Bid 19-14608-RR, 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 maybe 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 19-14608-RR is by
reference incorporated in this contract. The Bid Form must be completed in blue or black ink or by typewriter.
T EXTENDED **DELIVERY
,
ERI
ITEM Y UOM DESCRIPTION UNIT COSTS COST DAYS
(+/-) ARO
1 100 EA Chemical Toilet Rental,daily $80.00 $8,000.00
2 50 EA Chemical Toilet Rental,weekly $80.00 $4,000.00
3 35 EA Chemical Toilet Rental, monthly $80.00 $2,800.00
4 50 EA ADA Accessible Chemical Toilet
Rental,daily $$0.00 $4,500.00
5 25 EA ADA Accessible Chemical Toilet
$so.00 $2,250.00
Rental,weekly
6 10 EA ADA Accessible Chemical"toilet
Rental, monthly S90.00 $900.00
7 5 EA Mobile Unit with Sink and Air
Conditioner, daily S500.00 $2,500.00
8 5 EA Mobile Unit with Sink and Air 55,000.00
Conditioner,weekly S1,000.00
9 5 EA Mobile Unit with Sink and Air
Conditioner, monthly $2,000.00 $10,000.00
10 30 EA Additional Cleaning and Service
$25.00 $750.04
Charge
Mileage Rate Outside of 25 Mile
11 Radius of the city limits.Does not ! Cost per Mile
include Lake Alan Henry. $5.00
Total Annual Bid (Items 1- 10) _.$ 40,700.00
*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.
The Cityof Lubbock is seeking a contract for Chemical Toilet Rentals for Various Departments with one
or more contractors. In order to assure adequate coverage, the City may make multiple awards,selecting
multiple vendors to provide the products desired, if multiple awards are in the best interest of the City. A
decision to make a multiple award of this Bid, however, is an option reserved by the City, based on the
needs of the City.
PAYMENT TERMS AND DISCOUNTS-Bidder offers a prompt payment discount of ---6— %,net_6acalendar days.
Discounts will not be considered in determining love 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 FAVORED PRICING: The Bidder certifies that the price quoted is not in excess of the lowest price charged anyone
else, including its most favored 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 prod ucts'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 ail 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 Countv, and City of Wolfforth.
YES NO XXXXXXX
• 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 ofthis 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 oven materials/service as needed.
THIS BiD IS SUBMITTED BYBerryhill Sewer Service Inc a corporation organized under the laws of the State of
Texas , ora partnership consisting of
or individual trading as
of the City of
Firm:Berryhill Sewer Service, Inc.
Address:PO Box 5009
City:Lubbock State:TX zip79408
Bidder acknowledges receipt of the following addenda:
p.7
Addenda No. Addenda No. Addenda No, Addenda No.
Date Date Date Date
M/WBE Firm:1 I Woman Black American Native American
Hispanic American Asian Pacific Americl Other(Specify)
03/29/2019
Bye ���� .�f /�- �,• /.�..c.,-c/ Date
Authors ed Representative must sign by hand
Officer Name and Title:Millard L Berryhili President
Please Print
Business Telephone NumberS06-762-1166 FAX:806-762-1176
E-mail Address: berryhillsewer@gmail.com
FOR CITY USE ONLY
Bid Form Item Number(s)Awarded to Above Named Firm/Individual:
Date of Award by City Council (for bids over S50,000): 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.
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
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2019-480285
Berryhill Sewer Service Inc
Lubbock,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 04123/2019
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.
14608
Chemical Toilet Rental
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Berryhill, Ryan Lubbock,TX United States X
Berryhill, Millard Lubbock,TX United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name ls� " 14 A rR p �— Q (� f'let and my date of birth is
My address is 6/ 0 R 0 y Zz ,
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in c,/L County, State of t V-� :n ; on theme Z day of^pLf 6 ,20 1 111.
(month) (year)
Signature of autliorize agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.39f8039c
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
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2019-480285
Berryhill Sewer Service Inc
Lubbock,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 04123/2019
being filed.
City of Lubbock Date Acknowledged:
04/23/2019
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.
14608
Chemical Toilet Rental
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Berryhill, Ryan Lubbock,TX United States X
Berryhill,Millard Lubbock,TX United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of ,20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.39f8039c