HomeMy WebLinkAboutResolution - 2000-R0032 - Grant Application - Susan G. Komen Breast Cancer Foundation - Cancer Education - 02_10_2000Resolution No. 2000-R 0032
February 10, 2000
Item No. 31
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the City Council of the City of Lubbock hereby approves and ratifies a
grant application and grant contract submitted by the City Health Department to the
Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation for the
provision of breast cancer education for women throughout Lubbock during 2000. A
copy of grant contract and associated documents are attached hereto and made a part of
this Resolution as if fully copied herein in detail.
Passed by the City Council this 10rh day of February , 2000.
Max Ince, Mayor Pro Tern
A ST:
/ (Aj� &W a —
Ilaytho5arnell, City Secretary
APPROVED AS TO CONTENT:
Tommy CaAdelh, Public Health Manager
AS TO FORM:
Donald G. Vandiver, First Assistant City
Attorney
DDres/Con-Rat.res
January 12, 2000
Resolution No. 2000-R 0032
February 10, 2000
Item No. 31
LUBBOCK AREA AFFILIATE
uJ Oic
SUSAN G. KOMEN BREAST CANCER FOUNDATION
DATE: 7 December, 1999
TO: 1999 Grant Recipients
FROM: Cindy Reinhardt, Grants Chair -
RE: Grant Contracts and Award Information
Congratulations on your selection as a 1999 Grant recipient from the Lubbock Area
Affiliate of the Susan G. Komen Breast Cancer Foundation! We are excited about your
project and its contribution to the Komen mission.
Enclosed are two copies of the grant contract and a "Report of Grant Awarded" form.
Please review the contract, then sign both copies and return one copy to the Komen office
(address below) along with the completed Report of Grant Awarded form no later than
Monday, December 13 so that we can complete processing and forward funds to you.
If you have questions or need additional information or clarification regarding the
contract document, please call me at 806-829-2105.
Again congratulations and thank you for your role in helping eradicate breast cancer on
the South Plains.
I-xuo-I'%I AWAItF. , 1.800-462-92731
KOMEN NATIONAL TOLL -FREE BREAST CANCER IIELPLIYE
�!X) br,uJua%. *iwte I 292 • Luhhrxl:. Teas 7Q101 • Kow65-5281 • FAX 806n.44-2144
•.c:r:� Lrnncn-I uhhirk.rrr¢
1999 GRANT AWARDS for PROJECTS BEGINNING JANUARY, 2000
Funds Awarded by the
Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation
The Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation is awarding a
total of $127,490 to seven (7) agencies serving Lubbock and the 16-county South Plains area for
breast cancer education and screening projects. The grantees and projects are:
City of Lubbock
"Chain of Prevention" Fourth year funding for continuation of the
$ 9,180
effort to educate women in Lubbock about breast health & creating
a new effort to target women in 2 specific neighborhoods.
Covenant Health System
'Increasing Access to Breast Health Services on the South
$ 33,700
Plains" Third year funding for mobile mammography providing
screening and diagnostic services, breast health education,
transportation assistance to individuals who need services in
Lubbock.
Planned Parenthood of
'Breast Cancer Health Screening" Third year funding of
Lubbock
collaborative effort with YWCA & South Plains Food Bank to
$ 8,390 ''
provide clinical breast exams, BSE education, referrals for
mammograms to under -served population.
South Plains Food Bank,
"Cooking With Class" Third year funding for highly successful
Inc.
program which offers nutrition, diet guidelines and cooking classes
$ 8,445
for under -served, economically disadvantaged women.
South Plains Health
"South Plains Health Provider Education Initiative" First year
Provider Organization, Inc.
funding to provide training supplies & equipment for clinics in
$ 4,131
Plainview, Matador, & Muleshoe.
Southwest Cancer Center
"High Risk Cancer Genetics Clinic" Second year funding to
at UMC
support establishment of a high -risk clinic to identify & screen
$ 14,801
individuals who may be genetically predisposed to developing
breast cancer.
YWCA of Lubbock
"Breast & Cervical Cancer Initiative" Fourth year of funding for a
$ 48,843
highly successful program which provides free clinical breast
exams, screening & diagnostic mammograms to clients who meet
guidelines in Lubbock & 15 counties.
Resolution No. 2000-R 0032
February 10, 2000
Item No. 31
Lubbock Area Affiliate of THE SUSAN G. KOMEN
BREAST CANCER FOUNDATION, INC.
Date:
Period of Grant:
Amount:
Grantee:
Project Director:
Project Title:
Grant Number:
December 7, 1999
January 1, 2000 - December 31, 2000
$ 9,180.00
City of Lubbock Health Department
Mary Croyle, M.S., Health Education Coordinator
Chain of Prevention
99-002
The Lubbock Area Affiliate of the Susan G. Komen Breast Cancer
Foundation, Inc. ("Komen Affiliate") does hereby grant City of Lubbock Health
Department ("Grantee") funds in the amount of $ 9,180.00 ("Grant Funds" or "Grant")
subject to the following terms and conditions ("Grant Contract"):
1. Use of Grant Funds:
A. Grant Funds are to be applied as set forth in the budget ("Budget") included in
Grantee's grant proposal to Komen Affiliate ("Grant Proposal"). A copy of the
Grant Proposal is attached hereto as Exhibit "A" and made a part hereof for
all purposes.
B. Grant Funds must be expended as set forth in the Budget. No changes or
modifications to the Budget or to the persons named as personnel in the
Grant Proposal, or to the project as described in the Grant Proposal ("Breast
Cancer Project") may be made without the prior written approval of Komen
Affiliate. (See Section 3 Paragraph D for making grant change requests).
2. Termination of Grant: Within twenty-four (24) hours of the occurrence of any one
or more of the following events, Grantee shall provide written notice thereof to
1, : a. ;6 Al „. r
Komen Affiliate, cease any and all expenditures of Grant Funds and return to
Komen Affiliate any and all remaining Grant Funds:
A. The Grant Funds cannot be expended in accordance with the Budget;
B. The personnel and/or the Breast Cancer Project change and any or all of
these changes are not approved by Komen Affiliate; or
C. Grantee loses or changes its Internal Revenue Service tax exempt status.
3. Reports/Submission Items: Grantee shall submit to Komen Affiliate the following:
A. Progress reports every six (6) months during the Grant period. Report for the
first six months will be due on July 30, 2000 using the Grant Progress Form or
any revisions thereof. Grant Progress Form is attached to the Grant Contract
as Exhibit "B" and made a part hereof for all purposes. Reports shall include,
but not be limited to, the following information: progress made toward
meeting objectives outlined in Grant Application, number of people served,
notice or receipt of other sources of support for this Project, copies or
examples of any materials produced as a result of this project, and a listing of
articles submitted for publication and the status of those articles, and
presentations made at scientific conferences regarding this work;
B. Within sixty (60) days following the expiration date of the Grant, a Final
Report, using Final Report form or any revisions thereof. Final Report Form is
attached to this Grant Contract as Exhibit "C" and made a part hereof for all
purposes. The Final Report shall include an accounting of the Grant Funds
expended during the term of this Grant Contract;
C. Any and all surveys or other forms or information submitted by Komen
Affiliate to Grantee for completion regarding this Grant.
D. When required (see Section 1 Paragraph B) requests for grant changes shall
be submitted using the Grant Change Request forms attached as Exhibit "D"
and made a part hereof for all purposes.
4. Licensed Marks: Komen Affiliate grants Grantee a limited non-exclusive license
to use the Susan G. Komen name and logo ("Licensed Marks") solely in
connection with the Breast Cancer Project. Upon request, Komen Affiliate will
provide Grantee with camera-ready artwork of said Licensed Marks. It is agreed
and understood that Komen Affiliate retains all right, title and interest in and to
said Licensed Marks, all of which shall remain the exclusive property of Komen
Affiliate. Grantee must return such artwork to Komen Affiliate upon completion of
the Breast Cancer Project or upon termination of this Grant Contract, whichever
occurs first.
5. Publications:
A. Komen Affiliate may release information regarding this Grant, including the
project summaries and Final Report, to the general public and news media.
Grantee represents to Komen Affiliate that it has the authority to grant Komen
Affiliate the right to publish the works of the Project Director.
B. Grantee may release information regarding this Grant to the public and news
media, upon the following terms and conditions:
(1) Grantee must acknowledge Komen Affiliate as a funding source on all
publications related to this Grant in clear, unambiguous and readily -
identifiable fashion, such as "supported by a grant from the Lubbock
Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.";
(2) Grantee will present to Komen Affiliate for its approval, prior to printing,
distribution, publication, display, or use, any and all promotional
materials, publications, articles, pictures, press releases and scripts of
all statements, oral or written, to be made by Grantee, its agents or
spokespersons, which use or refer to any Licensed Marks. Such
materials or statements must be of a high quality consistent with
Komen Affiliate's outstanding public image;
(3) Copies of all other news releases, articles, pictures and any and all
other published material, which may develop in connection with this
Breast Cancer Project, or this Grant must be furnished to Komen
Affiliate by Grantee prior to publication, or as soon thereafter as
practicable.
6. Non -Guarantee of Additional Support: This Grant is accepted by Grantee with
the understanding that Komen Affiliate is not obligated to provide any additional
financial support, or other support, to Grantee, its agents or spokespersons, in
connection with the Grant, the Grant Contract, the Breast Cancer Project or for
any other reason.
7. Governmental Compliance: Grantee will cooperate with Komen Affiliate in
supplying additional information to Komen Affiliate, or in complying with any
procedures which might be required by any governmental agency in order for
Komen Affiliate to establish that it has observed all requirements of the law with
respect to this Grant.
8. Authority: All persons and individuals executing this Grant Contract certify and
warrant that they have the capacity and have been duly authorized to execute
this Grant Contract on behalf of the entities so indicated and that no additional
authorization or approval is required.
9. Indemnity: Each party agrees to indemnify and hold the other harmless from and
against any and all costs, losses or expenses, including reasonable attorneys'
fees, that either party may incur by reason of any third -party claim or suit arising
out of or in connection with the other party's performance or failure to perform
pursuant to this Grant Contract.
10. Arbitration: The parties will arbitrate any dispute, claim or controversy relating to
or arising out of this Grant Contract. Any party may initiate arbitration by giving
written notice to the other party of an intention to arbitrate and by filing with the
regional office of the American Arbitration Association which serves Lubbock,
Texas three (3) copes of such notice and three (3) copies of the Grant Contract
together with the appropriate filing fee. Such notice shall contain a statement
setting forth the nature of the dispute and the remedies sought. The arbitration
shall be conducted in Lubbock, Texas in accordance with the rules of the
American Arbitration Association in effect at the time the notice to arbitrate is
served. The arbitrator's decision will be final and binding on the parties.
11. Entire Agreement: This Grant Contract supercedes any prior understandings or
oral agreements between the parties regarding the subject matter hereof and
constitutes the entire understanding and agreement between the parties with
respect to the subject matter hereof, and there are no agreements,
understandings, representations or warranties among the parties other than
those set forth herein.
12. Governing Law: This Grant Contract shall be governed by and construed in
accordance with the laws of the State of Texas.
This Grant is expressly conditional upon Grantee's acceptance of the terms
and conditions set forth above. The signature on this Grant Contract by an
authorized representative of Grantee represents Grantee's acceptance of this award
and agreement to comply with all of the above terms and conditions.
AGREED AND ACCEPTED TO BY:
The Lubbock Area Affiliate of
The Susan G. Komen Breast Cancer Foundation, Inc.
Claudia Griffin
Affiliate President
V
City of Lubbock Health Department
r
(Signature)
Name (typed): R. D. Cbmirnn
Title: I-balth Director
Attachments to grant contract:
Exhibit A: Grant Proposal
Exhibit B: Progress Report Forms
Exhibit C: Final Report Forms
Exhibit D: Grant Change Request Forms
kc&,'1,01-lq
Date
i Z *�_
Date
LUBBOCK AREA AFFILIATE - SUSAN G. KOMEN BREAST CANCER FOUNDATIOt
REQUEST FOR FUNDING
FOR BREAST HEALTH/BREAST CANCER PROJECT
1999 Grant Cycle
Please type this form.
Project Director, Title, and Degree:
Applicant:
Address:
Phone:
FAX:
Title of Project:
Mary Crovle, V.S., Health Education Coordina
Citv of Lubbock Health neDartment
1902 Texas Ave
Lubbock, TX 79405
806 775-2p19
8( 06 ) 775-3907
Funding Category: under $5,000 Yx $5,000-15,000 $ 15,000-30,000 $30,000-50,000
(check one)
Total Amount Requested: $ 9,1 s0.00
Grant Period: JAnunry 1. 2 0 0 0 - January 1. 2001
Signature and Title of
Authorized Applicant Representative: Date:
Name and Title of Authorized
Applicant Representative (typed): Mary Crovle, Health Education Coordinator
Please check type of application: 15 Education Q Screening 0 Treatment
Please provide a short summary paragraph suitable for release to the general public if this application is
chosen for funding.
The Chain of Prevention program is a continuation of the effort to educate._
all women in T,nhbock about breast health, as well as to join in a new
collaborative effort to specifically target women in two neighborhoods by
encouraging them to visit a clinic for their annual exam.
(Photocopies of this form are acceptable.)
1 of 9
Chain of Prevention
B. Project Description
1. Project Summary: The City of Lubbock Health Education Team's Chain of
Prevention program is in its 2"d year of funding by the Susan G. Komen
Foundation. This year's program will be a continuation of the effort to
educate all women of Lubbock about breast health, as well as to join in a new
collaborative effort to specifically target women in 2 neighborhoods by
encouraging them to visit a clinic for their annual exam. The project's theme
is Learn It/ Live It/ Teach /it All women should learn the message about
breast health", live the message, and teach the message to others. The
message that we are promoting is that early detection is the best way to win
the battle against breast cancer. Every woman should know about the
benefits of a breast self -exam, a clinical breast exam, and mammography.
Our goal is to get all women in Lubbock to be the "link" in the Chain of
Prevention by spreading the message to family, friends, and co-workers.
Each year we hope to build the project and join other entities in a
collaborative effort to win the battle against breast cancer.
2. Statement of Need: It is estimated that 11,300 women in Texas will be
diagnosed with breast cancer this year in Texas, and 2,400 will die from this
disease. Breast cancer accounts for nearly a third of all new cases of cancer
diagnosed in women. The number of female breast cancer deaths has
increased 25% from 1,914 in 1987 to 2,400 in 1993 (Texas Cancer Data
Center). In The Heart of Lubbock Neighborhood (a target neighborhood from
the current Komen grant), we found that only 32% of women who are 40 and
older actually have had a mammogram. In regards to minority populations,
even though the lifetime risk for getting breast cancer among African -
American women (1 in 11) is lower than in Anglo women (1 in 8), the death
rates from breast cancer are higher in the African -American population (ACS,
1996). With this in mind, the project will target women in 2 medically under -
served neighborhoods, however, we will not preclude other populations since
breast cancer does not discriminate.
3. Population Served: The project will specifically target women in the Harwell
and Parkway/Chevy Point Neighborhoods, and will also include all women
throughout Lubbock. Lubbock is composed of approximately 94,774 women,
of whom 67.7% are Anglo, 22% are Hispanic, and 8.7% are African -
American. In the Harwell neighborhood 78% of the population are Hispanic,
and 4.9% are African -American. In the Parkway/Chevy Point neighborhood
64.5% of the population are African -American and 31.8% are Hispanic.
Therefore, the majority of the women that will be targeted within these
neighborhoods are either African -American or Hispanic. In addition, we will
also target younger age groups including adolescents and college -age
women by conducting breast health courses in LISD and at local universities.
It is critical to learn the importance of early detection at a young age, so that
women will develop a lifelong habit of good breast health.
Page 2 of 9
Chain of Prevention
4. Goals and Objectives: The City of Lubbock Health Education Team (HET)
will provide all of the education. The primary goal of the Chain of Prevention
is to educate women about the importance of breast health, resulting in lives
being saved. There are three very important guidelines which will be taught:
1. A mammogram is recommended every year for women age 40 and
over.
2. A clinical breast exam by a health professional is recommended every
year for women age 40 and over, and every 3 years for women age
20-39.
3. A monthly breast self -exam is recommended for women age 20 and
over.
In addition to education, we will be working collaboratively with the Texas
Tech School of Nursing Wellness Center. HET will go door-to-door in Harwell
and Parkway/Cherry Point neighborhoods to recruit women for an annual
physical exam (given at the Wellness Center). This exam will include a
clinical breast exam and pap smear. The effort will hopefully bring in
approximately 150 women who may not otherwise have gone to the doctor.
The measurable objectives for the Chain of Prevention program will be
measured by:
1. Number of pamphlets distributed to women in Lubbock.
2. Number of people who will see billboards.
3. Number of phone calls (from billboards and mail -outs) received for
information and/or referral.
4. Number of women educated in door-to-door surveys.
5. Number of women who received an exam after being recruited by
HET.
6. Number of people reached through health fairs, presentations, and
events.
5. Activities: Through the Chain of Prevention campaign, HET plans to use
as many mediums as possible to reach as many women as possible. It is our
goal to make a long term and lasting impact on breast cancer throughout
Lubbock. The following are some of the planned activities:
• 10,000 mail -outs to residents in Harwell and Parkway/Chevy Point.
• Promotional breast health billboards displayed in Parkway/Cherry Point
throughout the year displaying HETs phone number for more information
and/or referral.
• A new activity will be added to this year's program. HET will recruit 150
women from the Harwell and Parkway/Chevy Point neighborhoods by going
door-to-door with a women's health survey. As an incentive for completing
the survey, women will be given a "goody bag" related to breast health.
During this time, women will be given a coupon to receive an annual physical
Page 3 of 9
Chain of Prevention
exam at the Texas Tech School of Nursing's Wellness Center. The exam will
Include a pap smear and a clinical breast exam. The clinic operates on a
sliding scale basis and is a Medicare/Medicaid provider. The School of
Nursing will provide a one-on-one counselor to assist each of the women with
their questions, concerns, fears, etc.. The collaborative effort will hopefully
bring in women who may not otherwise have gone to the doctor.
• Use media to promote the Chain of Prevention program as an avenue to
educate the public by sending press releases, appearing on local TV shows,
and showing an educational video.
• Breast health talks to high school and college females.
• Breast health talks to senior centers throughout Lubbock.
6. Timetable:
• One-time mail out to targeted neighborhoods.
• Every month a new breast health billboard will be posted in targeted
neighborhoods.
• Door-to-door surveys will be conducted 2X per year and include recruiting
women for clinical exam.
• Educational information will be distributed throughout the year via health
fairs, presentations, and events.
• Commemorate Breast Cancer Awareness Month in October.
7. Cooperative Efforts: The City of Lubbock HET will be working closely with
the Texas Tech School of Nursing to recruit women in medically under -served
neighborhoods for an annual physical exam. Also, we will be working with
LISD to gain access to schools to continue to educate students on the
importance of breast health.
8. Long Term Plan: It is the goal of HET that the Chain of Prevention project
will continue for years to come. Each year, we hope to join together with
more agencies in a collaborative effort to win the battle against breast cancer.
It is our hope to establish a strong relationship with the community, so that
our message will.be taken to heart by.all women of Lubbock.
9. Comparable Projects: HET has conducted highly successful door-to-door
general health surveys in the past. Valuable information has been gained
about the citizens of Lubbock and their health status. And, most importantly,
the citizens gain important knowledge about what services are available to
the community. We hope to have equal success with the breast health door-
to-door surveys/recruiting. Currently, HET is unaware of any other
comparable projects. However, this year we will begin to work with Texas
Tech School of Nursing to prevent overlap and to ensure the greatest use of
our resources.
10. Success: The success of the project will be measured by the following:
Page 4 of 9
Chain of Prevention
• Approximately 10,000 pamphlets will be mailed -out to residents in Harwell
and Parkway/Cherry Point. Recipients can call for more information and/or
referral. All calls will be documented.
• The billboards will be highly effective in promoting breast health
awareness. Thousands of vehicles pass by each location on a daily basis.
The locations of the billboards will be near both Harwell and Parkway/Chevy
Point neighborhoods. Each billboard will have HETs phone number so that
women can call for information, and/or we can refer the caller for a
mammogram or exam at a local clinic/hospital. The phone calls will be
documented.
• Door-to-door surveys will be conducted, which will include recruiting
approximately 150 women for clinical exam.
• Approximately 5,000 women and teenagers will be reached in Lubbock
through presentations and health fairs provided by HET throughout the year.
11. Results: The results of this project will allow HET and other agencies to
evaluate the need for breast health education and medical care in the
Lubbock community. We will evaluate the success of our program in Harwell
and Parkway/Chevy Point. From this, we can design similar programs in
other neighborhoods throughout Lubbock.
Page 5 of 9
! BUDGET FORM
Lubbock Area Affiliate of The Susan G. Komen Breast Cancer Foundation
Grant Application Required Budget Form
Detailed Budget for
From 111 M
Through Il1169-
Entire Budget Period
Personnel
Dollar amount requested
Type
% Effort
Base
No personnel funds request
Months
Pran
ed
Salary
N/A
Name
Role on
Salary
Fringe
Totals
Project
Requested
Benefit
N/A
N
Subtotals
Supplies (Itemize by category)
Office supplies (mostly paper and convince)
$1,50().00
Bulk -rate mail of approximately 10,000 mail -outs
$1,700.00
Breast Care Awareness Incentives
$ 580.00
Equipment
N/A
L
Travel
IF / A
Patient Care Costs
inpatient
N / A
Outpatient
Other Expenses (Itemize by category)
Billboards: 12/$450.00=
5,,400.00
Subtotal - Direct Costs
9,180.00
Indirect cost allocation
N/A
Total
$9, 180.00
Consortium/Contractual Costs
Direct $
Indirect $
Contractual $
N/A
Total Funding Request
$ 9 ,180.0 0
Please attach budget justification.
6 of 9
Chain of Prevention
C. Financial Information
1. Budget for requested funds: (Budget form attached)
2. Budget Justification: Funding will be for bulk -rate mailing for
approximately 10,000 mail -outs ($1,700) to residents in Harwell and
Parkway/Cherry Point. This includes the purchasing of the paper and
the printing costs ($1,500). Promotional breast health billboards
(12@$450=$5,400) will be displayed in both neighborhoods. These
billboards will display HET's phone number for more information and/or
referral. HET will recruit 150 women from the Harwell and
Parkway/Chevy Point neighborhoods by gong door-to-door with a
women's health survey. As an incentive for completing the survey,
women will be given a Breast Health take-home `goody
bag"(250@$87.50) including: BSE reminder stickers (500@$185),
emery boards (500@$85) and lifesaver rolls(1100@$198) promoting
Mammograms.
3. Other sources: Funding for relative projects will be provided from the
general fund of the City of Lubbock Health Department. If any extra
expenses should occur, the general fund will absorb the cost; i.e. if we
need to order more supplies, shower cards, etc..
7 of 9
BIOSKErCH FORW
Mary Crovle M.S.
PROJECT DIRECTOR a" m &=md fta
BIOGRAPHICAL 1NFORLIATION
Information should be submided for the project director and other persormel included in budget request. Please use a
NAME Mary Crovle. M.S. I Trnjr= Health Education Coordit
INST ni mON
Texas Tech University
Texas Tech University
DEGREE I YEAR I FIELD OF STUDY
B.S. 1 1992 1Biology/Spanish
M.S. 1 1995 (Sports Medicine
PROFESSIONAL EXPERIENCE. Please list. in chronological order, concluding with present Position. previous
employment, experience and honors.
00 NOT ATTACH ADDITIONAL PAGES
The Cooper Institute for Aerobics Research- Intern
Texas Tech University- Center Manager/Rec Sports
Texas Tech University- Instructor
City bf Lubbock Health Department- Health -Educator
-ACS FreshStart Instructor
-ACS Exemplary Service award 1996
City of Lubbock ?Health Department- Health Education Coordinator
-ACS Exemplary Service award 1997 & 1998
-Physical Fitness Specialist - The Cooper Institute for Aerobics Research
-Breast Cancer Coalition of West Texas
-Advocacy Chair- Texas Society of Public Health Education
-Texas Statewide Public Health Awareness Committee
M
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+� Office o
Purckasiai
City of Lubbock
R.O. Sox 2000
Lubbock. Texas 79457 ,
606-767-29 67
EXEMPTION CERTIFICATE
(For use by United States, Territories, or political subdivisions
thereof, or of the District of Columbia.) -
February 23, 1993
The undersigned hereby certifies that he is Purchasing Manager of the
CITY OF LUBBOCK, TEXAS, Lubbock, Texas, and that he is authorized to execute
this certificate and that the article or articles specified'in the
accompanying order or on the reverse side hereof, are purchased from
for the exclusive use of Municioality Tax Exempt No.
1-75-6000590-6 of the CITY OF LUBBOCK, Lubbock, Texas.
It is understood that the exemption from tax in the case of sales of
articles under this exemption certificate to the United States, States, etc.,
is limited to the sale of articles purchased for their exclusive use, and it
is agreed that if articles purchased tax-free under -this exemption certificate
...:are used otherwise or are sold to employees or others, such fact must be
reported to the manufacturer of the article or articles covered by this
certificate. It is also understood that the fraudulent use of this
certificate to secure exemption will subject the undersigned and all guilty
parties to a fine of not more than $10,000, or to imprisonment for not more
than five years, or both, together with costs of prosecution.
CITY OF LUBBOCK
VICTOR KIL
PURCHASING MANAGER
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