HomeMy WebLinkAboutResolution - 2022-R0389 - Amendment No. 2 Contract 15202 with Lee Lewis Construction 9.13.22Resolution No. 2022-RO389
Item No. 5.28
September 13, 2022
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for
and on behalf of the City of Lubbock, Amendment No. 2 to the Professional Services Agreement
Contract No. 15202 for services related to the construction and renovation of a building for the
municipal courts facility, by and between the City of Lubbock and Lee Lewis Construction, Inc.,
and related documents. Said Amendment 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
ATTEST:
Reb ca Garza, City Sec t
APPROVED AS TO CONTENT:
Erik Rejino, Assistant City Manager
APPROVED AS TO FORM:
VelliLeisure, Assistant City Attorney
September 13, 2022
TRA AYN AYOR
ccdocs/RES.Amend #2 to PSA 15202 Muni court build LLCI
8.22.22
Resolution No. 2022-RO389
Amendment To Agreement Between
The City of Lubbock, TX
And
Lee Lewis Construction, Inc.
THIS IS THE SECOND AMENDMENT TO THE AGREEMENT (Contract 15202) dated and
entered into the 14th day of April 2020 by and between the City of Lubbock ("City") and Lee
Lewis Construction, Inc. ("LLCI") of Lubbock Texas, for providing Construction Manager at Risk
services for the construction/renovation of an existing building into the Municipal Courts Facility,
(the "Project"), located at 1319 Avenue L, Lubbock, Lubbock County, Texas.
WITNESSETH:
WHEREAS, now the City desires to engage Lee Lewis Construction, Inc. for the performance of
additional services, details for which are provided in Exhibits "A" and `B", attached hereto and
incorporated herein. The additional services include, but are not limited to: waterproofing,
construction and installation of utilities, and electrical & security infrastructure.
WHEREAS, all other portions of the original Agreement and previous Amendments, if any, shall
remain in place and are not altered by this amendment.
NOW, THEREFORE, the City and LLCI agree to the following terms in this SECOND
AMENDMENT:
THAT LLCI shall perform the additional services detailed in Exhibits "A" and `B" for an
amount not to exceed one hundred fifty-eight thousand, eight hundred thirty-seven and 94/100
dollars ($158,837.94), of which includes fifty-two thousand and 00/100 dollars ($52,000.00) for
contingency costs, and said costs shall only be paid as reimbursement for work performed.
The original Contract Amount_______________________________________________________________________
$
4,415,200.00
The sum of all previous authorized Amendments (unchanged)__________________
$
0.00
Net Percentage of previous Amendments
+0.00%
The Contract Amount prior to this Amendment___________________________________________
$
4,415,200.00
The Contract Amount will be (increased) by this Amendment_ ___________________
$
158,837.94
Net Percentage of this Amendment
+3.60%
The new Contract Amount---------------------------------------------------------------------------------------$
4,574,837.94
Total Percentage of all Amendments
+3.60° o
IN WITNESS HEREOF, the parties have executed this Agreement as of this 13th
day of September , 2022
LEE LEWIS CO TRUCTION, INC.
Ryan Lewis, Executive Vice President
ATTEST:
Dg&��
Retie Garza, City Secret
APPROVED AS TO CONTENT:
Wesley D. Everett, Director of Facilities Management
O ED AS TO FORM:
K-,Ili Leisur , Assistant City Attorney
Exhibit A
Lee Lewis
Construction, Inc.
Lee Lewis Construction Inc. - HQ
7810 Orlando Avenue
Lubbock, Texas 79423
Phone: 806-797-8400
Fax: +1.806.797.1034
PCCO #CCR #022
Project: AA-2040 - Lubbock Municipal Courts
1214 14th Street
Lubbock, Texas 79401
Prime Contract Change Order #CCR #022: CE #CCR -22 - ASI #6
Additiona
TO:
CITY OF LUBBOCK
FROM:
Lee Lewis Construction - HQ
City of Lubbock 1314 Avenue 4th Floor
7810 Orlando Ave
LUBBOCK, Texas 79457
Lubbock, Texas 79423
DATE CREATED:
5/24/2022
CREATED BY:
Neil Easter (Lee Lewis Construction - HQ)
CONTRACT STATUS:
Draft
REVISION:
0
REQUEST RECEIVED
LOCATION:
FROM:
DESIGNATED REVIEWER: Neil Easter (Lee Lewis Construction - HQ)
REVIEWED BY:
DUE DATE:
REVIEW DATE:
INVOICED DATE:
PAID DATE:
REFERENCE:
CHANGE REASON:
Field
PAID IN FULL:
No
EXECUTED:
No
ACCOUNTING METHOD:
SIGNED CHANGE ORDER
RECEIVED DATE:
FIELD CHANGE:
Amount Based
No
DESCRIPTION:
CE #CCR -22 - ASI #6 Additional Conduit Run
This CCR is at the request of Randall Scott Architects per ASI #6
SCHEDULE IMPACT -
REVISED SUBSTANTIAL
COMPLETION DATE:
CONTRACT FOR:
TOTAL AMOUNT:
1:Lubbock Municipal Courts Prime Contract
$0.00
ATTACHMENTS:
6 Line Proposal Municipal Court Citizens Tyr Road Crossing�f, Municipal Court ASI 6. f, Lubbock Municipal Court -ASI #6 - Narrative with
Attachment of
CHANGE ORDER LINE ITEMS:
#
Budget Code
Description
Amount
1
1-004.1 OWNERS CONTINGENCY.MATERIALS
deduct for ASI #6
$(56,650.00)
2
16-500.2 LIGHTING.SUBCONTRACTOR
for additional work per ASI 6
$56,650.00
Grand Total:
$0.00
The original (Contract Sum) $4,415,200.00
Net change by previously authorized Change Orders $0.00
The contract sum prior to this Change Order was $4,415,200.00
The contract sum would be changed by this Change Order in the amount of $0.00
The new contract sum including this Change Order will be $4,415,200.00
The contract time will not be changed by this Change Order.
Lee Lewis Construction Inc. - HQ Page 1 of 2 Printed On: 7/18/2022 02:47 PM
19 Lee Lewis
Construction, Inc.
Dan Brantner (RANDALL SCOTT CITY OF LUBBOCK
ARCHITECTS)
July 18, 2022
SIGNATURE DATE
City of Lubbock 1314 Avenue 4th Floor
LUBBOCK, Texas 79457
SIGNATURE
DATE
PCCO #CCR #022
Lee Lewis Construction - HQ
7810 Orlando Ave
Lubbock, Texas 79423
SfG'NAYGkIE Y DA E
Lee Lewis Construction Inc. - HQ Page 2 of 2 Printed On: 7/18/2022 02:47 PM
Exhibit B
Lee Lewis
Construction, Inc.
Lee Lewis Construction Inc. - HQ
7810 Orlando Avenue
Lubbock, Texas 79423
Phone: 806-797-8400
Fax: +1.806.797.1034
PCCO #1
Project: AA-2040 - Lubbock Municipal Courts
1214 14th Street
Lubbock, Texas 79401
Prime Contract Change Order PCCO #1: Alley Vault Waterproofing
TO: CITY OF LUBBOCK
FROM:
Lee Lewis Construction - HQ
City of Lubbock 1314 Avenue 4th Floor
7810 Orlando Ave
LUBBOCK, Texas 79457
Lubbock, Texas 79423
DATE CREATED: 8/05/2022
CREATED BY:
Nolan Zuber (Lee Lewis Construction -
HQ)
CONTRACT STATUS: Draft
REVISION:
0
REQUEST RECEIVED
LOCATION:
FROM:
DESIGNATED REVIEWER:
REVIEWED BY:
DUE DATE:
REVIEW DATE:
INVOICED DATE:
PAID DATE:
REFERENCE:
CHANGE REASON:
Client Request
PAID IN FULL: No
EXECUTED:
No
ACCOUNTING METHOD: Amount Based
SCHEDULE IMPACT:
SIGNED CHANGE ORDER
REVISED SUBSTANTIAL
RECEIVED DATE:
COMPLETION DATE:
FIELD CHANGE: No
CONTRACT FOR:
1:Lubbock Municipal Courts Prime Contract
TOTAL AMOUNT:
$136,970.00
DESCRIPTION:
PCCO #1 - Alley Vault Waterproofing
PCCO #1 - Additional scope - (Chapman Harvey plans) for alley vault waterproofing.
Includes: Attached scope summary from LLCI has inclusions and allowances, as well as scope of work and
prices.
Excludes: Any scope of work not listed on LLCI Summary of work
This total is a "not to exceed price" and includes allowances for shoring/safety and hydro excavation. these scopes will be invoiced as actual costs and
any credits will be adjusted and submitted in the final approval / pay application.
Likewise any reduction in
scopes or duration will be adjusted
respectively.
ATTACHMENTS:
CHANGE ORDER LINE ITEMS:
#
I Budget Code
Description
Amount
1
2-010.2 Alley Vault Water Proofing
Vault Water proofing
$136,970.00
Grand Total:
$136,970.00
The original (Contract Sum)
Net change by previously authorized Change Orders
The contract sum prior to this Change Order was
The contract sum would be changed by this Change Order in the amount of
The new contract sum including this Change Order will be
The contract time will not be changed by this Change Order.
$4,415,200.00
$0.00
$4,415,200.00
$136,970.00
$4,552,170.00
Lee Lewis Construction Inc. - HQ Page 1 of 2 Printed On: 8/12/2022 11:48 AM
Lee Lewis
Construction, Inc.
Chapman Harvey Architects
612 Broadway St, Lubbock, TX
79401
(sIGNATURV DATE
CITY OF LUBBOCK
City of Lubbock 1314 Avenue 4th Floor
PCCO #1
Lee Lewis Construction - HQ
7810 Orlando Ave
LUBBOCK, Texas 79457 Lubbock, Texas 79423-- --�
SIGNATURE DATE SIGNATUf r DATE
Lee Lewis Construction Inc. - HQ Page 2 of 2 Printed On: 8/12/2022 11:48 AM
Lee Lewis
Construction, Inc.
LLM
August 12th 2022
City of Lubbock
1314 Ave K
Lubbock, Texas 79401
Attn: Darren Densford
Ref: Municipal Court Alley Vault
Mr. Densford,
Lee Lewis Construction proposes to complete scope of work as shown on Chapman Harvey Architects drawings
dated 7/26/22 for the not to exceed price of $ 136,970. This pricing includes allowances for shoring / safety and for
hydro -excavation for the installation of waterproofing the existing basement and vault wall connection. Any savings
and/or credits will be deducted from the final pay application.
Thank you for this opportunity, should you have any questions, please do not hesitate to contact our office. This
scope of work will be added to the current Contract via Contract Change Order.
Sincerely,
Kirk Hughlett
Chief Estimator — Vice President
17111 Preston Road
7810 Orlando Ave. Suite 100
P.O. Box 65197 P.O. Box 795037
Lubbock, TX 79464 Dallas, TX 75379
806-797-8400. 806-797-8492 972-818-0700 • 972-818-0706
Lee Lewis
Construction, Inc.
Lubbock Municipal Court - Vault Waterproofing
Date:8/12/2022 City: Lubbock
Owner: COL State: Texas
Architect: ChapmanHarvey Schedule (mo): 1.5
stimator: KH
..• �•
General Conditions
Building Permit
Temporary Fencing & Barricades
Allowances - Shoring & Safety
HydroVac/Excavation
Contingency
Remove Existing Fill & Drill Holes
Clean Existing CMU
Demolition / Sawcutting
Shotcrete / Gunite
Rebar
Waterproofing
Gravel Fill 8 cy
Flow Fill
Spoils, Rough Grading & Cleanup
Final Grading / Earthwork
Concrete Paving
27,707
none
2,500
Allowance
15,000
Allowance
27,000
5,000
2,000
5,000
1,200
ENCO
7,500
Destiny
7,500
627
Rudd Palmer
9,673
vol alternate
RE Jaynes
900
Ingram
9,900
1,600
not included
not included
1,600
800
640
160
1,320
a I ''a"
27,707
0
2,500
15,000
27,000
5,000
0
8,600
2,000
7,500
7,500
1,267
9,673
1,060
11,220
1,600
0
0
0
AddCheck -> IIIIIIIIIIAlUx
Percent Cost:
105,480
82.6%
17,627
13.8%
4,520
3.5%
127,627
(MISC)
LAB BURDEN 35.00% 42.00%
1,898
Bldrs. Risk $15
Sales Tax 0.00%
0
Gen. Liab. $518
Sub Total
129,525
OPL $0
B.R./G.L./OPL
533
P&P Bond $3,009
Fee 3.0%
3,902
P & P Bond
This total is a "not to exceed" price and includes allowances for shoring/safety and hydro -excavation. These scopes will be
invoiced as actual costs and any credits will be adjusted and submitted in the final approval / pay application. Likewise any
reduction in scopes or duration will be adjusted respectively.
009
Recap BaseCOL MC Vault Recap 1 of 1 8/12/2022 11:27 AM
r
OIMOlR6RtO1MO - VNJLT DP1O1.IflON
1R'•1'4'
ErRK,u��TORan�l. J
ZJ `i.b"'i'u s•_.. Y Ewn cur ETm Ev+..r.o \ .\\\�: �'.: •. ... \\\•:\�' ._..
`croseraee
Haut Row
lwTw.oa. TNe! D•ME.3 ntt.wnry TO D6TN6lOPTpp A
ccencwTnN. a neovo® Twr M cowao�ce d M sear~ tamucroN n
oaumnMroroc. de.T wTTesr..E ��.nc ro.+woe coynem wro
.e�in+a �vwevrwroe d wu lmrw eammvu n•e Nmer�lr.TnN r.e esN
iw� N�..�.T,.l,E o< Ue.iT• o.wrwacN nl.rm NU em. ruanu
a.nnar,mx.nv..e e�we.vrt nvoeeew,,.riaa M.�amei uroT..,c
DOelrwT avMAVISMSCOrKY q,wih4 N•OawrnM `a w5aA0 M011.E�'
TalTlOw!
1 M•sCww.Ks.fdfed OM T.GEl genWE3, IfM K6/M iO emr.:a l.PPICEEO
IIi.Cr101.. N.tl MT RBt.Gtl M 6C14LL CON111KTMl Nua+ M mrgaBurc
Oa •.BWM LOH.ta6T wL. /6D W WNp� l6Alnf TO /.�O IlIG1W M
DKNILN OI TITlgIC U COO1Gm N M5l CgOTRK.TKN OO4Yprt6.
rt O�•O.OMpIT' p M OCOewi. f011RKTOt iO N6DVAlT Na D[x,O¢•O
ti. ms or¢vyo.a,aciwweno ler.«wm. wTeu.taww �enrco3w
ccTeTccmu rwT wT.m rol ee w..aT®xw.nwK,.wn ro coowoNwTe
lYCw T6D IlaNGM+ �M Gp6TRWT�DPWa,ri NOMOZfMKT1 OrM
MRK OS(X•nK6 MO CPfULlE NV0.vN3 VK�wTD7 OmTW GQ.DrtWA
ES.LI a!lltgMlrt TO M A114RRLTE wT1Drtq.3+.�A1RT.
• MwYrrtILTT�POTAVO•m iOOe.'T'UldRL16T U.'OlOatNM CwwrEH!
efaRN rtOq Q C2�YPT •la (OATAKIIGM t•wT wR! •!4R® LO
M11bP/[DOlOMRTal DDg1J0)3OUrO wtIGMM UPliilun Or •Oy�IR' K.
roa NNJwwTp, 6 rwsom raa M coMve.arl OI M aeava fLwI�KTOR, ND 6
�rtEov NIB.DD7 TO �4 T.wi ODW�lY.M 6�nRD PLT TO TrP!lIM YIY/Gi.LT
M 6M1,W GOKA/.LTOIE •tlIOC!l�M1TO CQYiR! DDgrMN IWM
U Ya1nO) rO.LLLOn MWtVIW O) Knrolic
f. M 6eeO1 cpf�K.iOR wO wNlGT �4�pt!lKTgS YULE vtlrt M �O¢T
T >$4rtTN3 wTlOIOYL OR M1/i.L ElGOC6eB4t1V
/'� M N10.pLT, UO NT+ M MKTOI M ISn Npl<pr M DOaIW
Mr'/ w4lU C tO�:RN aM116! dW.ENf TO M wTCROn Cr M
wrtO.rL:T.ECR TO b.6VTMANTG74YL NS TOMOnat
NLL R A•nO�m n.Ylr O wTT1{plTUl2 TO M lA �iw�rOwE T�•t TO OO TO.
3, KMND rOMQ'iOl A�pRiE1W rtM •Rl TO ElTQl MM /Epp.TT O•VM w�O
GLNIwK.tOl TOR VKNK
rt a M •bw6wrcp M Ex�N. GOv�R.cTOa TO Exae M IMTW cowerz
T P b EalT1a1 GY VwTPOMWIfAl4 wll flLw FL.NUC�AOGm
I lR.Va wornienJ
I•
ti
Ruts R. RYVI_ '
M '�y
y p O
pU�
� 4
•y
r
I,
I � j
I I
I . I
I
I j 4
I I ro.ewvwTen G
-.1 �an3a avwwry R�
I , coRea 0
I aeau. � T I waMoo•n3 FF
I � ti Eyo
I I 6E
1 I
I I
1 I
I 1
I
I I
I I
I' pf .v woo crd I
� earN3 o+wN
-
I I
A101
r
O
I
1
I
N I
urodannna(rm - VAVLT MDWWAT1
Irr . ro•
�fd•xAtTo, i0 f.o IGfI.TOx p GW MLL Ntl btlfperz..(sTtGG.x o.e. GNI
Awwwworrarrvai
rt e M xaweevrcw M sear cdm.scrcx rosnwee M omTxe
'wvcxerz rwi uo uxna+owvwmn nxfa �eau.n. rvon.uwem(
.00m (.ef.wm,
.x>,.AGefx�ANw,a.
nwAce..er se snwcnwA�ir suw Aro rxxpvooe rAum AReb (tone
weewwrz Axb xwe! fwreenie .e.ove covrAwwrzsuw b sviee w..+.n
.av fle.• ecnnm N.wrwces xnwie w•sr o.er (tune eTo•e Afo Dare ox vexrrk
Afnrrrwe. emrnc�e Ao(evc f<.a ea wc>«w. ee wm ra ww. ferAuwron
.Noe•a>aw..e a..unow.x.ar corao(nw,®.xeb se�ee a..w
flxm (evNoe.fo low w•ru vas oM NbowY NwfAces. w+�....xee ccvr ro
LDVGeIe HQ'x w•O MK MUA OR 1RG'O.GV(.q[f/.e Y' Nle nYx i0 M
IA:e p MldfKrz e14LKS MD N.L x016� LRYaerz WIAClS YDlRAI!
ADMty. SxlKb bb31KnN00(x Mp CVW
b fRffNe
- AfRr bNbO.e wplene fIV¢l eJ lVG M w tM!! nO.A xpiyl wT wtolw.se
Mrz�ms-.a some fear fee Mud wuas fxssa TO oRr oro nOA oN Wfa
-PM rfL vwY eC LOtl0.lNtaDreyPAMtll.e/tK MW •CtMAveAT®M
M•alY. fNwxe NKLlD0.0e LfG(®TO �Gw�V O[GOTD7 nMN N+0.xeA Oxi x
MN,r ww frte�bl OMO 0.TJI10l.0Tx/dt
G AfRY..xT OM vet1YX exfAGe!
�sr roexue N uAenev ro e�c onxw Au srwya wT �s n:.es w (feNaa
ICxGl0.T Tl bt19�NOO •0.L�AL1eMBMMl Rfw wxMp eOUA M
rev�..Arz M f00.wY wT exwbe irn fxese M.2��exwnn fsoLY roM ruu.
M nYft PD p A+MpvO y f00. pY� M A+Mxmt wiwp�L Ox WiR! MO w
xf6LCf IAtY1e iO lGe x4vf InHlOf! wT Te�xxwTIC.O CAx.pt�l N A RV' a YJL µy
O.a aMO� O. p NHt leV•INh'f0 W1T lK n6�®MM MN�!! YDID.ONW!
bllG.wrzy(xAT(y ye 4WGL ee(l�TO eetwlwmxrnw. ATM
DO pW� IWM OAr ! M YW.L 1x8 e�olYlMxwLLY GOVRm ATIr A
ftN Of pbN11OC Nb+G TOO�el Mxp0.N�K 1l�iO bERk!
MPYM DIO• 606pM•�bM/Gt wi (IS reIiOR/AT 1etNVTgpTO
TpbMrz TG (02.w•C wi M abed M rtVllw'DQufxN M �.M! Md�.M
AwAw 1Be(NwTICx Mt A•JewID .OerOfRwLLr rTl M f0! p M
(oexne a bcw.00m fcw mwxfaaw ov
a. xosAre wANs
lM rzAas AAO NUf 0.lO.T V+fm XMOrIM Me.�•e N?�M/a!H(Im CxM
4NtN.JNe EIf1fKe ue/N M nflwLe WexMe NM w DAtT GO(x M0
(OTIlI6i p[+, Yl(I'+plly pD.NAx iT• w IATG URDOW a xGYd N ALL
DNCLrY.Mn fRW MNI(uO:f m6bpMlwiGw RM MUxp•L yp�O
fOMM! bTtf M NDlMM.xp10WY.Y eOCwe COA11N AxJ N42 ALL
119A/NI f�pt TO 1bTfM, GOVO(W Olt e.fi1111.e.
• fxOiftlYHp�bMMC
fR0(Iti NNf.ff! (OMMO rO AVOD DANMe fRP10(Mt Txh'fee coram(cm+
1l+v.L60apY�fLL. AT�Wetwlytp.pp2iT1(XL/TOAVCOfOlp11W-
�R phDtObflKifxO(eOlq(wfy(.fgr CN YHa�Y IMRKAIGTA.I�!
Vw 14�Wd0/�Y(W-rG .MOIdRO
1 �LL
f1wGe CwWal b Yq� b IOnnCIL 10e CM[ OtNNO e.0[fl1 pQAlpl TO •VOO
DANVC TO M eAe1V.rz xlfOM1T 1vil. AW M MTafwCAfA Mnipr, Igytw
.W. 06x/AWL�I eNOilGee wNLVLLlM MO CP�/Gr\'x.WRa1 xCNDe!
2206
(ov
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
lofl
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.
2023-984512
Lee Lewis Construction, Inc.
Lubbock, TX United States
Date Filed:
02/16/2023
2
Name of governmental entity or state agency that is a party tot 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
15202
General Construction
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
Lewis, Lee
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 authorized authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V3.5.1.3ac88bc0
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.
2023-984512
Lee Lewis Construction, Inc.
Lubbock, TX United States
Date Filed:
02/16/2023
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:
02/16/2023
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.
15202
General Construction
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
Lewis, Lee
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 V3.5.1.3ac88bc0