HomeMy WebLinkAboutResolution - 2016-R0197 - Clarke Mosquito Control Products - 06_09_2016Resolution No. 2016-R0197
pItem No. 5.15
JJune 9, 2016
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, Contract No. 12799 for Mosquito Larvacide and Adulticide
Chemicals, as per ITB 16-12799-KK, by and between the City of Lubbock and Clarke Mosquito
Control Products, Inc., of St. Charles, Illinois, 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 June 9, 2016
DANIEL M. P PE, MAYOR
ATTEST:
P6 �_OA - w -
Reb cca Garza, City Se rctary
APPROVED AS TO CONTENT:
APPROVED AS TO FORM:
Justin Prui t, Assistan City Attorney
ccdocs/RES. Contract 12799 —Clarke Mosquito Control Products. Inc. -- Larvacide & Adulticide
May 5, 2016
Resolution No. 2016-RO197 Contract 12799
City of Lubbock, TX
Contract for Services
Mosquito Larvacide and Adulticidc Chemicals
THIS CONTRACT made and entered into this 9th day of June.2016. by and between the City of Lubbock
("City"), and Clarke Mosquito Control Products, Inc., ("Contractor").
WITNESSETH:
WHEREAS, the City of Lubbock duly advertised for bids for Mosquito Larvacide and Adulticide
Chemicals 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 Mosquito Larvacide and Adulticidc Chemicals.
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, Mosquito Larvacide and
Adulticide Chemicals and more specifically referred to as Items 3, 4 and 7 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 (I) year. with the option of a one (1) year extension,
said date of term be -inning upon formal approval. The City does not �4)uarantee any specific
amount of compensation, volume, minimum or maximum amount of services under this
contract.
I. This contract shall remain in effect until the expiration date, performance of services ordered,
or termination of by either party with a thirty (30) day written notice. Such written notice
must state the reason for cancellation. 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.
5. 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 behalfol'City.
6. INSURANCE 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.
INSURANCE COVERAGE REQUIRED
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. 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'fcxas and acceptable to the City, in
the following type(s) and amount(s):
TYPE OF INSURANCE
GENERAL LIABILITY
® Commercial General Liability ❑ Other
❑ Claims Made ® Occurrence
❑ WiI[eav Equipment
❑ l-o Include Products of Complete Operation Endorsements
PROFESSIONAL LIABILITY
AUTONIOTIVE LIABILITY
®
Any .Auto
❑
Scheduled Autos
❑
Non -Owned Autos
EXCESS LIABILITY
❑
Umbrella Forth
GARAGE LIABILITY
❑ Any Auto
11
❑ BUILDER'S RISK
❑ INSTALLATION FLOATER
® POLLUTION
❑ CARGO
❑ All Ox%ned Autos
❑ Ifired Autos
COMBINED SINGLE LIMIT
General Aggregale $1.000,00U
Products-Conip'Op AGG N
Personal R Ad%. Injun
Contractual Liabilit% X
lire: Damage (An}, one Fire)
heed Exp (Am' one Person)
General r�g,regate
Combined Single Limit
Each Occurrence $1.000.000
Each Occurrence
Aggregate
Auto Only - Each Accident
Each Accident Agercgatc
❑ IOWo of the Total Contract Price
❑ 10010 of the Total Material Costs
$1.000,000
® WORKERS COMPENSATION — STATUTORY ANIOU-NTS OR OCCUPATIONAL, MLD[CAL AND DISABILITY
® EMPLOYERS' LIABILITY $1.000.000
COPIES OF ENDOSEMEITS ARE REQUIRED
® Cit}- of Luh bock nunted as additional insured on Azaa General Liahilit} ar a priuiar.l and non cartrihrttart 6etsls,
® To include products of completed operations etrdorsernent.
® II-crn•er ofsrrbrogation in favor oftlre CitY qJ Luhhock on all coverages, except
The City of Lubbock shall be named as an additional insured on a primary and non-
contributory basis and shall include a waiver of subrogation in favor of the City on all liability
coverage's except professional liability. A waiver of subrogation will be required on workers
comp coverages. All Copies of the Certificates of Insurance and all applicable endorsements
are required.
ADDITIONAL POLICY ENDORSEMENTS
The City shall be entitled, upon request. and without expense, to receive copies of the policies
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 1ak1` Ot' 1-eglllatl011 bl[ldlllg Upon either of the parties hereto
or the underwriter of any of such policies). Upott such request by the City, the Contractor
shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall
pay the cost thereof.
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:
Name the City of Lubbock and its officers, employees, and electcd 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;
C. 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 ol` 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 and 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.
7. 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.
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.
City of Lubbock
Bid ITB 16-12799-KK
9. At any time during the term 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 thirty
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.
10. 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 nonappropriation 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 termination.
11, 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 of insurance from
the Subcontractor that complies with all contract insurance requirements
12. This Contract consists of the following documents set forth herein; Invitation to Bid 16-I2799-
KK, Specifications, and the Bid Form.
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 Lu"'BOCK
DANIEL M. POPE, MAYOR
ATTFST;
Q . 0,
Reb t
ca Garza, City Secretary
APPROVED AS TO CONTENT:
Bill Ha , Assist ty Manager
APPROVED AS TO rvRivl:
Justin ruitt, ssistan City Attorney
T CT
B � �
Authorized ep a entative
Joel Fruendt
Print Name
675 Sidwell Ct
Address
St. Charles, IL 60174
City, State, Zip Code
3/11/2016 12:45 PM P. 39
City of Lubbock
Bld ITB 16-12799-KK
BID FORM
Mosquito Larvacide and Adulticide Chemicals
City of Lubbock, TX
ITB 16-12799-KK
In compliance with the Invitation to Bid 16-12799-1iQ{., 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 it 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 16-12799-KK is by reference incorporated in this contract. The Bid Form
must be completed in blue or black ink or by typewriter.
ITEM
QTY
(+/-)
p
U/M
DESCRIPTION
UNIT
PRICE BID
(B)
EXTENDED
COST
=(A X B)
Delivery
Days
ARO*
be delivered in 5 gallon cases (2-2.5 gallon
containers
Equal, to be delivered in 5 gallon cases (2-2.5 gallon
containers
3.
35
CS
30 Day Extended Release Multi Brood Larvaecidal
Pellet or Equal to, to be delivered in 2-221b. 'u case
-
4.
1650
GL
U.L.V. Concentrate, or Approved Equal, Contains
12% Chlorpyrifos & 4% Permethrin, to be delivered
in 275 gallon containers. Delivery Truck Must Have
Lift Gate.
$35.00
$57,750.00
3-5
container
insecticidal toxins
0
container
insecticidal toxins
No Bid
7.
20
Per case
BTI briquettes (mosquito dunks) with a minimum
10.31% solid, spores, and insecticidal toxins.
$66.50
$1330.00
3-5
approved equal I
No
*ARO, After Receipt of Order
Total $80,086.30
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 City of Lubbock reserves the right to reject any or all bids, reject any particular item on a quote, and to waive
immaterial formalities.
PAYMENT TERMS AND DISCOUNTS - Bidder offers a prompt payment discount or 0 %, net _ 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.
S: PuichasrJ id DuesATB 16-12799-KK Mosquito t.nrvaeide and Aduldcide Chemicals
3/11/2018 12:45 PM P- 6
City of Lubbock
laid ITS 16 12799-KIC
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 producWservices; does not include
an element of profit on the sale in excess of that normally obtained by the Bidder on the sale of products/scrvices 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 We 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 pricc(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 Freaship 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.
YES x NO
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 Clarke Mosquito Control Praductsolrteorporation organized under the laws of the State of
Illinois , or a partnership consisting of
of the City of
or individual trading as
Firm: Clarke Mosquito Control Products, Inc
Address: 675 Stilwell Ct
City: St Charles State: IL Zip 60174
Bidder acknowledges receipt of the following addenda:
Addenda No. Date
Addenda No. Date
S: PurcFwelBid Doc&IITB 16-12799-KK Mosquito tarvacide and Adulticidencmieals
3/1112016 12:45 PM
p. 7
Cite of Lubbock, TX
1TB 16-12799-KK
Mosquito Lat-vacide and Adultieide Chemicals
Specifications
1. Intent
The City of Lubbock is requesting bids for mosquito larvicide and adulticide chemicals. The
vendor must provide written documentation that the product meets the required specifications.
MSDS sheets must come with each shipment.
2. Statement of Work
The following is the breakdown of the mosquito larvacidc/adulticide chemicals and the bid
specifications.
Larvicides
Product: Liquid concentrate BTI 12 AS or Approved Equal
Contains: Bacillus thuringiensis israelensis (13-I I)
Container Size: 5 gallon cases (2-2.5 gallon containers)
Estimated Quantities: 300 gallons
Product: Surface Oil Larvaecidal film agent or Approved Equal
Contains: Monomolecular film
Container Size: 5 gallon cases (2-2.5 gallon containers)
Estimated Quantities: 200 gallons
Product: 30 day extended release multi brood larvaecidal pellet or Approved Equal
Contains: Temephos
Container Size: 2-22 lb. jugs/cases
Estimated Quantities: 35 cases
Adulticides
Product: U. L. V. Concentrate or Approved Equal
Contains: 12% Chlorpyrifos and 4% Permethrin
Container Size: 275 gallon tote container
Estimated Quantities: 1650 gallons
Delivery Truck Must Have a Lift Gate
Product: BTI Granular minimum 2.86 % solid, spores and insecticidal toxins
Container Size: 30 oz container or 20 lb container
Estimated Quantities: 6 containers
Product: BTI Briquettes (mosquito dunks) with a minimum 10.31% solid, spores and
insecticidal toxins
Container Size: Per case
Estimated Quantities: 20 cases
Product: ULV concentrate 96.5% Malathion or approved equal
Container Size: Gallon
5: 1'urchasei13id Docs/ITB I6-12799-kk Mosquito Lan 'acide and :\dulticide Chemicals
32
Estimated Quantities: 550 Gallons
3. Contract Period
The contract shall be for a term of one (1) year. xvith the option of a one (1) year extension, said
date of term beginnilig upon formal approval.
4. Delivery Location
City of Lubbock
Vicetor Control Department
102 Municipal Drive
Lubbock. TX 79403
Attn: Jaime Coy
Phone Number 806-767-2271
S: Purchase?Bid Docs/ITB 1 b-12799-KK Mosquito Lan acide and Adulticide Chemicals
33
Cite of Lubbock,'rx
Bid Tabulation
Mosquito Larvacide and Adulticide Chemicals
,tune 9, 2016
FFB 16-12799-KK
Mosquito Larvacide and Adulticide Chemicals
Item Qty U01M
Description/Vendor
Location
Unit Cost
Extended
Cost
1 300 GI.
Liquid Concentratc BTI 12 AS
Target Specialty Products
Coppell,'Fx
S 32
9,585
Clarke Mosquito Control Products. luc.
St. Charles, 1L
33
9.750
ADAPCO. Inc.
Sanford. FL
36
10.944
Univar USA
Grand Prairie, TX
37
1 1,100
2 200 GL
Sin"I lCC Oil Larvaccidal Film Aoent
Univar USA
Grand Prairie, TX
IO
1,968
ADAPCO, htc.
Sanford. FL
11
2.196
Target Specialty Products
Coppell. TX
14
2.854
Clarke 1"40squito Control Products, hic.
St. Charles, IL
22
4.310
3 35 CS
30 Day Extended Release Multi Brood Larvaecidal Pellet
Clarke Mosquito Control Products, Inc.
St. Charles, 11,
00
21,006
Target Specialty Products
Coppell. TX
1.124
39.347
Univar USA
Grand Prairic, TX
1,124
39.347
4 1650 GL
U.L.V. Concentrate
Clarke Mosquito Control Products, Inc.
St. Charles, 1L
35
57,770
Palm Beach Laboratories, Inc. dba Hilton head Laboratories, Inc.
Boca Raton, FL
194
320A59
5 6 30 oZ
oxlns
B 1 t Granular Mlnmluln 2.86%, Solid. Spore's and InsecticidalToxins
Univar USA
Grand Prairie, TX
2
-NQAS
Target Specialty Products
Coppell, TX
16
94
6 6 2011)
BTI Granular Mininwm 2.86'%, Solid. Spores and Insecticidal Toxins
Univar USA
Grand Prairic. "['X
2
NQAS
Target Specialty Products
Coppell. TX
121
724
7 20 Case
BTI briquettes
Clarke MOS(luitn Control Products, Inc.
St. Charles, 1I,
67
1,330
Univar USA
Grand Prairie, TX
70
1.399
Target Specialt} Products
Coppell. TX
76
1.519
ADAPCO, Inc.
Sanford. FL
76
1,527
3 550 GL
Adullicidcs-ULV concentrate 96.5°„ Malalhian
ADAPCO, Inc.
Sanford. FL
49
26,675
Univar USA
Grand Prairie. TX
51
NQAS
Item by Item
Univar USA - ltcm 2
Grand Prairic, TX
S 1,969
Target Specialty Products - ]tun I
Coppell, TX
9,595
ADAPCO, Inc.
Sanford, FL
39.146
Clarke Mosquito Control Products. Inc., - Items 3,4 and 7
St. Charles, 11-
80.086
Palm Beach Laboratories. Inc. dba Hilton Head Laboratories. Inc.
Boca Raton, Fl.
320,859
Ruins, 5, 6 alld 8 ]lot awarded {over bndgCO
*NQAS - Not Quoted As Specified
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 cf 1
Complete Nos. 1 - 4 and 6 if there are interested parries.
Complete Nos. 1. 2. 3, s, and 6 if there are no interested panes.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016.53362
Date Filed,
05/11/2016
Date Acknowledged:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Clarke Mosquito Control Products, Inc
St Charles, IL United States
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
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.
ITB 16-12799-KK
mosquito control products
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
5 Check only if there is NO Interested Party. ❑
X
6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
PATRICIA
offi E ORISCOLL
Official Seal
No�t�ary Public - State of Illinois
My Conv0stlon EKplres Feb 17, 2020 Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP I SEAL ABOVE j }
Sworn to and subscribed belore me, by the said L Gov, Or,) Ay}J � r woe, this the f I day of
24_L(,e—, to cenify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of othcer administering oath Title of oftJer administering oath
Forms provided by Texas Ethics Commission wiwr.ethics.state. tx.us Version V1.0.1021
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
lafl
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-53362
Date Filed:
05/11/2016
Date Acknowledged:
05/17/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Clarke Mosquito Control Products, Inc
St Charles, IL United States
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
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.
ITB 16-12799-KK
mosquito control products
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
5
Check only if there is NO Interested Party.
X
6
AFFIDAVIT I swear. or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP 1 SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oalh Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.1021