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HomeMy WebLinkAboutResolution - 2018-R0378 - PO Syn-Tech Systems - 10/25/2018Resolution No. 2018-RO378 Item No. 6.8 October 25, 2018 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, Purchase Order No. 31041502 in accordance with Buy Board Contract 510-16 for the purchase of Fuelmaster Fuel Dispensing and Tracking System Upgrade, by and between the City of Lubbock and Syn-Tech Systems, Inc., of Tallahassee, Florida, and related documents. Said Purchase Order is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on October 25, 2018 DANIEL M. POPE, MAYOR ATTEST: — -OA�e' , )K - Re e ca Garza, City Secret APPROVED AS TO > n Scott Snider, Assistant City APPROVED AS TO FORM: & - (4v �� -- elli Leisure, Assistant City Attorney ccdocs/RES. PurchaseOrd 31041502 Fuelmaster Fuel Dispensing and Tracking System Upgrade October 8, 2018 City of ;-Lubbock TEXAS PURCHASE ORDER TO: SYN-TECH SYSTEMS INC 100 FOUR POINTS WAY TALLA1 ASSE FL 32305 INVOICE TO: CITY OF LUBBOCK ACCOUNTS PAYABLE P.O. BOX 2000 LUBBOCK, TX 79457 Ordered 10/5/2018 Freight Requested I0,' 19/2018 Taken By Delivery L LOERWALD REQ 52766 Description/Supplier Item CC3526 FNIU-3505 PLUS ILRU2.4ANTENNA CC3526 NETWORK CARD CC3526 AIM 2.4 MODULE, CC3526 941BO404 AIM 2 RADIO BOARD CC3526 INSTALLATION LABOR CC3526 AIM 2.4 DASH ODOMETER CC3526 SHIPPING CHARGE SHIP TO: Page - 1 Date - 10; 5/2018 Order Number 31041502 000 OP CITY OF LUBBOCK FLEET SERVICES 206 MUNICIPAL DRIVE LUBBOCK TX 79404 actor otPurchasing & Contract J MONTES BUY BOARD 510-16 Ordered _ Unit Cost UNI _Extension Request Date 9.000 2.015.1000 EA 18,135.90 10/19'2018 9000 321.3000 F,A 2,891.70 10/19/2018 1.352.000 181.7640 EA 245,744.93 10/19,'2018 9.000 793.8000 EA 7,144.20 10/19./2018 9.000 2,250.0000 EA 20,250.00 10/19/2018 748.000 227.6640 EA 170,292.67 10/19/2018 1.000 7,300.0000 EA 7,300.00 10/19/2018 Total Order City of Lubbock TEXAS PURCHASE ORDER TO SYN-TECH SYSTEMS INC 100 FOUR POINTS WAY TALLAHASSE FL 32305 SHIP TO: Page - Date - Order Number 1 10/5/2018 31041502 000 OP 526 CITY OF LUBBOCK FLEET SERVICES 206 MUNICIPAL DRIVE LUBBOCK TX 79404 INVOICE TO: CITY OF LUBBOCK ACCOUNTS PAYABLE P.O. BOX 2000 LUBBOCK, TX 79457 BY: b4arta A arez, Director of Purchasing & Contract Management Ordered 10/5/2018 Freight Requested 10/ 19/2018 Taken By Delivery L LOERWALD REQ 52766 INSURANCE REQUIRED: BUY BOARD 510-16 J MONTES Commercial General Liability, per occurrence, $1,000.000 Automo:i%e Liability- Any Auto, Per Occurrence-$1,000,000 General Aggregate, $1,000.000 Workers Compensation- $500,000 Technical Errors and Omissions, General Aggregate, $1,000.000 Em loycrs' Liability- 51,000,000 City of Lubbock is named as an additional insured on Auto/General Liability e a primary and non-contributory basis to include products of complete operations endorsement. Waiver of subrogation in favor of the City of Lubbock on all coverage. Copies of endorsements required. This purchase order encumbers funds in the amount of $471. 7 59.40 awarded to Svn-Tech Systems Inc of Tallahasse, FL on October 25 , 2018. The following is incorporated into and made part of this purchase order by reference: Buy Board Contract 510-16 from Svn-Tech Systems Inc. Tallahasse, FL. Resolution # 2018-RO378 City of Lubbock ATTEST: Daniel M. Pope, Mayor qe cea Garza, City Settary Seller and Buyer agree as follows: a Il.l.0 yJG ""rA% TERMS AND CONDITIONS IMPORTANT: REND CAREFCLLF STANDARD TERMS AND CONDiTIONS CITY OF LUBBOCK. T\ 1. SELLER TO PACIC.AGE GOODS- Seller wil: package goods it accordance with acrid commercial practice ner Each shipping contaishall be clearly and permanently marked as follows (a) Seller's name and address. (b) Coosigoee s name, address and purchase order or purchase release number and the supply agreement number if applicable. (c) Container number and total number of containers. a z' box 1 of q bows. and (d) the number of the container bearine the packing slip Seller shall bear cost of packaging unless otherwise pro, ided. Goods shall be suitably packed to same lowest transportation costs and to conform with requirements of common carriers and any applicable specifications Bu_.er's count or weight shall be final and conclusa a on shipments not accompanied by packing lists. SHIPMENT UNDER RESERVATION' PROHIBITED. Seller is not authcrzed to ship the eoods under reservation and no tenderof a bill of ladine will operate as a tender of goods I. TITLE AND RISE: OF LOSS. The title and risk of loss of the goods shall not pass to Buyer until Buser actually receives and takes possession of the goods at the point or points of delivery T. NO REPLACEMENT OF DEFECTIVE TENDER. E%-, tender a,` deiiver. oC goods must fulls comr?y with all provisions of this contract as to time of dehverc. quality and the like If a temda is made •,chick does net full, confirm. this shah constitute a breach and Sella shall net ha: a the riaht to substitute i cop. farming tends. pro, ided. where the time for performance has not ye: expired. the Sete: ma, resorab?: notif: Buser of b_s intenrinn to cure and ma% then make a conforming tender within, the contract tine bur act a.`.` -vu:l S INVOICES & PAYMENTS a. S e 11 e r shall submit separate mtoices, it duplicate. one each pur:^ase order or purchase release after each deli•: cry Im Pices shall indicate the purchase order or purchase release rumba and the supply agreement number if applicable Invoices sha':! be itemized and rr:nsFCrtat:an char_r_•s. if an- shall be listed separately A copy of the bill of iadm_. and the freight wit}b ! "her appbcabie. stir old be attached to the in: Dice Mail To Accounts Pa• -able. City ell Lubtrek P O Bcx 2'10u. Lul-rcck. Texas '9T5' Paymna char: rot bra due antra :he abote re :^_^ears ±-e snbm::':.i i._ 'd_. ••- 6 GRATUITIES. The Bu_.er ma by written notice the Sit tt, can:_s , t - -; ha':r:r•to Seller if c isdetermined be Bu that gratuouls. in the Corm cf ,ttr �airmert. � err olemur ice. were o or gi-can by the Sella, or any agent or reprvsentatr. e of the Seller. to an, of`•.ca err er..loyee of :he Cm of Lubbock with a view to securing a contract or securr.sir fa:or_hle trc*trunt •sit: rsrr.:; to the rtar+tri_ cr amerdirg. or :he ma -kin_ of art.} de!arriut tors 'w ith respect to the par orn:ng of s:; b a -, mr.i: Ira tee c, this cont-act: is caneeled b, Bu}era pursuant *his pr. - _. Bi tm er sha:i ' ._. .t err.•. rights and remedies. to reco'.•_T n m _r withild the acum of he _oit it c_... r�Se .a:r. p ..d:r a __ > ._.. SPECIAL TOOLS & TEST EQUIPMENT If the price stated.+n the faze haze," mc'sdts the cost cf v:y necial nxlin_ or Special test equipment far treated or reurea c t.`. puttall of -Fi or.!t.. such spccial tattling equipment and any pncess sheets rclaad t1:c-an ask i i•rc;n;e :he pi }per': of the B,.er and to the extent feasible shall be identified by the Seller as such - 1VARR.-ItNTY-PRICE a. The price to be paid b•, the Buser s:.all be that c'r.:a_ rid I. Sc::t 's 1:_4 which Seiler w ,rats to be no higher that. Sell-,- current process in order-, b• hers fir pre.._, s Nthe k and spe fcat!ca z •toned b, this agreement for simlar quar:a:e.s under s:m: ; f it's: rodams aii-d T . - of purchase Ira the e:ati Sella: breaches this ttarranr.. the price:; of the it niii _.._ ve redux I - tie Seller's current peas on orders by others, or in dte alt_rn-at::e Bu%era ma, ter..." this corm.:, .nth out liabilit, to Seller for breach or Seller's actual expense b Tee Salver w,irar2:i that ro person, or se!iing agerc, has been employed or retained to solicit or Secure this contract Leper art: air, or ur.• ersiandieg for commission. percauage. brokerage. or contingent fee excerurg hora fide anplcyces of bona fide estahlished commercial or selling ageocies maintained b•, the Scala for the purrese of ;ecura:_ leeriness For hreazli viciatioe of this warrant, die B❑}c shall have the right in addition t) an, ather r •'.t o: rtgh:s :o zancel tones contract without habits; acd to deduct from the contras price, Zr othawse roc: •.era •without liabila. and it deduct from the ccutract price. era nthencisc rove•, r. the ;u!? imrur,: of ;rich err-s:. c. razerta_e. �r. aa_e or cortrrgent fee 9 W A.RR.ANTY-PRODUCT Seller shall not lire, or exclude at.y urptred warat:es .anal ait, ar:emrt tc dC so shall reader this contract tcidabie at the option of the Bc}er Seller tvarants that the g+rids furnished till: confnratto the specification. drawings- and descriptions listed in the bid aeitati; a aG'.:o the samr?ersa Straitsl-eJ bt the Seller. if an: Ie the cram of a conflict or bet'.teer the sreci2cauons. v. _.t toga. and !,.nt ;ncificarers shad gocem, N'utw i:ns:anding art,;. pnts:ors onto!red at the ccr-act::a! agremeEt'•he Seiler represents and warran-s fault -free performance and fault -fry resc!: it the pre cessm_ date and date :e!h:rid data (ircludii.a. but net lm:!md to calculatine. comrar:r_^ and scquencirgl of ! h d:wue. sc final are era! f aria are pnduets delivered and serices provided under this Contract. indr.:du ;:} or to cambiru:ran, as t`.a case ma•. be from the cffz .ice date of this Contract, The abii-pluons :rramcd to rrs•-- eson., ic_ protided by the Seller, its sub- Seiler or any thud parrid m •. insol the c, a?:cr. _+ ,.i`..loet producs and services to he deVered to the Cit;. of Lubbock under this Contract Faiisre- pm cm-1% with m, of :be obligations contained hr•,ein. ma- result it.. the Cir. of Labneck a'. a:P.^d :tse't of any of its rights order :he law and undo this Contract ineludinz. but not limited to. its rich: pertambn; is etuiaton cr default Tie warranties contained halm are separate and discrete from an, ether wa:.cties specified in this Contract. and are net subject to any disclaimer of warranty. implied or expressed, or liRi:tatlo❑ of the Seller's liabilir, which may be specified in this Contract, its appendices, its schedules, its annexes err any document incorporated in this Contract by refactice 10, SAFETY R'ARRANTY Scala warants that the product sold tc :he Buyer Shall carfarm to 'be star 1� 5 pramulgited by the C S Derarmtent of Later under the Occupa!:oral Safe: and Heath Act: of t )-0 I.^.:he event the product does act conform to OSHA standards. Bu}e: ma% ret>" he product for caret en or replacement at the Seller's expensein the a at Sella fils tc make :he apprrpra:e corer::cn within a reasonable time, correction made by Buyer hill be at the Seller's expense. 11. NO WARRANTY BY BUYER AGAINST INFRINGEMENTS As part of this contract for sale Sella agrees to ascertain whether goods manufactured in accordance with the specifications arached to the agreement will give rise to the rightful claim of an:. third person by a'a, of inkmgenrent of the like. Buy,: makes no warranty that the production of goods according to the specification will net tore r ise to such a churn, and in no event shall Buser be liable to Sella' for ihderuni`:cation in :he -tent that Seller is sued on the arounds of infringement of the tilt- if Seller is of the opinion that an insngemeot or the like will result. he twill notif', the Buyer to this effect in writing within two week, after the signing of this agreement- If Buyer does not reserve notice and is subsequently held liable for the Infringement or the like. Sella will save Bu-.a harmless. If Seiler in good faith ascertains the production oftbe goods in accordance with the specifications will result in infringement or the like, the contract shall be null and void. 12. NON .APPROPRIATION, 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 ❑oneppropriation or funs by the City Council of the City of Lubbock for the goods or services provided under the contract, the Cir will terminate the contract, without termination charge or other liabilir., on the last da•: of :he then -current fatal year or when the appropriation made for the ;hen -current year for the goods or serices covered by this contract is spent, whichever event occurs first- If at any time funds are nut appropriated for the continuance of this contract, cancellation shall be accepted by the Seller on thirty (30) days prior written notice, but failure:. give ahh,4 14 CA\CE:.LA:ION Bu:e. s. ...... ie rgit :n cnrc,. fort ..... or errs rant _.... sr. portion ii thus order of Sella breaches any of the teams haeof mc:udlt:g 'tvaraa➢es of Seiler s :f the Seiler hominess insrhem or ,:rmmirs lots of iarkomrcv Siren rivet nC rnrrtl!adrn is in-irditirn n, and nni in lieu of any other remedies which Buyer mac have in law or equit% IS TERMINATION The paferon mce o f work under this order maybe terminated no whole. or in part by the Buyer in accordance with this provision. Termination of work hereunder shall be effected by the delivery, of the Seller of a "Notice of Termination" specifying the extent to which performance of work under the order is terrrimated and the date upon which such termination becomes effectne. Such tight or termination is in addition to and not in lieu of the rights of Buyer set forth in Clause IJ, herein. 15. FORCE %LAJEURE. ' eaber party shall be held resporsib?e for losses. resulting if the fulfillment of any terms of provisions of this contract is delayed or prevented by any cause not within the control of the party whose performance is interfered with. and which by the exercise of reasonable diligence said party is unable to pre, air 17, ASS IGN'N•IENT-DEL EGATiON. No right or interest in this contract shall be assigned or delegation of any obligation made by Seller without the uon ter, permission of the Buyer Aa_. attempted assignment or delegation by Seiler shall be w'hcll,. void and totally iteffenr c far allpurpose:gtless made in conformitywith this paragraph IS R-.AA'ER No claim, or relit arsine out of a breach of this coat:ac: car. be dtschatged whole or it., par by a tcar:e: or rennneratice of the claim or right unless the wars- or rereactatrea is supFortal bl, consderanon and is it., writing signed by the ag eted pa. 19. INTERPRETATION -PAROLE FViDENCE. This wrung plus err_ sFec:fsaticns for bids and Ferfermarce protided by Buyer ir, its ad, a-userrient for bids. and an: other dociuriccs rratideo by ScCer as Far of h:s bid. is intended by- the Farces as a fn.,: expression of th,:r asree.cact and intended a!so as a complete and exclusi•:e statement ofthe te—s of th,rr air.zemerr Whenever a tea defnel b,, the Um:orm Counter: al Cede is use it. this acreeaert- the de.`:rincr. cur:i: ne'_ to the Ccde is tc ccr-t:al. "i APPLICABLE LAW This ag•eeme^:t shall be eaten,! by the CriFr... Ccrune._:a! Ccde T5 ieroe-era the tt^n ' T'nifcrm Cominacial Coda' s used, it ;ha;i be ce:s:rated as meacx_ the Cnu::rm CiIrui ziai Code as adopted it, the State of Texas as e.:erite and rc force on _,"this agreement. 21 RIGHT TO ASSUK-MNCE Ulicaete: or., parr, to this contract in _cad fait. ba_s r_as r: to goes::cr, the at;.: curt•. s icteat t: rerf:rm he ma der•the e tc, r pa,- _ nttt --_ = his in:. o ea`crm In the etcrt that a demand isrradearo ass - a ISc cn'a i:1--it f:, v �': Ss _. L-- Je:itan-_ota trait? this fa•!ure as an arcefpatcr- repodic:,.r. -."-he- _- INDE}LV11-IC ATION Seger shag: it. dararr .. kzep and save ha.-m!ess the Buyer, rrs agarts. ofraals and ernplo,ee.s..v_ainst all injuries. deaths. less, damaees, c6un:a. pat.:: -:aura. s::nt,, habr:itnes. jud_mcns, c: st., anal expenses, which ma: in anywise accrue against the Buz a no zr.rsequenco c f the g-iriting of this C'urtrict or which ma; an;rsfse result theresom. whether or not it shall he a:`eae' .;r dacrm:red that the act ,as caused thrrcgh nei:i_eece.r omissior of the Seller or it, emp::}pes, or :t:he suv.S,:a cr _ err its emplcgees. if art... arid the Sc!ler shall. at his own ex;7asc. arrear. !_f..,. a rat art el-.zr_es o m., attac and ail cosy and other ex,erses arising dtcrefro r: cf into¢,-, ea u: c'rreca: r. elia z•a it . and. if.tr juairnemt ZM shn!' be rendaed against the Buyer ir ar, such ac::hr,-, the Sella, shall. at I" o•an exilerse•,. satnsf and dsehuae the same Seiler expressly understands and agrees that an,. bond regair!d It, this contract. or omervse protided by Seller. shall in no way hind the r•sponsibtint% I, ir.demntF•. l-ep drd>a•.e harmless acd ,,fend the Buyer as herein. protided -- TIME It is hereby expressly agreed and urdermed that trite is i , saute for the paf;rmznce of this contract. and failure by contract to meet the rime SFecifl,aticrs of th.; agreement •si!I cause Seller to bent default of this agreement :S %IBE The Cat- of Lubbock harty notifies all bit as that in rz;err'.:e an�. cattract entered tot•.: Fursuant to this request. ninon_. and women bus:nUs aiiaprses w:C be aC:arde,r equal oprortur-ities to submit bus ia response to this ram. itation and '.till nor be du.riminatcd asa:r_ i or- the er,ur„s of race. color. see or natural crivin in eorsidaation for an svar.: __ \ON•A-BITR.ATION The Cis reserves the rag;:^.t t: exerne aria r of rat c a-. t • it by lac. crntr cI. equity. or itheraise, ineludmg without limitah:r.. the neat:::,. -. -! ;'c;m, no a coup of competent jurisdiction Fur. a h. the Cit. shall net 'cc subject to .•ar;�t: grin r, Fr. cess prier to exercising asurrestr.,ted ngat to seek judicial ramed:. T.ie:e.. dies se: fir.: ier-!n are :umu!a:;•.eand rot exdusce. and ma he exorcised cpnrurentl; Ta the extent iFar} c)rd.c:'catceer. t a i r: son. and anotha pr)vsot m. or rc!ateJ! tC. this document. this rant ieu-n;bttii :or ,.., ]6 RIGHT I'0 AUDIT At any time during the tam, of the c:r:sac.. cr thaea°era. the Cir.. or a du.. atu orzed audit representative of the City or the Stare of Texas. at s ex-easo and a: resorable times. reser-: es he neht to audit Cortractots moors and cocks rz?c•.ar: to •.a:: sue: ices pro: ided to the Cir: under the Contract In the evert such err audit c: the Ca, re:es:s arty eras e; e•.cr,::.±ae:, b:' the Ca,,. Contractor shall refund the City the full amount o'such o, ra•.ments -,hu they (30) days of such audit findings. or the Cit.. at its apticn. rasa•; es the rich: m deduct such accurts owin_ the Cat from arty payments due Contractor. '" HOUSE BILL'_015. Home Bill 2015. signet: by the Gee.,^, nor on June h.:013 and effeuti:e ran January I. MI4. authorzes a paalty to be imposed on a poss. or, ahc ,ntrac,s or corm sera, ices with a o•:ernmt-.tal attliv, and who fags to proper!% dassif. their workers This arrhes r subcarnractcrs as well. Contractors and subcontractors uhe roll tc proper!% classify irdi•:ndua:s cairrmme w xk oa de a go•.errrineata: contract wig be pma:ized S_06 for each individual that has been Wsc'ssific' (Texs Gcve:tr-ant Code Section '_1?_.001). 25 ASSIGNING OR SUBLETTING THE CONTRACT The Contractor shal! not assign orsublet the contract. or any portion of the contract, without written consent from the Director of Purchasing and Contract %lanagement Should consent be given, the Contractor shall insure the Subcontractor or shall provide Proof on irs•.trance from :he Subcpnrr_ror that complies with all contract Iasuracce requirements. 29 HOUSE BILL 1295 DISCLOSURE OF INTERESTED PARTIES House Big lips. adopted by the sJth Legislature. created §2-'5= )G3. Texas Goterrment Code. Section =2_52 908 requires a business entity entering into certain contracts with a go%ernmental emit;, or state agent; to 51e with the governmental entip. or state agency a disclosure of interested parties at the time the business emir' submits the signed contract to the got-ermneotal entity or state agency Iastmaicns for completing Form I_95 are available at: 134Sp" �v3 :c ci.luF ck tt its deparm ntallgeiiites ;afinert!Szep_gLcha tag} erd4r_i�grmat: 30 CONTRACTOR ACR\ON LEDGES, by supplyme any Goods or Sep ices that :be 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 document, and .Amendmemt,. The City disclaims any terms and conditions protided by the Contractor unless agreed upon in writing by the parties In the event of conflict between these terms and conditions and any terms and conditions provided by the Contractor, the terms and conditions provided herein shall prevail. The tetras and conditions provided herein are the final terms agreed upon by the parties, and any prior conflicting terms shall be of ou force or effect. 31 By accepting this purchase order. the Vendcr verifies that it does not Beycor Israel, and agrees that durnc 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. 2018-415884 SYN-TECH SYSTEMS INC. Tallahassee, FL United States Date Filed: 10/17/2018 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Lubbock Date Acknowledged: 3 Provide the identification number used by the governmental entity or slate agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. Fuelmaster Fuel and Fleet Management System 4 Name of Interested PartY City, State, Country (Place of business)(check Nature of interest applicable) Controlling Intermediary Oglesby, David Tallahassee, FL United States X Dunlap, Doug Tallahassee, FL United States X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION My name is Dan. C. Phillips and my date of birth is August address is 100 Four Points Way Tallahassee FL 32305 USA . (street) (city) (state) (zip code) (country) 1 declare under penalty of perjury that the foregoing is true and correct. Executed in Leon County, State of FL on the 17 day of October, 20 18 . .,s (month) (year) Signature of afut-horized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us version V1.0.6711 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. 2018-415884 SYN-TECH SYSTEMS INC. Tallahassee, FL United States Date Filed: 10/17/2018 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Lubbock Date Acknowledged: 10/17/2018 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. Fuelmaster Fuel and Fleet Management System 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Oglesby, David Tallahassee, FL United States X Dunlap, Doug Tallahassee, FL 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.U.6711