HomeMy WebLinkAboutResolution - 2018-R0442 - Employee Medical Clinic Services - 12/17/2018Resolution No. 2018-RO442
Item No. 6.11
December 17, 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 to execute for and on
behalf of the City of Lubbock, an Agreement for Employee Medical Clinic Services, by and
between the City of Lubbock and UMC Physicians, and related documents. Said Agreement 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 December 17, 2018
DANIEL M. POPE, MAYOR
IN81 111
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Rebec a Garza, City Secretary 0
APPROVED AS TO NT:
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Leisa Hutc eson, Director of Human Resources & Risk Management
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ccdocs/RES.Agrmt- Employee Medical Clinic Services
November 16, 2018
Resolution No. 2018-RO442 AGREEMENT FOR SERVICES
for
City of Lubbock Employee Medical Clinic Services
This Agreement is between UMC Physicians ("UMCP") and the City of Lubbock ("the City").
City is a Texas municipality. It maintains the City of Lubbock Health Care Plan for its employees and their
eligible dependents (hereinafter called "Plan Members"). City desires to establish medical clinic locations
within the city limits of Lubbock, Texas for City's Plan Members. The availability of one or more medical
clinics would provide convenience and greater access to quality health care for Plan Members at an
efficient and affordable cost to the City.
UMCP is a Texas nonprofit corporation that operates and manages medical clinics and physician practices.
UMCP desires to provide medical services to Plan Members.
Therefore, the parties agree:
ARTICLE 1: TERM AND TERMINATION
1.1 Term. The term of this Agreement begins on February 1, 2019 for one year with four additional
one year terms, not to exceed five (5) years.
1.2 Renewal. This Agreement shall renew only upon further written agreement of the parties.
1.3 Termination. Either party may terminate this Agreement at any time without cause by giving the
other party ninety (90) days written notice of termination. Either party may terminate the agreement for
cause provided the other party fails to cure a default within fifteen days prior written notice of the default.
ARTICLE 2: RESPONSIBILITIES
2.1 Medical Clinics. UMCP shall provide access to Plan Members age two years and above at 10
medical clinic locations as described below.
2.1.1. West Wind Primary Health Center. West Wind is located at 4th Street and Elkhart Avenue,
Lubbock, Texas (Northwest location). West Wind Primary Health Center will provide primary and
acute health care services. All of the services will be directed by the health care provider as
needed to provide the high quality health care. If the Plan Member needs care outside the scope
of the services offered at West Wind, UMCP will assist in obtaining an appointment for the Plan
Member with an appropriate health care provider within the Plan Member's Health Plan Network.
West Wind will be open seven days a week with extended hours. West Wind will be open Monday
through Friday 8:00 AM until 8:00 PM, Saturday 9:00 AM until 5:00 PM, and Sunday 1:00 PM until
5:00 PM. If these hours change substantially, UMCP will notify the City. Plan Members may
obtain services on a walk-in or appointment basis.
2.1.2 Express Care Boston and Express Care Avenue Q. The Boston Express Care clinic is
located in the United Supermarket at 82"d and Boston Avenue, Lubbock, Texas (South location).
The Avenue Q Living Express Care clinic is located in the Untied Supermarket at 50th Street and
Avenue Q. The clinics will provide acute care services. The Health Care Provider will determine if
the Plan Member needs to be treated at a different location. If the Plan Member needs care
outside the scope of the services offered at the clinic, UMCP will assist in obtaining an
appointment for the Plan Member with an appropriate health care provider within the Plan
Agreement for Services: City of Lubbock Medical Clinic Services Page 1 of 9
Member's Health Plan Network. The Boston clinic will be open Monday through Friday 9:00 am
until 7:00 PM, Saturday 9:00 AM until 6:00 PM, and Sunday 1:00 PM until 6:00 PM. The Avenue
Q clinic will be open Monday through Friday 7:00 AM until 4:00 PM. If these hours change
substantially, UMCP will notify the City. Plan Members may obtain services on a walk-in basis.
2.1.3. Express Care Clinic at South Plains Mall. Express Care Clinic is located at 6002 Slide Road,
Lubbock, Texas (inside the South Plains Mall). Express Care Clinic Primary Health Center will
provide acute health care services. All of the services will be directed by the health care provider
as needed to provide the high quality health care. If the Plan Member needs care outside the
scope of the services offered at Express Care Clinic, UMCP will assist in obtaining an appointment
for the Plan Member with an appropriate health care provider within the Plan Member's Health
Plan Network. Express Care Clinic will be open seven days a week with extended hours. Express
Care Clinic will be open Monday through Saturday 9:00 AM until 8:00 PM, and Sunday 12:00 PM
until 6:00 PM. If these hours change substantially, UMCP will notify the City. Plan Members may
obtain services on a walk-in or appointment basis.
2.1.3 Milwaukee Family Medicine. Milwaukee Family Medicine is located at 7301 Milwaukee
Avenue Lubbock, TX. This clinic will provide primary and acute medical services. The Health Care
Provider will determine if the Plan Member needs to be treated at a different location. If the Plan
Member needs care outside the scope of the services offered at the clinic, UMCP will assist in
obtaining an appointment for the Plan Member with an appropriate health care provider within
the Plan Member's Health Plan Network. The clinic will be open Monday through Friday from
8:00 AM until 8:00 PM, Saturday 9:00 AM until 5:00 PM and Sunday 1:00 PM until 5:00 PM. If
these hours change substantially, UMCP will notify the City. Plan Members may obtain services
on a walk-in or appointment basis.
2.1.4. 1-27 Medical Center. 1-27 Medical Center is located at 1-27 and 42th Street, Lubbock,
Texas. 1-27 Medical Center will provide primary and acute health care services. All of the services
will be directed by the health care provider as needed to provide the high quality health care. If
the Plan Member needs care outside the scope of the services offered at 1-27 Medical Center,
UMCP will assist in obtaining an appointment for the Plan Member with an appropriate health
care provider within the Plan Member's Health Plan Network. 1-27 Medical Center will be open
seven days a week with extended hours. 1-27 Medical Center will be open Monday through Friday
8:00 AM until 8:00 PM, Saturday 9:00 AM until 5:00 PM, and Sunday 1:00 PM until 5:00 PM. If
these hours change substantially, UMCP will notify the City. Plan Members may obtain services
on a walk-in or appointment basis.
2.1.5. Orchard Park Family Medicine. Orchard Park Family Medicine is located at 4420 114tn
Street, Lubbock, Texas. Orchard Park Family Medicine will provide primary and acute health care
services. All of the services will be directed by the health care provider as needed to provide the
high quality health care. If the Plan Member needs care outside the scope of the services offered
at Orchard Park Family Medicine, UMCP will assist in obtaining an appointment for the Plan
Member with an appropriate health care provider within the Plan Member's Health Plan Network.
Orchard Park Family Medicine will be open seven days a week with extended hours. Orchard Park
Family Medicine will be open Monday through Friday 8:00 AM until 8:00 PM, Saturday 9:00 AM
until 5:00 PM, and Sunday 1:00 PM until 5:00 PM. If these hours change substantially, UMCP will
notify the City. Plan Members may obtain services on a walk-in or appointment basis.
2.1.6 Northwest Pediatrics located at 416 Frankford Avenue, Lubbock, Texas. Northwest
Pediatrics will provide primary and acute health care services. All of the services will be directed
by the health care provider as needed to provide the high quality health care. If the Plan Member
needs care outside the scope of the services offered at Northwest Pediatrics, UMCP will assist in
Agreement for Services: City of Lubbock Medical Clinic Services Page 2 of 9
obtaining an appointment for the Plan Member with an appropriate health care provider within
the Plan Member's Health Plan Network. Northwest Pediatrics will be open Monday through
Friday 8:00 AM until 5:00 PM. If these hours change substantially, UMCP will notify the City. Plan
Members may obtain services on a walk-in or appointment basis.
2.1.7 KingsPark Urgent Care is located at 7501 Quaker Avenue, Lubbock, Texas. KingsPark Urgent
Care will provide acute health care services. All of the services will be directed by the health care
provider as needed to provide the high quality health care. If the Plan Member needs care outside
the scope of the services offered at KingsPark Urgent Care, UMCP will assist in obtaining an
appointment for the Plan Member with an appropriate health care provider within the Plan
Member's Health Plan Network. KingsPark Urgent Care will be open seven days a week with
extended hours. KingsPark Urgent Care will be open Monday through Friday 8:00 AM until 9:00
PM, Saturday and Sunday 9:00 AM until 6:00 PM. If these hours change substantially, UMCP will
notify the City. Plan Members may obtain services on a walk-in or appointment basis.
2.1.8 UMC Urgent Care Center is located at 808 Joliet Ave Suite 110, Lubbock, Texas. UMC Urgent
Care will provide acute health care services. All of the services will be directed by the health care
provider as needed to provide the high quality health care. If the Plan Member needs care outside
the scope of the services offered at UMC Urgent Care Center, UMCP will assist in obtaining an
appointment for the Plan Member with an appropriate health care provider within the Plan
Member's Health Plan Network. UMC Urgent Care will be open Monday through Friday 7:00 AM
until 4:00 PM. If these hours change substantially, UMCP will notify the City. Plan Members may
obtain services on a walk-in or appointment basis.
2.2 Services. UMCP shall use its best efforts to provide safe, high -quality, efficient healthcare to Plan
Members.
2.2.1 Primary and Acute Medical Services. Plan Members may obtain medical care for primary
and acute health care issues at any of the ten clinics. Primary and acute medical services include
the services listed in Exhibit A.
2.2.2 Health Screening. UMCP will perform Health Screenings for the Plan Members to include:
(1) Blood draw (CBC, CMP, PSA (males over 50), Lipid Profile), Body Mass Index, Body Fat
Percentage, weight, height, blood pressure, and pulse. UMCP will mail the Plan Member their
results with explanations and meanings of each result. UMCP will perform pre -scheduled Health
Screenings in coordination with the City's preferences at the KingsPark Lab.
2.2.3 Reporting. UMCP will provide to the City, no later than the 15th day of the month
immediately following the end of each month of the calendar year, a written report with respect
to the provision of the medical services during the immediately preceding month. The written
report shall be in a form reasonably satisfactory to the City and shall specifically indicate (a) the
number of covered Plan Members seen with diagnosis codes, (b) the number of Health Risk
Assessments conducted, and (c) savings report in a form to be agreed upon by UMCP and the City.
UMCP will also work with the City's ASO, Blue Cross Blue Shield of Texas, to ensure clinic data is
integrated with the City's Health Plan. This data share will be complete no later than the 15th of
the month immediately following the end of each month of the calendar year.
2.3 Medical Staffing. The Express Care clinics and the Urgent Care clinics will be staffed with nurse
practitioners and physician assistants under the supervision of a physician. The West Wind, Milwaukee,
Orchard Park, 1-27 Northwest Pediatrics clinics will be staffed with physicians, nurse practitioners,
physician assistants, laboratory technicians, radiology technicians, and other ancillary personnel. All
Agreement for Services: City of Lubbock Medical Clinic Services Page 3 of 9
personnel will be appropriately qualified, licensed and credentialed to provide medical services in the
State of Texas.
2.4 Operational Issues. UMCP and the City designate the following contact persons for operational
issues and coordination of services, as well as for any notices required to be delivered hereunder:
UMCP: Glen Frick
Executive Director
5219 City Bank Parkway, Suite 135
Lubbock, TX 79407
(806)761-0333
glen.frick@umchealthsystem.com
City: Leisa Hutcheson
Director of Human Resources & Risk Management
1625 13th Street
Lubbock, TX 79408
(806)775-2277
lhutcheson@mylubbock.us
With copy to:
City Attorney
City of Lubbock
1625 13th Street
Lubbock, Texas 79401
A party will notify the other party promptly of any change to the contact information.
2.5 City Health Plan. UMCP will cooperate with the City to work within the City's health benefit
structure and assure proper services and referrals within the provider network and available benefits.
This provision shall not restrict a healthcare providerfrom discussing all health care options with a patient.
The parties will cooperate to promote the use of the clinics to Plan Members.
2.6 Plan Member Identification. The City will provide its Plan Members with identification cards that
show the person's status as a Plan Member.
2.7 Patient Information. All medical records and patient information maintained by the medical clinic
shall be the property of UMCP. UMCP shall protect the confidentiality of patient information in
compliance with all state and federal laws. UMCP shall not disclose patient information to the City without
the Plan Member's written authorization unless disclosure is permitted by law. If UMCP ceases operation
of a medical clinic, UMCP will transfer medical records and patient information to a successor medical
provider in accordance with applicable laws.
2.8 Insurance. UMCP shall maintain professional liability insurance for itself and its medical providers
throughout the term of this Agreement, in the minimum annual coverage amounts and type acceptable
to the City. In the alternative, if UMCP self -insures as defined under the Texas Insurance Code, UMCP
shall provide to the City all state filings indicating solvency of any self -insured plan and any other proof of
solvency as may be required by the City. UMCP shall maintain general liability insurance with a combined
single limit of a minimum of $500,000 each occurrence and in the aggregate. UMCP shall maintain
automobile liability with a combined single limit of a minimum of $500,000 each occurrence and in the
aggregate. UMCP shall maintain professional/medical malpractice liability with limits of
$300,000/$900,000 each occurrence and in the aggregate. UMCP shall maintain cyber liability insurance
Agreement for Services: City of Lubbock Medical Clinic Services Page 4 of 9
of a minimum of $1,000,000 in the aggregate. UMCP shall maintain worker's compensation insurance for
its employees and shall provide a waiver of subrogation in favor of the City.
2.9 Indemnity. UMCP SHALL PROTECT, DEFEND, INDEMNIFY, AND HOLD HARMLESS, TO THE
FULLEST EXTENT PERMITTED BY LAW, THE CITY AND CITY'S OFFICERS, EMPLOYEES, ELECTED OFFICIALS,
AND/OR AGENTS FROM AND AGAINST ANY AND ALL LOSSES, DAMAGES, CLAIMS OR LIABILITIES, OF
ANY KIND OR NATURE, WHICH ARISE DIRECTLY OR INDIRECTLY FROM, OR ARE RELATED TO, IN ANY
WAY, MANNER OR FORM, THE ACTIVITIES OF UMCP CONTEMPLATED HEREUNDER, OR THE OMISSION
OF THE ACTIVITIES OF UMCP CONTEMPLATED HEREUNDER. UMCP FURTHER COVENANTS AND AGREES
TO DEFEND ANY SUITS OR ADMINISTRATIVE PROCEEDINGS BROUGHT AGAINST THE CITY AND/OR THE
CITY'S OFFICERS, EMPLOYEES, ELECTED OFFICIALS, AND/OR AGENTS ON ACCOUNT OF ANY SUCH CLAIM,
AND, WITHOUT LIMITING THE INDEMNITY PROVIDED HEREIN, TO PAY OR DISCHARGE THE FULL
AMOUNT OR OBLIGATION OF ANY SUCH CLAIM INCURRED BY, ACCRUING TO, OR IMPOSED ON THE
CITY, OR THE CITY'S OFFICERS, EMPLOYEES, ELECTED OFFICIALS, AND/OR AGENTS, AS APPLICABLE,
RESULTING FROM ANY SUCH SUITS, CLAIMS, AND/OR ADMINISTRATIVE PROCEEDINGS OR ANY
MATTERS RESULTING FROM THE SETTLEMENT OR RESOLUTION OF SAID SUITS, CLAIMS, AND/OR
ADMINISTRATIVE PROCEEDINGS. UMCP DOES NOT AGREE TO PROTECT, DEFEND, INDEMNIFY, AND
HOLD HARMLESS THE CITY AND CITY'S OFFICER, EMPLOYEES, ELECTED OFFICIALS, AND/OR AGENTS
FROM AND AGAINST CLAIMS AND LIABILITIES ARISING FROM THE CITY'S DUTIES, ACTS, OR OMISSIONS
REGARDING ACTIVITIES UNDER THIS AGREEMENT.
THE INDEMNITY AND RELEASE PROVIDED HEREIN SHALL SURVIVE THE TERMINATION OR VOIDANCE OF
THIS AGREEMENT.
ARTICLE 3: COMPENSATION
3.1 Fees. The City will pay UMCP the following amounts, payable within 30 days of the City's receipt
of a monthly invoice from UMCP:
Primary/Acute Medical Services - $67,500 each month for up to 750 Plan Member visits per
month PLUS $75 for each Plan Member visit over 750 per month. Member Visits for the purpose
of counting against the base 750 visits shall include only those visits where the Member is seen
and treated by the health care professional. Member Visits shall not include paperwork drop-offs
by Members, telephone consultations, if any, setting of appointments by Members, or other
contacts wherein direct, in -person professional medical services are not rendered.
• Lab tests and radiology tests will be excluded from this agreement and billed separately
to the City's existing health insurance plan.
• The health care provider will administer allergy injections if the Plan Member provides
the allergy serum. The administration of the injection is included in the visit fee.
• Workers Compensation is not part of this agreement.
Health Screening -- $75 per Health Screening billed separately from medical services.
Immunizations available at West Wind, Milwaukee, Orchard Park, 1-27, Northwest Pediatrics only
and will be charged separately at the standard rates. The administration of the immunizations
will be included.
If UMCP provides services to Plan Members and the services are not covered by this Agreement,
UMCP will bill the Health Plan, and the Plan Member will be responsible for applicable
copayments.
Agreement for Services: City of Lubbock Medical Clinic Services Page 5 of 9
3.2 Nonappropriation. All funds for payment by the City under this Contract are subject to the
availability of an annual appropriation for this purpose by the City. In the event of non -appropriation of
funds by the City Council of the City of Lubbock, for the services provided under this Agreement, the City
may terminate the Agreement, 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 services is spent,
whichever event occurs first. If at any time funds are not appropriated for the continuance of this
Agreement, cancellation shall be accepted by UMCP on thirty (30) days prior written notice.
ARTICLE 4: RELATIONSHIP OF THE PARTIES
INDEPENDENT CONTRACTOR STATUS: Nothing in this agreement is intended nor shall be construed to
create an employer/employee relationship between the contracting parties. The sole interest and
responsibility of the parties is to ensure that the services covered by this agreement shall be performed
and rendered in a competent, efficient and satisfactory manner.
ARTICLE 5: GENERAL PROVISIONS
5.1 Non -Discrimination. Each party shall provide services without discrimination on the basis of race,
color, religion, sex (including pregnancy), national origin, age, physical or mental disability, genetic
information, status as a protected veteran, or any other legally protected category, class or characteristic.
5.2 Waiver. The waiver by either party of a breach or violation of any provision of this Agreement
shall not operate as or be construed to be a waiver of any subsequent breach of any provision of the
Agreement.
5.3 Severability. If any term or provision of this agreement is held to be invalid for any reason, the
invalidity of that section shall not affect the validity of any other section of this agreement provided that
any invalid provisions are not material to the overall purpose and operation of this agreement. The
remaining provisions of this agreement shall remain in full force and shall in no way be affected, impaired,
or invalidated.
5.4 Assignment. Neither party shall have the right to assignor transfer their rights to any third parties
under this agreement.
5.5 Governing Law and Venue. This agreement shall be governed by and construed and enforced in
accordance with the laws of the State of Texas and any applicable Federal Law or Statute. Venue shall be
in Lubbock, Lubbock County, Texas for all purposes.
5.6 Amendment. This agreement may be amended in writing to include any provisions that are
agreed to by the contracting parties. The City Manager is authorized to agree to changes regarding
medical clinic locations and services without need for further review or action by the City Council.
5.7 Exclusion. Each party certifies that neither it nor its employees or contractors is presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in any government program by any federal department or agency or by the State of Texas.
EACH PARTY WILL NOTIFY PROMPTLYTHE OTHER PARTY if this status changes and the name of any person
who provides services under this Agreement or is an agent or managing employee who is convicted of a
criminal offense related to the person's involvement in a government program or is suspended, debarred,
or excluded from participation in a government program.
Agreement for Services: City of Lubbock Medical Clinic Services Page 6 of 9
5.8 Notice. All notices required or permitted to be given under this Agreement shall be sufficient if
furnished in writing, sent by certified mail, return receipt requested to the party's last known principal
office.
5.9 Authority. The undersigned to this Agreement hereby represent and warrant their respective
authority to execute this Agreement.
Date: — /2- b fi Date: // Z y /0
CITY OF LUBBOCK UMC PHYSICIANS
By: By:
Daniel M. Pope, Mayor Glen Frick, Executive Director
ATTEST:
Rebec(a Garza, City Secretary U
APPRVDA T�ONTENT:
Leisa Hutcheson, Director of Human Resources
& Risk Management
c
Agreement for Services: City of Lubbock Medical Clinic Services Page 7 of 9
EXHIBIT A
CLINIC LOCATIONS AND SERVICES
Acute Care Services provided on a walk-in or appointment basis
Express Care 806-761-0428
2703 82"d St. (82"d & Boston)
Inside United Supermarket
M-F 9:00 am-6:00pm; Sat 9:00am-6:00pm; Sun 1:00pm-6:00pm
Express Care 806-761-0429
1701 50th St. (50th & Ave. Q)
Inside United Supermarket
M-F 7:00 am-4:00pm
Express Care at South Plains Mall 806-761-0450
6002 Slide Road #D24
Inside the South Plains Mall
M-F 9:00 am — 8:00pm; Sat 9:00am — 8:00pm; Sun 12:00pm — 6:00pm
UMC Urgent Care Center 806-761-0546
808 Joliet Ave Suite 110
On the UMC Campus
M-F 7:00 am-4:00pm
KingsPark Urgent Care 806-788-3306
7501 Quaker Avenue
M-F 8:00 am-9:00pm; Sat and Sun 9:00am — 6:00pm
Services provided under this Agreement include but are not limited to:
Diagnosis of diabetes and referral to PCP for treatment
Asthma
Acute conditions -sore throats, ears, headache, fever, body aches
Allergies/Cough/Sinus
Rashes
Stomach aches
Strains/sprains/musculoskeletal problems
Immunizations/Injections:
• Will be charged separately at standard rates
• Administration included
Agreement for Services: City of Lubbock Medical Clinic Services Page 8 of 9
Primary Care and Acute Care Services
Services are provided on a walk-in or appointment basis.
Northwest Pediatrics 806-761-0536
416 Frankford Avenue
M-F 8:00 am — S:OOpm
1-27 Medical Center 806-762-2633
4105 1-27
M-F 8a-8p, Sat 9a-5p, Sun 1p-5p
West Wind Primary Health Care 806-761-0475
5520 4th Street
M-F 8a-8p, Sat 9a-5p, Sun 1p-5p
Milwaukee Family Medicine 806-761-0464
7301 Milwaukee Ave
M-F 8:00 am — 8:OOpm; Sat 9:OOam — S:OOpm; Sun 1:OOpm — S:OOpm
Orchard Park Family Medicine 806-761-0420
4420 114th Street
M-F 8:00 am — 8:OOpm; Sat 9:OOam — S:OOpm; Sun 1:OOpm — S:OOpm
Services provided under this Agreement include but are not limited to:
Ordinary and routine healthcare
Chronic conditions- diabetes, hypertension, etc.
Asthma
Acute conditions- sore throat, ears, headache, fever, body aches
Allergies/Cough/Sinus
Rashes
Stomach aches
Strains/sprains/musculoskeletal problems
Immunizations/Injections:
• Will be charged separately at standard rates
• Administration included
Agreement for Services: City of Lubbock Medical Clinic Services Page 9 of 9
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1of1
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.
2018-426247
UMC Physicians
Lubbock, TX United States
Date Filed:
11116/2018
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 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,
914210
Medical Clinic Services
4
'
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
UMC Physicians
Lubbock, TX United States
X
5
Check only if there is NO Interested Party.
6
UNSWORN DECLARATION
My address is �v 3�y Ce - "14 7 t3 LQggoC.1,e_ Tn , 7-qt1L j U S
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
I
Executed in �%�ba County, State of E—EX.-I—e- on the lv day of NJ�+ ��L , 20
(month) (year)
l
5i nature of autho ized agent of contracting business entity
(Declarant)
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