HomeMy WebLinkAboutResolution - 2022-R0479 - PO 31070078 with E.H. Wachs 11.16.22Resolution No. 2022-RO479
Item No. 7.29
November 16, 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
and on behalf of the City of Lubbock, Purchase Order No. 31070078 in accordance w
BuyBoard 597-19 for the purchase of Valve Maintenance Trailer, by and between the City
Lubbock and EH Wachs of Chicago, IL and related documents. Said Purchase Order is attacl
hereto and incorporated in this resolution as if fully set forth herein and shall be included in
minutes of the City Council.
Passed by the City Council on November 16, 2022
TRAL YOR
ATTEST:
Re ecca Garza, City SecrAry
APPROVED AS TO CONTENT:
Uj drM 1.1
Brooke Witcher, Assistant City Manager
APPROVED AS TO FORM:
Leisure, Assistant City Attorney
ccdocs/RES.PurchaseOrd 31070078 Valve Maintenance Trailer
11.02.22
Page -
Lubbock PURCHASE ORDER Date -
r Order Number
TEXAS
Branch/Plant
E H WACHS
TO: PO BOX 71598
CHICAGO IL 60069
1 of 2
10/31 /2022
31070078 000 OP
3526
CITY OF LUBBOCK
SHIP TO: FLEET SERVICES
206 MUNICIPAL DRIVE
LUBBOCK TX 79404
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 QBY:
Af
Marta A14erez, Director of Purchasing & Contract Management
Ordered 10/31/2022 Freight
Requested 1/23/2023 Taken By S BALLANCE
Delivery PER B RODRIGUEZ, REQ 59516 PUR 16960/ BUYBOARD 597-19
If you have any questions, please contact Breana Rodriguez: BRodriguez@myluhhock.us or 806-775-2374
Description/Supplier Item Ordered Unit Cost UM Extension Request Date
Valve Maintenance Trailer 1.000 83,755.0700 EA 83,755.07 1/23/2023
Total Order
Terms NET DUE ON RECEIPT
83,755.07
This purchase order encumbers funds in the amount of $83,755.07 awarded to E H Wachs of Chicago, 1L, on
November 16 , 2022. The following is incorporated into and made part of this purchase order by reference: Quote dated
October 26, 2022, from E H Wachs of Chicago, IL, and BuyBoard Contract 597-19.
Resolution # 2022-RO479
CITY OF CK:
Tray Pa ne, a or
AEST:
! �'v
Reb cca Garza, City Secretary
Rev. 3/2022
Seller and Buyer agree as
follows:
ACCEPTANCE OF THIS PURCHASE ORDER:
CONTRACTOR ACKNOWLEDGES. Iry suomlvine am, Goods or Services that the
understands. and will be in full comoliance_with_all tents and conditions and the descrintiv
PURCHASE ORDER
TERMS AND CONDITIONS
STANDARD TERMS AND CONDITIONS
the Contractor unless agreed upon in writing by the parties In the event of conflict between the City's terms and
conditions and any terms and conditions provided by the Contractor, the terms and conditions orovided herein shall
prevail. The terns and conditions provided herein are the final terms agreed upon by the panes. and any prior
conflictine terns shall be of no force or effect.
1. SELLER TO PACKAGE GOODS. Seller will package goods in accordance with good commercial practice.
Each shipping container shall be clearly and permanently marked as follows (a) Seller's name and address, (b)
Consignee'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, e.g box I of 4 boxes, and (d) the number of the
container bearing the packing slip. Seller shall bear cost of packaging unless otherwise provided. Goods shall be
suitably packed to secure lowest transportation costs and to conform with requirements of common carvers and any
applicable specifications. Buyer's count or weight shall be final and conclusive on shipments not accompanied by
packing lists.
2. SHIPMENT UNDER RESERVATION PROHIBITED. Seller is not authorized to ship the goods under
reservation and no tender of a bill of lading will operate as a tender of goods.
3. TITLE AND RISK OF LOSS. The title and risk of loss of the goods shall not pass to Buyer until Buyer actually
receives and takes possession of the goods at the point or points of delivery.
4. NO REPLACEMENT OF DEFECTIVE TENDER Every tender of delivery of goods must fully comply with all
provisions of this contract as to time of delivery, quality and the like. If a tender is made which does not fully conform,
this shall constitute a breach and Seller shall not have the right to substitute a conforming tender, provided, where the
time for performance has not yet expired, the Seller may reasonably notify Buyer of his intention to cure and may
then make a conforming tender within the contract time but not afterward.
5. INVOICES & PAYMENTS. a S e 1 I e r shall submit separate invoices, in duplicate, one each purchase order or
purchase release after each delivery. Invoices shall indicate the purchase order or purchase release number and
the supply agreement number if applicable. Invoices shall be itemized and transportation charges, if any, shall be
listed separately. A copy of the bill of lading, and the freight waybill when applicable, should be attached to the
invoice. Mail To: Accounts Payable, City of Lubbock, P. 0. Box 2000. Lubbock, Texas 79457. Payment shall not
be due until the above instruments are submitted afterdelivery.
6. GRATUITIES. The Buyer may, by written notice to the Seller, cancel this contract without liability to Seller if
it is determined by Buyer that gratuities, in the Porn of entertainment, gifts or otherwise, were offered or given by the
Seller, or any agent or representative of the Seller, to any officer or employee of the City of Lubbock with a view to
securing a contract or securing favorable treatment with respect to the awarding or amending, or the making of any
determinations with respect to the performing of such a contract. In the event this contract is canceled by Buyer
pursuant to this provision, Buyer shall be entitled, in addition to any other rights and remedies, to recover or withhold
the amount of the cost incurred by Seller in providing such gratuities.
7, SPECIAL TOOLS & TEST EQUIPMENT If the price stated on the face hereof includes the cost of any special
tooling or special test equipment fabricated or required by Seller for the purpose of filling this order, such special
tooling equipment and any process sheets related thereto shall become the property of the Buyer and to the extent
feasible shall be identified by the Seller as such.
S. WARRANTY -PRICE a The price to be paid by the Buyer shall be that contained in Seller's bid which
Seller warrants to be no higher than Seller's current process on orders by others Por products of the kind and
specification covered by this agreement for similar quantities under similar of like conditions and methods of purchase.
In the event Seller breaches this warranty, the prices of the items shall be reduced to the Seller's current prices
on orders by others, or in the alternative. Buyer may cancel this contract without liability to Seller for breach
or Seller s actual expense. b. The Seller warrants that no person or selling agency has been employed or retained to
solicit or secure this contract upon an agreement or understanding for commission, percentage, brokerage, or contingent
fee excepting bona fide employees of bona fide established commercial or selling agencies maintained by the Seller for
the purpose of securing business For breach of vitiation of this warranty the Buyer shall have the right in addition to
any other right of rights to cancel the contract without liability and to deduct from the contract price, or otherwise
recover without lability and to deduct from the contract price, or otherwise recover the full amount of such commission,
percentage, brokerage or contingent fee.
4. WARRANTY -PRODUCT Seller shall not Irma or exclude any implied warranties and any attempt to do so shall
render this contract voidable at the option of the Buyer. Sellerwarrants that the goods furnished will conform to the
specmficatton, drawings, and descriptions listed in the bid invitation, and to the sample(s) famished by the Seller, if any.
In the event of a conflict or between the specifications, drawings, and descriptions, the specifications shall govern
Notwithstanding any provisions contained in the contractual agreement, the Seller represents and warrants fault -Gee
perfornanceand fault -free result in the processing date and date related data (including, but not limited to calculating,
comparing and sequencing) of all hardware, software and ftrmvare products delivered and services provided under
this Contract, individually or in combination, as the case may be from the effective date of this Contract The
obligations contained herein apply to products and services provided by the Seller, its sub- Seller or any third patty
involved in the creation or development of the products and services to be delivered to the City of Lubbock under this
Contract. Failure to comply with any of the obligations contained herein, may result in the City of Lubbock
availing itself of any of its rights under the law and under this Contract including, but not limited to, its right pertaining
to termination or default. The warranties contained herein are separate and discrete from any other warranties
specified in this Contract and are not subject to any disclaimer of warranty, implied or expressed, or limitation of the
Seller's liability which may be specified in this Contract, its appendices, its schedules, its annexes or any document
incorporated in this Contract by reference.
10. SAFETY WARRANTY. Seller warrants that the product sold to the Buyer shall conPonm to the standards
promulgated by the U. S. Department of Labor under the Occupational Safety and Health Act of 1970. In the event the
product does not conform to OSHA standards, Buyer may return the product for correction or replacement at the
Seller's expense. In the event Seller fails to make the appropriate correction within a reasonable time, correction
made by Buyer will be at the Seller's expense.
11. NO WARRANTY BY BUYER AGAINST INFRINGEMENTS. As part of this contract for sale Seller agrees
to ascertain whether goods manufactured in accordance with the specifications attached to this agreement will give
rise to the rightful claim of any third person by way of infringement of the like. Buyer makes no warranty that the
production of goods according to the specification will not give rise to such a claim, and in no event shall Buyer be
liable to Seller Por indemnification in the event that Seller issued on the grounds of infringement of the like. If Seller
is of the opinion that an infringement or the like will result, he will notify the Buyer to this effect in writing within two
weeks after the signing of this agreement. If Buyer does not receive notice and is subsequently held liable for
the infringement or the like, Seller will save Buyer harmless. If Seller in good faith ascertains the production of the
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 Por 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 Por
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
thirty (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 termmalion
13 RIGHT OF INSPECTION. Buyer shall have the right to inspect the goods at delivery bePore accepting them
14 CANCELLATION Buyer shall have the right to cancel for default all or any part of the undelivered portion of
this order if Seller breaches any of the terns hereof including warranties of Seller or if the Seller becomes insolvent or
commits acts of bankruptcy. Such right ofcancellation is in addition to and not in lieu of any other remedies which
Buyer may have in law or equity.
to accordance with this provision. Termination of work hereunder shall be effected by the delivery of the Seller of
a "Nonce of Termination" specifying the extent to which performance of work under the order is terminated and the
date upon which such termination becomes effective. Such right or termination is in addition to and not in lieu of the
rights of Buyer set forth in Clause 14, herein.
16. FORCE MAJEURE. Neither party shall be held responsible for losses, resulting if the fulfillment of any
terns 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 prevent.
17. ASSIGNMENT -DELEGATION. No right or interest in this contract shall be assigned or delegation of any
obligation made by Seller without the written permission of the Buyer. Any attempted assignment or delegation by
Seller shall be wholly void and totally ineffective for all purpose unless made in conformity with this paragraph.
IS WAIVER. No claim or right arising out of a breach of this contract can be discharged in whole or in part by a
waiver or renunciation of the claim or right unless the waiver or renunciation is supported by consideration and is in
writing signed by the aggrieved party.
19. INTERPRETATION -PAROLE EVIDENCE. This writing, plus any specifications for bids and performance
provided by Buyer in its advertisement for bids, and any other documents provided by Seller as part of his bid,
is intended by the parties as a final expression of their agreement and intended also as a complete and exclusive
statement of the terns of their agreement. Whenever a term defined by the Uniform Commercial Code is used in this
agreement, the definition contained in the Code is to control.
20. APPLICABLE LAW. This agreement shall be governed by the Uniform Commercial Code. Wherever the tern
"UniPonn Commercial Code" is used, it shall be construed as meaning the Uniform Commercial Code as adopted in
the State of Texas as effective and in force on the date of this agreement.
11. RIGHT TO ASSURANCE. Whenever one party to this contract in good faith has reason to question the other
party's intent to perform he may demand that the other party give written assurance of his intent to perform. In the
event that a demand is made and no assurance is given within five (5) days, the demanding party may treat this
Failure as an anticipatory repudiation of the contract.
22. INDEMNIFICATION. Seller shall indemnify, keep and save harmless the Buyer, its agents, officials and
employees, against all injuries, deaths, loss, damages, claims, patent claims, suits, liabilities, judgments, costs and
expenses, which may in anywise accrue against the Buyer in consequence of the granting of this Contract or which
may anywise result therefrom whether or not it shall be alleged or determined that the act was caused through
negligence or omission of the Seller or its employees, or of the subSeller or assignee or its employees, if any, and the
Seller shall, at his own expense, appear, defend and pay all charges of attorneys and all costs and other expenses
arising therefrom of incurred in connection therewith, and, if any judgment shall be rendered against the Buyer in any
such action, the Seller shall, at its own expenses, satisfy and discharge the same Seller expressly understands and
agrees that any bond required by this contract, or otherwise provided by Seller, shall in no way limit the
responsibility to indemnify, keep and save harmless and defend the Buyer as herein provided.
23. TIME. It is hereby expressly agreed and understood that time is of the essence Por the performance of this
contract, and failure by contract to meet the time specifications of this agreement will cause Seller to be in default
of this agreement.
14. MBE. The City of Lubbock hereby notifies all bidders that in regard to any contract entered into pursuant to
this request, minority and women business enterprises will be afforded equal opportunities to submit bids in response
to this invitation and will not be discriminated against on the grounds of race, color, sex or natural origin in
consideration for an award.
25. NON -ARBITRATION. The City reserves the right to exercise any right or remedy 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 ofany conflict between this provision and another provision in, or related to, this document,
this provision shall control.
26. RIGHT TO AUDIT. 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.
27. 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.
28. Contracts with Companies Engaged in Business with Iran, Sudan, or Foreign Terrorist Organization Prohibited.
Pursuant to Section 2252.152 of the Texas Goverment Code, prohibits the City from entering into a contract with a
vendor that is identified by The Comptroller as a company known to have contracts with or provide supplies or smice
with Iran. Sudan or a Freign terrorist organization
29. Texas Government Code. Section 2252.908 requires a business entity entering into certain contracts with a
governmental entity or state agency to file with the governmental entity or state agency a disclosure of interested parties
at the time the business entity submits the signed contract to the governmental entity or state agency. Instructionsfor
completing Form 1295 are available at: htto, www.ci.lubbock.tx.us/deoarmncntal-
30. No Boycott of Israel. Pursuant to Section 227 L 2 of the Texas Government Code, Respondent certifies that
either (i) it meets an exemption criteria under Section 2271.002; or (ii) it does not boycott Israel and will not boycott
Israel during the term of the contract resulting from this solicitation. Respondent shall state any facts that make it
exempt from the boycott certification in its Response.
31. No Boycott of Energy Companies. Pursuant to Section 2274 of the Texas Government Code, Respondent
certifies that either (i) it meets an exemption criteria under Section 2274.002; or (ii) it does not boycott Energy
Companies and will not boycott Energy Companies during the term of the contract resulting from this solicitation.
Respondent shall state any facts that make it exempt from the boycott certification in its Response.
32. No Boycott of a Firearm Entity or Firearm Trade Association. Pursuant to Section 2274 of the Texas
Government Code, Respondent certifies that either (i) it meets an exemption criteria under Section 2274.002; or (ii) it
does not boycott a Firearm Entity or Firearm Trade Association and will not boycott a Firearm Entity or Firearm
Trade Association during the term of the contract resulting from this solicitation. Respondent shall sate any facts that
make it exempt from the boycott certification in its Response.
33. Contracts with Companies Engaged in Business with Iran, Sudan, or Foreign Terrorist Organization Prohibited.
Pursuant to Section 2252.152 of the Texas Government Code, prohibits the City from entering into a contract with a
vendor that is identified by The Comptroller as a company known to have contracts with or provide supplies or
service with Iran, Sudan or a foreign terrorist organization
34. TEXAS PUBLIC INFORMATION ACT. The requirements of Subchapter J. Chapter 552, Government Code,
may apply to this contract and the contractor or vendor agrees that the contract can be terminated ifthe contractor or
vendor knowingly or intentionally fails to comply with a requirement of that subchapter.
35. Pursuant to Section 552.301(c) of the Texas Government Code, the City of Lubbock has designated the Pollowing
email address Por which public information requests may be made by an emailed request: QaLei m,, u bhpyk.0 . Please
send this request to this email address for it to be processed
15. TERMINATION The performance of work under this order maybe terminated in whole, or in part by the Buyer
REV. 32022
Utility Products
The Valve Maintenance Experts"
TO: Dominic Esperat
Director of Fleet Operations
Lubbock - Fleet Dept
206 Municipal Dr
Lubbock. TX 79457
600 Knightsbridge Parkway, Lincolnshire, Illinois 60069
(847) 537-8800 ! Fax (847) 520-1147
turnvalves.com
E.H. Wachs is pleased to offer the following quotation.
Item Number Description
Quotation
Page 1 of 2
Date:
10/26/2022
Quotation Number.
JB185303
Payment Terms:
Net 30 Days
Shipping Terms:
FOB Origin
Valid Through:
12125/2022
Estimated Delivery:
See Below
Reference:
Buyboard#597-19
Unit Price
Line Total
Qty U/M (USD)
Disc% (USD)
1 77-000-36 Standard LX (Gas) — VMT (RH): Single turner valve maintenance trailer,
1 EA 81,995.00 1.5% 80,765.07
includes Wachs 750 FtAb (1020 Nm) Extended Reach Valve operator for
those preventive maintenance activities, telescoping valve key and Wachs
ruggedized TC-100 with GPS controller/datalogger. A 27 HP (20 kW)
gasoline powered Kohler overhead cam air cooled engine provides ample
power for all contained functions, including an auxiliary HTMA Class II circuit;
10 gallon (38 L) reservoir, fan cooled heat exchanger, continuous duty rated
for 8 GPM (30.3 LPM) @ 2,000 PSI (140 bar). A positive displacement blower
provides 500 CFM (14.2 cmm)-11" (280mm) Hg vacuum, with spoils
containment provided by a 250 (950 L) gallon tank with power hydraulic dump
(rear discharge) and latching rear door. Also driven from the common power
train is a 2.5 GPM (9.5 LPM) @ 3000 PSI (210 bar) pressure washer system
with 3 gallon (11.4 L) anti -freeze tank and 95 gallon (360 L) water tank.
Includes 2-1/2" (63.5mm), 1-1/4" (31.75mm) & 7/8" (22mm) suction wands
and one each short and long wash -down guns. The LX package bundles the
service light bar with arrow board, 45' (14 M) auxiliary hydraulic hose reel for
operation of hydraulic power tools & Bluetooth tethering module (installed in
ERV-750) for wireless communication between the exerciser and
Controller/Data Logger and 24" (61cm) X 18" (46cm) x 18" (46cm) aluminum
job box.
Other options available include: Under deck mounted Spare Tire Kit
(77-411-00), 2-5/16" Ball Tongue (77-215-01), 451b Breaker, Mount and 14"
Moil Point (08-000-10, 08-405-00 & 08-410-02) or already GPS enabled
controller/datalogger, however adding Trimble R2 GNSS receiver (79-412-02)
provides capability of submeter to centimeter level positioning accuracy
(highest accuracy in real-time with the use of correction sources).
2 79-430-20 Field training -1 day program. Training topics range from field operation of
1 EA 2,495.00 100.0% 0.00
the mechanical systems like hydro -excavation and Valve operator; to training
of computerized controllers and preventive maintenance software like
VITALS Field crews and participants will be shown, in detail, standard
procedures for safe and efficient operation and use of valve maintenance
tools.
Subtotal 80,765.07
Motor Freight 2,990.00
Total (USD) $83,755.07
Thank you for the opportunity to quote your application needs. If you have any questions or if I may be of any further assistance to you please
do not hesitate to notify me.
We will prepay and add shipping charges to your order, or we can ship collect via your choice of carrier service.
(SALES TAXIIII) We collect sales tax in all but the following states: AK, DE, MT, OR and NH. If you are tax exempt please supply your
identification number and certificate with your order. If your exempt number is not on file, tax will be added to your order
Jeffrey Brehm
Sales Manager
512-348-0171
jeffrey.brehm@ehwachs.com
i Utility Products
m The Valve Maintenance Experts"
TO: Dominic Esperat
600 Knightsbridge Parkway, Lincolnshire, Illinois 60069
(847) 537-8800 . Fax (847) 520-1147
turnivalves.com
Quotation
Page 2 of 2
Date: 10/26/2022
Quotation Number: JB185303
Sales of E.H. Wachs products and services are expressly limited to and made conditional on acceptance of its current Terms and Conditions of Sale , found at
www ehwachs corn ('Terms') Any additional or different terms are hereby rejected Commencement of work by E H Wachs or acceptance of delivery of products by
you constitutes your acceptance of the Terms
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:
2022-956068
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
E.H. WAchs -A- Division of Illinois Tool Works
Lincolnshire, IL United States
Date Filed:
11/16/2022
2 Name of governmental entity or state agency that Is a party to the contract for which the form Is
being filed.
E.H. Wachs
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.
JB185303
Valve Maintenance Trailer
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
L
5 Check only if there is NO Interested Party.
x
6 UNSWORN DECLARATION
My name is Off S1A/i.Q'-- and my date of birth is
My address is y__, LincQ1nshire _ 1.,.. •., 60069 . us
(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)
Sig t f author zed agent of contracting business entity
(Declarant)
run us piuviueu uy i exas tinics Commission www.emics.state.tx.us Version V3.5.1.eb87ef42
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.
2022-956068
E.H. WAchs -A- Division of Illinois Tool Works
Lincolnshire, IL United States
Date Filed:
11/16/2022
2
Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
E.H. Wachs
Date Acknowledged:
11/16/2022
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.
JB185303
Valve Maintenance Trailer
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
5
Check only if there is NO Interested Party. ❑
X
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.eb87ef42