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HomeMy WebLinkAboutResolution - 2023-R0014 - Contract 16855 with Lubbock Wrecker for Junked Vehicle Towing 1.10.23Resolution No. 2023-R0014 Item No. 5.15 January 10, 2023 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. 16855/23-16855-SB for junked vehicle towing services, by and between the City of Lubbock and Lubbock Wrecker Service, Inc., of Lubbock, Texas, 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 ATTEST: Rebe ca Garza, City Se ret APPROVED AS TO CONTENT: rt �' 4:: � -- �"* EriklZeiino, Assistant City Manager APPROVED AS TO FORM: y s, Deputy CNIFXttorney RES.Contract-Lubbock Wrecker 16855 12.9.22 January 10, 2023 TRAY P E, Resolution No. 2023-R0014 City of Lubbock Junked Vehicle Towing Agreement Contract 16855 This Service Agreement (this "Agreement') is entered into as of the loth day of January , 2023 ("Effective Date") by and between Lubbock Wrecker Service, Inc. (the Contractor), and the City of Lubbock (the "City"). RECITALS WHEREAS, the City has issued a Request for Proposals 23-16855-SB Junked Vehicle Towing and WHEREAS, the proposal submitted by the Contractor has been selected as the proposal which best meets the needs of the City for this service; and WHEREAS, Contractor desires to perform as an independent contractor to provide Junked Vehicle Towing, upon terms and conditions maintained in this Agreement; and NOW THEREFORE, for and in consideration of the mutual promises contained herein, the City and Contractor agree as follows: City and Contractor acknowledge the Agreement consists of the following exhibits which are attached hereto and incorporated herein by reference, listed in their order of priority in the event of inconsistent or contradictory provisions: 1. This Agreement 2. Exhibit A — General Requirements 3. Exhibit B — Best and Final Offer 4. Exhibit C — Insurance Requirements Scope of Work Contractor shall provide the services that are specified in Exhibit A. The Contractor shall execute services as the named provider. The Contractor shall comply with all the applicable requirements set forth in Exhibit B and Exhibit C attached hereto. Article 1 1.1 The contract shall be for a term of one (1) year, with the option of four (4), one (1) year extensions, said date of term beginning upon formal approval. This Contract will renew automatically for the additional terms, unless either Party gives (90) day written notice to terminate the Contract. 1.2 It is estimated that 340 to 400 junk vehicles will be removed annually under this contract. The City of Lubbock does not guarantee any specific amount of compensation, volume, minimum, or maximum amount of services under this bid and resulting contract. 1.3 The Contractor must maintain the insurance coverage required during the term of this contract including any extensions. It is the responsibility of the Contractor to ensure that valid insurance is on file with the Purchasing and Contract Management Department as required by contract or contract may be terminated for non-compliance. 1.4 This contract shall remain in effect until the first of the following occurs: (1) the expiration date, (2) performance of services ordered, or (3) termination of by either party with a 30 day written notice. 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. Article 2 Miscellaneous. 2.1 This Agreement is made in the State of Texas and shall for all purposes be construed in accordance with the laws of said State, without reference to choice of law provisions. 2.2 This Agreement is performable in, and venue of any action related or pertaining to this Agreement shall lie in, Lubbock, Texas. 2.3 This Agreement and its Exhibits contains the entire agreement between the City and Contractor and supersedes any and all previous agreements, written or oral, between the parties relating to the subject matter hereof. No amendment or modification of the terms of this Agreement shall be binding upon the parties unless reduced to writing and signed by both parties. 2.4 This Agreement may be executed in counterparts, each of which shall be deemed an original. 2.5 In the event any provision of this Agreement is held illegal or invalid, the remaining provisions of this Agreement shall not be affected thereby. 2.6 The waiver of a breach of any provision of this Agreement by any parties or the failure of any parties otherwise to insist upon strict performance of any provision hereof shall not constitute a waiver of any subsequent breach or of any subsequent failure to perform. 2.7 This Agreement shall be binding upon and inure to the benefit of the parties and their respective heirs, representatives and successors and may be assigned by Contractor or the City to any successor only on the written approval of the other party. 2.8 All claims, disputes, and other matters in question between the Parties arising out of or relating to this Agreement or the breach thereof, shall be formally discussed and negotiated between the Parties for resolution. In the event that the Parties are unable to resolve the claims, disputes, or other matters in question within 30 days of written notification from the aggrieved Party to the other Party, the aggrieved Party shall be free to pursue all remedies available at law or in equity. 2.9 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 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. 2.10 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 of any conflict between this provision and another provision in, or related to, this document, this provision shall control. 2.11 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 document, this provision shall control. 2.12 Contractor acknowledges by supplying any Goods or Services that the 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 documents and Amendments. The City disclaims any terms and conditions provided 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 terms and conditions provided herein are the final terms agreed upon by the parties, and any prior conflicting terms shall be of no force or effect. 2.13 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. 2.14 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 if the contractor or vendor knowingly or intentionally fails to comply with a requirement of that subchapter. To the extent Subchapter J, Chapter 552, Government Code applies to this agreement, Contractor agrees to: (1) preserve all contracting information related to the contract as provided by the records retention requirements applicable to the governmental body for the duration of the contract; (2) promptly provide to the governmental body any contracting information related to the contract that is in the custody or possession of the entity on request of the governmental body; and (3) on completion of the contract, either: (A) provide at no cost to the governmental body all contracting information related to the contract that is in the custody or possession of the entity; or (B) preserve the contracting information related to the contract as provided by the records retention requirements applicable to the governmental body. 2.15 No Boycott of Israel. Pursuant to Section 2271.002 of the Texas Government Code, a) This section applies only to a contract that: (1) is between a governmental entity and a company with 10 or more full-time employees; and (2) has a value of $100,000 or more that is to be paid wholly or partly from public funds of the governmental entity. (b) A governmental entity may not enter into a contract with a company for goods or services unless the contract contains a written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract. 2.16 Texas Government Code 2274. By entering into this Agreement, Contractor verifies that: (1) it does not, and will not for the duration of the contract, have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association or (2) the verification required by Section 2274.002 of the Texas Government Code does not apply to the contract. If Contractor is a company with 10 or more full- time employees and if this Agreement has a value of at least $100,000 or more, Contractor verifies that, pursuant to Texas Government Code Chapter 2274, it does not have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association; and will not discriminate during the term of the contract against a firearm entity or firearm trade association. 2.17 Contractor represents and warrants that: (1) it does not, and will not for the duration of the contract, boycott energy companies or (2) the verification required by Section 2274.002 of the Texas Government Code does not apply to the contract. If Contractor is a company with 10 or more full-time employees and if this Agreement has a value of at least $100,000 or more, Contractor verifies that, pursuant to Texas Government Code Chapter 2274, it does not boycott energy companies; and will not boycott energy companies during the term of the Agreement. This verification is not required for an agreement where a governmental entity determines that these requirements are inconsistent with the governmental entity's constitutional or statutory duties related to the issuance, incurrence, or management of debt obligations or the deposit, custody, management, borrowing, or investment of funds. 2.18 Confidentiality. The Contractor shall retain all information received from or concerning the City and the City's business in strictest confidence and shall not reveal such information to third parties without prior written consent of the City, unless otherwise required by law. 2.19 Indemnify. The Contractor shall indemnify and save harmless the city of Lubbock and its elected officials, officers, agents, and employees from all suits, actions, losses, damages, claims, or liability of any kind, character, type, or description, including without limiting the generality of the foregoing, all expenses of litigation, court costs, and attorney's fees, for injury or death to any person, or injury to any property, received or sustained by any person or persons or property, to the extent arising out of, related to or occasioned by, the negligent acts of the Contractor, its agents, employees, and/or subcontractors, related to the performance, operations or omissions under this agreement and/or the use or occupation of city owned property. The indemnity obligation provided herein shall survive the expiration or termination of this agreement. IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed the day and year first above written. Executed in triplicate. Dvo'o-f -0- - A " Reb cca Garza, City Sec t =A SgL ENT: er, Director of Code Enforcement APPROVED AS TO FORM Amy Si , puty City Attorney CONTRACTOR Authorized Representative Print Name 3-7o Address City, State, Zip Code Exhibit A City of Lubbock RFP 22-16855-SB Junked Vehicle Towing GENERAL REQUIREMENTS 1 Intent The City of Lubbock (hereinafter called "City") is seeking proposals from interested firms and individuals, (hereinafter called "Proposer") to provide for removal of Junk Vehicles as authorized by the Junked Vehicle Compliance Board or any other board or commission designated by the City Council. 2 Project Description Provide the City with a single dependable vehicle towing company in which the City must arrange for the removal of junk vehicles as authorized by the order of the Junked Vehicle Compliance Board, or any other board or commission designated by the City Council. 3 Scope of Work The Contractor shall tow and store all vehicles designated by the Code Administration Manager or his/her designee (hereinafter called "Codes Department") in a safe and secure manner so as to avoid damage to the vehicles or danger to any motorists, pedestrians or Contractor's employees. Adequate space to accommodate an annual volume of approximately 350 — 400 vehicles at the Contractor's storage facilities for the storage and disposal of junked vehicles will be maintained. The Contractor shall observe all applicable state laws, municipal ordinances and Code Administration policies regulating junked vehicles. Tow Orders: issued by the Junked Vehicle Board. Contractor shall respond to all tow orders from the Codes Department within 48 hours of receiving tow orders unless otherwise specified in this agreement. Tow Requests: refers to a voluntary tow by a property owner. Contractor shall respond to all tow requests from the Codes Department within one (1) hour of receiving such a request unless otherwise specified in this agreement. All such tow requests shall be completed in a timely manner. Contractor shall use authorized vehicles and equipment that he owns or leases unless such vehicles and equipment are not available for use. In such event, the Contractor may then use authorized vehicles and equipment from other towing services pursuant to agreements he may have with such other towing services, provided the vehicles and equipment comply with all state, federal and local laws, rules and regulations necessary to perform such tows and the requirements of this Agreement. Contractor shall be allowed to dismantle and salvage for resale any and all useable parts of any junked vehicle removed pursuant to the notification and hearing process performed by the Code Administration Department and after receiving a CRUSH ORDER from the Code Administration Department. A ten (10) day waiting period as to allow a vehicle owner or an authorized agent of the owner ample time to claim the removed vehicle and bring it into compliance. Contractor shall not restore or make any junked vehicle that has been towed pursuant to this contract operable. Contractor will be required to crush all towed vehicles within 45 days of receiving a CRUSH ORDER from the Codes Department if no vehicle owner or authorized agent of the owner has claimed the vehicle. Contractor herein agrees to dispose of all vehicles removed and stored pursuant to this Contract and those vehicles that remain at the expiration of this Contract in accordance with the Codes Department instructions at no additional cost to the City or to the owners or operators of such vehicles. Contractor shall not return such junked vehicle to its owner, or in any way settle charges or claims with a vehicle owner without prior written consent of the Codes Department. It is estimated that 340 to 400 junk vehicles will be removed annually under this contract. 5 Non Response Penalty Contractor agrees to stand ready to ably, professionally and promptly respond to any and all tow requests made by the Codes Department regardless of the time of such request or the number of such requests. The Codes Department reserves the right to use tow trucks owned by other towing services should the Contractor be unable or unwilling to respond to a tow request by the Codes Department in a timely manner. Should it be necessary for the Codes Department to utilize another towing service for any reason other than severe weather, disaster or some other reason beyond reasonable control of the Contractor, the Codes Department may instruct such towing service to tow and deliver the vehicle to the Contractor's storage facilities. Upon completion of delivery, the Contractor shall immediately pay the other towing service's customary charges for the services performed, take possession of the vehicle, and perform all obligations in regard thereto as though the Contractor had made the tow. The Contractor hereby agrees to make his storage facilities available at all times to any substitute towing service utilized by the Codes Department pursuant to terms of this section. 7 Month Billing and Payments Contractor may retain any compensation paid for such vehicles by any company or individual, which demolished the junked vehicle. Payment to the City for each junked vehicle removal will be paid monthly to include an itemized list of such removals. Exhibit B City of Lubbock Junked Vehicle Towing Proposed Pricing Sheet Best and Final Offer In compliance with the Request for Proposal (RFP), the undersigned Offeror having examined the RFP and Specifications, and being familiar with the conditions to be met, hereby submits the following price sheet for furnishing the material, equipment, labor, and everything necessary for providing the services. Payment to the City for each junked vehicle removal will be paid monthly to include an itemized list of such removals. State the guaranteed payment amount to be paid to the City of Lubbock by the Contractor during the term of this contract. Lubbock Wrecker Service, Inc. agrees to pay the City of Lubbock $ 306.00 per vehicle. TEXAS GOVERNMENT CODE SECTION 2252.152 The undersigned representative of the undersigned company or business, being an adult over the age of eighteen (18) years of age, pursuant to Texas Government Code, Chapter 2252, Section 2252.152, certify that the company named above is not listed on the website of the Comptroller of the State of Texas concerning the listing of companies that are identified under Section 806.051, Section 807.051 or Section 2253.153. I further certify that should the above -named company enter into a contract that is on said listing of companies on the website of the Comptroller of the State of Texas, which do business with Iran, Sudan or any Foreign Terrorist Organization, I will immediately notify the City of Lubbock Purchasing and Contract Department. TEXAS GOVERNMENT CODE SECTION 2271.002 Company hereby certifies the following: 1. Company does not boycott Israel; and 2. Company will not boycott Israel during the term of the contract. The following definitions apply to this state statute: (1) "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and (2) "Company" means an organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, or limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company, or affiliate of those entities or business associations that exists to make a profit. TEXAS GOVERNMENT CODE 2274 By entering into this Agreement, Contractor verifies that: (1) it does not, and will not for the duration of the contract, have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association or (2) the verification required by Section 2274.002 of the Texas Government Code does not apply to the contract. If Contractor is a company with 10 or more full-time employees and if this Agreement has a value of at least $100,000 or more, Contractor verifies that, pursuant to Texas Government Code Chapter 2274, it does not have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association; and will not discriminate during the term of the contract against a firearm entity or firearm trade association. Contractor represents and warrants that: (1) it does not, and will not for the duration of the contract, boycott energy companies or (2) the verification required by Section 2274.002 of the Texas Government Code does not apply to the contract. If Contractor is a company with 10 or more full-time employees and if this Agreement has a value of at least $100,000 or more, Contractor verifies that, pursuant to Texas Government Code Chapter 2274, it does not boycott energy companies; and will not boycott energy companies during the term of the Agreement. This verification is not required for an agreement where a governmental entity determines that these requirements are inconsistent with the governmental entity's constitutional or statutory duties related to the issuance, incurrence, or management of debt obligations or the deposit, custody, management, borrowing, or investment of funds. Vendor Acknowledgement In compliance with this solicitation, the undersigned offeror having examined the request for proposal, instructions to offerors, documents associated with the request for proposals, and being familiar with the conditions to be met, has reviewed the information regarding: • Insurance Requirements • Suspension and Debarment Certification • Texas Government Code Section 2252.152 • Texas Government Code Section 2271.002 • Texas Government Code 2274 • Federal and State Regulations • Master Agreement An individual authorized to bind the company must sign the following section. Failure to execute this portion may result in proposal rejection. l� Authorized Signature Scott Brown Print/Type Name Lubbock Wrecker Service Inc. Company Name President Title 10-20-22 Date 3209 Slaton Hwy. Address Lubbock TX 79404 City, State Zip Code Contact for questions, clarifications, etc. Name and Title: Chad Wilson Mailing Address: PO Box 3834 City, State, Zip: Lubbock TX 79452 Telephone No: 806-748-1044 Fax No: >rMail: cwilson lubbockwrecker.com Exhibit C INSURANCE REQUIREMENTS 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. 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. Subject to the Contractor's right to maintain reasonable deductibles in such amounts as are approved by the City, 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 Texas and acceptable to the City, in the following type(s) and amount(s): Commercial General Liability Requirements: $1M occurrence/ $2M aggregate (can be combined with an Excess Liability to meet requirement). CGL is required in ALL contracts. It is perhaps the most important of all insurance policies in a contractual relationship. It insures the Contractor has broad liability coverage for contractual activities and for completed operations. Automobile Liability Requirements: $1M/occurrence is needed Workers Compensation and Employer Liability Requirements• Statutory. if the vendor is an independent contractor with no employees and are exempt from providing Workers' Compensation coverage, they must sign a waiver (obtained from COL Purchasing) and include a copy of their driver's license. * The City of Lubbock (including its officials, employees and volunteers) shall be afforded additional insured status on a primary and non-contributory basis on all liability policies except professional liabilities and workers' comp. * Waivers of Subrogation are required for CGL, AL, and WC. * To Include Products of Completed Operations endorsement. * Carriers must meet an A.M. Best rating of A- or better. * Subcontractors must carry same limits as listed above. IMPORTANT: POLICY ENDORSEMENTS The Contractor will provide copies of the policies without expense, to the City 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 law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the City, the Contractor shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall pay the cost thereof. Any costs will be paid by the Contractor. 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: a. Name the City of Lubbock and its officers, employees, and elected 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; e. 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 of 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 & Contract Management City of Lubbock 1314 Avenue K, 9t' Floor Lubbock, Texas 79401 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. 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. 2022-965105 Lubbock Wrecker Service Inc. Salt Lake City, TX United States Date Filed: 12/15/2022 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: 12/16/2022 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. 16855 towing 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Wilson, Chad Lubbock, TX United States X Brown, Scott Lubbock, TX United States X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION My name is and my date of birth is My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of on the day of , 20 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V3.5.1.3ac88bc0 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 2022-965105 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Lubbock Wrecker Service Inc. Salt Lake City, TX United States Date Filed: 12/15/2022 2 Name of governmental entity or state agency that is a party to the contract for which th being filed. City of Lubbock 71Date 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. 16855 towing 4 Name of Interested Party City, State, Country (place of business) Nature of Interest (check applicable) Controlling Intermediary Wilson, Chad Lubbock, TX United States X Brown, Scott Lubbock, TX United States X 5 Check only If there Is NO Interested Party. 6 UNSWORN DECLARATION My name is A-,- ' / and my date of birth is My address is 1,1906 TKZZ31; ,_ �6�� �, yZ3 A-, (streeU (Car) (state) (zip code) (country) I declare under penalty ofperjurythat the foregoing is true and correct. Executed In _ u, Uy600L County, State of on the day of 6604� 20 X , / (Moft) (Yeffi) �v v ignature of authorized agent of contracting business entity rve 1110 PIUVRMu uy I VA= r=usrs wmmtissron www.etnics.state.w.us Version V3.5.1.3aC88bC0