HomeMy WebLinkAboutResolution - 2023-R0020 - PO 31071215 with GTS Technology Solutions for LPD 1.10.23Resolution No. 2023-R0020
Item No. 5.22
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 fo!
and on behalf of the City of Lubbock, Purchase Order No. 31071215 in accordance with DIR
CPO-4697 for the purchase of video recording systems, by and between the City of Lubbock an(
GTS Technology Solution, Inc. of Austin, TX and related documents. Said Purchase Order i
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:
. . � " 0 'V t,-JC
Reb ca Garza, City Se et
APPROVED AS TO CONTENT:
January 10, 2023
41�k� Al"KAA -
Brooke Witcher, Assistant City Manager
APPROVED AS TO FORM:
�24elli Leisure, Assistant City Attorney
ccdocs/RES.PurchaseOrd 31071215 Video Recording Systems
01.03.22
�01
City of
Lubbock PURCHASE ORDER
TEXAS
TO: GTS TECHNOLOGY SOLUTIONS INC
PO BOX 660003
DEPT 6877
DALLAS TX 75266
Page - 1 of 2
Date - 12/29/2022
Order Number 31071215 000 OP
Branch/Plant 3526
SHIP TO: CITY OF LUBBOCK
FLEET SERVICES
206 MUNICIPAL DRIVE
LUBBOCK TX 79404
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 BY:
Marta A arez, Director of Purchasing & Contract Management
Ordered 12/29/2022 Freight
Requested 1/31/2023 Taken By
Delivery PER B RODRIGUEZ REQ 59670
E GARCIA
PUR 17072/ DIR-CPO-4697
If you have any questions, please contact Breana Rodriguez. Email: BreanaRodriguez@mylubbock.us Phone: 806-775-2374
Description/Supplier Item
Ordered
Unit Cost
UM
Extension
Request Date
Panasonic Recording Unit
20.000
2,796.2000
EA
55,924.00
1/31/2023
5735-inv
Arbitrator
20.000
892.1100
EA
17,842.20
1/31/2023
5735-inv
Back Seat Camera
20.000
387.6400
EA
7,752.80
1/31/2023
5735-inv
Power Dist Box Battery
20.000
631.4600
EA
12,629.20
1/31/2023
5735-inv
Panorama Shark Fin Antenna
20.000
333.1700
EA
6,663.40
1/31/2023
5735-inv
Software Maintenance & Support
20.000
360.8300
EA
7,216.60
1/31/2023
5735-inv
SSD Reader
1.000
258.6000
EA
258.60
1/31/2023
5735-inv
Total
Order
Terms NET 30
108,286.80
City of
Lubbock
PURCHASE ORDER
TO: GTS TECHNOLOGY SOLUTIONS
PO BOX 660003
DEPT 6877
DALLAS TX 75266
Page -
Date -
Order Number
Branch/Plant
2 of 2
12/29/2022
31071215 000 OP
3526
SHIP TO: CITY OF LUBBOCK
FLEET SERVICES
206 MUNICIPAL DRIVE
LUBBOCK TX 79404
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 QV:k
Marta kyarez, Director of Purchasing & Contract Management
Ordered 12/29/2022 Freight
Requested 1/31/2023 Taken By E GARCIA
Delivery PER B RODRIGUEZ REQ 59670 PUR 17072/ DIR-CPO-4697
This purchase order encumbers funds in the amount of $108,286.80 awarded to GTS Technology Solutions, Inc. of
Austin, TX, on January 10 , 2023. The following is incorporated into and made part of this purchase order
by reference: Quote - QT0086751. dated November 7 2022, from GTS Technology Solutions, Inc. of Austin, TX, and DIR
Contract DIR-CPO-4697.
Resolution # 2023-R0020
CITY OF r K: ATTEST:
Tray Payn a r Re cca Garza, City Sec retarA
Rev. 3/2022
Seller and Buyer agree as
follows:
ACCEPTANCE OF THIS PURCHASE ORDER
CONTRACTOR ACKNOWLEDGES. by sunn
PURCHASE ORDER
TERMS AND CONDITIONS
STANDARD TERMS AND CONDITIONS
the Contractor unless agreed noon in writme 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 provided herein shall
prevail. The terms and conditions provided herein are the final terms agreed upon by the parties, and any prior
conflictine terms 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 carriers 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
provistons of this contract as to time of delivery, quality and the like Ito tender is made which does riot 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 I 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 O. Box 2000. Lubbock, Texas 79457 Payment shall not
be due until the above instruments are submitted after delivery
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 form 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.
8 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 for 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 fight in addition to
any other right of rights to cancel this contract without liability and to deduct from the contract price, or otherwise
recover without liability and to deduct from the contract price, or otherwise recover the full amount of such commission,
percentage, brokerage or contingent fee
9 WARRANTY -PRODUCT Seller shall not lint or exclude any implied warranties and any attempt to do so shall
render this contract voidable at the option of the Buyer Seller warrants that the goods furnished will conform to the
specification, drawings, and descriptions listed in the bid invitation, and to the samples) furnished 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 -free
performance and 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 firmware 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 party
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 fights under the law and tinder 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 lability 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 conform 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
1 I 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 for 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 for this purpose by the City In the event of nonappropnatmon 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 lability, on the last day of the then -current fiscal year or when the appropriation made for
the then -current year for the goods or services covered by this contract is spent, whichever event occurs first If at any
time funds are not appropriated for the continuance of this contract, cancellation shall be accepted by the Seller on
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 termination
13 RIGHT OF INSPECTION Buyer shall have the right to inspect the goods at delivery before accepting them
14 CANCELLATION Buyer shall have the right to cancel for default all or any pan of the undelivered portion of
this order if Seller breaches any of the tems hereof including warranties of Seller or if the Seller becomes insolvent or
comments acts of bankruptcy Such right of cancellation is in addition to and not in lieu of any other remedies which
Buyer may have in law or equity
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 terminated and the
date upon which such termination becomes effective Such right or termination is in additton to and fiat 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
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 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 percussion of the Buyer Any attempted assibmment 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 artsing 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 parry
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 terms 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 term
"Uniform 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
21 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 many
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 it= is of the essence for 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 the agreement
24 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 opportwmtes 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 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
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 uuarwed parties
at the time the business entity submits the signed contract to the governmental entity or state agency Instructions for
completing Form 1295 are available at hflp-u—w ci_luhbockix.us�depanmtmal-
websnes/depart ments/ourchasin Uvendor-info rmat ion
30 No Boycott of Israel. Pursuant to Section 2271 002 of the Texas Government Code, Respondent certifies that
either (t) it meets an exemption criteria under Section 2271 002, or (it) 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 cenifcation in its Response
31 No Boy con of Energy Companies Pursuant to Section 2274 of the Texas Government Code, Respondent
certifies that either (t) it meets an exemption criteria under Section 2274 002, or (it) 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 (it) 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 state any facts that
make it exempt from the boycott certification in its Response
33 Contracts with Companies Engaged in Business with Ira. 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 Ira. 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 if the 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 following
email address for which public information requests may be made by an entailed request orrwnnlubbpck es Plcase
send this request to this email address for it to be processed
15 TERMINATION The performance of work under this order may be terminated in whole, or in pan by the Buyer
REV 3/2022
c:;F,,
Quote #:
QT0086751
TECHNOLOGY SOLUTIONS
Date:
11/7/2022
Delivery Date:
GTS Technology Solutions, Inc.
Expire Date:
1/31/2023
9211 Waterford Centre Blvd
Customer ID:
TXCLU613002
Suite 275
Sales Contact:
Jacob Jiongo
Austin, TX, 78758
Phone: (512) 452-0651
Lubbock
SOLUTIONS CORPORATION OF AMERICA :
VPU4000 RECORDING UNIT ONLY
2 WV-VC35: PANASONIC I -PRO SENSING
SOLUTIONS CORPORATION OF AMERICA :
ARBITRATOR IN -CAR AS-1 COMPATIBLE
CAMERA
3 WV-VC31: PANASONIC I -PRO SENSING
SOLUTIONS CORPORATION OF AMERICA :
BACK SEAT CAMERA
4 IPS-ICV4-ACC: PANASONIC I -PRO SENSING
SOLUTIONS CORPORATION OF AMERICA : I -
PRO ACC KIT FOR VPU4000, 256GB SSD,
POWER DIST BOX, BATTERY BKUP, 25
ETHERNET X3
5 IPS-ICV4-ANT-BL: PANASONIC I -PRO
SENSING SOLUTIONS CORPORATION OF
AMERICA : PANORAMA SHARK FIN FOR
ICV4000, 4 WLAN, 1 BT, 1 GPS BLACK
6 ARB-SOFUDEICV-OP3: PANASONIC I -PRO
SENSING SOLUTIONS CORPORATION OF
AMERICA : ICV ON-PREM DEVICE LIC 3 YRS,
INCL. UNIFIED DIGITAL EVIDENCE W/
CLOUD DEVICE MGMT, STREAMING AND
BASIC REDACTION. SERVICE
ENTITLEMENTS: 24X7 HELP DESK,
SOFTWARE MAINT & SUPPORT
7 IPS-ICV4SSDREAD: PANASONIC I -PRO
SENSING SOLUTIONS CORPORATION OF
AMERICA : ICV4 VPU4000 SSD READER
DIR-CPO-4697
20.00
EACH
$892.11
$17,842.20
DIR-CPO-4697
20.00
EACH
$387.64
$7,752.80
DIR-CPO-4697
20.00
EACH
$631.46
$12,629.20
DIR-CPO-4697
20.00
EACH
$333.17
$6,663.40
DIR-CPO-4697
20.00
EACH
$360.83
$7,216.60
DIR-CPO-4697 1.00 EACH $258.60 $258.60
Total Weight (EACH): 0 Sales Total: $108,286.80
Total Volume (EACH): 0 Freight & Misc.: $0.00
Prices do NOT include taxes, insurance, shipping, delivery, setup fees, or any cables or cabling services or Tax Total: $0.00
material unless specifically listed above. if a customer requests expedited or special delivery, causes carrier delays Total (USD): $108,286.80
or requests redelivery, customer will be responsible for any additional charges for these services directly billed by
the carrier. All prices are subject to change without notice. Supply subject to availability.
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.
2023-973263
GTS Technology Solutions, Inc
Austin, TX United States
Date Filed:
01/18/2023
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.
31071215 000 OP
IT Goods and Services QT0086751
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
Grant, Laura
Austin, TX United States
X
5
Check only if there is NO Interested Party. ❑
6
UNSWORN DECLARATION
My name is Ashley Ambroso and my date of birth is
My address is 9211 Waterford Centre Blvd. Ste 275 Austin TX 78758 USA
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in Travis County, State of Texas on the 18 day of January , 20 23 .
(month) (year)
Lwpl��
Signature of authorized g nt of contracting business entity
(Dec arant)
Forms provided by I exas 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:
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2023-973263
GTS Technology Solutions, Inc
Austin, TX United States
Date Filed:
01/18/2023
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:
01/18/2023
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.
31071215 000 OP
IT Goods and Services QT0086751
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
Grant, Laura
Austin, 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