HomeMy WebLinkAboutResolution - 2023-R0207 - PO 22300086 with Prime Controls, L.P. 4.25.23Resolution No. 2023-RO207
Item No. 6.17
April 25, 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, Purchase Order No. 22300086 for the purchase of
Replacement of the Genius Bus Data Network System for the North Water Treatment Plant as
per RFP 23-17060-YB, by and between the City of Lubbock and Prime Controls, L.P. of
Lewisville, Texas, and related documents. Said Purchase Order is attached hereto and
incorporated in this resolution as if fully set forth herein and shall be included in the minutes of
the City Council.
Passed by the City Council on April 25, 2023
APPROVED AS TO CONTENT:
Erik Rejino, Assistant City Manager
APPROVED AS TO FORM:
iey
RES.Prime Controls, LP-Purchase0rd
3.24.23
401 '1 City of
Lubbock PURCHASE ORDER
TEXAS
TO: PRIME CONTROLS, L.P.
1725 LAKEPOINT DRIVE
LEWISVILLE TX 75057
Page - I of 2
Date - 3/23/2023
Order Number 22300086 000 OP
Branch/Plant 92809
SHIP TO: CITY OF LUBBOCK
WATER TREATMENT PLANT
6001 N GUAVA AVE
LUBBOCK TX 79403
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAVABLE
P.O. BOX 2000
LUBBOCK, TX 79457 BY: 4f
Marta Alvarez, Di for of Purchasing & Contract Management
Ordered
3/23/2023 Freight
Requested 6/30/2023 Taken By
Delivery PER R MARTINEZ REQ 60001 RFP 23-17060-YB
YBUSBY
If you have any questions contact Renata Martinez: RMartinez@mylubbock.us Phone 806-775-2611
Description/Supplier Item Ordered Unit Cost UM Extension Request Date
Training with 1 year warranty 1.000 4,500.0000 EA 4,500.00 6/30/2023
Replacement Genius Bus Data 1.000 156,275.0000 EA 156,275.00 6/30/2023
Total Order
Terms NET DUE ON RECEIPT
160,775.00
This purchase order encumbers funds in the amount of $160,755.00 awarded to Prime Controls, L.P. of Lewisville,
TX, on April 25 , 2023. The following is incorporated into and made part of this purchase order by reference:
Proposal dated February 8, 2023, from Prime Controls, L.P. of Lewisville, TX, and RFP 23-17060-YB.
Resolution # 2023-RO207
CITY OF LUB
YZ
Tray Payne, ay
A zs't')
Courtney Paz, I erim Ci ecret
4000. City of
U1bt)ock
TEXAS
PURCHASE ORDER
TO: PRIME CONTROLS, L.P.
1725 LAKEPOINT DRIVE
LEWISVILLE TX 75057
Page - 2 of 2
Date - 3/23/2023
Order Number 22300086 000 OP
Branch/Plant 92809
SHIP TO: CITY OF LUBBOCK
WATER TREATMENT PLANT
6001 N GUAVA AVE
LUBBOCK TX 79403
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 BY:
- 4f
Marta Alvar , Director of Purchasing & Contract Management
Ordered
3/23/2023 Freight
Requested 6/30/2023 Taken By
Delivery PER R MARTINEZ REQ 60001
INSURNACE REQUIRED:
RFP 23-17060-YB
Commercial General Liability:
$1,000,000 occurrence / $2,000,000 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.
YBUSBY
Workers Compensation and Employer Liabilitv:
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. Employer Liability ($1,000,000) is required with
Workers Compensation.
Commercial General Liability to include Products — Additional Policies: N/A
Completion/OP, Personal and Advertising Injury, Contractual
Liability, Fire Damage (any one fire), and Medical Expenses
(any one person).
Automotive Liability:
Combined Single limit for Any Auto - $1,000,000/occurrence is
needed.
*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. *Carrier will provide a 30-day
written notice of cancellation, 10-day written notice for non-payment. *Carriers must meet an A.M. Best rating of A- or better.
*Subcontractors must carry same limits as listed above.
Rev. 3/2022
Seller and Buyer agree as
follows:
PURCHASE ORDER
TERMS AND CONDITIONS
STANDARD TERMS AND CONDITIONS
ACCEPTANCE OF THIS PURCHASE ORDER:
CONTRACTOR ACKNOWLEDGES. by supplving 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 ponies. 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 tens 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.
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 tamers 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 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. 0. Box 200D. 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 right 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 limit 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 sample(s) furnished by the Seller, if any.
In the event of a conflict or between the specifications, drawings, and descriptions, the specifications shall govem.
Notwithstanding any provisions contained in the contractual agreement, the Sella represents and warrants fault -Gee
performance and fault -Gee 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 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 Inability which may be specified in this Contract, its appendices, its schedules, its annexes or any document
incorporated in this Contract by reference
Itl 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 rerun 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 Seiler sexpense
I 1 NO WARRANTY BY BUYER AGAINST INFRINGEMENTS. As pan 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 infiingement 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 Qry In the event of nonappropriation of funds by the City Council of the
City Of Lubbock for the go.ids 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 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 terms hereof including warranties of Seller or if the Seller becomes insolvent or
commits 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
15 TERMINATION The performance of work under this order may be terminated in whole, or in pan by the Buyer
in accordance with this provision Termination of work hereunder shall be effected by the delivery of the Seller of
a "Notice of Termination specifying the extent to which performance of work under the order is terminated and the
date upon which such termination becomes effective Such right or termination is in addition to and not in tin of the
rights of Buyer set forth in Clause 14. herein
16. FORCE MAJEURE Neither party shall be held responsible f r 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 a f reasonable diligence said patty 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.
18 WAIVER. No claim or right arising out of a breach of this contract can be discharged in whole or in pan 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 patty
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 teen 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
'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 grantmg 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 tune is of the essence for the performance of this
contract, and failure by contract to meet the tune specifications of this agreement will cause Seller to be in default
of this 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 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 eampelaa
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.
26. RIGHT TO AUDIT. At any time during the tern 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 io
audit Contractor's records and books relevant to all services provided to the City under this Contract. In the u:vcrrt such
an audit by the City reveals any errors or overpayments by the City. Contractor shall refund the City the full amvum
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 mterested parties
at the tune the business entity submits the signed contract to the governmental entity or state agency Instructions for
completing Form 1295 are available at hop, www.ci.lubbock.tx.usrdeoartmemtal-
websnes(dcl=ments/purchasmg vendor -information
30. No Boycott of Israel Pursuant to Section 2271.002 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 :t
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 (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 22--4 of the Texas
Government Code, Respondent certifies that either (i) it meets an exemption criteria under Section 2274, 002; or (h) it
does not boycott a Firearm Entity or Firearm Trade Association and will not boycott a Firearm Entityor Firearm
Trade Association during the tern 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 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 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 Goverment Code, the City of Lubbock has designated the following
email address for which public information requests maybe made by an emailed request: omit mvlubboek.is. Pleas
send this request to this email address for it to be processed
REV. 3 2022
# Items
City of Lubbock
RFP 23-17060-YB
Replacement of the Genius Bus Data Network System
for North Water Treatment Plant
Bid Form
Location
Total Cost
Quantity UOM
Required
#0-1 Replacement of Genius Bus Data 1
Network System Hardware and
Software, One Year System Hardware
Warranty - Per Specifications
#0-2 Training/With One Year Warranty - Per 1
Specification
Prime Controls, L.P.
Lewisville, TX
$160,775.00
Unit Total
Price Cost
Each $156,275.00 $156,275.00
Each $4,500.00 $4,500.00
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.
6 &
Authorize ignature
Jace McNiel
Print/Type Name
Prime Controls, L.P.
Company Name
President & General Partner
Title
02/08/2023
Date
1725 Lakepointe Drive
Address
Lewisville, TX 75057
City, State Zip Code
Contact for questions, clarifications, etc.
Name and Title:
Mailing Address:
City, State, Zip:
Telephone No:
Fax No:
E-Mail:
CERTIFICATE OF INTERESTED PARTIES FORM 1295
101
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.
2023-992125
Prime Controls, L.P.
Lewisville, TX United States
Date Filed:
03/08/2023
2 Name of governmental entity or state agency that is a party tot the contract for which the form is
being filed.
City of Lubbock, TX
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.
RFP 23-17060-YB
Replacement of the Genius Bus Data Network System for North Water Treatment Plant.
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
McNiel, Jace
Lewisville, TX United States
X
Davis, Heather
Lewisville, TX United States
X
McMillon , James
Lewisville, TX United States
X
Barrett, Miller
Lewisiville, TX United States
X
Bivens, Bill
Lewisville, TX United States
X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARA O
My name is and my date of birth is
My address is ! �13,%�r�.-- I.1�f 1/t l�� _� GIEA.
(fit) (cty) (state) (zip code) (country)
I declare under pe ty of perjury that the foregoing is true and correct
Executed in �„ County, State of _W on the f�day of , 20�.
(month) (year)
Signature of authorized agent oNonfracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V3.5.1.3ac88bc0
CERTIFICATE OF INTERESTED PARTIES
FORM 3.295
loft
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 parses.
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.
2023-992125
Prime Controls, L.P.
Lewisville, TX United States
Date Filed:
03/08/2023
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, TX
Date Acknowledged:
03/22/2023
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
RFP 23-17060-YB
Replacement of the Genius Bus Data Network System for North Water Treatment Plant.
4
Name of Interested Parry
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
McNiel, Jace
Lewisville, TX United States
X
Davis, Heather
Lewisville, TX United States
X
McMillon , James
Lewisville, TX United States
X
Barrett, Miller
Lewisiville, TX United States
X
Bivens, Bill
Lewisville, 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 Drovided by Texas Ethics Commission www.ethics.state.tx.us
Version V3.5.1.3ac88bc0