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HomeMy WebLinkAboutResolution - 2024-R0135 - Contract 17662, West Texas Services, Inc. Dba Tom's Tree Place For Pids - 03/26/2024Resolution No. 2024-R0135 Item No. 5.22 March 26, 2024 ItESOLUTYON 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, Service Contract No. 17662 for Installation of Water Well and Electrical Equipment Protective Coverings for Public Improvement Districts (PID) as per RFP 24-17662-KM, by and between the City of Lubbock and West Texas Services, Inc. dba Tom's Tree Place of Lubbock, TX, 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 March 26, 2024 �_ - TRAY PAYNE, MAYOR AT EST: - Co ney Paz, City Secretary APPROVED AS TO CONTENT: D. Blu Kos ich, Chief Fi ' Officer APPROVED AS TO FORM: Ke li Leisure, Senior Assistant City Attorney ccdocs/RES.ServiceContract 17662 Installation of Water Well and Electrical �quipment 2.27.24 Resolution No. 2024-R0135 Contract 17662 City of Lubbock Installation of Water Well and Electrical Equipment Protective Coverings for Public Improvement Districts (PID) Agreement This Service Agreement (this "Agreement") is entered into as of the26thday of March 2024 ("Effective Date") by and between West Texas Services, Inc. dba Tom's Tree Place (the Contractor), and the City of Lubbock (the "City"). RECITALS WHEREAS, the City has issued a Request for Proposals 24-17662-KM, Installation of Water Well and Electrical Equipment Protective Coverings for PID 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 Installation of Water Well and Electrical Equipment Protective Coverings for PID, 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 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 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 All stated annual quantities are approximations of usage during the time period to be covered by pricing established by this bid. Actual usage may be more or less. Order quantities will be deternuned by actual need. 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 A) Prices quoted shall be guaranteed for a period for six (6) months upon City approval. The rate may be adjusted at the City's discretion for the effective change in Consumer Price Index (CPI) or Product Price Index (PPI) as appropriate. B) Further, if the Contractor can provide documentation for actual charges for material, labor, etc. that demonstrates that the change in CPI or PPI is not sufficient, the Contractor shall provide such documentation to the City, and at the City's sole discretion, the contractual rate may be further adjusted. If agreement regarding a new rate cannot be reached, the City shall terminate at the end of the current contract period. C) If an adjustment to pricing is granted under this section, the Contractor must provide the Director of Purchasing and Contract Management written, quarterly documentation to justify the ongoing adjustment. If no such documentation is timely received, the rate will automatically revert to the initial, awarded rate. 1.5 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 ternunated 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 verifes 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 ternunation of this agreement. TN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed the day and year first above written. Executed in triplicate. CITY OF LUBBOCK CO TRACTOR �� ��° � BY: � Tray Payne, Mayor Auth ize epresentati ATT T: � Courtney Paz, City Secretary AP �R ED AS TO CO T• , � .�. Brianna Brown, Director of Business Development �. . Sc.a.�� rb� _ � 1 Print Name 5 lo�- � 3��—' Address �..-J �a �v� `�� aS � R `�"� � City, State, Zip.Code APPR V S TO F RM � Kelli Le sure, Senior Assistant City Attorney Exhibit A City of Lubbock, TX RFP 24-17662-KM Installallon of Water Well and Electric Equipment Protective Coverings for Public Improvement Districts (PID) GENERAL REQUIREMENTS 1. INTENT The Bell Farms, North Point, Quincy Park, and Valencia Public Improvement District (PID) Advisory Boards intend to install protective coverings on water wells and electric equipment at community parks, medians, a walking track, and other areas as applicable. The duration of this agreement is for twelve months, with an optional extension of an additional six months. The standards to which these services are requested are contained within these specifications. The City of Lubbock reserves the right to add or remove Public Improvement Districts, equipment, and water wells to have protective coverings installed from the Scope of Services at any time. 2. SCOPE OF WORK The vendor shall purchase, deliver, and install protective coverings to prevent damage and vandalism to water well and electrical equipment. The materials may include brick, concrete, metal, plastic, or other materials recommended by the contractor and approved by the City of Lubbock. The specified locations are shown in Exhibits A and B. Pricing should include the purchase of the equipment, delivery, and installation, as well as any required electrical work or site preparation. All purchases must also be approved by City of Lubbock, Business Development Representative, by using Attachment A. All equipment covers should be; - easily opened - able to be locked with a standard padlock - a material rated for commercial outdoor use - able to drain if submerged in flood water 1�:1:11:3YII:1 1. Bell Farms —1-Acre Park � :e - �4 .;; �..;��r,�;� • ." -�;„ �'�. . 5� . .,yxa .. :!•k•�':�...f++ lY4J'Y1 .� ^i"y � .. .,. �'i�` -�': 2. Bell Farms — Basin Park 1 `���+'�'-- �. - - _� , =---�:-��� i�''� r��,�''�'��''�; �. ,�'�^ �., V. :. � . _..J _.. _ il�e �1-�^ .� 8';1� • �,t "�� • : J. : r� �• ' y r� � � � r. "6 wYl'�. �_�, �. F• 'C, . - ,yc .�tAs,.t,::.: .`.:cc;.,e�,��i :r. ",r. ` ' �� ':+'F_ -�� •-.e�,-,,�M,� ; }�, i. ..#'"T.�`,x+'�} « ` ; :. _ : �^ :"�.�;. �� � ,Y�a,..�A�,�:,,:�� �,•�';"a �. , ... . � � .�!�.='�"�,•� ...; -" �; Q,,y �µ�.°g��{',y,��� ��I:y� .�e,;�rd .... _ � , : F+�ir� '�LSI'S'?.`r:,i.�na�' 3. Bell Farms — Basin Park 2 ` , ���' , 4. Bell Farms — Playa Lake Park 1 � �.- , _ �_' � �y �.:..�.. ' : . - -� .. - !S�-..�'- - .,, �r + '. . . �.•. _ . I� � • i`a; : '.._i �.-r.� - . - t��:-..�'..'k t"-ti' � .k' 4�,�,`�:.. +`..�-�4 _ .,n+� .: r`".' . .;��;�:,;.,, . _ � � , ,� _ �: � * ► _,� `i ... .k �i�•., - . •:, - , . • . ��:;.. �-,��:,. . .. ,� �:;,, , w� ��r _ � :. , ��` �. �� �� �� : , ..� �. . ' r�� '� �:7� w! ..,_�4 Ir �� : �� �,,.� �y���? �e� '`` � i S I �,�,s�! ";��,�-�,,�.�� �E yf+���� � r_ 3 k^ "� kY �`'�`�"��':t'--��K���.�� � �� � �� �� 5. Bell Farms — Playa Lake Park 2 �*i���,� �. vs:��` � - _ .-� �rl 6. North Point — South Median 7. North Point — North Median 8. North Point - Walking Track 9. Quincy Park — 1 10. Quincy Park — 2 �.�; �: r-:•-._ .. . ---'- �- ._ � r._i= F f 1 •C � ' T ' -:1+ �. �_ �: � � � .. . �.. . - { ��E �' 4 � j �l�: � �. �}:�?;+; _ 1 ,� . .. ��,--_• �•�- . - � ' � � .��{ i��� . -i� t .�. �}.p.. _. ��-- 11. Valencia —1 � �. 12. Valencia — 2 ti` ? ��ta. -- l ` � r'— �4 �. �. � � �'„ 'i� r. "'. �. �k;. 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U "!� � :.,� s:e 2 Q y�iF U `__ . `�j7�Ei �SE3� •f _� ��: :; #�: a� O LL O 0 N r 0 0 � N Z �a\ r� � C � a � Q. '.� W ca U �L .. U � W « � Q L r..� O c — a> � E � m > • 0 a E _ � U � � � � � a a v= �' 0 U� ` ; � � � � � ■� v _ � � � � A� n� ��n�n��i� � IRONTOI a a x H 00 00 �� �� �� � � x H � � lCi ,,; V sj; �� ili ++ :•; Q cii ��j � - �; .0 �s; � �,ai � =�' U ��; � � oLL � 0 � a 0 0 � 0 � -6 � a� > c� a� z� c � � cu �• d Q. .3 a' W � U �L d�+ U V .` � y w � � ..+ 0 C — N � � > N � > • O Q � _ N U � � ` 7 � a a U" �O U� `� � Attachment A City of Lubbock, TX RFP 24-17662-KM Installation of Water Well and Electric Equipment Protective Coverings ESTIMATING FORM — EQUIPMENT/MATERIALS PRICING SHEET (PLEASE PRINT CLEARLI� LOCATION: SHEET NO. OF JOB/PROJECT WORK: CONTRACTOR 1 ESTIMATE BY: DATE EQUIPMENT/MATERIAL DESCRIPTION ACTUAL % MARK UP AMOUNT COST TOTAL MATERIALS PRICING Materials — Materials are to be quoted on a cost-plus basis; percentage of markup to be based on net cost to Contractor. NOTE: TRANSFER AMOUNT OF TOTAL MATERIAL PRICING TO JOB SUMMARY SHEET APPROVED BY: DATE: Exhibit B City of Lubbock, TX RFP 24-17662-KNI BAFO West Texas Services, Inc. dba Tom's Tree Place Location: Lubbock, TX Total Cost: $10,000.00 Quantity Required Unit Extended # Items (+/-) UOM Price Cost _ _ . . . - ' - -� � #0-1 Installer Labor Rate 50 HR � $ 200.00 $ 10,000.00 #0-2 Material Mark-Up Percentage 0 °ro 100.00 - 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 indushy 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 �11 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: $1 M 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. Commercial General Liability to include Products — Completion/OP, Personal and Advertising Injury, Contractual Liability, Fire Damage (any one fire), and Medical Expenses (any one person). Automobile Liability Requirements: $1 M/occurrence is needed Workers Compensation and Emplover Liabilitv 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. Employer Liability ($1 M) is required with Workers Compensation. • 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. IMPOI2TANT: 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, Floor 9 Lubbock, Texas 79401 1.1. 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 FORnn 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 1 Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number: of business. 2024-1127356 West Texas Services, Inc. DBA Toms Tree Place Lubbock, TX United States Date Filed: 2 Name of governmental entiry or state agency that is a party to the contract for which the form is 02/23/2024 being filed. City of Lubbock Date Acknowledged: g 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. 17662 Installation of Water Well and Electrical Equipment Protective Coverings for Public Improvement Districts Nature of interest 4 Name of Interested Party City, State, Country (place of business) (check appllcable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECLARATION My name is L. ���_� �� � , and my date of birth is + My address is QS%L F--� - � � . �. ` , w � �.].,L�'�' � (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. � �] r r Executed in �� _.►"� f��� County, State of , on theO� day of �e CJ , 20� (month) (year) � 5����,� - Signature of authorized agent of contracting busr ess entity (Declarant) Forms orovided bv Texas Ethics Commission www.ethics.state.tx.us Version V3.5.1.9000c47f CERTIFICATE OF INTERESTED PARTIES FORnn 1295 1 of 1 Complete Nos.1- a 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 1 Name of business entity filing form, and the ciry, state and country of the business entity's place Certificate Number: of business. 2024-1127356 West Texas Services, Inc. DBA Toms Tree Place Lubbock, TX United States �ate Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 02/23/2024 being filed. City of Lubbock Date Acknowledged: 02/27/2024 g 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. 17662 Installation of Water Well and Electrical Equipment Protective Coverings for Public Improvement Districts 4 Nature of interest Name of Interested Party City, State, Country (place of business) (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 penalry of perjury that the foregoing is true and correct. 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