HomeMy WebLinkAboutResolution - 2017-R0122 - Sale Of Building At 4406 E. FM 835 - Paulo And Gloria Flores - 04/13/2017Resolution No.2017-R0122
Item No.6.9
April 18,2017
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT City of Lubbock Bid No.ITB 17-13309-KW is awarded to Paulo and Gloria
Flores, of Crosbyton, Texas, for the Sale of Building Located at 4406 E. FM 835, Lubbock,
Texas.
BE IT FURTHER RESOLVED BY THE CITY COUNCIL OF THE CITY OF
LUBBOCK:
THAT the Mayor of the City of Lubbock is authorized and directed to execute, for and on
behalfofthe City of Lubbock a Contract for Salebyand between the Cityof Lubbock and Paulo
and Gloria Flores,and related documents.Said Contract for Sale 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 13,2017
DANIEL M.POPE,MAYOR
ATTEST:
in,P.E.,Director of Public Works
Zy^Vr^^/jo>7-^—-
Dave Booher,Right-of-Way Agent
ccdocs/RES.Contract of Sale-13309
03.22.17
APPROVED AS TO FORM:
i
R n ooke, Assistant City Attorney
ccdocs/RES.Contract of Sale-13309
03,22.17
Resolution No. 2017-R0122
Contract 13309
City of Lubbock
Contract for Sale
of Building Located at 4406 E. FM 835, Lubbock, TX
This Contract is entered into as of the 13tb day of April, 2017 ("Effective Date") by and
between, Paulo and Gloria Flores (the "Buyer"), and the City of Lubbock (the "Seller").
WHEREAS, Seller owns that certain tract of land located in Lubbock County, Texas, being
described on Exhibit "A" attached hereto (the "Property"); and
WHEREAS, Seller desires to sell and convey the personal property located on the Property,
and the fixtures affixed to the Property (collectively the "Improvements") to Buyer.
ARTICLE I
SALE AND PURCHASE
Section 1.1. Sale and Purchase. Subject to the terms and conditions of this Contract, Seller
shall sell and Buyer shall purchase and pay for, on the 131" day of April, 2017, or at such time
thereafter as the Seller may direct (the "Date of Sale"), without warranty, either expressed or implied,
the Improvements.
ARTICLE II
PURCHASE PRICE
Section 2.1. Purchase Price. The Purchase Price (herein so called) to be paid by Buyer to
Seller for the Improvements shall be $500.00.
Section 2.2. Payment of Purchase Price. The Purchase Price shall be payable to Seller, in
cash or other immediately available funds, on the Date of Sale. The sale shall take place in the offices
of the City of Lubbock, Office of the Right -of -Way Agent, Davy Booher, 1625 13th Street, Lubbock,
Texas.
Section 2.3. Responsibilities of Buyer. Notwithstanding anything to the contrary herein,
this Section 2.3 shall survive the Date of Sale. Buyer shall be solely responsible for the following
items:
(a) Ad valorem taxes relating to the Property for the calendar years prior to the year in
which the Closing shall occur, if any, shall be the sole responsibility of, and shall be paid by Buyer,
at Closing. Further, all ad valorem taxes relating to the Property for the calendar year in which the
Closing shall occur, if any, shall be the sole responsibility of Buyer and Buyer shall promptly pay
such ad valorem taxes when same become due and owing.
ARTICLE III
INDEPENDENT INVESTIGATION AND DISCLAIMER
Section 3.1. Independent Evaluation. Buyer has made an independent inspection and
evaluation of the Improvements and the title to same and acknowledges that Seller, except as provided
in the Contract Documents, as defined below, has made no statements or representations concerning
the present or future value of the Improvements, the state of the title to the Improvements, the
condition, including the environmental condition of the Improvements, or the anticipated income,
costs, or profits, if any, to be derived from the Improvements. FURTHER, SELLER MAKES NO
REPRESENTATION OR WARRANTY WHATSOEVER, EXPRESSED, STATUTORY, OR
IMPLIED, INCLUDING, BUT WITHOUT LIMITATION, AS TO THE DESCRIPTION, TITLE,
INCLUDING, WITHOUT LIMITATION, TO THE EXISTENCE OF LIENS AGAINST THE
IMPROVEMENTS, THE VALUE, QUALITY, PHYSICAL AND ENVIRONMENTAL
CONDITION OF THE IMPROVEMENTS AND/OR MATERIALS CONTAINED OR LOCATED
IN, ON OR UNDER THE IMPROVEMENTS AND/OR IMPROVEMENTS LOCATED
THEREON, THE NATURE OF THE PAST OR HISTORIC USE OF THE IMPROVEMENTS,
MERCHANTABILITY, OR FITNESS FOR PURPOSE OF ANY OF THE IMPROVEMENTS.
Buyer further acknowledges that, in entering into this Contract, he/she/it has relied solely upon
his/her/its independent evaluation and examination of the Improvements and public records relating
to the Improvements and the independent estimates, computations, evaluations and studies based
thereon. Seller makes no warranty or representation as to the accuracy, completeness or usefulness
of any information furnished to Buyer, if any, whether furnished by Seller or any other third party.
Seller, its officers, employees, elected officials and agents assume no liability for the accuracy,
completeness or usefulness of the material furnished by the Seller, or any of its officers, employees,
elected officials and/or agents, if any, and/or any other person or party. Reliance on any material so
furnished shall not give rise to any cause, claim or action against Seller, its officers, employees,
elected officials and/or agents, and any such reliance shall be at Buyer's sole risk.
Section 3.2. Disclaimer -No Warranty, Expressed or Implied. THE BILL OF SALE OF
THE IMPROVEMENTS DESCRIBED ON EXHIBIT `B" SHALL BE ON A "WHERE IS", "AS
IS" AND "WITH ALL FAULTS" BASIS, AND SHALL BE WITHOUT REPRESENTATION OR
WARRANTY WHATSOEVER, EXPRESSED, STATUTORY OR IMPLIED, INCLUDING, BUT
WITHOUT LIMITATION, AS TO TITLE, INCLUDING, BUT NOT LIMITED TO THE
EXISTENCE OF LIENS AGAINST THE IMPROVEMENTS, THE DESCRIPTION, PHYSICAL
AND ENVIRONMENTAL CONDITION OF THE IMPROVEMENTS AND/OR MATERIALS
CONTAINED OR LOCATED IN, ON OR UNDER THE PROPERTY AND/OR IMPROVEMENTS
LOCATED THEREON, THE NATURE OF THE PAST OR HISTORIC USE OF THE
IMPROVEMENTS, QUALITY, VALUE, FITNESS FOR PURPOSE, MERCHANTABILITY, OR
OTHERWISE. Buyer has satisfied himself/herself/itself, as to the title, type, condition, quality and
extent of the property and property interests which comprise the Improvements he/she/it is receiving
pursuant to this Contract.
ARTICLE IV
REPRESENTATIONS, WARRANTIES
AND COVENANTS OF BUYER
Section 4.1. Representations, Warranties and Covenants of Buyer. To induce Seller to enter
into this Contract and to consummate the sale and purchase of the Improvements in accordance
herewith, Buyer represents and warrants to Seller, as of the Date of Sale, that:
(a) Buyer has the full right, power and authority to purchase the Improvements from Seller
as provided in this Contract and to carry out all of Buyer's obligations under this
Contract, and all requisite action necessary to authorize Buyer to enter into this
Contract and to carry out Buyer's obligations hereunder have been, or on or before the
Date of Sale, will have been taken.
(b) Buyer hereby acknowledges that Buyer has been advised by Seller that it should
conduct, and Buyer acknowledges, and represents and warrants to Seller, that it has
conducted all investigation activities described herein.
(c) Buyer has not contracted or entered into any agreement with any real estate broker,
agent, finder, or any other parry in connection with this transaction and has not taken
any action which would result in any real estate broker commissions or finders' fee or
any other fee or fees payable to any other parry with respect to the transaction
contemplated in this Contract.
(d) Buyer shall comply with all applicable federal, state and local laws, statutes,
ordinances, rules and regulations relating, in any way, manner or form, to any aspect
of the transaction contemplated by this Contract.
Section 4.2. Survival Beyond Closing. The representations, warranties and covenants of
Buyer contained in this Contract, as set forth in this Article IV shall survive the Closing.
ARTICLE V
INDEMNITY AND RELEASE
Section 5.1. Indemnily. TO THE FULLEST EXTENT PERMITTED BY LAW, BUYER
RELEASES AND SHALL INDEMNIFY AND HOLD HARMLESS SELLER, AND SELLER'S
RESPECTIVE OFFICERS, EMPLOYEES, ELECTED OFFICIALS AND AGENTS, FROM AND
AGAINST ANY AND ALL CLAIMS WHICH ARISE DIRECTLY OR INDIRECTLY, OR ARE
RELATED, IN ANY WAY, MANNER OR FORM, TO THE TRANSACTIONS AND ACTIVITIES
CONTEMPLATED HEREUNDER, THE OMISSION OF THE TRANSACTIONS AND
ACTIVITIES HEREUNDER, OR CAUSED BY, CONNECTED WITH, OR RELATED TO THE
PRESENCE, DISPOSAL, OR RELEASE OF ANY MATERIAL OF ANY KIND INCLUDING,
WITHOUT LIMITATION, HAZARDOUS SUBSTANCES, AS DEFINED IN THE
COMPREHENSIVE ENVIRONMENTAL RESPONSE, COMPENSATION AND LIABILITY
ACT (42 U.S.C.S. §9601(14)), AND THE REGULATIONS PROMULGATED THEREUNDER, AS
EACH OF SAME MAY BE AMENDED, PETROLEUM AND PETROLEUM PRODUCTS AND
BYPRODUCTS AND/OR ASBESTOS IN ANY FORM, FROM OR UPON THE
IMPROVEMENTS AT THE TIME IT IS CONVEYED TO BUYER OR THEREAFTER, EVEN
THOUGH ANY OF THE ABOVE ARE CAUSED, OR CONTRIBUTED TO, BY THE
NEGLIGENCE OR FAULT OF SELLER, ITS RESPECTIVE OFFICERS, EMPLOYEES,
ELECTED OFFICIALS AND/OR AGENTS. THE BUYER FURTHER COVENANTS AND
AGREES TO DEFEND ANY SUITS OR ADMINISTRATIVE PROCEEDINGS BROUGHT
AGAINST THE SELLER, AND/OR THE SELLER'S RESPECTIVE OFFICERS, EMPLOYEES,
ELECTED OFFICIALS AND/OR AGENTS ON ACCOUNT OF ANY SUCH CLAIM, AND TO
PAY OR DISCHARGE THE FULL AMOUNT OR OBLIGATION OF ANY SUCH CLAIM
INCURRED BY, ACCRUING TO, OR IMPOSED ON THE SELLER, THE SELLER'S
RESPECTIVE OFFICERS, EMPLOYEES, ELECTED OFFICIALS AND/OR AGENTS, AS
APPLICABLE, RESULTING FROM ANY SUCH SUITS, CLAIMS AND/OR
ADMINISTRATIVE PROCEEDINGS OR ANY MATTERS RESULTING FROM THE
SETTLEMENT OR RESOLUTION OF SAID SUITS, CLAIMS, AND/OR ADMINISTRATIVE
PROCEEDINGS. IN ADDITION, THE BUYER SHALL PAY TO THE SELLER, THE SELLER'S
RESPECTIVE OFFICERS, EMPLOYEES, ELECTED OFFICIALS AND/OR AGENTS, AS
APPLICABLE, ALL ATTORNEYS' FEES INCURRED BY SUCH PARTIES.
Section 5.2. Survival Beyond Closing. The indemnity provisions contained in this
Contract, as set forth in this Article V, shall survive the Date of Sale.
ARTICLE VI
CONDITIONS PRECEDENT TO SELLER'S PERFORMANCE
Section 6.1. Breach of Buyer's Representations, Warranties and Covenants. Seller is not
obligated to perform under this Contract unless all of the representations, warranties, covenants and
agreements of Buyer set forth in this Contract are true and correct in all material respects as of the
Date of Sale.
ARTICLE VII
DEFAULTS AND REMEDIES
Section 7.1. Seller's Default, Buyer's Remedies.
(a) Seller's Defaults. Seller is in default under this Contract if Seller fails to meet, comply
with, or perform in any material respect any obligation on Seller's part required herein within the time
limits and in the manner required by this Contract.
(b) Buyer's Remedies. If Seller is in default hereunder, Buyer may, as Buyer's sole and
exclusive remedy, terminate this Contract and, following the expiration of five (5) calendar days after
written notice delivered to Seller, receive the Earnest Money as liquidated damages.
Section 7.2 Buyer's Default; Seller's Remedies.
(a) Buyer's Defaults. Buyer is in default under this Contract if Buyer fails to:
(i) meet, comply with, or perform in any material respect, any obligation on
Buyer's part required herein within the time limit and in the manner required
by this Contract; or
(ii) remove or cause to be removed any and all Improvements on the Property by
the 180th day after the Date of Sale.
(b) Seller's Remedies. If Buyer is in default under this Contract, Seller may terminate this
Contract and brinan action for specific performance or damages, and pursue any other remedy
available To —Seller -at law, in equity and under the terms of this Contract. The exercise of any right or
remedy shall not preclude the concurrent or subsequent exercise of any other right or remedy and all
rights and remedies shall be cumulative. Seller reserves the right to dispose of or remove any and all
Improvements remaining on the Property after 180 days from the Date of Sale.
ARTICLE VIII
NOTICE
Section 8.01. Notice. Whenever notice from Buyer to Seller or from Seller to Buyer is
required or permitted by this Contract and no other method of notice is provided, such notice shall be
given by (i) actual delivery of the written notice to the other party by hand or telephone facsimile (in
which case such notice shall be effective upon delivery); or (ii) by depositing the written notice in the
United States mail, postage prepaid, properly addressed to the other party at the address provided in
this article, registered or certified mail, return receipt requested, in which case such notice shall be
effective on the third business day after such notice is so deposited.
Section 8.02. Seller's Address. The Seller's address and numbers for the purpose of notice
are:
are:
SELLER: CITY OF LUBBOCK
Davy Booher
Right -of -Way Agent
P. O. Box 2000
Lubbock, Texas 79457
(806) 775-2352
Section 8.03. Buyer's Address. The Buyer's address and numbers for the purpose of notice
BUYER: Paulo and Gloria Flores
303 South Hyrshire
Crosbyton, TX 79322
(806) 549-5364
ARTICLE IX
MISCELLANEOUS
Section 9.01. Entire Agreement. This Contract, including all exhibits and parts hereof,
including the Invitation to Bid, Bid Form and Instructions to Bidders relating to Invitation to Bid
Number 16-13004-MA hereto (the "Contract Documents"), contain the entire agreement between the
Seller and Buyer, and there are no other written or oral promises, conditions, warranties, or
representations relating to or effecting the matters contemplated herein.
Section 9.02. Amendment. No amendment, modification, or alteration of the terms of this
Contract shall be binding unless such amendment, modification, or alteration is in writing, dated
subsequent to the date of this Contract, and duly executed by the Seller and Buyer.
Section 9.03. Construction and Venue. THIS CONTRACT AND THE TRANSACTIONS
CONTEMPLATED HEREIN SHALL BE GOVERNED BY AND CONSTRUED IN
ACCORDANCE WITH THE LAWS OF THE STATE OF TEXAS. THE PARTIES HERETO
HEREBY IRREVOCABLY CONSENT TO THE EXCLUSIVE JURISDICTION AND VENUE OF
THE COURTS OF THE STATE OF TEXAS, COUNTY OF LUBBOCK, FOR PURPOSES OF ALL
LEGAL PROCEEDINGS ARISING OUT OF OR RELATING TO THIS AGREEMENT OR THE
TRANSACTIONS AND ACTIVITIES CONTEMPLATED HEREBY.
Section 9.04. Severability. If any provision, or part thereof, of this Contract is ever held to
be invalid or ineffective by any court of competent jurisdiction with respect to any person or
circumstance, the remainder of this Contract and the application of such provision to persons and/or
circumstances other than those with respect to which it is held invalid or ineffective shall not be
affected thereby.
Section 9.05. Successors and Assigns. This Contract binds and inures to the benefit of the
Seller and Buyer, and to Seller's, and to the extent permitted, Buyer's, respective successors, legal
representatives, heirs, devisees and assigns.
Section 9.06. Risk of Loss. If any part of the Property is materially damaged or destroyed
by fire or other casualty loss, Buyer may either (i) terminate this Contract, provided that notice of
termination is given by Buyer to Seller, as provided herein, on or before the Date of Closing; or (ii)
accept the Property in its damaged condition and close the transaction contemplated by this Contract.
Section 9.07. Attorney's Fees. If either parry hereto shall be required to utilize an attorney
to enforce or defend the rights of such party hereunder, the prevailing party shall be entitled to
recover its reasonable attorney's fees. Except as otherwise provided herein, each party hereto shall
be solely responsible for all expenses, including but not limited to attorney's fees, incurred by him
or her, in connection with the Contract and the transaction contemplated hereby.
Section 9.08. Captions. The captions of articles and sections in this Contract are inserted in
this Contract strictly for the parties' convenience in identifying the provisions to this Contract and
shall not be given any affect in construing this Contract.
Section 9.09. Incorporation of Contract Documents. The terms and provisions of the
Contract Documents are hereby incorporated into this Contract for Sale for all intents and purposes.
Section 9.10.Non -Arbitration. The City reserves the right to exercise any right or remedy
available 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.
IN WITNESS WHEREOF, this Agreement is executed as of the Effective Date.
City of Lubbock, Texas:
DANIEL M. POPE, MAYOR
ATTEST:
4DAe-4�
eb cca Garza, City Secreta
APPROVED AS TO CONTENT:
Davy Boolier, Right of Way Agent
Buyer:
Printed Name: i CAL) 1 0- t_r 1.:�/L'v l t /u'r.5-
Title Jib
ALA bhoC 1;, 1 1C
VED AS TO VONTENT:
Woo(yFraAlin, P.E., Director of Public Works
APPROVED AS TO FORM:
Rydff r e, 746ant City A ey
City of Lubbock
Purchasing and Contract Management
ITB No. 17-13309-KW
Sale of Building Located at 4406 E. FM 835, Lubbock, TX
Exhibit "A"
11 t MUM
W�I115pu� �L .
Exhibit "B"
TO
CONTRACT OF SALE
BILL OF SALE
STATE OF TEXAS §
KNOW ALL MEN BY THESE PRESENTS
COUNTY OF LUBBOCK §
The undersigned, City of Lubbock, Texas, a Home Rule Municipal Corporation (the
"Grantor"), for and in consideration of the sum of FIVE HUNDRED DOLLARS ($500.00) and
other good and valuable consideration to Grantor in hand paid by Paulo and Gloria Flores ("the
Grantee"), the receipt and sufficiency of which are hereby acknowledged, has BARGAINED,
SOLD and CONVEYED and by these presents, does BARGAIN, SELL and CONVEY unto
Grantee, all of Grantor's right, title, and interest, if any, to the personal property located on Exhibit
"A" attached hereto and incorporated herein (the "Improvements").
Grantee has made an independent inspection and evaluation of the Improvements and
acknowledges that Grantor has made no statements or representations concerning the present or
future value of the Improvements, the condition, including the environmental condition of the
Improvements, or the anticipated income, costs, or profits, if any, to be derived from the
Improvements. FURTHER, GRANTOR MAKES NO REPRESENTATION OR WARRANTY
WHATSOEVER, EXPRESSED, STATUTORY, OR IMPLIED, INCLUDING, BUT WITHOUT
LIMITATION, AS TO THE DESCRIPTION, TITLE, VALUE, QUALITY, PHYSICAL AND
ENVIRONMENTAL CONDITION OF THE IMPROVEMENTS, MERCHANTABILITY, OR
FITNESS FOR PURPOSE OF ANY OF THE IMPROVEMENTS. Grantee further acknowledges
that he/she has relied solely upon his/her independent evaluation and examination of the
Improvements and public records relating to the Improvements and the independent estimates,
computations, evaluations and studies based thereon. Grantor makes no warranty or representation
as to the accuracy, completeness or usefulness of any information furnished to Grantee, whether
furnished by Grantor or any other third party and acknowledges that he/she is not relying upon any
such information. Grantor, its officers, employees, elected officials and agents assume no liability
for the accuracy, completeness or usefulness of the material furnished by the Grantor, or any of its
officers, employees, elected officials and/or agents, and/or any other third party. Reliance on any
material so furnished shall not give rise to any cause, claim or action against Grantor, its officers,
employees, elected officials and/or agents, and any such reliance shall be at Grantee's sole risk.
against Grantor, its officers, employees, elected officials and/or agents, and any such reliance
shall be at Grantee's sole risk.
THE CONVEYANCE OF THE IMPROVEMENTS IS ON A "WHERE IS", "AS IS"
AND "WITH ALL FAULTS" BASIS, AND SHALL BE WITHOUT REPRESENTATION OR
WARRANTY OF ANY KIND OR NATURE, WHETHER EXPRESS, STATUTORY OR
IMPLIED, INCLUDING, BUT WITHOUT LIMITATION, AS TO TITLE, DESCRIPTION,
PHYSICAL AND ENVIRONMENTAL CONDITION OF THE IMPROVEMENTS, QUALITY,
VALUE, FITNESS FOR PURPOSE, MERCHANTABILITY, OR OTHERWISE. Grantee has
satisfied his or herself, as to the type, condition, quality and extent of the Improvements and
property interests which comprise the Improvements he/she is receiving pursuant to this Bill of
Sale.
TO HAVE AND TO HOLD all of Grantor's right, title and interest in and to the
Improvements unto said Grantee and Grantee's successors and assigns forever, so that neither
Grantor nor Grantor's successors and assigns shall have, claim or demand any right or title to the
Improvements.
Effective this 13th day of April, 2017.
GRANTOR:
CI OF L BO K
GRANTEE:
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2017-188302
Date Filed:
04/05/2017
Date Acknowledged:
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Paulo and Gloria Flores
Crosbyton, TX United States
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
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.
17-13309
4406 E FM 835 Lubbock tx
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
5
Check only if there is NO Interested Party. ❑
X
6
AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
CRAIG DONALD BUGGENotary Public, State of Texas
'� My Commission Expires Signature of au orized agent of contracting business entity
.� July 17, 2017
Ell �ia`` -
AF ABOVE
i / n
Sworn to and subscribed before me, by the said !ti-ea 6- dJ�- ' G� �1�y17Tf9'the day of
20 to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.883
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1 of 1
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2017-188302
Date Filed:
04/05/2017
Date Acknowledged:
04/06/2017
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Paulo and Gloria Flores
Crosbyton, TX United States
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
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.
17-13309
4406 E FM 835 Lubbock tx
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling I
Intermediary
5
Check only if there is NO Interested Party.
X
6
AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.U.883