HomeMy WebLinkAboutResolution - 2017-R0159 - Ronco Fire Protection, LLC - 04/27/2017Resolution No.2017-R0159
Item No.6.23
April 27,2017
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and
on behalf of the City of Lubbock,Contract No. 13251 and related documents for fire
suppression systems certification and repair for Citibus as per ITB 17-13251-TF,by and
between the City of Lubbock and Ronco Fire Protection,LLC,of Abernathy,Texas.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 CityCouncil.
Passed by the City Councilon April 27,2017
ATTEST:
aMjL^e-
Rebecca Garza, City Secretary
APPROVED AS TO CONTENT:
Ho\y6rtori,Assistant uity^.Manager
APPROVED AS TO FORM:
Justin Pfcuitt,Assistant City Attorney
DANIEL M.POPE,MAYOR
ccdocs/RES.Contract 13251 -Ronco Fire Protection,LLC-Citibus Fire Suppression Systems
February 27,2017
Resolution No. 2017-RO 159
Contract 13251
City of Lubbock, TX
Contract for Services
Fire Suppression Systems Certification and Repair for Citibus
THIS CONTRACT made and entered into this 2711 day of April, 2017, by and between the City of
Lubbock ("City"), and Ronco Fire Protection, LLC, ("Contractor").
WITNESSETH:
WHEREAS, the City of Lubbock duly advertised for bids for Fire Suppression Systems
Certification and Repair for Citibus and bids were received and duly opened as required by law; and
WHEREAS, after careful consideration of the bid submitted by Contractor, the City authorized
the execution, in the name of the City of Lubbock a contract with said Contractor covering the purchase
and delivery of the said Fire Suppression Systems Certification and Repair for Citibus.
NOW, THEREFORE, in consideration of the mutual agreement contained herein, as well as the
financial consideration hereinafter referred to, the parties hereby covenant and agree as follows:
1. In accordance with City's specifications and Contractor's bid, copies of which are attached
hereto and made part hereof, Contractor will deliver to the City, Fire Suppression Systems
Certification and Repair for Citibus and more specifically referred to as Items One thru Seven
on the bid submitted by the Contractor or in the specifications attached hereto.
2. The City promises and agrees to employ, and does employ, the Contractor to cause to be done
the work provided for in this Contract and to complete and finish the same according to the
attached specifications, offer, and terms and conditions contained herein.
3. The Contractor shall perform the work according to the procedures outlined in the Bid Form
and Specifications attached hereto. The contract shall be for a term of one year, with the option
of four, one year extensions, said date of term beginning upon formal approval. The City does
not guarantee any specific amount of compensation, volume, minimum or maximum amount of
services under this contract.
4. This contract shall remain in effect until the first of the following occurs: (1) the expiration
date, (2) performance of services ordered, or (3) termination of by either party with a 30 day
written notice. Such written notice must state the reason for cancellation. 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.
5. Contractor shall at all times be an independent contractor and not an agent or representative of
City with regard to performance of the Services. Contractor shall not represent that it is, or hold
itself out as, an agent or representative of City. In no event shall Contractor be authorized to
enter into any agreement or undertaking for or on behalf of City.
6. SECTION A. 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.
INSURANCE COVERAGE REQUIRED
SECTION B. The City reserves the right to review the insurance requirements of this section
during the effective period of the contract and to require adjustment of insurance coverages and
their limits when deemed necessary and prudent by the City based upon changes in statutory
law, court decisions, or the claims history of the industry as well as the Contractor.
SECTION C. The Contractor shall obtain and maintain in full force and effect for the duration
of this contract, and any extension hereof, at Contractor's sole expense, insurance coverage
written by companies approved by the State of Texas and acceptable to the City, in the following
type(s) and amount(s):
TYPE OF INSURANCE
GENERAL LIABILITY
® Commercial General Liability ❑ Other
❑ Claims Made ® Occurrence
❑ W/Heavy Equipment
❑ To Include Products of Complete Operation Endorsements
PROFESSIONAL LIABILITY
AUTOMOTIVE LIABILITY
®
Any Auto
❑
Scheduled Autos
❑
Non -Owned Autos
EXCESS LIABILITY
❑
Umbrella Form
GARAGE LIABILITY
❑ Any Auto
❑
BUILDER'S RISK
❑
INSTALLATION FLOATER
❑
POLLUTION
❑
CARGO
❑ All Owned Autos
❑ Hired Autos
COMBINED SINGLE LIMIT
General Aggregate $1,000,000
Products-Comp/Op AGG X
Personal & Adv. Injury X
Contractual Liability X
Fire Damage (Any one Fire)
Med Exp (Any one Person)
General Aggregate
General Aggregate
Combined Single Limit $1,000,000
Each Occurrence
Aggregate
Auto Only - Each Accident
Each Accident Aggregate
❑ 100% of the Total Contract Price
❑ 100% of the Total Material Costs
® WORKERS COMPENSATION —STATUTORY AMOUNTS OR OCCUPATIONAL MEDICAL AND DISABILITY
® EMPLOYERS' LIABILITY $1,000,000
OTHER: COPIES OF ENDOSEMENTS ARE REQUIRED
® City of Lubbock named as additional insured on Auto/General Liability on a primary and non-contributory basis.
® To include products of completed operations endorsement.
® Waiver of subrogation in favor of the City of Lubbock on all coverages, except
The City of Lubbock shall be named as an additional insured on a primary and non-contributory
basis and shall include waivers of subrogation in favor of the City on all coverage's. Copies of
the Certificates of Insurance and all applicable endorsements are required.
ADDITIONAL POLICY ENDORSEMENTS
The City shall be entitled, upon request, and without expense, to receive copies of the policies
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.
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 thirty (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 and Contract Management
City of Lubbock
1625 13'b Street, Room 204
Lubbock, Texas 79401
SECTION D. 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.
7. Neither the City nor the Contractor shall assign, transfer or encumber any rights, duties or
interests accruing from this Contract without the written consent of the other.
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.
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 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.
10. 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 nonappropriation 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 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 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.
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 on insurance from
the Subcontractor that complies with all contract insurance requirements.
12. This agreement includes incorporation of Federal Transit Administration (FTA) Terms. The
preceding provisions include, in part, certain Standard Terms and Conditions required by the
Department of Transportation (DOT), whether or not expressly set forth in the preceding
contract provisions. All contractual provisions required by DOT, as set forth in FTA Circular
4220.1F, are hereby incorporated by reference. Anything to the contrary herein
notwithstanding, all FTA mandated terms shall be deemed to control in the event of a conflict
with other provisions contained in this agreement. The Contractor shall not perform any act,
fail to perform any act, or refuse to comply with any requests which would cause Citibus to be
in violation of the FTA terms and conditions.
13. This Contract consists of the following documents set forth herein; Invitation to Bid 17-13251-
TF, Specifications, and the Bid Form.
IN 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 CONTRACTOR _
BY, -
Daniel M. Pop , Mayor Authorized Representative
ATTEST:
'Q &,, --'2
Rebe ca Garza, City Secreta
APPROVED S TO CON NT:
I.
Bill H erton, As City Manager
APPROVED AS TO FORM:
r,
tt, Assistant City Attorney
Print Name
Holy) .4—t-/e r,
Address
&Lh(,4)a(j %C
City, State, Zip ode
City of Lubbock, TX
ITB 17-13251-TF
Fire Suppression Systems Certification and Repair for Citibus
Specifications
Scope of Work
1. Inspection, Certification and Repair of "Amerex" type fire suppression systems on city
transit buses.
2. Work will include but not be limited to Semiannual certification, 12 year hydro test and
repair of systems. Removal of agent cylinder from bus, Hydrostatic Test Agent
Cylinder, rebuild Valve Body Assembly, replace AMEREX #05239 Quad Seals (2)
Recharge Agent Cylinder with AMEREX 550 ABC Chemical. Install a new AMEREX
#14036 Linear Actuator. Attach blow down adapter to agent line and blow out line to
remove any debris and check agent nozzle output. Replace Agent cylinder in bracket
connect all connections. Reset system and tag system. Onsite, afterhours and weekend
work.
Please include with bid, certificate of completed Training for Amerex Vehicle Fire
Suppression Systems and Gas Detection.
4. Citibus requires each vehicle certified and inspected to have a separate certification on
file at Citibus.
5. Exhibit A shows which vehicles have Amerex systems and which have Kiddie systems.
This agreement includes incorporation of Federal Transit Administration (FTA) Terms.
The preceding provisions include, in part, certain Standard Terms and Conditions
required by the Department of Transportation (DOT), whether or not expressly set forth
in the preceding contract provisions. All contractual provisions required by DOT, as set
forth in FTA Circular 4220.1F, are hereby incorporated by reference. Anything to the
contrary herein notwithstanding, all FTA mandated terms shall be deemed to control in
the event of a conflict with other provisions contained in this agreement. The Contractor
shall not perform any act, fail to perform any act, or refuse to comply with any requests
which would cause Citibus to be in violation of the FTA terms and conditions.
S: Purchase/Bid Does/ITB 17-13251-TF Fire Suppression Systems Certification and Repair for Citibus
1
BUS ROTATION SHEET EXHIBIT A
■ 1 7,1S)Dlp
NOVA .0•ARBOC STAFF VEHICLES
2001 AMERE 0001 0401 1301 AMERE 1601 OPERATIONS
2002 AMEREX 0002 0402 E1302AMERE 16023006
2003 AMERE 0003 0403 AMERE 1603 3007
2004 AMERE 0004 0404 AMEREX 1604 3008
2005 AMEREX 0005 0405 1605 3009
2006 AMEREX 0006 0406 1606 3010
2007 AMEREX 0007 1607 3011
2008 AMEREX 0008 1608 3012
2009 AMEREX 0009 e . 1609 3013
2010 AMEREX 0111 AF 1610 3014
2011 AMERE 0112 10602
601 1611 3015
2012 AMERE 0114 1612 3016
0603 1613 3018
0604 1614 3020
0 ' 0605 3021
2101 AMEREX 2060 AMEREX 0606 • ' = 3022
2102 AMEREX 2061 AMEREX 0607 2901 3023
2103 AMEREX 2062 AMEREX 2902
2104 AMEREX 2063 AMEREX I I - ' - • - • 2903 PINNIMA; WIN
2105 AMERE 2064 AMEREX 2904 0608
2106 AMERE 2065 AMEREX 0901 KIDDE 2056 2905 0783
2107 AMERE 0902 KIDDE 2057 2906 3017
2108 AMERE 0903 KIDDE 2059 2907
2109 AMERE 0904 KIDDE 2908
TOTAL 2110 AMEREitiBu
TACTIVE
0905 KIDDE 2909 C TLs FLEET
2111 AMERE ' • 0906 KIDDE 2910
2112 AMERE T92 2911 127
2113 AMERE T93 1 2912
2114 AMEREX H4 2913 FLEET
2115 AMEREX 1101 AMEREX 2914 BREAK -DOWN
2116 AMEREX 1102 AMEREX 2915 Fixed= 25
2117 AMEREX 2916 T/Tech= 50
2118 AMEREX Para= 33
Non Rev= 19
Printed: 2/3/2017 @8:48 AM
BID FORM
Fire Suppression Systems Certification and Repair for Citibus
City of Lubbock, TX
ITB 17-13251-TF
In compliance with the Invitation to Bid 17-13251-TF, the undersigned Bidder having examined the Invitation to
Bid and Specifications, and being familiar with the conditions to be met, hereby submits the following Bid for
furnishing the material, equipment, labor and everything necessary for providing the items listed below and agrees
to deliver said items at the locations and for the prices set forth on this form. A bid will be subject to being
considered irregular and may be rejected if it shows omissions, alterations of form, conditional alternate bids,
additions or alternates in lieu of the items specified, if the unit prices are obviously unbalanced (either in excess of
or below reasonably expected values), or irregularities of any kind. The Invitation to Bid 17-13251-TF is by
reference incorporated in this contract. The Bid Form must be completed in blue or black ink or by typewriter.
ITEM
QTY
DESCRIPTION
Price
Extended Cost
44
Initial Inspection, Certification and Repair of
"Amerex"
1.
fire suppression systems on City
$ 1 �5,�0
$ G („ O
✓( D
transit buses, as specified
,
2.
6
Initial Inspection, Certification and Repair of
"Kiddie" Fire Suppression Systems on City
$ S .
$ (0 7n0''0Q
Transit buses, as specified
3.
75
Semi -Annual Inspection (Twice Yearly)
$Cc c
$ $ I i WSCG
4.
46
Six Year Certification / Inspection, as needed
$
$ ID of (;)
ITEM
QTY
(+/-)
DESCRIPTION OF REPLACEMENT PARTS —
AS NEEDED
Unit Price'
Extended Cost
5.
10
End of Line Circuit Module AMEREX #
$ (��
COW
`
114010 (replace as needed)
6.
10
Detector Thermostat 350 Degrees F. AMEREX
$ �l ,{
)
OO
$ ,LIp,
I
# 140$8 (replace as needed)
!
ti
7
25
Backup Battery Pack AMEREX # 15960
$)OD
1� o
$ 3 05, 00
(replace as needed)
TOTAL(Items 1-7)
Ls3L,, b i t1 o V
•PRICE: F.O.B. Destination, Freight Pre -Paid and Allowed
Unless otherwise specified herein, the City may award the bid either Item -by —item or on an all -or -none basis for any
Item or group of items shown on the bid.
The City of Lubbock Is seeking a contract for Fire Suppression Systems Certification and Repair for Citibus with one
or more contractors. In order to assure adequate coverage, the City may make multiple awards, selecting multiple
vendors to provide the products desired, If multiple awards are in the best Interest of the City. A decision to make a
multiple award of this Bid, however, Is an option reserved by the City, based on the needs of the City.
PAYMENT TERMS AND DISCOUNTS - Bidder offers a prompt payment discount of !, net k calendar days.
Discounts will not be considered in determining low bid. Unless otherwise indicated on the Bid Form, payment terms will be
NET THIRTY DAYS. The City will pay the successful bidder within thirty days after the receipt of a correct invoice or after
the date of acceptance, whichever event occurs later. Discounts for prompt payment requiring payment by the City within a
stipulated number of days will be interpreted as applying within the stipulated number of calendar days after the date of receipt
by the City of a correct invoice or after the date of acceptance that meets contract requirements, whichever event occurs later.
Discounts for payment in less than ten days will not be considered.
MOST FAVOURED PRICING: The Bidder certifies that the price quoted is not in excess of the lowest price charged anyone
else, including its most favoured customer, for like quality and quantity of the products/services; does not include an element
of profit on the sale in excess of that normally obtained by the Bidder on the sale of products/services of like quality and
quantity; and does not include any provision for discounts to selling agents. If at any time during the contract period, the
supplier should sell or offer for sale to any other customer, an equal or less quantity of similar contract products of like or better
quality, at a lower net price(s) than provided herein, supplier agrees to notify the City and sell same product(s) at the lower
price(s) on all deliveries made during the period in which such lower price(s) is effective.
INTERLOCAL PURCHASING (optional): The City desires to make available to other local governmental entities of the State
of Texas, by mutual agreement with the successful bidder, and properly authorized interlocal purchasing agreements as
provided for by the Interlocal Cooperation Act (Chapter 791, Government Code), the right to purchase the same services, at
the prices quoted, for the period of this contract. Each bidder shall indicate on the Bid Form in the space provided below if
he/she will honor Political Subdivision orders in addition to orders from the City of Lubbock. Should these other governmental
entities decide to participate in this contract, would you (the bidder) agree that all terms, conditions, specifications, and pricing
would apply?
Other governmental entities that might have interests is this contract are Frenship Independent School District,
Lubbock Housing Authority, Lubbock County, Lubbock County Hospital District, Lubbock Independent School
District, South Plains Association of Governments, City of Texarkana, Texas Tech University, West Texas Municipal
Power Ag , Lynn County, and City of Wolfforth.
YES, NO
• If you (the bidder) checked YES, the following will apply:
• Governmental entities utilizing Interlocal Agreements for Cooperative Purchasing with the City of Lubbock will be
eligible, but not obligated, to purchase materiaWservices under the contract(s) awarded as a result of this solicitation.
All purchases by governmental entities other than the City of Lubbock will be billed directly to that governmental
entity and paid by that governmental entity. City of Lubbock will not be responsible for another governmental entity's
debts. Each governmental entity will order their own materials/service as needed.
THIS BID IS SUBMITTED BY �MPDV Ia_ R�je(402& corporation
Rk( , or a partnership consisting of
of the City of
organized under the laws of the State of
or individual trading as
State -TX Zip 7!2//
Bidder acknowledges receipt of the following addenda:
Addenda No. Date
Addenda No. Date
Addenda No. Date
Addenda No. Date
Officer Name and Title: & ra Ca.mlti — Q(A) h ---r
Please Print
Business Tclepbone Number ffin FAX:
E-mail Address: C.IariS ® rMl'ng- fe. tcyr)k (fibk7 - a !/Li
FOR CITY USE ONLY
Bid Form Item Number(s) Awarded to Above Named Firm/Individual:
Date of Award by City Council (for bids over $50.000): Date P.O./Contract Issued.
RETURN COMPLETED & SIGNED BID FORM ALONG WITH CITY OF LUBBOCK SPECIFICATIONS.
LABEL THE OUTSIDE OF YOUR SEALED BID WITH THE ITB NUMBER, THE CLOSING DATE AND TIME,
AND YOUR COMPANY NAME AND ADDRESS.
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.
2017-181432
Ronco Fire Protection LLC
Abernathy , TX United States
Date Filed:
03/22/2017
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 Acknowled ed:
04/05/2017
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.
13251
Fire Suppression Systems Certification and Repair for Citibus
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
Cantu, Christopher
Abernathy, TX United States
X
5 Check only if there is NO Interested Party. ❑
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 V1.0.883
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1of1
OFFICE USE ONLY
Complete Nos. i - 4 and 6 it there are interested parties. CERTIFICATION OF FILING
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
'1 Name of business entity filing farm, and the city, state and country of the business entity's place Certifcate 2017'Number:
181432
of business.
Ronco Fire Protection LLC
Date Filed:
Abernathy , TX United States 03/2212017
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed. Date Acknowledged:
City of Lubbock
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.
13251
Fire Suppression Systems Certification and Repair for Citibus
Nature of interest
4 Name of Interested Party City, State, Country (place of business) (check applicable)
Controlling lntermed
Cantu, Christopher
Abernathy, TX United States X
5 Check only if there is NO Interested Party. ❑
6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
LpAY Pinto i. �.3P1 C. $"'HCS V E-- 1-I0
* Notary Pubis, Staffs o i exas = .• :w._ ..._-�
�T 'r kph t �owissiori Expkes 05-18-2019 Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP ( SEAL ABOVE g
P
Sworn orn to and subscribed before me, by the said 1 ` , this the _. day of ?A
20, to certify which, witness my hand and 1-11 seal of office.
IiJ
Signature of officer adminiszeying oath Printed name of officer administering oath
Title of offieet)administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.883