HomeMy WebLinkAboutResolution - 2017-R0245 - DACO Fire Safety Equipment - 07/13/2017Resolution No.2017-R0245
Item No.6.15
July 13,2017
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock,Purchase Order No.
10018426,encumbering funds in the amount of $1,154,388.86,awarded to DACO Fire
Safety Equipment Co.of Lubbock,TX,under Buy Board Contract No.524-17,for
Self-Contained Breathing Apparatus (SCBA)Paks and related equipment,fees and
expenses,and related documents.
Passed by the City Council this
ATTEST:
;becba Garza,CitvRebecca
I
lty Secretary
APPROVED AS TO CONTENT:
Lance Phelps,Fire Chief
APPROVED AS
July 13.2017.
DANIEL M.POPE,MAYOR
S:\cityatt\CCDOCS\RES.Daco_PO10018426_SCBAPaks.2017.doc
City of
*Lubbock
TEXAS
TO:
PURCHASE ORDER
DACO FIRE SAFETY EQUIPMENT
201 AVENUE R
PO BOX 5006
LUBBOCK Texas 79408 5006
SHIP TO:
Page -
Date -
Order Number
1
06/20/2017
10018426 000 OP
- 15619
CITY OF LUBBOCK
CENTRAL FIRE STATION COMPL
RAULSALAZAR
1515 EAST URSULINE
LUBBOCK Texas 79401
INVOICE TO: CITY OF LUBBOCK
ACCOUNTSPAYABLE
P.O. BOX 2000
LUBBOCK, TX 79457 BY:
Marta Alvarez, Director of Purchasing & Contract Management
Ordered 06/20/2017 Freight
Requested 07/31/2017 Taken By S SUMMERS
Delivery PER R SALAZAR REQ #50267 BUYBOARD 524-17
Description/Supplier Item Ordered Unit Cost UM Extension Request Date
SCBA Paks 179.000 10,205.0000 EA 1,826,695.00 07/31/2017
SCOX3414N22200401
Buy Board Discount 1.000 (672,306.1400) EA (672,306.14) 07/31/2017
Total Order
Terms NET 30 DAYS 1,154,388.86
This purchase order encumbers funds in the amount of $1,154,388.86 awarded to Daco Fire Safety Equipment of Lubbock, TX on
July 13 , 2017. The following is incorporated into and made part of this purchase order by reference: BuyBoard Contract 524-17
from Daco Fire Safety Equipment of Lubbock, TX. Resolution # 2017-F -) ,,4 c
CITY OF LUBBOCK
��V
Daniel M. Pope, Mmyor
ATTEST:
"--t
Rebe ca Garza, City Secretary
DACO FIRE EQUIPMENT
201 AVE R
PO BOX 5006
LUBBOCK, TX 79408
Phone # Fax #
8067630808 806-763-9151
Name /Address
LUBBOCK, CITY OF
PO BOX 2000
LUBBOCK, TX 79456
Ship To
LUBBOCK FIRE DEPT.
1515 EAST URSULINE
LUBBOCK, TX 79401
Estimate
Date Estimate #
6/14/2017 2828
Terms
Rep
FOB
tics 30
GD
Item
Description
Qty
Rate
Total
SCOX3414N22200401
4.5 Air -Pak X3 with Snap-Cliange with Standard
179
10,205.00
1,826,695.00
Harness and EZ-Scape Pro, Fixed Belt with No Escape
Rope, Regulator with Quick Connect Hose, Dual EBSS ,
No Airline Connection, SEMS II, 30 Minute 4500 psi
30 Year Life Cylinder 200128-35
DISCOUNT
DISCOUNT
-36.80451%
-672,306.14
BUYBOARD CONTRACT 524-17
Subtotal $1,154,388.86
Sales Tax (0.0%) $0.00
Total $1,154,388.86
NFPA 2013 EDITION SCOTT PRODUCTS
SCOTT AIR-PAK AND ACCESSORIES
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NFPA 1981 AND 19825
2013 EDITION
When the call comes in, there is one SCBA trusted more than any other by firefighters and emergency
responders throughout the world. The Scott Safety Air -Pak is the most trusted, durable and easy -to -use SCBA
in the fire service because only Scott Safety uses redundant safety features, has a low cost of ownership and
is firefighter -designed and -tested. Plus, the Scott Safety Air -Pak SCBA is the only SCBA to meet the stringent
requirements to be labeled "Made in the USA" It is no surprise that for over 80 years, hundreds of thousands
of firefighters have relied on the Scott Air -Pak every day.
Building on this tradition, Scott proudly offers a new platform of products which meet the requirements
established in the 2013 Edition of NFPA 1981 and 1982 Standards.
2013 EDITION NFPA 1981/1982 STANDARDS HIGHLIGHTS
• Increased facepiece lens durability requirements through two additional tests to measure facepiece
performance against high temperature, flame and radiant heat
• New voice intelligibility requirements to eliminate the subjectivity of the testing and enhance overall
intelligibility using new test protocols:
• Speech Transmissibility Index (STI) for improved repeatability and reproducibility in the test results
• Mechanical communication performance test protocol
• Amplified communication performance test protocol
• End -of -Service Time Indicator (EOSTI), or low air alarm, has moved from 25% to 33% of the cylinder's
operating pressure
• All PASS devices have a universal sound regardless of the manufacturer
• NFPA committee worked with NIOSH to establish minimum performance and approval requirements
for Emergency Breathing Support Systems, which were previously not approved for use
AV=3000 HT
FACEPIECE
Driven to meet the rigorous requirements of the 2013 Edition NFPA 1981/1982 Standards,
Scott Safety designed the AV-3000 HT facepiece, a platform enhancement to the Scott Safety
Air -Pak, the highly durable, comfortable and most trusted SCBA in the industry. The facepiece
is based on the industry -leading AV-3000 facepiece with SureSeal platform, and incorporates
next -generation material technology to enhance user experience and meet the stringent NFPA
2013 Edition Standards.
• BUILDING ON TRUST
The Scott Safety fire service -proven SureSeal technology is a reverse reflex sealing surface
designed for enhanced fit and comfort. The U-shape of the reverse reflex seal maintains a
continuous circumferential seal around the user's face, allowing the AV-3000 HT to flex with
every move.
• THERMAL DURABILITY
The AV-3000 HT meets the facepiece requirements set forth in the 2013 Edition of the NFPA
1981 Standard for high heat and flame and radiant heat by utilizing new lens and bezel materials.
These new materials provide enhanced thermal durability and enhanced wearer safety by
ensuring the facepiece stays under positive pressure when exposed to the heat and flame loads
measured under NFPA 2013.
• MAXIMUM VOICE INTELLIGIBILITY
In response to the voice intelligibility tests —one for mechanical communication and one for
electronic, or amplified, communications —included in the 2013 Edition Standards, the AV-3000 HT:
• Exceeds the mechanical measurement requirement with the redesigned location of the
ducts, nosecup and voicemitter
• Uses two voicemitters to provide a sphere of intelligibility to those around the respirator
wearer, not just the individuals directly in front of the wearer
• Enables right- or left -side mounting for Scott Safety EPIC 3 voice amplifiers, with a
robust communications bracket attachment
• COMPATIBILITY
Providing an upgrade path for current Air -Pak SCBA users, AV-3000 HT facepiece is
approved on all 2002 and 2007 Edition Scott Safety Air -Pak Fifty, AP75, NxG2 and NxG7
respirators. Current 2002 and 2007 users can utilize the AV-3000 HT with either the EPIC
or EPIC 3 voice amplification products, or with mechanical communications only.
• ADDITIONAL BENEFITS
• High -visibility inhalation valves for easy inspection and added safety
• Designed for Top -Down Convertibility, the AV-3000 HT will allow for a single facepiece
to be used for all NFPA/CBRN/NIOSH respiratory applications, reducing fit testing,
training and inventory for lower total cost of ownership (approvals pending).
Redesigned Ducts
Open Bracket with
robust attachment
High -temperature
Polycarbonate Lens
and High -temperature
Nylon Bezel
High-v1sibility
Inhalation Valves
Dr Left -side
inications Mount
AIR=PAK 75,
2013 EDITION
The Air -Pak 75 has been the leading SCBA used by first responders and municipal and industrial firefighters
since its introduction in 2007 The Scott Air -Pak has been trusted by more firefighters than all brands of SCBA
combined. The key reasons for its success are:
• Redundancy of Safety Features - giving firefighters confidence in their life-saving equipment and
allowing them to focus on the critical job at hand.
• Ease of Use - provides firefighters a simple -to -use and easy -to -understand SCBA that requires minimal
training, increases operational efficiencies and reduces training costs.
• Low Cost of Ownership - lower costs after initial sale through its rugged design, assembly and warranty
policy enables the department to direct valuable funding to training and other PPE rather than on
maintenance costs.
In order to meet the 2013 Edition of the NFPA 1981 and 1982 Standards, the following changes were
implemented:
1. Unit must be used with new AV-3000 HT facepiece
2. A new PASS device equipped with the universal PASS sound (required by NFPA 1982, 2013 Edition)
3. The new 33% End -of -Service Time Indicator (EoSTI) along with a gauge and Heads -Up Display (HUD)
that reflects the EoSTI changes
AV-3000
HT Facepiece
Vibralert Activated at
33% of Air Remaining
Remaining Indicator
X '* w
AM SUMLY
Gauge with
3396 Alarm Point
al PASS Alarm
AIR=PAK X3
The new Air -Pak X3 SCBA platform carries forward many of the features and designs
of previous Air -Pak models, including the redundant safety features, ease of use and
durability Scott Air -Pak users have grown to trust. The Air -Pak X3 was designed with
additional emphasis on enhancements to comfort, hose and wire management, weight
distribution, fire ground communications and serviceability.
Articulating Shoulder
Hidden hoses
and wires for a
streamlined design
"Check Console" Indicator
when PASS Console
requires attention
Vibralert at 33% •
of Remaining New Console with
Cylinder Pressure Large Sweep Gauge
and "External" HUD
Waist -Mounted Reducer available with either
a CGA or Snap -Change Cylinder Connection
EPIC 3 RI VOICE
COMMUNICATION SYSTEM
Voice Clarity and Field Radio Interoperability with Bluetooth® Technology
Communicate clearly and effectively on the fireground and easily switch from non -tactical to tactical
communications with the EPIC 3 Radio Interface (RI) Voice Communication System. We developed the
EPIC 3 RI system to address the changing communication needs of firefighters and emergency personnel.
The lack of clear fire scene voice communications is a leading concern for fireground situational awareness
and safety. Working closely with first responders around the world, Scott Safety developed the EPIC 3 RI
Voice Communication System — voice amplifiers, lapel speaker microphones, specialized accessories, and
programming utilities — to meet the demanding needs and conditions while complimenting the performance
and safety benefits of Scott Safety SCBA and personal protective equipment (PPE).
BEST -IN -CLASS FEATURES AND BENEFITS
• Enhances SCBA facepiece voice communication intelligibility and loudness
• Advances safety through easy -to -use wireless communication interoperability with mobile field radios
• Provides easy transition from non -tactical to tactical communication modes
• Ensures operational compatibility with both legacy and new Scott SCBA and PPE
• Consolidates device functionality to reduce technology costs
• Improves user communications from the incident scene to remote locations
Future -Proof Your Equipment
Upgrade capabilities and system compatibility with new and existing equipment make the EPIC 3 RI Voice
Communication System virtually future -proof so you can maximize your investment. The EPIC 3 RI System
delivers multi -purpose communications utility and system compatibility with new and existing equipment.
Specialized communication accessories can also be used with the Lapel Speaker Mic, allowing you to further
customize the EPIC 3 RI system to meet your specific requirements.
Supports connectivity and use with EPIC 3 communication accessories such as remote PTT Paddle, remote
ring PTT switch, command headset, throat microphone and earpiece, and other future accessories.
PATENTED CYLINDER
TECHNOLOGY
rt
Responding to the need for
smaller, lighter SCBA, Scott
Safety created the 5.5
Air -Pak SCBA. By increasing
the pressure in the cylinder to
S500 psig, Scott Safety was
able to maintain the traditional
form, durability and capacity
of the standard cylinder while
offering a significant reduction
in weight and profile. The
5.5 cylinders are available
in 30-minute, 45-minute,
60-minute and 75-minute
durations and compatible with
the Air -Pak 75 and Air -Pak X3
SCBA. To facilitate integration
into the fire service, Scott
Safety worked with leading
manufacturers to ensure the
cylinders work with existing
seats and brackets already in
the market.
r5COTT
ACCOUNTABILITY
PAK-ALERT PASS DEVICE
Compliant to NFPA 1982, 2013 edition, the Scott Safety Pak -Alert
integrated PASS device monitors and alerts for man -down situations,
utilizing the new universal sound required by NFPA 1982, 2013 edition..
All Pak -Alert PASS devices that are compliant with 2007 or 2013
Editions of NFPA 1982 may be upgraded to enable Pak -Tracker locator
functionality.
PAK-TRACKER FIREFIGHTER LOCATOR SYSTEMS
To complement the Pak -Alert, Scott Safety offers the Pak -Tracker
firefighter locator system. The Pak -Tracker enabled SCBA will notify
remote users of a man -down situation via the HHR (hand-held
receiver). The HHR is also a directional receiver that assists with
directing rescue teams to the down personnel.
SEMS II & BLUETOOTH® ENHANCED TELEMETRY
SEMS II includes all of the Pak -Alert PASS and Pak -Tracker locator
features but also provides a robust and reliable radio -frequency
network to provide PASS and air level status to incident command,
and sends evacuation requests to interior teams, reducing radio traffic
during emergency conditions. SEMS 11 utilizes a patented self -healing
mesh network, whereby each operating SEMS II enabled Air -Pak SCBA
acts as a repeater to help extend the range of the network.
Scott Safety Bluetooth® Enhanced Telemetry is a feature available on
the Scott Safety Air -Pak X3 SCBA that can be used in conjunction with
specific Motorola® APX radios to communicate PASS and air status
information to incident command in scenarios where SEMS II radio
connectivity may be limited due to building construction or other
environmental conditions.
SEMS II and Bluetooth Enhanced Telemetry are designed to integrate
seamlessly with the Scott Safety Imperium ICS for Windows solution
to provide critical telemetry information to incident command.
SELF -RESCUE
EZ-SCAPE PRO'"
Based on feedback from firefighters, Scott Safety developed the
EZ-Scape Pro- Integrated Self -Rescue Belt to improve performance and
provide greater versatility on the fireground. The belt is lighter, quicker
to deploy, and is equipped with an NFPA 1983 attachment point. Offered
in a one -size -fits -most configuration, the belt integrates seamlessly with
the Scott Air -Pak X3 SCBA and provides a double -pull adjustment in a
stronger, more versatile, and more comfortable configuration than the
existing OEM waist belt.
New features include a quick release buckle, one of the strongest
load -bearing buckles available, the Lightning GT hook for reduced weight,
and a belt -only option for maximum flexibility. A multi -use strap may
be used for a variety of different applications, including as a ladder belt,
positioning point, escape anchor, one -leg harness, and for RIT operation.
NFPA 2013 UPGRADE KITS
Upgrade legacy model Air -Pak SCBA to the most current edition of the
NFPA 1981 and 1982 standards with the new Air -Pak SCBA NFPA 2013
Compliant Upgrade Kit. The kit provides a lower cost alternative to
purchasing new SCBA, allowing fire departments to maximize the service
life of existing equipment (i.e. cylinders) without the burden of a full fleet
replacement. A new 10-year warranty provides peace of mind, knowing
that out-of-pocket maintenance costs are kept to a minimum.
Customers can also choose to take advantage of innovative technology
enhancements, including the Pak -Tracker'" Firefighter Locator System or
SEMS II Air Management System with Imperium Incident Command Suite.
Upgrading the operating pressure of the Air -Pak SCBA to 5500 psig is
also an option, allowing customers to realize the maximum benefits from
this Scott Safety "industry first."
Upgrade kits are offered for both the NFPA 1981, 2002 edition and NFPA
1981, 2007 edition Air -Pak SCBA.
ORDERING INFORMATION
SCBA CONFIGURATOR
SCBA Model
Wireframe
Air -Pak 75
Air -Pak X3 with CGA
Air -Pak X3 with Snap -Change
Wireframe less pads'
X3
Belt Type' Escape Rope / Anchorage Connector / Descender Regulator
Standards-'' Stantlartl Hose
50' wehhing / Crosby hook / =ire A_2 descender Quick Conned Hose
cZ-Scope I Rescue Belt
75' webbing / Crosby hook / =Ire A'_2 descender
EZ-Scat II small 50'T-Sat=rope/dosby hook/r4 cioscender'
--Z-Scape Pro. Jettison
EZ-Scape Pro. Fxed
=Z-Scape Pro. =:xed
(A'75)
�l
0�
®
2
1
3
`
®
7
1 Wireframe requires the use of the spring clip harness
2 EZ-Scape 1/11 available on AP75 and Wireframe SCBA only; EZ-Scape Pro available on AP75 or X3 SCBA as either a belt -only
configuration or full escape system
3 Lightning GT hook option only available on EZ-Scape Pro
4 Airline option not available on Air -Pak X3 SCBA or when dual EBSS is installed on Air -Pak 75 and Wireframe SCBA
5 SEMS II / Bluetooth available only with Air -Pak X3 SCBA
6 When ordering a case (soft or hard plastic) with any Air -Pak SCBA, you must choose one per box
NFPA 2013 UPGRADE KITS CONFIGURATOR
s LISS 'SCBA Style
Preassura
Regulator Hose
Regulator Console / G 9
Current Certification
Console's
Pnce includes a oewre90a/or
'
Rating
+•K•+..Wm.. •m ,.,: �..w...�;
`I=PA 198i - 2002
Wireframe SCBA
2216
Standard -iose
Standard Hose auge &HUD Only
Ncne
N=PA 1981 - 2002 (CBRN)
Air -Pak 50 SC3A
4500
Quick Disconnect -lose
Quick Connect Hose PASS
Wireframe SCBA
NFPA 1981 - 2007 (CBRN)
Au -Pak 75 SCBA -
5500
- PASS w/Pak-Tracker
Au -Pak Ill/ Al( -Pak 75
w/o Adlustabie Seats
SCBA
Air -Pak 75 SCBA -
PASS w/5=`•1511
Air -Pak 1IxG2 / Air -Pak NxG7
-,v/Adlustabie Seats
_
SC3A
Ai-=ak NxG2 SC3A
Air -Pak N.G2 SC3A - Reduc-
P N 200060 or 200061
Ar Pak NxG7 SCBA
w/o Adjustable Seats
_
Air -Pak NxG7 SCBA -
�
IM- w/ Adjustable Seats
I
13 U G X X "' A X X
l For those customers currently using Air -Pak 75 SCBA with the adjustable seat pressure reducer (part number 200925-01, 200925-02,
or200925-03), please select option 4.
2 For those customers currently using Air -Pak NxG7 SCBA with the adjustable seat pressure reducer (part number 200926-01, 200926-02,
or 200926-03), please select option 7.
201215-01
201215-02
201215-03
201215-04
201215-05
201215-06
201215-07
201215-08
201215-09
AV-3000 HT, small, Kevlar ,, - Fyn r, ,•
AV-3000 HT, medium, Kevlar
AV-3000 HT, large, Kevlar
AV-3000 HT, small, Kevlar with right bracket
AV-3000 HT, medium, Kevlar with right bracket ' °""" z �; ft`' trt r
AV-3000 HT, large, Kevlar with right bracket
AV-3000 HT, small, Kevlar with left bracket
tis.....k
AV-3000 HT, medium, Kevlar with left bracket
AV 3000 HT, large ;Kevlar with left bracket
Open bracket designed to connect the EPIC 3 Communication System to the AV-3000 H7 facepece to meet NFPA 1967. 201S Edition requirements
201275-02 EPIC 3 Voice Amplifier, Closed Bracket Configuration
201276-01 EPIC 3 Radio Interface Voice Amplifier, Open Bracket Configuration
a
" L ■e, nS d 22`GG_ Qpflone for use ikh,Mot rota HT1000 XTS series radios
�:.,.:.::..�,,.,..:..��,u:,µ..a,�...,....,:,.....,,�..�,,...:�m..
201224-04 EPIC 3 Lapel Speaker Microphone, for use with Motorola HT750/1250/1550 series radios
201224-07 EPIC 3 Lapel Speaker Microphone, for use with Kenwood TK280/290/380/390 series radios
201224-22 EPICS Lapel Speaker; Microphone, for use with Harris P ,,0/7300, Unity Series, XG series, rl
201277-04 EPIC 3 Bluetooth® Lapel Speaker Microphone, for use with Motorola HT750/1250/1550 series radios
201277 06 EPIC 3 Bluetooth0 Lapa a E or > to XPR Series,.APX;series radio_ s
201277-07 EPIC 3 Bluetooth® Lapel Speaker Microphone, for use with Kenwood TK280/2p90/380/390 series radios
lu
201277-22 EPIC 3 Bluetooth0R, Lapel Speaker Microphone, for use with Harris P5400/7300, Unity Series, XG series radios
• •
201228-01 EPIC 3 Throat
201243-01 EPIC 3 Bluetooth® Programmer Interface Module with USB cable
2016 Scott Safety. SCO TT. the SCO TT SAFETY Logo. Scott Health and Safety. Air -Pak, Air -Pk Fifty,
Air -Pak 75. AV-3000. SureSeat NxG2. NxG7. SEMS. Vbralert and EPIC are registered and/or unregistered marks of Scott
Technotogies, inc or its affiliates
Monroe Corporate Center • PO. Box 569 • Monroe. NC 28711
Telephone8002477257 • Facsimile 704.2918330
www.scottsafety com • sh-sale@tycointcon,
Kevlarrs is a registered trademark of Et Dv Pont de Nemours and Company.
HIS 7090C EN 6/76 ISO 9001 Registered All rights reserved
®Contract Holder � 5ISCOTT
canon cs-otp-sss�, A F 6 T Y
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1of1
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:
2017-223941
Date Filed:
06/14/2017
Date Acknowledged:
06/21/2017
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Daco Fire Equipment
Lubbock, 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.
524-17
SCOTT AIR PAKS
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
1-orms provided by I exas Ethics Commission www.ethics.state.tx.us Version V1.0.883
CERTIFICATE OF INTERESTED PARTIES FORM 1295
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 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.
2017-223941
Daco Fire Equipment
Lubbock, TX United States
Date Filed:
06/14/2017
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 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.
524-17
SCOTT AIR PAKS
Nature of interest
4
Name of Interested Party
City, State, Country (place of business)
(check applicable)
Controlling I
Intermediary
5 Check only if there is NO Interested Party. ❑
6 AFFIDAVIT I swear, or affirm, a er pens y of perjury, that the above disclosure is true and correct.
TEIN
LIC" -
"*' *;62
asSignature of authorized agent of contracting business entity
-2020
M
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said E (�%�� this the l day of� (1
20_, to certify which, witness my hand and seal of office.
� L , n
Signature of officer bninistering oath Printed name of officer administering oath Title of officer adrdnistering oath
Forms provided by Texas Ethics Commission www.ethics, state.tx,us Version V1.0.883