Contract - Freese & Nichols Inc. - 6/8/2017 STATE OF TEXAS §
COUNTY OF WILLIAMSON §
SUPPLEMENTAL CONTRACT NO. 1
TO CONTRACT FOR ENGINEERING SERVICES
FIRM: FREESE AND NICHOLS, INC. ("Engineer")
ADDRESS: 10431 Morado Circle, Suite 300,Austin, TX 78759
PROJECT: West Wastewater Treatment Plant Force Main
This Supplemental Contract No. 1 to Contract for Engineering Services is made by and between
the City of Round Rock, Texas, hereinafter called the "City" and Freese and Nichols, Inc.,
hereinafter called the "Engineer".
WHEREAS, the City and Engineer executed a Contract for Engineering Services, hereinafter
called the "Contract", on the 23rd day of February, 2017 for the West Wastewater Treatment
Plant Force Main Project in the amount of$40,629.00; and
WHEREAS, it has become necessary to amend the Contract to modify the provisions for the
scope of services and to increase the compensation by$35,087.00 to a total of$75,716.00;
NOW THEREFORE, premises considered, the City and the Engineer agree that said Contract
is amended as follows:
I.
Article 1, City Services and Exhibit A, City Services shall be amended as set forth in the
attached Addendum To Exhibit A.
II.
Article 2, Engineering Services and Exhibit B, Engineering Services shall be amended as set
forth in the attached Addendum to Exhibit B. Exhibit C, Work Schedule shall be amended as set
forth in the attached Addendum to Exhibit C.
III.
Article 4, Compensation and Exhibit D, Fee Schedule shall be amended by increasing by
$35,087.00 the lump sum amount payable under the Contract for a total of$75,716.00, as shown
by the attached Addendum to Exhibit D.
IN WITNESS WHEREOF, the City and the Engineer have executed this Supplemental
Contract in duplicate.
Supplemental Contract Rev.06/16
0199.1722;00378588 84275
FREESE AND NICHOLS, INC.
By:
Date
Supplemental Contract Rev.06/16
0199.1722;00378588 84275
2
CITY OF ROUND ROCK AP OVE AS TO FORM:
By:
_ /�M N-� -<�n1b
Craig Vor n, Mao 4StepL. Sheets, City Attorney
Date
Supplemental Contract Rev.06/16
0199.1722;00378588 84275
3
ADDENDUM TO EXHIBIT A
City Services
The City of Round Rock will furnish to the Engineer the following items/information as well as
services:
1. Record drawings and documents pertaining to projects in the area, including easement
documents, construction plans, test records, aerial photography, topography, system maps,
etc.
2. CAD files forthe 2012"BCRWWS West Wastewater Treatment Plan Rehabilitation
Project"will be provided by City of Round Rock.
3. City of Round Rock Standard Design Details and Specifications.
4. Perform Tree Survey of the alignment and procure necessary tree permits.
5. Advertise and distribute Bid Documents.
6. Facilitate the Pre-Bid Meeting.
7. The City of Round Rock will be responsible for environmental compliance with all local,
state, and federal laws.The Engineer will perform one site visit for environmental
investigation and will communicate findings to the City of Round Rock.
ADDENDUM TO EXHIBIT B
Engineering Services
Project Description
Provide additional design,bid and construction phase services for replacement of existing pumps and
valves for the WAS Lift Station at the West Wastewater Treatment Plant. Also,develop metes and
bounds for proposed pipeline easement, confirm no environmental issues exist,design new duplex
pump control panel and inspect electrical and control equipment to ensure it is compatible with
proposed pumps.
Basic Services:
Project Management
1. Update the Quality Assurance&Quality Control Plan for the project.
2. Provide monthly progress reports and invoices to the City of Round Rock(City).
3. Manage project integration, scope, schedules, cost, quality, staff resources, subconsultants,
communications,risk and procurements as necessary.
Preliminary Design Phase
1. Perform system curve calculations. Confirm existing pumps need replacement.
2. Perform site visit to inspect existing pumps/valves and determine scope of electrical work
required to replace existing pumps.
3. Provide metes and bounds documentation for Dedication for Wastewater Line Easement
around new forcemain and existing 27"sanitary sewer line,by subconsultant.
Design Phase
1. Identify and recommend proposed pumps.
2. Confirm pipe size for new forcemain.
3. Environmental investigation including one(1) site visit to perform a pedestrian survey of the
proposed ROW to verify that no environmental issues are present and a documenting
memorandum.
4. Provide 30%Pump Replacement Submittal,
5. Provide 30%plans and specifications for new duplex pump control panel.
6. Provide 30%plans and specifications for new submersible power cable from the pumps to the
SS terminal cabinet and from the terminal cabinet to the new pump control panel.
7. Produce additional 95%Specifications.
8. Produce additional 95%Plans(11"x17").
9. Perform Constructability Review on additional Plans/Specifications.
10. Provide additional cost items for 95% Opinion of Probable Construction Cost.
11. Provide additional Bid Plans and Specifications for pump and electrical design.
Bidding Phase
1. Produce additional sheets to incorporate into Conformed Plans and Specifications.
1
Construction Phase
1. Review additional submittals associated withthe project(10 additional submittals maximum).
2. Review additional RFPs associated with the project(2 additional RFls maximum).
3. Perform one additional site visit and one additional monthly progress meetings during
construction duration.
4. Produce additional sheets to incorporate into Record Drawings.
Additional Services:
The following services are not included in the scope of work. These services can be added by
amendment.
Design Phase
1. Design additional electrical improvements:
a. Replacing SCADA instrumentation.
b. Replacing existing conduits for new power cabling.
C. Replacing the feeder and/or circuit breakers upstream of the pump control panel.
d. Additional site visits beyond a site visit during preliminary design.
2. Additional Environmental Investigation:
a. Desktopreviews forwetlands and federally-listed species habitat.
b. Permitting coordination.
Assumptions:
1. CAD files for the 2012"BCRWWS West Wastewater Treatment Plan Rehabilitation Project"
will be provided by City.
2. New pump horsepower is anticipated to be the same, or less than,the existing pump
horsepower.
3. A new duplex pump station control panel will be designed. Existing feeder to Blower building
is assumed to be adequate and will be reused to re-feed new control panel. Control panel to be
mounted in same location as existing.
4. Existing control/monitoring wiring from pump control panel to SCADA terminal cabinet is
assumed to be adequate and will be re-used.Operation and monitoring of control
panel/pumps shall remain the same.It is assumed that no SCADA modifications will be
required under this contract.
5. The existing instrumentation will be re-used.This includes the level sensor/transmitter and
the combustible gas sensor/analyzer/controlpanel.
6. Existing conduit for the new cabling is adequate and will be re-used.
7. Existing floats will be re-used and re-configured for anticipated wet well liquid levels.
8. Existing wet well and valve vault will be re-used.
9. A maximum of one addendum will be issued.
10. The construction phase for the project will not exceed.
2
ADDENDUM TO EXHIBIT C
Work Schedule
Attached Behind This Page
Exhibit C-West Wastewater Treatment Plant Force Main-Supplemental Services Contract No.1
SID Task Task Name D.s.A.0o Start
Mode Fd+ah ;nnumy hp,li iuiY October January
i 12/18 2(12 4/9 6/4 7/30 9/24 11/19 I(14
1 o Notice to Proceed 0 days Mon 3/6/17 Mon 3/6/17 3/6
2 Preliminary Design Phase 60 days Mon 3/6/17 Fri 5/26/17
I
3 Pipeline Route Determination 7 days Mon 3/6/17 Tue 3/14/17
1
4 Topographic Survey and Boundary Survey 7 days Wed 3/15/17 Thu 3/23/17
5 44 Metes and Bounds Production 2 days Thu 5/25/17 Fri 5/26/17
6 s Geotechnical Investigation 20 days Wed 3/15/17 Tue 4/11/17
7 "v Design Phase 87 days Fri 3/24/17 Mon 7/24/17 yy.
e . " Develop 30%Pipeline Layout Schematic 3 days Fri 3/24/17 Tue 3/28/17
9 30%Review Meeting 0 days Wed 4/26/17 Wed 4/26/17 • 4E7
to Design pump replacement to 30% 14 days Tue 5/16/17 Fri 6/2/17
11 Production of 95%Specifications 21 days Thu 5/25/17 Thu 6/22/17 —.-
12 Production of 95%Plans 14 days Mon 6/5/17 Thu 6/22/17
13 Production of 95%OPCC 6 days Fri 6/23/17 Fri 6/30/17
14 95%Internal QC and Incorporation of Comments 5 days Mon 7/3/17 Fri 7/7/17
15 ' 95%Review by City 5 days Mon 7/10/17 Fri 7/14/17
1
16 3 95%Review Meeting 0 days Fri 7/14/17 Fri 7/14/17 j17/14
17 Production of Issue for Bid Plans and Specifications 6 days Mon 7/17/17 Mon 7/24/17 1.
18 p Bid Phase 15 days Tue 7/25/17 Mon 8/14/17 ,
19 Contract Preparation 30 days Tue 8/15/17 Mon 9/25/17 „
20 Construction 90 days Tue 9/26/17 Mon 1/29/18 (---
Task Project Summary Inactive Milestone Manual Summary Rollup Deadline
Project:Round Rock West WWTP Split +... External Tasks Inactive Summary Manual Summary W —""-""W Progress
Dater Fri 5/12/17 Milestone • External Milestone Manual Task 4� Start-only C
Summary Inactive Task Duratlon.onlY Finish-only 3
Page 1 .. ._
ADDENDUM TO EXHIBIT D
Fee Schedule
Attached Behind This Page
Exhibit D
Fee Schedule
Project Name: West Wastewater Treatment Plant Force Main -Supplemental Services Contract No. 1
Total Total Other
Task Labor Hours Loaded Labor Cost Direct Costs Subconsultants TOTALS
Task 1: Surveying 0 $0.00
$0.00 $4,043.00 $4,043.00
Task 2: Geotechnical Investigation 0 $0.00
$0.00 $0.00 $0.00
Task 3: Project Management, Preliminary Design and
Final Design 144 $24,316.00
$409.00 $0.00 $24,725.00
Task 4: Bid Phase 3 $524.00 $0.00 $0.00 $524.00
Task 5: Construction Phase 39 $5,634.00 $161.00 $0.00
$5,795.00
GRAND TOTAL: 186 $30,474.00 $570.00 $4,043.00 $35,087.00
* Rates for additional work are shown in Exhibit D-1 of the West Wastewater Treatment Plant Force Main contract
H.t.and Nkhd.,kxG
City of Round Rock Protect Foe Sunarta
Wast Wastewater Treatment Planm
t Force Main Amendment No.1 Baalc Servkas ..,:1,87
371552017 $peelai Service.
Detailed Cast Breakdown Tolai Pro ct l:J5i
Bask Sarvtces
Total
Phu. Task PrvJecl Rob
Total Rosin TotaL.bor Expense TEM Sob
b Total Effort
Tasks 4 Current Rau, BIII Rate-, $178 $156S157 We $209 $173 $173 3299 $299 5175 S17B $113 3:17 $137 $140 $137 Effort Eft t
P.Jaet Man."nvent
S S t S
lJpdate lite Dually Assurance d OuaMy Cantrd
Plan $ 1 S 5
Prevde monthly wogs.,.report.and m —,in 4
me CKy of Round Rock,Cny: 2 r• s 920 5 f
Msnaga PMI l mts9ralwn.cope schedule.
colt q.."M.!f.........subc«swkann
_-attcm nsk and procurements ac S $ $ - s -
na:.fury
Pn Hln nary t)..4M
5 S 5 S
Perform system curve cakvlatlans ,
) 1 471 1
Conh,m 11,,11:9 Pumps need,eplscamem ,
1 5 156
SO&visit to inspect pump%N.Wes and electneel 3 4 7 5 t!89 f 161 f S 1741
Prevd.mete,and bounds documentatlnn by
$ubcvn.Uttnnl. S S $ 4 043 3 4 043
Design Phase
S S S 3
Idenrfy and recommend proposed pump. 1 1
3 3 471 3 - s S 471
Confrtm wpe sue t«new lorcema:n ,
2 3 '.93 3 - $ f 297
Envllvnmental mestpativn and documenlman
mart. 1 4 5 S 630 S - $ - 3 630
Produce atldtlona195%$pecdrcalaM. 7 4 i 12 4 23 S 3873 S 20 $ - E 3...
Pmduca add i:xl95%Plan. 1 4 12 1 1 10 4 53 $ 8913 $ 104 1 - S 9917
C- mclatiNy Resaew on addkroO.1
P1.ns7SpeciIx Sons 4 - 6 $ 1 110 S - S 5 1 110
95%OPI—.of Prababte--.nM—I—Cast
- 4 3 70' S - S f 702
Addewnal OC 2 4 B S 1610 S 121 S - S 1774
Bid Plan.and Specdka8ont 23 S 3 997 $ - S f 7 987
Dldding Phase
$ - S - S f -
Produce aM0o 1 addenda If necessary
3 s $
S
Produce atlditwara
nai sheets to mcorple Into
Confomwd Plans and Sp.ahcahon, 2 3 7 524 S S - s 524
Conshuctlon Phase
-
Reviewadtl4wnalaubrtdlak 1 1 6 3 11 5 1 B13 S - 1 - 5 1 B13
Re—additional RFI, i 1
` 1 5 f 827 S - S - f 827
P.O.—one adddronal ut w 9 and ono addyon.1
monthly wopre s.meeting Z-g co tnii bon 4
4 f 124 S 161 S - f 785
Pint—fi I wek Ihmugh 1«Eiechkal Wo,k 4 4 i 712 3 - $ - 3 712
Prod..add:bonal shoals to nc p.,.le ml.
Record Otawmg. 1 1 4 4 10 S 1 658 f $ - f 1 658
-
S -
S S - 3 f
Total Daslc$.furca.Nourt B 28 2! 4 2 6 2 4 7 76 1 d 2 1181 S 70 4T4 S 570 f d 047 S IS 087
Tvlal Basic$ervket Labor Effort 3 1 424 j 4 958 S J 672 S 712 3 418 f 1 O]8 S J46 S e76 f 148] f 1]521! $ 178 3 452 1 3 i 296 j 2,05j
L9 ,mat-L91orr•wt-
Phaae Task Ea - sly R&W cdBmn:ng Bond- Giaslynd 01her -e,•., Oiher .'_reit Other Other Other Total Exp
pens.. e<h U•ar,c r,r;l,.. ... •n:1,: N
Isheel) laheetl learn) PAW I,a r-DDW
Effort
r, fig n
Prc)ect Management
t
Updala the Ou.idy Assurance 6 Ouakty Control
Plan $
Proved.monthly piog,. '.parts and Invmces tv
the Clry of Round Rock(City) ` s _
Manage p,a)ecl Ol.g,.Ii.n scope schedule,
1st qu.liry s!.it resources subconsuaanh
c nun.ri atwns,,Isle and woc ..omits es i
n��es:ary
1d4 L!ReaaacM,OLCRVMood Rmk Cry MWeaI,W/TP Fvice Man IRRKIT.12115up1Sm+cn Arendmer41U21.vN Odakd F1e_:peatlahrel-Wra1WWTP Fdceman,S'p*n wCon,w1
Preece W HktWs,Inc.
City of Round Rock Pro mt Fee Sumumary
West Wastewater Treatment Plant Force Main Amendment No,1 Baalc Services 35 987
5!1672017 Spe W Services -
Detailed Cost Breakdown Total Protect 75 067
Preliminary Design
5
Perform system curve calculations S
Confirm ensting pumps need replacement S
59.—11..,spec[pumpslralves and electrical
S 161
Provde metes and bounds documentation(by
Subcamuhanlj f -
Design Phase
S -
Identify and recommend proposed pumps +
f
Confirm pipe sure for new farcemam I S
Enwronmental invesbgabon and documentation
memo S
Produce.1d'Aicnal 95%Specifications a S ZO
Produce edd:h...195%Plans 4 415 S 104
Construclabil:ry Review on additional
PlanslSpecificahons f
95%Opinion or Probable Construction Cost S
Bid Plans and Specifications __. 415 f 124
Bidding Phase
S -
Produce additional addenda,it necessary S
Produce add;::...I sheets to incorporate mro
Conformed Plans and Specifications $
Construction Phase S
Review additonal submnels S
Renew addNanai RFPs S
Perform one additional site visit and one additional
monthly progress meeting during construction 1 S -
Perform final walk through for Electrical Work 339 f 161
Produce additional sheers to mcarparate into
Record Dnwsn s S
Teem Basis sarneea nems
Total Bas to Services Expenses Effort S S 721 f 3 S 40 $ S f 20a S f S S S S S f 5 0
Phu. Task Subconsunanta 'intend INeme 21 (Name 31 IName 41 Total Sub
c.-deet:
Effort
Project Management S
Update the Quality Assurance d Oual:ty Control
Plan 5
Provide monthly Progress!,pons and.,voices to
me City of Rcund Rock(City) f
Manage project mfagrabon scope schedules
coal,quality stall resources subconsutants
m
comu kation,risk and pmcui emenis
necassary
Preliminary Design S
Perform system curve calculations S
Confirm mating pumps need reptacsmam
f -
Sea vtsd ro inspect pumpsfvalves and eliou—t S
Providemetes and bounds documentation Iby
Subcansultant) 7650 S 4047
Design Phase
S -
Identify and recommend proposed pumps S
Cantam pipe arse for new mrcemain
5 -
Environmental mvest:gahcn and documentation
memo S
Produce additional 95%Specifications S
2 d 4 L iSI—ceslOLCRIR1Roud Rack Cry oM1W nr WY/TP Feica Man IRRnI T212)LSuot S—Merdmer4 11RerssN Dna i tea SPre4da!aes-W-W WTP Forceman Sul,,_iksk,Coated t
Fre,.and NkhW,.klc
City of Round Rock M Fee Summa
ry
West Wastewater Tmarrnent Punt Force Main Amendment No,1 Basic S.,A.. 35 087
5/182017 speclal SerMce. -
Detallad Cost 8-1cd—it Total Project 35 087
Produce addmon.195%Plan%
S
Constluctabalty R.—on add,fi—I
PlanslSpauficnlons
$
95%Op.tlon of Prob.We C...t—hon Cost S
BM Plan. no Sp-A-1,ona
$
BMdag Phase
S -
Produce edddion.1 edd..d..If necessary 3
Produce adMhonal sheets to,n-u-1.elle
CZlon—d Pians and SpecOmahons S
Con.I—bon Phase 3
Rewew addaronal.ubn.hais S
R—edf.nal RFI'.
f
Pedmm one addalwlel.Ile-4 and one.ddd—1
—Ighiy progress mea1n9 d.nng con.buclion
3
Pedwm itn.l walk Ihrough for Efecf.ai Worts S -
Preduce.dddronel•heel.lolnearporale Into
Record Orawi f
S
Total Bole SerMpe.Subeonsuttants Ga.l 3 3,150
Total B..k serNee.Subeon.uttant.ERon ! 4 dal f f 3 - f 3 f 3 S 3 It
Sala
1-111es m%GLCRVIWo Rock UycllWnlYNJiP Fucs Man lRRk772iZ115t</5ervan arnmdmere twnaed Denko Fee_SPeMt.el-W,IWWTP Fvicem.n Suppknrcnd Conradi SriYZ017
1501 Chisholm Trail Road
r. Suite 103
IN 1_ A N ) t! Round Flock, TX 78681
512-238-1200
C �L )DF"I'lC-S , 512-238-1251 fax
PROFESSIONAL LAND SURVEYORS TBPLS Firnn Reg. No. 10059100
2 May 2017
Kira Iles, P.E., ENV SP
Water/Wastewater Treatment,Transmission: and Utilities
Freese and Nichols. Inc.
10431 Morado Circle, Ste.300
Austin,TX 713759
RE: Boundary Surveying
Project. Brushy Creek West WWTP WWL Irnprovement Project Easernent Preparation
Ms lies
Inland Geodetics, LLC (Inland) Is pleased to submit our proposal for professional land surveying services
related to the above referenced project. Our proposal Is to generate a survey plat and accompanying
metes and bounds description for the CORR tract proceeding northerly from the plant and crossing Brushy
Creek
Below is a specific list of our proposed Scope of Services and estimated costs
SCOPE OF SERVICES
1. Inland will recover and calibrate to the nearest CORR GPS Control System Monument to the
project. The values will be relative to NAD 83 Texas State Plane Coordinates, Central Zone 4203
(GRID values scaled to surface position).
2. Inland will survey and depict improvements within the tract (if any) Tho data wi l include edges of
pavement, fences, buildings, fences, adjoiner property corners, utilities and other pertinent
Information to boundary reconstruction
3. Inland will perform sufficient research and field surveying to determine the boundary of the
affected tracts as limited above.
4. Inland will prepare a survey plot with accompanying metes and bounds description for one
parcel.
NOTE: Title review is not included In this proposal. If this service is required, an additional $500.00 will be
added to fee.
The ESTIMATED fee for the above services: $ 3,850.00
Additional time requirements resulting from project scope changes, plan revisions, field recovery of or
discrepancies of control provided will be considered reasonable cause for us to seek additional
compensation for services not included In these amounts. A valid tax exemption certificate from the City
of Round Rock for purchase of taxable goods and services will be required for this task
Sinc jereelly, 1
M.Stephen Truesdnle
Registered Professional Land Surveyor
Licensed State Land Surveyor
Inland Geodetics, LLC
CERTIFICATE OF INTERESTED PARTIES
FORM 3.295
1of1
Complete Nos.l-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. 2017-213627
Freese and Nichols, Inc.
Fort Worth,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 05/25/2017
being filed.
City of Round Rock 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
W.WWTP Force Main-Sup Con#1
Engineering Services
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Coltharp, Brian Fort Worth,TX United States X
Pence, Bob Fort Worth,TX United States X
Herchert, Robert Fort Worth,TX United States X
Payne,Jeff Frisco,TX United States X
New,John San Antonio,TX United States X
Hatley,Tricia Oklahoma City,OK United States X
Gooch,Tom Fort Worth,TX United States X
Milrany,Cindy Fort Worth,TX United States X
Nichols, Mike Fort Worth,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.
r r a SUSANNE M.JOHNSON
* Notary public,Sure of Texas
may,Expir"03-19-2020
Notary 1012693216-4
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP/SEAL ABOVE
Swom to and subscribed before me,by the said Kelly J. Shriver -.this the 25th day of May
20 17 ,to certify which,witness my hand and seal of office.
A 1 n la 1/ r 1
1 _ 1 Susanne M. Johnson Notary
ignature of officer admi f tering 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
77
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. 2017-213627
Freese and Nichols, Inc.
Fort Worth,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 05/25/2017
being filed.
City of Round Rock Date Acknowledged:
05/25/2017
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.
W.WWTP Force Main-Sup Con#1
Engineering Services
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Coltharp, Brian Fort Worth,TX United States X
Pence, Bob Fort Worth,TX United States X
Herchert, Robert Fort Worth,TX United States X
Payne,Jeff Frisco,TX United States X
New,John San Antonio,TX United States X
Hatley,Tricia Oklahoma City,OK United States X
Gooch,Tom Fort Worth,TX United States X
Milrany, Cindy Fort Worth,TX United States X
Nichols, Mike Fort Worth,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