Contract - Chastang Ford - 1/24/2019 ffGACBUy CONTRACT PRICING WORKSHEET Contract Date
For MOTOR VEHICLES Only No.: 11`I`OG-I8 Prepared: 11/8/2018
I"Iris Worksireet iv prgp(rr'ed by Contractor and given to..iii User: If a PO is issrtedl, both t1'ac.=wtzews
MUST he faxedtv H GAC @ 713-993-4548. .Tlrereft)rre ple(tse tvoe oi,pr iitt legibIJ I1�. w
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dgc�enc)-: CITY OF ROUND ROCK Contrnetor: CHASTANG FORD
Contact MARSHALL REYNOLDS 1 rcpnrc�d
Person: tty: ED MILLER
Phonc: Phonc: 713-678-5007
Fay. Fax: 713-678-5001
FinaU: t ntai►: emiller a chastangford.com
tCock: B4 csrriptIon: 2019. TORI)F550 DIESEL
A.Product Item Base Unit Price Per Contractor's 1=1-GAC Contract: 33,749
B.Published Options-Itemize below-Attach additional slteet(s)if necessary-Include Option Code in description if applicable.
(Note:Published Options arc options which were submitted and priced in Contractor's bid.)
Description Cost Description Cost
165WB-165"W13/84"CA 174
512-SPARE TIRE/WFIEEL 350 VST-40-I 74456
68►1M-19500 GVWR 1155 DOT4-STRODE LIGHT KIT 675
X81,-4.88 LIMITED SLIP AXLE 360 DOT-SAFETY KIT-FIRE EXTINGUISHER AND REFL 195
90L-POWER EQUIP GROUP 915 STROBE W/SB AND-SINGLE MOUNT STROBES X2 990
62R-PTO PROVISION 280 DF 138-CONTBO PINTLE HITCH AND 2"BALL 375
CV i-ENGINEERING CHASSIS LAYOUT AND DESIGN 998 711RONGF-7 PRONG LIGHT PLUG INCL
585-Arvi/FM/MP3/SYNV 550 STROBE KIT DOT3 878
67P-7500 LB FRONT AXLE 285
FLRI-FLOOR PLAN INTEREST 14X210 29=10
IN -LOT INSURANCE 7 X 210 1470 Subtotal From Additional Sheet(s):
I SA-UPFITTER INTERFACE MODULE 295 Subtotal 13: 87341
C.Unpublished Options-Iterni-re below/attach additional shect(s)if necessary.
(Notc:Unpublished options etre items which were not submitted and priced in Contractor's bid.)
Description Cost Description Cost
FURNISH AND INSTALL ARROWSTICK 795 UPGRADE TO SST-40-EIH NIC
REAR SPRING UPGRADE 1178 REAR CAMERA 672
2400 W INVERTER 1087
Subtotal C: 3732
Check:Total cost of Unpublished Options(C)cannot exceed 25°x,of the total of the Base For this transaction the percentage is: 3%
Unit Price plus Published Options(A+I3).
D.Total Cost Before Any Applicable Trade-In/Other Allowances/Discounts(A+B+C)
Quari ity Ordered: i X Subtotal of A+B+C: 124822 = Subtotal D: 124822
E.H-GAC Order Processing Charge(Amount Per Current Policy) Subtotal E: 1000
F.Trade-Ins!Other Allowances/Special Discounts/Freight/Installation
Description Cost Description Cost
(ADD 52985 FOR 4X4)
Subtotal F: 0
Delivery Date: 240-270 DAYS ARO G.Total Purchase Price(D+E+F); 1Ss22
CERTIFICATE OF INTERESTED PARTIES FORM 1295
10f1
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. 2018-433852
Chastang Ford
HOUSTON,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 12/13/2018
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.
190783
ford f550 versalift
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party.
X
6 UNSWORN DECLARATION
My name is Gy /3r-R--z / ,,r i
1 , and my date of birth is
My address is r1
A� 17-Z U
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 20
(month) (year)
'tAai'ure of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711
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
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2018-433852
Chastang Ford
HOUSTON,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 12/13/2018
being filed.
CITY OF ROUND ROCK Date Acknowledged:
01/24/2019
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.
190783
ford f550 versalift
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party. ❑
X
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711