Contract - Patin Construction, LLC - 6/27/2019 City of Round Rock,Texas Contract Forms
i Standard Form of Agreement: Section 00500
f City of Round Rock, Texas
Standard Form of Agreement between
Owner and Contractor
AGREEMENT made as of the
efday of ` in the year 20 ft.
BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City")
221 East Main Street
Round Rock,Texas 78664
and the Contractor Patin Construction LLC ("Contractor")
3800 W 2nd St
Taylor TX 76574
The Project is described as: Westside Trails Improvement Project
demolition and replacement of existing asphalt and
decomposed granite trail with concrete, installation and
purchase of various site amenities
The Engineer is: Brent Luck PLA
Luck Design Team LLC
9600 Escarpment Blvd,Suite 745-4
Austin TX 78749
For and in consideration of the mutual terms, conditions and covenants of this Agreement and all
accompanying documents between Owner and Contractor, the receipt and sufficiency of which are hereby
acknowledged,Owner and Contractor agree as follows:
ARTICLE I THE CONTRACT DOCUMENTS
The Contract Documents consist of this Agreement,Conditions of the Contract(General,Supplementary and
other Conditions), Drawings, Specifications,Addenda issued prior to execution of this Agreement, other documents
listed in this Agreement and Modifications issued after execution of this Agreement;these form the Contract,and are
as fully a part of the Contract as if attached to this Agreement or repeated herein.The Contract represents the entire
and integrated agreement between the parties hereto and supersedes prior negotiations,representations or agreements,
either written or oral.An enumeration of the Contract Documents,other than Modifications,appears in Article 7.
ARTICLE 2 THE WORK OF THIS CONTRACT
IContractor shall fully execute the Work described in the Contract Documents,except to the extent specifically
indicated in the Contract Documents to be the responsibility of others.
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ARTICLE 3 DATE OF COMMENCEMENT;DATE OF SUBSTANTIAL COMPLETION;DATE OF
FINAL COMPLETION
3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated
T,
below or provision is made for the date to be fixed in a Notice to Proceed issued by Owner.
3.2 The Contract Time shall be measured from the date delineated in the Notice to Proceed.
3.3 Contractor shall commence Work within ten ( 10 ) calendar days
from the date delineated in the Notice to Proceed.
3.4 Contractor shall achieve Substantial Completion of the items of Work listed on Attachment A to this
Agreement no later than one hundred twenty ( 120 )calendar days from issuance by Owner of Notice to
Proceed, and Contractor shall achieve Substantial Completion of the entire Work no later than
one hundred twenty ( 120 )calendar days from issuance by Owner of Notice to Proceed,subject to
adjustments of this Contract Time as provided in the Contract Documents.
3.5 If Contractor fails to achieve Substantial Completion of the Work(or any portion thereof)on or before the
date(s)specified for Substantial Completion in the Agreement,Contractor shall pay to Owner,as liquidated damages,
the sum of two hundred fifty dollars and No/100
Dollars($250.00 )for each calendar day that Substantial Completion is delayed after the date(s)
specified for Substantial Completion. It is hereby agreed that the liquidated damages to which Owner is entitled
hereunder are a reasonable forecast of just compensation for the harm that would be caused by Contractor's failure to
achieve Substantial Completion of the Work(or any portion thereof)on or before the date(s)specified for Substantial
Completion in the Agreement.It is agreed that the harm that would be caused by such failure,which includes loss of
expected use of the Project areas,provision of alternative storage facilities and rescheduling of moving and occupancy
dates,is one that is incapable or very difficult of accurate estimation.It is hereby agreed that if Substantial Completion
of the Work (or any portion thereof) is not achieved on or before thirty (30) days after the date(s) specified for
_ Substantial Completion in the Agreement,the Owner shall have the option to either collect liquidated damages as set
forth herein or to thereafter rely on its remedies under the Contract Documents and at law and in equity, including
without limitation,the recovery of actual damages.The date(s)specified for Substantial Completion of the Work(or
any portion thereof)in the Agreement shall be subject to adjustment as provided in the Contract Documents.
3.6 Contractor shall achieve Final Completion of the entire Work no later than one hundred fifty
( 150 )calendar days from issuance by Owner of Notice to Proceed.
ARTICLE 4 CONTRACT SUM
4.1 Owner shall pay Contractor the Contract Sum in current funds for Contractor's performance of the Contract.
The Contract Sum shall be five hundred forty-one thousand three hundred thirty-four and 65/100 dollars
($541,334.65 ),subject to additions and deductions as provided in the Contract Documents.
—' 4.2 Does the Contract Sum include alternates which are described in the Bid Form?
No . Yes X .If yes,please provide details below.
Alternate 3
Alternate 4
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ARTICLE 5 PAYMENTS
5.1 PROGRESS PAYMENTS
5.1.1 Based upon Applications for Payment submitted to Engineer and Owner by Contractor,and Certificates for
Payment issued by Engineer and not disputed by Owner and/or Owner's lender,Owner shall make progress payments
on account of the Contract Sum to Contractor as provided below, in Article 14 of the City of Round Rock General
Conditions,and elsewhere in the Contract Documents.
5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of
the month.
5.1.3 Provided that an Application for Payment is received by Engineer and Owner, and Engineer issues a
Certificate of Payment not later than the tenth(10th)day of a month,Owner shall make payment to Contractor not
later than the tenth(10th)day of the next month.If an Application for Payment is received by Engineer and Owner
after the application date fixed above,payment shall be made by Owner not later than one month after the Engineer
issues a Certificate for Payment.
- 5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by Contractor
in accordance with the Contract Documents.The schedule of values shall allocate the entire Contract Sum among the
various portions of the Work.The schedule of values shall be prepared in such form and supported by such data to
substantiate its accuracy as Engineer and Owner may require.This schedule,unless objected to by Engineer or Owner,
shall be used as a basis for reviewing Contractor's Applications for Payment.
5.1.5 Applications for Payment shall warrant the percentage of completion of each portion of the Work as of the
end of the period covered by the Application for Payment.
5.1.6 Subject to other provisions of the Contract Documents, the amount of each progress payment shall be
computed as provided in Article 14 of the City of Round Rock General Conditions.
5.1.7 Except with Owner's prior written approval, Contractor shall not make advance payments to suppliers for
materials or equipment which have not been delivered and stored at the site.
5.2 FINAL PAYMENT
5.2.1 Final payment, constituting the entire unpaid balance of the Contract Sum, shall be made by Owner to
Contractor when:
.1 Contractor has fully performed the Contract except for Contractor's responsibility to correct Work,
and to satisfy other requirements,if any,which extend beyond final payment;and
.2 a final Certificate for Payment has been issued by Engineer.
5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of
Engineer's final Certificate for Payment. In no event shall final payment be required to be made prior to thirty(30)
days after all Work on the Contract has been fully performed.Defects in the Work discovered prior to final payment
shall be treated as non-conforming Work and shall be corrected by Contractor prior to final payment,and shall not be
treated as warranty items.
ARTICLE 6 TERMINATION OR SUSPENSION
6.1 The Contract may be terminated by Owner or Contractor as provided in Article 15 of the City of Round Rock
General Conditions.
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6.2 The Work may be suspended by Owner as provided in Article 15 of the City of Round Rock General
Conditions.
ARTICLE 7 ENUMERATION OF CONTRACT DOCUMENTS
7.1 The Contract Documents,except for Modifications issued after execution of this Agreement,are enumerated
as follows:
7.1.1 The Agreement is this executed version of the Cityof Round Rock, Texas Standard Form of Agreement
between Owner and Contractor,as modified.
7.1.2 The General Conditions are the "City of Round Rock Contract Forms 00700," General Conditions, as
modified.
7.13 The Supplementary,Special,and other Conditions of the Contract are those contained in the Project Manual
dated April 8,2019
7.1.4 The Specifications are those contained in the Project Manual dated April 8,2019
7.1.5 The Drawings,if any,are those contained in the Project Manual dated April 8,2019
7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated
April 8,2019
7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form,and Addenda,if any,are those contained in the
Project Manual dated April 8.2019
7.1.8 If this Agreement covers construction involving federal funds, thereby requiring inclusion of mandated
contract clauses, such federally required clauses are those contained in the "City of Round Rock Contract Forms
03000,"Federally Required Contract Clauses,as modified.
7.1.9 Other documents,if any,forming part of the Contract Documents are as follows:
Construction Documents,Westside Trails Improvement Project
ARTICLE 8 MISCELLANEOUS PROVISIONS
8.1 Where reference is made in this Agreement to a provision of any document, the reference refers to that
provision as amended or supplemented by other provisions of the Contract Documents.
8.2 Owner's representative is: Katie Baker,Park Development Manager
City of Round Rock Parks and Recreation
301 W Bagdad Ave,Round Rock,TX 78664
512.341.3355
8.3 Contractor's representative is: Jimmy Patin,Vice-President
Patin Construction,LLC
3800 W 2nd St
Taylor,TX 76574
I 8.4 Neither Owner's nor Contractor's representative shall be changed without ten(10)days'written notice to the
other party.
8.5 Waiver of any breach of this Agreement shall not constitute waiver of any subsequent breach.
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8.6 Owner agrees to pay Contractor from available funds for satisfactory performance of this Agreement in
accordance with the bid or proposal submitted therefor,subject to proper additions and deductions,all as provided in
the General Conditions, Supplemental Conditions, and Special Conditions of this Agreement,and Owner agrees to
make payments on account thereof as provided therein. Lack of funds shall render this Agreement null and void to
the extent funds are not available. This Agreement is a commitment of City of Round Rock's current revenues only.
8.7 Although this Agreement is drawn by Owner,both parties hereto expressly agree and assert that,in the event
of any dispute over its meaning or application,this Agreement shall be interpreted reasonably and fairly,and neither
more strongly for nor against either party.
8.8 This Agreement shall be enforceable in Round Rock,Texas,and if legal action is necessary by either party
with respect to the enforcement of any or all of the terms or conditions herein,exclusive venue for same shall lie in
Williamson County,Texas. This Agreement shall be governed by and construed in accordance with the laws and
court decisions of the State of Texas.
8.9 Both parties hereby expressly agree that no claims or disputes between the parties arising out of or relating
Ito this Agreement or a breach thereof shall be decided by an arbitration proceeding,including without limitation,any
proceeding under the Federal Arbitration Act(9 USC Section 1-14)or any applicable state arbitration statute.
8.10 The parties, by execution of this Agreement, bind themselves, their heirs, successors, assigns, and legal
representatives for the full and faithful performance of the terms and provisions hereof.
This Agreement is entered into as of the day and year first written above and is executed in at least three(3)
original copies, of which one is to be delivered to Contractor, one to Engineer for use in the administration of the
_ Contract,and the reiiainder to Owner.
OWNER CO CTOR
CITY OF RO;r ROCK,TE
Printed Name: `v Printed Name:
_ Title I' `Wy 1 01r Title:
Date Signed: '!J . �- 1 Date Signed: �S l
ATTEST:
(4k L
City Clerk
FOR ,APPROVE AS TO FORM:
City Atto ey
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PERFORMANCE BOND BOND NO.: SUR0046066
THE STATE OF TEXAS §
KNOW ALL BY THESE PRESENTS:
COUNTY OF WILLIAMSON §
That Patin Construction,LLC of the City of Taylor County of
Williamson , and State of Texas , as Principal, and Argonaut Insurance Company
authorized under the law of the State of Texas to act as surety on bonds for principals, are held
and firmly bound unto THE CITY OF ROUND ROCK,TEXAS,(Owner),in the penal sum of
five hundred forty-one thousand three hundred thirty-four and 65/100 dollars
Dollars ($ 541,334.65 ) for the payment whereof, well and truly to be made the said
Principal and Surety bind themselves, and their heirs, administrators, executors, successors and
assigns,jointly and severally,by these presents:
WHEREAS, the Principal has entered into a certa' written Agreement with the Owner dated the
_ 0 '�
day of 20_K to which the Agreement is
hereby referred to and made a part hereof a fully and to the same extent as if copied at length
herein consisting of: Westside Trails Improvement Project
(Name of the Project)
NOW, THEREFORE, THE CONDITIONS OF THIS OBLIGATION IS SUCH, that if the said
I Principal shall faithfully perform said Agreement and shall, in all respects, duly and faithfully
observe and perform all and singular the covenants, conditions and agreements in and by said
Agreement, agreed and covenanted by the Principal to be observed and performed, including but
I not limited to, the repair of any and all defects in said work occasioned by and resulting from
defects in materials furnished by or workmanship of, the Principal in performing the Work
covered by said Agreement and occurring within a period of twelve(12) months from the date of
I Final Completion and all other covenants and conditions, according to the true intent and
meaning of said Agreement and the Plans and Specifications hereto annexed,then this obligation
I shall be void; otherwise to remain in full force and effect;
l J PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253,
Texas Government code, as amended, and all liabilities on this bond shall be determined in
accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at
length herein.
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00610 7-2009 Performance Bond
00090656
V
PERFORMANCE BOND(continued)
Surety, for value received, stipulates and agrees that no change, extension of time, alteration or
addition to the term of the Agreement, or to the Work performed thereunder, or the Plans,
Specifications, or drawings accompanying the same, shall in anywise affect its obligation on this
bond, and it does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the Agreement, or to the work to be performed thereunder.
IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument
this 22nd day of July , 2019 .
Patin Construction,LLC Argonaut Insurance Company
Princi �a Surety
Kenneth Nitsche
Printed Name _ Printed Name
By: ✓ By:
Title: /o e Title: Attorn -In-Fact
Address: 3800 West 2nd Street Address: A5 W.Washington,24th Floor
Taylor.TX 76574 Chicago,IL
Resident Agent of Surety:
Signa e
Ke eth Nitsche
Printed Name
143 E.Austin
Street Address
Giddings,TX 78942
City, State&Zip Code
F
Page 2
00610 7-2009 Performance Bond
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PAYMENT BOND BOND NO.: SUR0046066
THE STATE OF TEXAS §
§ KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF WILLIAMSON §
T That Patin Construction, LLC , of the City of Taylor County of
Williamson , and State of Texas as Principal, and Argonaut Insurance Company
authorized under the laws of the State of Texas to act as Surety on Bonds for Principals, are held
and firmly bound unto THE CITY OF ROUND ROCK, (OWNER), and all subcontractors,
workers, laborers, mechanics and suppliers as their interest may appear, all of whom shall have
the right to sue upon this bond, in the penal sum of
five hundred forty-one thousand three hundred thirty-four and 65/100 dollars Dollars
($ 541,334.65 ) for the payment whereof, well and truly be made the
said Principal and Surety bind themselves and their heirs, administrators, executors, successors,
and assigns,jointly and severally,by these presents:
WHEREAS, the Principal has entered into a certain written Agreement with the Owner, dated
the n '4�1— day of 'f 20-ft, to which Agreement is
hereby referred to and made a part hereof as Mly and to the same extent as if copied at length
herein consisting of. Westside Trails Improvement Project
(Name of the Project)
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said
Principal shall well and truly pay all subcontractors, workers, laborers, mechanics, and suppliers,
all monies to them owing by said Principals for subcontracts, work, labor, equipment, supplies
and materials done and furnished for the construction of the improvements of said Agreement,
then this obligation shall be and become null and void; otherwise to remain in full force and
effect.
PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253,
Texas Government code, as amended, and all liabilities on this bond shall be determined in
accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at
length herein.
k
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00090656
k.
PAYMENT BOND (continued)
Surety, for value received, stipulates and agrees that no change, extension of time, alteration or
addition to the terms of the Agreement, or to the Work performed thereunder, or the plans,
specifications or drawings accompanying the same shall in anywise affect it's obligation on this
bond, and it does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the contract, or to the work to be performed thereunder.
IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this Instrument
this 22nd day of July , 2019
Patin Construction,LLC Argonaut Insurance Company
Princi a Surety
< G f Kenneth Nitsche
Printed Name Printed Name
r
By: By:
Title: Title: A rneyZ-Fact
Address: 3 00 West 2nd Street Addres :.225 W.Washington,24th Floor
Taylor,TX 76574 Chicago,IL 60606
T4, Resident Age t of Sure
:.
Signa9e
Ken th Nitsche
Printed Name
143 E.Austin
Street Address
Giddings,TX 78942
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00090656
Luck Design Team,LLC
9600 Escarpment Blvd,Suite 745-4
Austin,Texas 78749
L U K DESIGN TEAM 512.810.0684
May 22, 2019
Michael Chau
Parks Development SPC
City of Round Rock
221 East Main Street
Round Rock, Texas 78664
Re: City of Round Rock Westside Trail Improvement Project
May 14, 2019 Bid Opening Recommendations
Dear Mr. Chau:
On May 14, 2019 the City of Round Rock received eight sealed bid proposal from prospective
contractor bids in association with the City of Round Rock Westside Trail Improvement Project. One
bid (from Avery's Lawn Care) was deemed unresponsive because not all parts of the bid form were
completed. LUCK Design Team, LLC evaluated the bid and checked for mathematical errors,
omissions and/or bid regularities.
The following is a summary of the bids, as submitted:
Contractor Base Bid Alternate Bid Base Bid
Total plus
Alternates
Bid Totals
D&S Concrete Contractors $573,788.25 $175,115.00 $748,903.25
Fazzone Construction Co., LLC $553,305.08 $186,183.76 $739,488.84
Myers Concrete Construction, LP $653,527.80 $234,959.00 $888,486.80
Partners Remodeling Restoration $576,614.05 $162,644.00 $739,258.05
and Waterproofing
Smith Contracting Co., Inc. $615,553.50 $208,992.00 $824,545.50
STR Constructors, LTD. $643,815.26 $162,857.09 $806,672.35
Patin Construction, LLC $421,984.85 $187,149.80 $609,134.65
On the next page is a list representing the order of the apparent bids (from low to high):
Page 1 of 3
L U C K DESIGN TEAM_
Low Base Bid Base Bid plus Bid Alternates
Bid Total
Order
1 Patin Construction, LLC Patin Construction, LLC
2 Fazzone Construction Co., LLC Partners Remodeling Restoration
and Waterproofing
3 D&S Concrete Contractors Fazzone Construction Co., LLC
4 Partners Remodeling Restoration and D&S Concrete Contractors
Waterproofing
5 Smith Contracting Co., Inc. STR Constructors, LTD.
6 STR Constructors, LTD. Smith Contracting Co., Inc.
7 Myers Concrete Construction, LP Myers Concrete Construction, LP
The apparent low bidder was Patin Construction, LLC. based out of Taylor, Texas with a base bid
total of $421,984.85. The apparent low bidder for the base bid plus alternates was also Patin
Construction, LLC with a base bid plus alternates bid total of$609,134.65.
D&S Concrete Contractors had a pricing discrepancy on their added base bid total; the corrected
base bid total reflected above is $0.25 higher than their written bid submitted. This corrected
base bid total did not change D&S Concrete Contractors' ranking as the apparent 3rd lowest base bid
bidder.
Fazzone Construction Co., LLC had six pricing discrepancies on their unit item base bid totals; the
correctedbase bid total reflected above is $180.51 lower than their written bid submitted. This
corrected base bid total did not change Fazzone Construction's ranking as the apparent 2nd lowest
base bid bidder. Additionally, Fazzone Construction had four pricing discrepancies on their unit item
alternate bid totals; the corrected alternate bid total reflected above is $54.69 higher than their written
bid submitted. This corrected alternate bid total plus the base bid total places Fazzone Construction's
ranking as the apparent 3rd lowest bidder.
Partners Remodeling Restoration and Waterproofing had one pricing discrepancy on their unit item
base bid totals; the corrected base bid total reflected above is $2,194.65 higher than their written bid
submitted. This corrected base bid total did not change Partners Remodeling Restoration and
Waterproofing's ranking as the apparent 4t" lowest bidder.
STR Constructors, LTD. had ten pricing discrepancies on their unit item base bid totals; the corrected
base bid total reflected above is $29.24 higher than their written bid submitted. This corrected
base bid total did not change STR Constructors, LTD's ranking as the apparent 6th lowest bidder.
Additionally, STR Constructors, LTD. had four pricing discrepancies on their unit item alternate bid
totals; the corrected alternate bid total reflected above is $38.32 higher than their written bid
submitted. This corrected alternate bid total plus the base bid total places STR Constructors, LTD.'s
ranking as the apparent 5th lowest bidder.
Patin Construction, LLC had one pricing discrepancy on their unit item base bid totals; the corrected
base bid total reflected above is $1,390.50 higher than their written bid submitted. This corrected
Page 2 of 3
L U C K DESIGN TEAM_
base bid total did not change Patin Construction, LLC's ranking as the apparent low bidder.
As stated above, Avery's Lawn Care's bid as the 8th bid submitted was deemed non responsive.
Addendum #1 was not acknowledged on the bid form and only 7 of the 22 unit price line items were
completed.
Upon review of the bids and contractor references in context of the City's budget for the park
improvements, we recommend that the City award a contract to Patin Construction, LLC for the base
bid improvement total of$421,984.85 plus the bid alternate #3 and #4 improvement total of
$119,349.80; therefore, we recommend that the City award a contract Patin Construction, LLC for
$541,334.65 for the City of Round Rock Westside Trail Improvement Project.
Please give us a call if you have any questions or comments.
Respectfully,
Brent Luck, PLA
Planner/ Landscape Architect
Page 3 of 3
CERTIFICATE OF INTERESTED PARTIES FORM 3.295
1of1
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. 2019-501133
Patin Construction LLC
Taylor,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 06/06/2019
being filed.
City of Round Rock Date Acknowledged:
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.
Westside Trail Improvements
Westside Trail Improvements Project-Sidewalk
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 �+
y , and my date of birth is
My address is77
r , y--
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in t County, State of e-, ,on the day of 20}�_�J .�.
---" -~•• -. (month) (year)
Signature of auth(6zed agent of contracting business entity
`" (Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.39f8039c
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. 2019-501133
Patin Construction LLC
Taylor,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 06/06/2019
being filed.
City of Round Rock Date Acknowledged:
06/12/2019
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.
Westside Trail Improvements
Westside Trail Improvements Project-Sidewalk
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)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 120
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.39f8039c