Contract - Gear Cleaning Solutions, LLC - 11/12/2020CITY OF ROUND ROCK AGREEMENT
FOR PURCHASE OF FIREFIGHTER TURN0LJT GEAR CLEANING,
INSPECTION AND REPAIR SERVICES
WITH.
GEAR CLEANING SOLUTIONS, L.LC
THE STATE OF TEXAS §
CITY OF ROUND ROCK § KNOW ALL BY THESE PRESENTS:
COUNTY OF'"'ILLIAMSON §
That this Agreement for firefighter turnout gear cleaning, inspection and repair services
I.-, z_n
(TC-(`errcd to herein as the "Agreement") is made and entered into on this the day of
')01) )UND ROCK, TEXAS, a
month of WN NO2.0_1 20.4- � by and between the CITY OF R(
home -rule municipality whose offices are located at 2_,',21 East Main Street., Round Rock, Tcxas
78664 (referred to herein as the "City"). and GEAR CLEANING SOLUTIO\S, LLC,
whose
offices are located at.2.2.2.1 -\4anana Drive, Suite 190, Dallas, Texas 75-.'2..20 (referred to herein as
the "Services Provider")
RECITALS:
WHEREAS, City desires to have Services Provider proN.ride firefighting turnout gear
cleaning, iii.specdon and repair sen;ices,- and
WHEREAS, expenditures that are for procurement of items from 0111y One source are
exempt from competitive bidding requirements pursuant to Section .,2521.0A2.2,. of the Texas Local
Gov,crnmcnt Cade; and
WHEREAS., the City has determined that Services Provider is a sole source provider for
these services; and
WHEREAS, tfic panics desire to entcr into this A,grcenicnt to set fort-h in writing thc1i,
*%. I - respectiv % rights, duties, and obligations.,
NONN', THEREFORE, WITNESSETH:
That for and in consideration of the niu.tual promises contained herein and other good and
vultiable consideration. the rc;,6-.cipt and sufficiency of which are hereby acknowtedged,, the parties
mutually aaree as follows:
4
� -
1.01. DEFINITIONS
A. Agreement means the binding legal contract between City and Services Provider
t) -,
whereby City agrees to b1,11v specified services and Services Provider is obligated to provide said
services.
0 0 4_`, 52 4 77f 'ss 2
Ke 24:2.0
Be City means the City of Round Rock, Williamson and Travis Counties, Texas.,
C. Force Vlajeure means acts of God, strikes, lockouts, or other industrial
disturbances, acts oi' the public enemy, orders of any kind from the government of the United
States or the State of Texas or any civil or military authority., insurrections, riots, epidemics,
landslides, lightning, earthquakes, Tres, hturricanes, slorm5, []oocts, restraint of the ni
9overncnt
and the people, civil disturbances, explosions, or other causes not reasonably within the control
of the parry claiming such inability.
Do Services mean the,.. specified services herein or in the attached exhibit(s).
E. Services Provider m.eails Gear Cleaning Solutions, LLC, its successors or
assigns..
2.O1. EFFECTIVE DATE, DURATION, AND TERM
A. This Agreement shall be effective on the date it has been signed by both parties
40
hereto, and shall remain in full force and effect unless and until it expires by operation of the
term stated herein, or until terminated as set forth herein,
B. The term of this Agreement shall be for sixty (60) months from the effective date
hereof.
Co City reserves the righ' t to review the Services Provider's Perfonnance at any tl*me
i4,and may elect to teminate this Agreement with or without cause or may elect to continue.
3.01 CONTRACT
AND EXHIBIT-S
00
The services which are the subject matter of this Agreement are described in Exhibitit 160A150,I *CPand theY %# %W.-*are ftilla -Part ofthiee-
.s ARrment as if .eated herei.nin full. Exhibit "A""
andpages one 1) throughnine of this agreement, comprise the total Acement.t)w.Agreement.
4.01 ITEMS
A. T'he services which are the subject matter of this Agreement are described
generally in the attached Exhibit 06A,!"
Be This Agreement shall evidence the entire understanding and agreement between
the parties and shall supersede any prior proposals, correspondence or discussions.
C. Services Provider shall satisfactorily provide all items described in Exhibit "A"
within the con -tract term specified. A change; in any tern of this Agreement, -must be negotiated
and agreed to in all relevant details, and must be embodied in a valid Supplemental Agreement
as described in Section 9.01 herein.
5*0 1 COSTS
A. City agrees to pay foa• services and/or supplies during the term of this Agreement
at the pricing set forth at in Exhibit "A." Services Provider specifically acknowledged and
agrees that City is not obligated to use or purchase any estimated annual quantity of services.
Only if and when needed by City, the costs listed, on. Exhibit "A" shall be the ba,is of any
charges collected by Services Provider.
B. The City shall be authorized to pay Services Provider a total amount not -to -
exceed Tw-o Hundred Sixty -Six Thousand Seven Hundred Forty and 10/100 Dollars
($266,740.10) for the term. of this Agreement.,
6.01 INVOICES
40 1b
All invoices shall. include, at a minimum, the following information,,
A. Name and address of Senrices Provider;
B. Purchase Order Number;
('. Description and quantity of items received; and
Do Delivery dates.
7.01 N*ON-APPROPRIATION AND FISCAL FUNDING
This Aareeinent is a commitment o-f C-Ity's current revenues ontly, ttis understood and
areed that CI*ty shall have the r-reemene enan9 9 yi ht to terminate this A t at thd of City fiscayl ear
ilftw
if the governing body of City does not appropriate funds sufficient to purchase- the services as
determined by City's budget for the fiscal year in question. City may effect such termination by
&nving Services Provider a written notice of termination at the end of its then current fiscal year.
S.Ol PROMPT PAYMENT POLICY
In accordance with Chapter 2251, V.T.C.A., Texas Government Code-, any payment to be
made by City to Senrices Provider will be 'made within thirty (30) days of the date City receives
goods -under this Agreement, the date the performance of the services under this Agreement are
completed, or the date City receives a correct invoice for the goods or services, whichever is
later. Services Provider may charge interest on an overdue payment a.t the "rate in e('f:ece" on
September I of the fiscal year in which the payment becomes overdue, in accordance with
V.T.C.A_, Tcxas Government Code, Section 2251.025(bl. This Prompt Payment, Policy does not
applytopayments made bv Ci in the, event,
ty
so
A. There is a bona tide dispute between Ci*ty and Servi'ces Provi'der, a contractor,
subcontractorl, or supplierabout the goods delivered or the service performed that
causes the payment to be late-,: or
B. There is a bona tide dispute between Services Provider and a subcontractor or
between a subcontractor and its supplier about the goods delivered or the service
performed that causes the payment to be late;or
a
C. The terms of a f'cderal contract, grant, regulation, or statute prevent C.Ity- -f-jrom
41making a timely payment wt*th federal funds;or
in D* The invoice is not mailed to City strict accordance with any instruction on the
purchase order relating to the -payment.
9.01 SUPPLEMENTAL AGREEMENTS
The ternls of th-l's A.Ueemeiat may be modified by wri*ften Supplemental Agreement.heretoI YCitydul authorizedbyCityCouncil or the Cityifthe v determines that there. has been a significant change in. (1) the scope, complexity, or character of the services to be
performed; (2) the costs of the work* or (3) the duration of the work. Any such Supplemental
Agreement must be executed by both parties within the period specified as the teen of this
Agreement. Services Provider shall not perform any work or incur any additional costs prior to
the execution, by both parties, of such Supplemental Agreement. Services Provider shall make
no claim for extra. WOTk done or materials ftimi*s'hed unless and unt1*1 there 1*s full executi"on of any
Supp,not responsibleemental Aa-reement and the CitY. S for actionsby Services Pr(",)vidcr
nor for any costs incurred by Services Provider relating to additional work not directly
authorized by Supplemental Agreement.
�33�t[BES'
10.01 G�TUITtESRAND
Citymay, by wrt"tten nobice to Senli.ces Provider, cancel this Agreem,ent wl^thout incurring
any liability to Services Provider if it is determined by City that gratuities or bribes in the form of
entertainment, gifts, or otherwise were offered or given by Services Provider or its agents or
representatives to any City officer, employee or elected representati*ve with respect to the
performance. of this Agreement. In addition, Services Provider may be subject to penalties stated
in Title 8 of the Texas Penal Code.
11.01 TAXES
City is exempt from Federal Excise and State Sales Tax* therefore, tax shall not be
included in Services Provider's charges.
12.01
Services 'Provider shall meet al1 City of Round Rock'InSUrance Requirc;menis at,
set
htt-p:,//w�v-Nv.round-rocktexas,._eov* -content/up1oads/,';1.() I 4/12/*corr insurance 07.2011?.pdf:
13.Q1 CITY'S REPRESENTATIVE
City Vherebdesignates the following representative authori*zed Lo act in its behalf with
re9ard to
Charles Dittman
Assistant Fire Chief'
203 Commerce Boulevard
Round Rock(, Texas 78664
512-6? 1 -2776
14.01 RIGHT TO ASSURANCE
Whenever either party to this Agreement, in Good fai*th3 has reason to question the other
pariy's intent to perform hereunder, then demand -may �made to the other party for written
is a.assurance of the 'intent to perform. In the event that no written assurance given within the
reasonable time speci-Fied when demand is made, 'then and in that event the demanding party may -
treat such failure as an anticipatory repudiation of this Agreement,,
15.01 DEFAULT
If Services Provider abandons or defaults -under this Agreement and is a cause of City
purchasing the specified goods anti services elsewhere, Services Provider agrees that it may be
charged the difference in cost, if any, and that it will not be considered in the re -advertisement of
the senli*cc- and that it maY not be consideredd inn t�'ttture bids for the same. tyne o-f-workunless the
scope of work is significantly changed.
Services Provider shall be declared in default of this Agreement if it does any of the
following:
A. Fails to fully, timely and faithfully perform any of its material obligations
under this Agreement;
Bo Fails to provide adequate assurance of performance under the "Right to
Assurance" section. herein; or
C , :Becomes insolvent or seeks relief under the bankruptcy laws of the United
States.
16001 TERMINATION AND SUSPENSION
A. The City has the right to terminate this Agreement, in Whole ar in part, for
(30) days' writtento the Services
convenience and without cause, at any ti*me upon thirty
Provider.
Be In. the event of any default by Servi*ces Provl*der. C-ity has the right to terminate
10this Aoreement for cause, upon ten (10) days" written notice to Services Provider.41MA
C. Services Provl*der has the iight to termi*nate thl*s Agreement only for cause, that
Isin
6
being the event of .material. and breach by upon one hundred and. twenty
& 0 to
days' wrl'tten noticeto Cityor by mutual agreement to terminate evi*denced i*n writing by,(1?0')
and between th.e parties.
D. In the cvf;nt Cify terniinates under subsection-s (A.) or (B) o.-F this section, t-b.c
followinay shall aPP..Y1 4*0Lipon City's deli -very of the referenced notice to Services Provider,
Services Provider shall discontinue all Services in connection. with the performance of this
Agreement and shall proceed to cancel promptly all existing orders and contracts 'insofar as such
orders and contracts are chargeable to this Agreement. Within thirty (30) days after such n.oiice
of termination, Serviczs Provider shall submit a statement showing in detail the Services
satisfactorily performed Linder this Agrccincnt to the date of termination. City shall then. pay
Services Provider that portion of the charges if tjnd1*SPUted. The parti*es agree that Servi*ces
Provider is notentitled to compensation for Services it would have performed under the
remaining term of the tlgreement exce-.&.d&P Pt as rovided herein.
17.0! INDEViNiFICATION
its
Services Provider shall de -fend ('at -the option of City).. indemnify, and hold City,
successors., assigns, officers, employees and elected officials harmless from and against all suits,
actions, legal -proceedings, claims, demands, damages, costs, expenses, attorneys fees, and- any -
and all other costs or fees arising out o(; or iYlcident to, concerning or resulting from the
negligent or will-ful acts or omissi*ons of Services Provt*der, or Services, Provl*der's agents,
emYeesP.0Ioor subcontractPors, in the er-f-ormance of Serviccs Provider's obobligations under this
Agreement, no matter how, or to whom, may such loss occur. Nothing herein shall be deemed to
limit the rights of City or Services Provider (including, but not limited to the right to seek
contribution) against any third party who may be liable for an indemnified claim.
18.01 CO.MA.PL1A-N._CE WITH LAWS, CHARTER ��1D ORDINANCES
A. Services Provider, its agents, employees and subcontractors shall use best efforts
to comply yvith a]-] applicable federal and state laws, the Charter and. Ordinatzces of the City of
Round Rock, as amended, and with all 1pplicable rules and regulations promulgated by local,
siaie and rational. boards, bureaus acid agencies.
B. *fn accordance with. Chapter 2270, Texas Government Code, a governmental entity
may not enter into a contract with a company for goods or services unless the contract contains
written veriCcation from the company that ii: (1) does -not boycott Isa•ael; and (2) will not boycott
Israel and will not boycott Israel during the term of. this contract. The signatory executing this
Agreement on behalf of Services Provider verifies Seiti�ices Provider does not boycott Israel and
will not boycott Israel during the term of this Agreement.
M
19.Q1 ASSIGNMENT AND DELEGATION
The parties each hereby bind themselves, their successors, assigns and legal
representatives to each other with respect to the terms of this Agreement. Neither party shall
�vrittf;n
assign., s*ubl.et or ttsatisf anyI*n thi.s Agreeitlent witliout prior .
other Party,,
2U.U1 NOTICES
All notices and. other communications in connection Lvith this Agreement shall be in
writing and shall be considered given as follows:
1. When delivered to the address as stated in this Agreement;
or
2. Three (3) days after being deposi*ted i*n the LTni'ted States mail, wl*th postage
prepaid
to the -recipient's address as stated in this Agreement,,
Yotice to Services Provider:
Gear Cleaning Solutions
2221 Manana Drive, Suite 190
Dallas, TX75220
yotice to City:
LaLirie Hadley, City Manager
221 Fast Main. Street
Round Rock., TX 78664
Stephan L. Sheets, City Attorney
AND TO, 309 East Main Street
Round Rock, TX 78664
Nothing contained herein shall be construed to restrict the transmission of routine
communications between representatives of City and Services Provider.
21.01 APPLICABLE LAW; ENFORCEMENT AND VENUE
I
This Agreemen! shall. be enforceable 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 Cor same shall lip -in Williamsozi County,Texas. This Agreement sha]_1 be
governed by and construed in accordance with the laws and court decisions of the State of Texas.
22.01 EXCLUSIVE AGREEMENT
This document, and. all appended documents, constitutes the entire Agreement between
Senrices Provider and Ciiy. This Agreement may only be amended or supplemented by mutual
agreement of the parties hereto in writing,duly authorized by action of the City Manager or City
Council,,
7
23.01 DISPUTE RESOLUTION
City and Services Provider hereby expressly agree that no claims or disputes'bet-Nveen the
parties arising out of or relating to this Agreement or a breach thereof shall be decided by any
arbitrltion proceeding, including without limitation, any, proceedingtinder the Federal
Arbitration Act (.9'U'SC Section 1-14) or any applicable state arbitration statute.
24.01 SE`'ERABILITY
The invalidity, illegality, or unenforceability of any provision of this Agreement or the
occurrence of any event rendering any portion or provision of this Agreement void shall in no
way affect the validity or enforceability of any otherportion or provision of thls A�r
eement. AnYvoid provision shall be deemed severed from thi*s A reement, and the balance of thl*s Agreeineut
9
shall be constt-ued and enforced as if this Agreement did not contain the particular poilion or
provision held to be void. The Per agreearties farthto amend this Agreement to replace any
stricken provision with a valid provision that comes as close as possible to the intent of the
stricken provision. The pro�risions of thi*s secti*on shall not -prevent this entire Agreement from
rovivost6on w
beisna id should ahich i's of the essence of this Agreement be determined to be
%._1 P
void.
25.O1. MISCELLANEOUS PROVISIONS
Standard of Care.. Services Provider represents that it enipluys trained, experienced and
competent persons to perform. all. of the. Services, responsibilities and dutt"es specified herein and
that sucli Services resPonsibi*ti*ties and duties shall'be.performed in a. manner according to
generally accepted industry Practi*ces.
Time is of the Essence, SenTices Provider understands and agrees that time is of the
essence and that any failure of Services Provider to fulfill obligations for each portion of this
Agreeillent within the agreed timefrarnes will constitute a material breach of this Agreement.
Services Provider shalt be fully responsible for its delays or for failures to use best efforts in
accordance with the terms of this Agreement. Where damage is caused to City due to Services
Provider's failure to perforni in these circumstances, City may pursue any remedy available
without waiver of anyCity'sof legaladditional rights
or remedies.
Force Viajeure. Neither City nor Services Provider shall be deemed in violation of this
Agreement if it is prevented from performing any of its obligations hereunder by reasons for
which it is not responsible as deCned hcrein. 'However, -notice of s-ucfi. i*mpediment or delay i*n
perforniance must be ti*mely at*venIand all reasonable efforts undertaken to mi*b6gatel"ts effects,
Z:�
Multiple Counterparts. This Agreement may be executed in multiple counterparts,, any
one of which. shall be considered an original of this docuanent; and all of which, when taken
together, shall constitute one and the same instrument.
[Signatures on the following page.]
IN ANITNESS WHEREOF, City and Ser-vices Provider have executed this AUeement on
the dates indicated,
A_
CITY OF OUM R CK) TEXAS
By:
Printed Nam &I
Title: MA 1A
Date Signed: J•
ATTEST:
Sara L. White, City Clerk
FOR I V, APPRO - NrED AS TO FORM:
IN
pa
Stephan _P_ Sheets, City Attorney
9
GEAR I G _"OL ONS, LLC
By:
Printed Npme:
Rt cK AbV&%n
Titic- _.f_ I I i8m
(At*wf -0 Uw IM,
Date Signed: (I / 11 /01_0
Price Sheet
FIREFIGHTING TURNOUT GEAR INSPECTION, CLEANING, AND REPAIR SERVICES
The Respondent represents by their signature below that they are submitting a binding offer.
Special Instructions: All prices must be quoted.
No.
Description
Estimated
Quantity
Unit
Unit Cost
nX
Extended Total
1
Advanced Cleaning Coat
300
EA
$26.00
$7,800.00
2
Advanced Cleaning Pants
300
EA
$26.00
$7,800.00
3
Advanced Cleaning Helmet
175
EA
$6.00
$11050.00
4
Advanced Cleaning Boots (rubber or leather)
175
EA
$6.00
$1,050.00
5
Advanced Cleaning Gloves
175
EA
$3.00
$525.00
6
Advanced Cleaning Hood
300
EA
$3.00
$900.00
7
Decontamination - Coat
30
EA
$82.50
$2,475.00
8
Decontamination - Pants
30
EA
$82.50
$2,475.00
9
Decontamination - Helmet
10
EA
$12.50
$125.00
10
Decontamination - Gloves
10
EA
$6.25
$62.50
12
Decontamination - Boots
10
EA
$12.50
$125.00
13
Decontamination - Hood
40
EA
$6.25
$250.00
14
Biological Disinfection - Coat
10
EA
$82.50
$825.00
15
Biological Disinfection - Pants
10
EA
$82.50
$825.00
16
Advanced Inspection Outer Shell Coat
300
EA
$0.00
$0.00
17
Advanced Inspection Outer Shell Pants
300
EA
$0.00
$0.00
18
Advanced Inspection Moisture and Thermal Liner Coat
300
EA
$15.00
$4,500.00
19
Advanced Inspection Moisture and Thermal Liner Pants
300
EA
$15.00
$4,500.00
20
Coat Repairs Rivets (each)
25
EA
$5.50
$137.50
21
Coat Repairs Zipper
25
EA
$66.34
$1,658.50
22
Coat Bartack
300
EA
$5.65
$1,695.00
23
Moisture Seam Tape
500
EA
$1.47
$735.00
24
Thermal Patch (per sq. inch)
1000
EA
$2.00
$2,000.00
25
Coat Repairs Pocket reinforcement or replacement
50
EA
$22.85
$11142.50
26
Coat Repairs Collar Material
50
EA
$5.00
$250.00
27
Coat Repairs Wristlets (Each)
50
EA
$12.00
$600.00
28
Coat Repairs Hole Repairs
50
EA
$13.92
$696.00
29
Coat Repairs Hanging Hook
10
EA
$1.00
$10.00
30
Coat Letters Replace (per letter)
10
EA
$4.00
$40.00
31
Velcro Repairs (per inch)
1000
EA
$1.23
$1,230.00
32
Pants Repairs Rivets (each)
25
EA
$1.00
$25.00
33
Pants Repairs velcro one side fly (Crotch)
50
EA
$13.53
$676.50
34
Pants Repairs Leather (Knees)
12
EA
$30.96
$371.52
35
Pants Repairs Pockets or Pocket Reinforcement
24
EA
$22.85
$548.40
36
Pants Repairs Snaps/Buttons
20
EA
$1.00
$20.00
37
Reflective Tr'lm Coat/Pants (per Inch)
500
EA
$1.23
$615.00
38
Pants Repairs Hole Repairs
50
EA
$13.92
$696.00
39
Advanced Inspection Helmet
175
EA
$4.00
$700.00
40
Advanced Inspection Boots (rubber or leather)
175
EA
$4.00
$700.00
41
Advanced Inspection Gloves
175
EA
$1.00
$175.00
42
jAdvanced Inspection Hood
300
EA
$1.00
$300.00
1of2
43
Removal of existing name on back of jacket and install blank
Velcro namepatch on back of jacket as needed.
25
EA
$18e00 $450eOO
44
Pants Bartack
300
EA
$5e62 $1,686000
45
Pants- add padding to knees
30
EA
$30e96 $928e8O
Annual Total: $53s374022
COMPANY NAME: Gear/Cie ning Solutions, LLC
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
PRINTED NAME: Rick Johnson
(PHONE NUMBER:
EMAIL ADD -RE -SS:
214-774-2213
rick@gearcleaningsolutions.com
2of2
CERTIFICATE OF INTERESTED PARTIES FORm 1295
10fl
Complete Nos. 1 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos, 1, 2, 31 5, and 6 if there are no interested parties. CERTIFICATION OF FILING
i Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number:
of business. 2020=672771
Gear Cleaning Solutions, LLC
Dallas, TX United States gate Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/29/2020
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.
OOOOOOPPE Cleaning Fire
Cleaning and Repair of Firefighter PPE
Nature of interest
4 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 Rick Johnson ,and my date of birth is
My address is 2221 Manana Drive Suite 190 Dallas TX 75220 USA
ow
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Dallas County, Stateof Texas.1-aw -13, , on the 29 day.of SeptembP�j 20
(month) (year)
Signature of aut riz agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version Vl,1,3a6aaf7d
CERTIFICATE OF INTERESTED PARTIES FORM 1295
10fl
Complete Nos, 1 - 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos, 1, 21 31 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. 2020-672771
Gear Cleaning Solutions, LLC
Dallas, TX United States Date Filed:
2 Name o governmental entity -- or state agency that is a party to the contract for which the form is 09/29/2020
being filed.
City of Round Rock Date Acknowledged:
10/01/2020
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.
OOOOOOPPE Cleaning Fire
Cleaning and Repair of Firefighter PPE
Nature of interest
4 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 , 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www,ethics,.state,tx,,us Version V1.1.3a6aaf7d