Contract - Shermco Inustries - 7/8/2021Attachment A- Bid Sheet
Siemens Model E18813-01-1 Electric Motor
IFB 21-016
The Respondent represents by their signature below that they are submitting a binding offer and are authorized to bind the respondent to fully comply with
the solicitation documents contained in IFB 21-016 Siemens Model E18813-01-1 Electric Motor. The Respondent acknowledges that they have received
and read the entire solicitation packet, attachments, addendums, and all documents incorporated by reference, and agrees to be bound by the terms
therein.
Special Instructions: All prices must be quoted in order to be considered responsive, be advised that exceptions taken to any portion of the solicitation will
jeopardize acceptance of the bid. Alternative bids will not be considered and unauthorized modifications to the bid sheet format will result in the rejection of
the bid. The City reserves the right to purchase more or less than the quantities indicated below.
No.
Description
Estimated
Unit
Unit Cost
Extended Total
Quantity
1
Siemens 800HP Electric Motor; Model E18813-01-1
1
EA
$49,775.00
$49,775.00
2
Shipping/Delivery
1
EA
$3,654.00
$3,654.00
Total:
$53,429.00
COMPANY NAME. -
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
PRINTED NAME:
PHONE NUMBER:
EMAIL ADDRESS:
1 of 1
SHERMCO INDUSTRIES
&t,.-A ptr�
CHRIS PERRY
214-704-3799
:K TEXAS
City of Round Rock, Texas
Purchasing Division
221 East Main Street
Round Rock, Texas 78664-5299
www. rou ndrocktexas.gov
INVITATION FOR BID (IFB)
SIEMENS ELECTRIC MOTOR
SOLICITATION NUMBER 21=016
APRIL 2021
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
SIEMENS ELECTRIC MOTOR
PART I
GENERAL REQUIREMENTS
1. PURPOSE: The City of Round Rock, herein after "the City" seeks a bid from firms experienced in Siemens
electric motor distribution. The City would like to purchase a brand-new spare "blower" motor for the
Brushy Creek Wastewater Treatment Plant.
2.
3.
SOLICITATION PACKET: This solicitation packet is comprised of the following -
Description
Index
Part I — General Requirements
Page(s) 2-4
Part II — Definitions, Standard Terms and Conditions and
Insurance Requirements
Page 5
Part III — Supplemental Terms and Conditions
Page(s) 6-7
Part IV — Specifications
Page 8
Attachment A — Bid Sheet
Page 9
Attachment B — Reference Sheet
Page 10
AUTHORIZED PURCHASING CONTACT(,: For questions or clarification of specifications, you may
contact:
Allen Reich
Purchaser
Purchasing Division
City of Round Rock
Phone: 512-218-6682
E-mail: areichroundrocktexas.gov
Amanda Crowell
Purchaser
Purchasing Division
City of Round Rock
Phone: 512-218-5458
E-mail: acrowell0roundrocktexas.gov
The individual(s) listed above is/are the only authorized City contact(s) for this solicitation. The authorized
purchasing contacts may be contacted by e-mail for clarification for this solicitation including specifications.
No other City employee or representative may be contacted about this solicitation prior to contract approval.
No authority is intended or implied that specifications may be amended, or alterations accepted prior to
solicitation opening without written approval of the City of Round Rock through the Purchasing Department.
4. SCHEDULE OF EVENTS: It is the City's intention to follow the solicitation timeline below.
EVENT
DATE
Solicitation released
April 15, 2021
Deadline for submission of questions
April 21, 2021 @ 5:00 PM, CST
City responses to questions or addendums
Approximately April 23, 2021 @ 5:00 PM)
CST
Deadline for submission of responses
May 6, 2021 @ 3:00 PM, CST
All questions regarding the solicitation shall be submitted in writing by 5:00 PM, CST on the due date noted
above. A copy of all questions submitted and the City's response to the questions shall be posted on the
City's webpage in the form of an addendum at-
https-://www.roundrocktexas.gov/businesses/solicitations/
Page 2 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
Questions shall be submitted in writing to the "Authorized Purchasing Contacts". The City reserves the right
to modify these dates. Notice of date change will be posted to the City's website:
https://www. roundrocktexas.gov/businesses/solicitations
5. SOLICITATION UPDATES: Respondents shall be responsible for monitoring the City's website at
https://www.roundrocktexas.gov/businesses/solicitations for any updates pertaining to the solicitation
described herein. Various updates may include addendums, cancellations, notifications, and any other
pertinent information necessary for the submission of a correct and accurate response. The City will not be
held responsible for any further communication beyond updating the website.
6. RESPONSE DUE DATE: Signed and sealed responses are due at or before 3.00 PM, on the due date
noted in PART I, Section 5 — Schedule of Events. Mail or hand deliver sealed responses to:
City of Round Rock
Attn: Allen Reich
Purchasing Department
221 E. Main Street
Round Rock, Texas 78664-5299
A. Sealed responses shall be clearly marked on the outside of packaging with the Solicitation title,
number, due date, and "DO NOT OPEN".
B. Facsimile or electronically transmitted responses are not acceptable.
C. Responses cannot be altered or amended after opening.
D. No response can be withdrawn after opening without written approval from the City for an acceptable
reason.
E. The City will not be bound by any oral statement or offer made contrary to the written specifications.
F. Samples and/or copies shall be provided at the Respondent's expense and shall become the property
of the City.
G. Late responses will not be considered and will be returned unopened if a return address is provided.
7. RESPONDENT REQUIREMENTS: The City of Round Rock makes no warranty that this checklist is a full
comprehensive listing of every requirement specified in the solicitation. This list is only a tool to assist
participating Respondents in compiling their final responses. Respondents are to carefully read the entire
solicitation.
Respondent shall submit one (1) evident signed "Original" and one identical -to -the -original electronic copy
of the IFB response on a flash drive. The submittal is required to include all addendums and requested
attachments. The bid response along with samples and/or copies shall be provided at the Respondent's
expense and shall become the property of the City.
This invitation for bid (IFB) does not commit the City to contract for any supply or service. Respondents are
advised that the City will not pay for any administrative costs incurred in response preparation to this IFB; all
costs associated with responding to this IFB will be solely at the interested parties' expense. Not responding
to this IFB does not preclude participation in any future RFP/RFQ/IFB.
For vour bid to be responsive. addendums and the attachments identified below shall be submitted
with your proposal.
Addendums: Addendums may be posted to this solicitation. Bidders are required to submit signed
addendums with their sealed response. The Bidder shall be responsible for monitoring the City's
website at https://www.roundrocktexas.gov/businesses/solicitations for any updates pertaining to the
solicitation.
Attachment A: BID SHEET: The bid response shall be submitted on itemized, signed Bid Sheet
provided in the solicitation packet. Failure to complete and sign the bid sheet will result in
disqualification. If there is a conflict between the unit price and extended price, the unit price will take
precedence. Submission of responses on forms other than the City's solicitation document may result in
disqualification of the response.
Page 3 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
Attachment B: REFERENCE SHEET: Provide the name, address, telephone number and E-MAIL of at
least three (3) valid Municipal/Government agencies, or firms of comparable size that have utilized
services that are similar in type and capacity within the last two (2) years. City of Round Rock
references are not applicable. References may be checked prior to award. If references cannot be
confirmed or if any negative responses are received it may result in the disqualification of submittal.
8. BEST VALUE EVALUATION AND CRITERIA: The City reserves the right to reject any or all responses, or
to accept any response deemed most advantageous, or to waive any irregularities or informalities in the
response received that best serves the interest and at the sole discretion of the City. All solicitations
received may be evaluated based on the best value for the City. In determining best value, the City may
consider.
A. Purchase price.
B. Reputation of Respondent and of Respondent's goods and services.
C. Quality of the Respondent's goods and services.
D. The extent to which the goods and services meet the City 's needs.
E. Respondent's past performance with the City.
F. The total long-term cost to the City to acquire the Respondent's goods or services.
G. Any relevant criteria specifically listed in the solicitation.
H. If the solicitation is evaluated with points, the respondent must earn a minimum of 15 points on criteria
not related to cost in order to be considered for contract award.
Respondents may be contacted for clarification of bid and/or to discuss details of the services they are
proposing.
9. CONFIDENTIALITY OF CONTENT: As stated in Section 16 of City of Round Rock Purchasing Definitions,
Standard Terms and Conditions, all documents submitted in response to a solicitation shall be subject to
the Texas Public Information Act. Following an award, responses are subject to release as public
information unless the response or specific parts of the response can be shown to be exempt from the
Texas Public Information Act. Pricing is not considered to be confidential under any circumstances
A. Information in a submittal that is legally protected as a trade secret or otherwise confidential must be
clearly indicated with stamped, bold red letters stating "CONFIDENTIAL" on that section of the
document. The City will not be responsible for any public disclosure of confidential information if it is not
clearly marked as such.
B. If a request is made under the Texas Public Information Act to inspect information designated as
confidential, the Respondent shall, upon request from the City, furnish sufficient written reasons and
information as to why the information should be protected from disclosure. The matter will then be
presented to the Attorney General of Texas for final determination.
10. SUSPENSION OR DEBARMENT CERTIFICATION: The provisions of the Code of Federal Regulations 2
CFR part 180 suspension and debarment may apply to this agreement. The City of Round Rock is
prohibited from contracting with or making prime or sub -awards to parties that are suspended or debarred
or whose principals are suspended or debarred from doing business with the Federal Government, State of
Texas, or the City of Round Rock.
11. CERTIFICATE OF INTERESTED PARTIES: Section 2252.908 of the Texas Government Code requires the
successful offeror to complete a Form 1295 "Certificate of Interested Parties" that is signed for a contract
award requiring council authorization. The "Certificate of Interested Parties" form must be completed on the
Texas Ethics Commission website, printed, signed and submitted to the City by the authorized agent of the
Business Entity with acknowledgment that disclosure is made under oath and under penalty of perjury prior
to final contract execution. Link to Texas Ethics Commission Webpage-
https-//www.ethics.state.tx.us/whatsnew/eIf info form1295.htm
Page 4 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APR I L 2021
PART 11
DEFINITIONS, STANDARD TERMS AND CONDITIONS
AND INSURANCE REQUIREMENTS
1. DEFINITIONS. STANDARD TERMS AND CONDITIONS: By submitting a response to this solicitation, the
Respondent agrees that the City's Definitions, Standard Terms and Conditions, in effect at the time of release
of the solicitation, shall govern unless specifically provided otherwise in a separate agreement or on the face
of a purchase order. Said Definitions, Terms and Conditions are subject to change without notice. It is the
sole responsibility of Respondents to stay apprised of changes. The City's Definitions, Standard Terms and
Conditions can be viewed and downloaded from the City's website at-
https-//www.roundrocktexas.gov/departments/purchasing/
2. INSURANCE: Insurance does not apply to this solicitation.
Page 5 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
PART III
SUPPLEMENTAL TERMS AND CONDITIONS
1. AGREEMENT TERM: The term of the Agreement shall begin from date of award and shall remain in full
force until delivery and acceptance of the product.
2. RESPONDENT QUALIFICATIONS: The City has established the following minimum qualifications.
Respondents who do not meet the minimum qualifications will not be considered for award. The
Respondent shall:
A. Be firms, corporations, individuals, or partnerships normally engaged in providing Siemens electric
motor distribution as specified herein and have adequate organization, facilities, equipment, financial
capability, and personnel to ensure prompt and efficient service to the City.
B. Be domiciled in or have a home office inside the United States. Respondents domiciled outside the
United States, or not having a home office inside the United States will not be included for consideration
in this procurement process.
3. SUBCONTRACTORS: Respondent shall not subcontract or otherwise engage subcontractors to perform
required services.
4. SAFE : The City reserves the right to remove any employee from City property for violation of federal,
state, and local health, safety and environmental laws, ordinances, rules, and regulations. The Respondent
shall:
A. Ensure that all employees comply with all Occupational Safety and Health Administration (OSHA), State
and City safety and occupational health standards and other applicable federal, state, and local health,
safety, and environmental laws ordinances, rules, and regulations in the performance of these services.
B. Indemnify and hold the City harmless from and against all claims, demands, suits, actions, judgments,
fines penalties and liability of every kind arising from the breach of the successful Respondents'
obligations under this paragraph.
5. PRICI : The Respondent shall determine and submit a fixed cost for the work and shall include all
incidental costs, labor, overhead charges, travel, payroll expenses, freight, equipment acquisition and
maintenance, demurrage, fuel surcharges, delivery charges, costs associated with obtaining permits,
insurance, bonds, and risk management. No separate line -item charges shall be permitted for either
response or invoice purposes.
6. PERFORMANCE REVIEW: The City reserves the right to review the awarded respondent(s) performance
at any time during the contract term.
7. ACCEPTANCE/INSPECTION: Acceptance inspection should not take more than five (5) working days.
The awarded respondent will be notified within the time frame if the product delivered is not in full
compliance with the specifications. In the event the product is not to the satisfaction of the City; the vendor
shall agree to provide a replacement to specification at no additional cost to the City. If any agreement or
purchase order is cancelled for non -acceptance, the needed product may be purchased elsewhere.
8. : The successful Respondent shall verify and obtain all necessary permits, licenses, and/or
certificates required by federal, state, and local laws, ordinances, rules, or regulations for the completion of
the services as specified if required for the project.
9. AWARD: The City reserves the right to enter into an Agreement or a Purchase Order with a single award,
split award, primary and secondary award, non -award, or use any combination that best serves the interest
and at the sole discretion of the City. Respondents to the solicitation will be notified when City staff
recommendation of award has been made. The award announcement will be posted to the City's website
at https://www.roundrocktexas.gov/businesses/solicitations/ once City Council has approved the
recommendation of award and the agreement has been executed.
Page 6 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
10. POINT OF CONTACT / DESIGNATED REPRESENTATIVE:
A. Contractor's point of contact: In order to maintain consistent standards of quality work performed
across the City, the City shall be provided with a designated and identified point of contact upon award
of the contract to include contact information. The City's designated representative shall be notified by
the Respondent immediately should the point of contact change.
B. The City's designated representative:
Michael De Santis
SCADA Specialist
Utilities and Environmental Services
Phone: 512-541-8517
E-mail: mdesantis anroundrocktexas.aov
Page 7 of 10
City of Round Rock
Siemens Electric Motor
111713 21-016
Class/Item: 285-71
APRIL 2021
PART IV
SPECIFICATIONS
I PRODUCT SPECIFICATIONS: The City requires a brand-new Siemens Model El 8813-01 -1 with 800 HP,
3600 RPM, 4160-volt, 3 phase, ODP enclosure, 508S frame motor that matches the below specifications.
Motor -Title
E18813=01=1 Replacement
Quantity
1
Orientation
Horizontal
Mounting
Foot
Enclosure
ODP (IP23)
Power
800HP
RPM
3600
Ph/Hz/Voltage
3/60/4160
S.F.
leis
Temp. Rise C/By/At
80/Res/1 .0
Estimated Frame
508S
Shaft Connection
Short
Rotor Construction
Alum. diecast
Stator Winding
Form
Bearing
Sleeve
Bearing Lubrication
Oil
DBA*
91
2. CONTRACTOR RESPONSIBILITIES6
: The Contractor shall -
A. Provide delivery to the following location:
Brushy Creek Wastewater Treatment Plant
3939 E. Palm Valley Blvd.
Round Rock, Texas 78665
B. Ensure that the product is new, functioning, and under the standard manufacturer warranty.
C. In the case of equipment malfunction or non -starting equipment, work with City personnel to ensure
issues are remedied appropriately and in a timely manner.
D. Coordinate with the City's designated personnel to schedule delivery.
3. CITY RESPONSIBILITIES: The City will -
A. Coordinate delivery and provide access to the delivery location.
B. Inspect the product upon delivery and notify the Contractor if any issues are found with the equipment.
C. Work with the Contractor to communicate any issues found with equipment.
Page 8 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APR I L 2021
ATTACHMENT A
BID SHEET
1. ATTACHMENT A — BID SHEET is posted in Solicitation Documents for IFB 21-016 Siemens Electric Motor
in an Excel format on the City of Round Rock website at:
https://www. roundrocktexas.gov/businesses/solicitations/
A. In order to be considered responsive Attachment A- Bid Sheet must be completed, signed by an
authorized representative and returned by the deadline for submission of response indicated in Part I
Section 4 — Schedule of Events.
B. The Respondent, by submitting and signing Attachment A — Bid Sheet, acknowledges that he/she has
received and read the entire document packet sections defined above including all documents
incorporated by reference, and agrees to be bound by the terms therein.
C. In order to do business with the City of Round Rock you must be registered with the City's Vendor
Database. To register, go to: https://roundrocktxvendors.munisselfservice.com/Vendors/default.aspx.
D. By the signature affixed on Attachment A — Bid Sheet, the Respondent hereby certifies that neither the
Respondent nor the entity represented by the Respondent, or anyone acting for such entity has violated
the antitrust laws of this State, codified in Section 15.01 et seq., Texas Business and Commerce Code,
or the Federal antitrust laws, nor communicated directly or indirectly, the response made to any
competitor or any other person engaged in such line of business.
E. The Respondent agrees, if this Offer is accepted within 120 calendar days after the Due Date, to fully
comply in strict accordance with the Solicitation, specifications and the amounts shown on bid sheet.
Page 9 of 10
City of Round Rock
Siemens Electric Motor
IFB 21-016
Class/Item: 285-71
APRIL 2021
ATTACHMENT B
REFERENCE SHEET
PLEASE COMPLETE AND RETURN THIS FORM WITH THE SOLICITATION RESPONSE
SOLICITATION NUMBER: Siemens Electric Motor #21-016
RESPONDENT'S NAME Shermco Industries DATE: 04/19/2021
Provide the name, address, telephone number and E-MAIL of at least three (3) valid Municipal, Government
agencies or firms of comparable size that have utilized services that are similar in type and capacity within the last
two (2) years. City of Round Rock references are not applicable. References may be checked prior to award. If
references cannot be confirmed or if any negative responses are received it may result in the disqualification of
submittal.
1. Company's Name
CITY OF DALLAS / CENTRAL WWTP
Name of Contact
KEVIN JOHNSTON
Title of Contact
ELECTRICAL SUPERVISOR
E-Mail Address
kevin.johnston(a)-daIlascityhall. com
Present Address
1020 Sargent Road
City, State, Zip Code
Dallas, TX 75203
Telephone Number
(214)-670-7416 Fax Number: ( )
2. Company's Name
DALLAS COUNTY - PARK CITIES MUD
Name of Contact
MIKE SWINT
Title of Contact
CHIEF OF MAINTENANCE
E-Mail Address
swint(d-)parkcitieswater.com
Present Address
1811 Regal Road
City, State, Zip Code
Dallas TX 75235
Telephone Number
(817)-739-4436 Fax Number: ( 214) 652-8643
3. Company's Name
CITY OF FAMERS BRANCH
Name of Contact
TODD BAKER
Title of Contact
PUMP STATION SUPERVISOR
E-Mail Address
todd.bakerCa-)farmersbranchtx.gov
Present Address
Wicker Pump Station 2412 Wicker
City, State, Zip Code
Farmers Branch, TX 75234
Telephone Number
(469)-835-0687 Fax Number: ( )
FAILURE TO PROVIDE THE REQUIRED INFORMATION WITH THE SOLICITATION RESPONSE MAY
AUTOMATICALLY DISQUALIFY THE RESPONSE FROM CONSIDERATION FOR AWARD.
Page 10 of 10
SIEMENS Type CG -Horizontal - Open Drip Proof / Weather Protected Type I
Sleeve Bearing - Direct Connected
Dimension Prints for Above NEMA Motors Frames 508 & 5010 - Rotatable Main Conduit Box
.421 DIA.-J
8-holes total
for doweling
1.125-7 TAP-
4-holes for
jackscrews
C*
3,11
C
FS1.5
24.4
2,11
C13
Low Noise
20.0
Vertical Air
Discharge Duct
on 12.2
(if required)
12.0 C12
.4 0 1
�r
i t I
%Y
Low Nose
Inlet Air Baffle
(if required)
FSl.5
1
7 '
I
i
28.5
1.7
17.0
DETAIL "A"
8.0 TYP. 'NN-(2) .50-13 UNC
2.5 TYP. ground bolts on
5.5 1.75 centers
3.0 TYP. (508tr.) 8-bolts total
i 2.0 TYP. (5010fr.) i
�-- -2F -BA
11
B .984 DIA thru
1.125-7 UNC-26
thru 4-holes for
Notes: founda tlon bolts
1. Main conduit box may be rotated in steps of 90°
A removable bottom plate is supplied on the FS1.5 conduit box.
A 5.0 N.P.T. is supplied on the C12 and C13 conduit boxes.
2. C = Length of motor from drive end of shaft to end of non -drive end of motor.
3. C - Length of motor from drive end of shaft to edge of low noise Inlet air baffle.
4. V = (N-W)-0.25" = length of shaft available for coupling.
5. Adding a low noise vertical air discharge duct requires a 6.0" spacer for all rotatable Standard Dimensions in Inches
conduit boxes. All associated conduit box dimensions will change accordingly.
6. 2 Pole machines may rotate in one direction only.
7. Shims may be necessary under motor feet for direct connection.
8. Rotor end float = 0.5"
9. End float of LEF coupling = 0.19„
10. Adding a rotating labyrinth seal to the drive end does not change any dimensions.
11. When adding a ground brush, consult the factory. (BA, C, and C* will increase.)
12. For motors equipped with provisions for proximity probes use this print for our
Low Noise
Inlet Air Baffle
(if required)
Low Noise
Vertical Air
Discharge Duct
(if required)
N
(N-W)-
E S
DETAIL "A"
Lubrication Per Bearing
2 Pole
4 Pole & Slower
140-160 SUS 0 100°F
290-350 SUS 0 100°F
1.4 qt. capacity
1.4 qt. capacity
���0��■Om0�0000mApprox.
Ship
M,
�=M��
Mel 1�0
4 Pole & Slower
Wo M11
4 Pole & Slower
oil
standard internai mountin . pi gg
Cer tif ication: Customer Shermco Industries P.O. S.O. Item �
HP 800 HP RpM 3600 Frame 508S PH/HZ/Volts 3/ 60 / 4160 Terminal Box Size C12C13❑ FS1.5❑ CG_508and5010_2pIusPL_SLV_R0T
By Date 4/19/2021 evision 1
R 01/27/09
Comments SNP05518-VogeRJ
Not for construction, installation or application purposes unless certified.
DocuSign Envelope ID: E5CCOD51-05CE,=4393mA207-165E24822OB3
CERTIFICATE OF INTERESTED PARTIES FORM 1295
l of l
Complete Nos. l - 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. 2021-769073
Shermco Industries, Inc.
Irving, TX United States Date Filed:
2 Name of governmental entity or state agency tha__t is a party to the contract for which the form is 06/21/2021
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.
000000
IFB 21=016 for the Siemens electric motor for the City of Round Rock Utilities and Environmental Services Department
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
5 Check only if there is NO Interested Party.
X
6 UNSWORN'DECLA RATION
mynameis. Kim Drake -Loy ,and my date of birth is March
address is4100 Parkvi*ew Court ,.Bedford TX , 76021 USA .
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executedin, Dallas County, State of Texas , on the 2 I St day of June , 20 21
(month) (year)
DocuSigned by:
lM V'
-C Vol e of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www,ethics.state,txus Version Vl,lceffd98a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10fl
-0 -0
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. 2021-769073
Shermco Industries, Inc.
Irving, 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 06/21/2021
being filed.
City of Round Rock Date Acknowledged:
06/29/2021
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.
000000
IFB 21a.016 for the Siemens electric motor for the City of Round Rock Utilities and Environmental Services Department
4 Name of Interested Party
City, State, Country (place of business)
Nature of interest
(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 I - - I �--
(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 Vl,l,ceffd98a