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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