Contract - Green Dream International - 9/9/2021CITY OF ROUND ROCK AGREEMENT FOR
PURCHASE OF FLEXIBLE AGGREGATE MATERIALS
WITH
GREEN DREAM INTERNATIONAL LLC
THE STATE OF TEXAS §
CITY OF ROUND ROCK §
COUNTY OF WILLIAMSON §
COUNTY OF TRAVIS §
KNOW ALL BY THESE PRESENTS:
THAT THIS AGREEMENT for the purchase of flexible aggregate materials, and for
related goods and services (referred to herein as the "Agreement"), is made and entered into on
this the S day of the month of , 2021 by and between the CITY OF
ROUND OCK, a Texas home -rule municipality, whose offices are located at 221 East Main
Street, Round Rock, Texas 78664-5299 (referred to herein as the "City"), and GREEN DREAM
INTERNATIONAL LLC, whose offices are located at 32 West 81h Street, Suite 607, Erie,
Pennsylvania 16501 (referred to herein as the "Vendor").
RECITALS:
WHEREAS, City desires to purchase flexible aggregate materials; and
WHEREAS, City has issued its "Invitation for Bid" for the provision of said goods and
services; and
WHEREAS, City has determined the bid submitted by Vendor is the lowest responsible
bid; and
WHEREAS, the parties desire to enter into this Agreement to set forth in writing their
respective rights, duties, and obligations;
NOW, THEREFORE, WITNESSETH:
That for and in consideration of the mutual promises contained herein and other good and
valuable consideration, the sufficiency and receipt of which are hereby acknowledged, it is
mutually agreed between the parties as follows:
1.0 DEFINITIONS
A. Agreement means the binding legal contract between City and Vendor whereby
City agrees to buy specified services and Vendor is obligated to sell same. The Agreement
includes the following: (a) City's Invitation for Bid, designated Solicitation Number 21-014
dated March 2021 ("IFB"); (b) Vendor's Response to IFB; and (c) any exhibits and/or addenda
00474819/ss2
T-0— U;q -4 ZLZ
16
thereto. Any inconsistencies or conflicts in the contract documents shall be resolved by giving
preference in the following order:
(1) This Agreement;
(2) Vendor's Response to IFB;
(3) City's Invitation for Bids, Addenda, exhibits, and attachments.
B. City means the City of Round Rock, Williamson and Travis Counties, Texas.
C. Effective Date means the date upon which the binding signatures of both parties
to this Agreement are affixed.
D. Force Maj*eure means acts of God, strikes, lockouts, or other industrial
disturbances, acts of the public enemy, orders of any kind from the government of the United
9
States or the State of Texas or any civil or military authority, insurrections, riots, epidemics,
landslides, lightning,ng, earthquakes, fires, hurricanes, storms, floods, restraint of the ent
and the people, civil disturbances, explosions, or other causes not reasonably within the control
of the party claiming such inability.
E. Goods and services mean the specified services, supplies, materials,
commodities, or equipment.
2.0 EFFECTIVE DATE AND TERM
A. This Agreement shall be effective on the date this Agreement has been signed by
each party hereto, and shall remain i*n full force and effect unless and until it expires by operation
of the term indicated herein, or is terminated or extended as provided herein.
B. The term of this Agreement shall be for sixty (60) months from the effective date
hereof.
C. City reserves the right to review the relationship at any time, and may elect to
terminate this Agreement with or without cause or may elect to continue.
3.0 CONTRACT DOCUMENTS AND EXHIBITS
City selected Vendor to supply the services as outlined in the IFB; Addenda to IFB; and
Response to IFB submitted by Vendor, all as specified in Exhibit "A," incorporated herein by
reference for all purposes. The intent of these documents is to formulate an Agreement listing
the responsibilities of both parties as outlined in the IFB and Addenda to IFB and as offered by
Vendor in its Response to the IFB.
0)
The services which are the subject matter of this Agreement are described in Exhibit "A"
and,,, together with this Agreement, comprise the total Agreement and they are fully a part of this
Agreement as 1*f repeated herein in full.
4.0 ITEMS AWARDED AND SCOPE OF WORK
Items Awarded. All bid items in "Attachment A - Bid Sheet' of Exhibit "A" are awarded to
Vendor.
Scope of Work.,* Vendor shall satisfactorily provide all services described in Exhibit "A,"
attached hereto, within the contract term specified in Section 2.0. Vendor's undertakings shall
be limited to performing services for City and/or advising City concerning those matters on
which Vendor has been specifically engaged. Vendor shall perform its services in accordance
with this Agreement, in accordance with the appended exhibits, in accordance with due care, and
in accordance with prevailing industry standards for comparable services.
590 COSTS
A. In consideration for the services to be performed by Vendor, City agrees to pay
Vendor the amounts set forth in "Attachment A — Bid Sheet"' of Exhibit "A."
B. The City shall be authorized to pay the Vendor an amount not -to -exceed Three
Hundred Thousand and No/100 Dollars ($300 000.00) for the term of this Agreement.
690 INVOICES
All invoices shall include, at a minimum, the following information:
A. Name and address of Vendore
B. Purchase Order Number;
co Description and quantity of items received or services provided; and
co Delivery or performance dates.
7.0 INTERLOCAL COOPERATIVE CONTRACTING / PURCHASING
Authority for local governments to contract with one another to perform certain
governmental functions and services, including but not limited to purchasing functions, 1*s
granted under Government Code, Title 7, Chapter 791, Interlocal Cooperation Contracts,
Subchapter B and Subchapter C, and Local Government Code, Title 8, Chapter 271, Subchapter
F, Section 271.101 and Section 271.102.
Other governmental entities within the State of Texas may be extended the opportunity to
purchase off of the City 1) s bid, with the consent and agreement of the successful service
3
provider(s) and the City. Such agreement shall be conclusively inferred for the Vendor from
lack of exception to this clause in the service provider's response. However, all parties hereby
expressly agree that the City is not an agent of, partner to, or representative of those outside
agencies or entities and that the City is not obligated or liable for any action or debts that may
arise out of such independently -negotiated "piggyback" procurements.
8.0 NON -APPROPRIATION AND FISCAL FUNDING
This Agreement is a commitment of City's current revenues only. It is understood and
agreed that City shall have the right to terminate this Agreement at the end of any City fiscal year
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 affect such termination by
giving Vendor a written notice of termination at the end of its then current fiscal year.
9.0 PROMPT PAYMENT POLICY
In accordance with Chapter 2251, V.T.C.A., Texas Government Code, payment to
Vendor will be made within thirty (30) days of the day on which City receives the performance,
supplies, materials, equipment, and/or deliverables, or within thirty (30) days of the day on
which the performance of services was complete, or within thirty (30) days of the dayon which
City receives a correct invoice for the performance and/or deliverables or services, whichever is
later. Vendor may charge interest on an overdue payment at the "rate in effect' on September 1
of the fiscal year i*n which the payment becomes overdue, in accordance with V.T.C.A., Texas
Government Code, Section 2251.025(b)-o however, this Policy does not apply to Payments made
by City in the event:
A. There is a bona fide dispute between City and Vendor, a contractor, subcontractor
or supplier about the goods delivered or the service performed that cause the
payment to be late; or
Be The terms of a federal contract, grant, regulation, or statute prevent City from
making a timely payment with federal funds; or
C. There is a bona fide dispute between Vendor 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
D. Invoices are not mailed to City in strict accordance with instructions, if any, on
the purchase order or the Agreement or other such contractual agreement.
10.0 GRATUITIES AND BRIBES
City may, by written notice to Vendor, cancel this Agreement without liability to Vendor
if 1*t is determined by City that gratuities or bribes in the form of entertainment, gifts, or
otherwise were offered or given by Vendor or its agents or representatives to any City officer,
4
employee or elected representative with respect to the performance of this Agreement. In
addition, Vendor may be subject to penalties stated in Title 8 of the Texas Penal Code.
11.0 TAXES
City is exempt from Federal Excise and State Sales Tax; therefore, tax shall not be
included in Vendor's charges.
12.0 ORDERS PLACED WITH ALTERNATE VENDORS
If Vendor cannot provide the goods as specified, City reserves the right and option to
obtain the products from another supplier or suppliers.
13.0 INSURANCE
Vendor shall meet all insurance requirements set forth in Part II of IFB 21-014 and on the
City's website at:
https://www.roundrocktexas.gov/wp-content/u loads/2014/12/corr insurance 07.20112.pdf
14.0 CITY'S REPRESENTATIVES
City hereby designates the following representatives authorized to act in its behalf with
regard to this Agreement:
Brandon Rainer
Logistics Officer
3400 Sunrise Road
Round Rock, Texas 78665
512-218-5570
brainer(4e,roundrocktexas. gov
15.0 RIGHT TO ASSURANCE
Whenever either party to this Agreement, in good faith, has reason to question the other
party's intent to perform hereunder, then demand may be made to the other party for written
assurance of the intent to perform. In the event that no written assurance is given within the
reasonable time specified when demand is made, then and in that event the demanding party may
treat such failure as an anticipatory repudiation of this Agreement.
16.0 DEFAULT
If Vendor abandons or defaults under this Agreement and is a cause of City purchasing
the specified goods elsewhere, Vendor 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 service and that it may not
be considered in future bids for the same type of work unless the scope of work is significantly
changed.
Wi
Vendor shall be declared in default of this Agreement if it does any of the following:
A. Fails to make any payment in full when due;
Be Fails to fully, timely and faithfully perform any of its material obligations
under this Agreement;
C. Fails to provide adequate assurance of performance under the "Right to
Assurance" section herein; or
D. Becomes insolvent or seeks relief under the bankruptcy laws of the United
States.
17.0 TERMINATION AND SUSPENSION
A. City has the right to terminate this Agreement, in whole or in part, for
convenience and without cause, at any time upon thirty (30) days' written notice to Vendor.
B. In the event of any default by Vendor, City has the right to terminate this
Agreement for cause, upon ten (10) days' written notice to Vendor.
C. Vendor has the right to terminate this Agreement only for cause, that being in the
event of a material and substantial breach by City, or by mutual agreement to terminate
evidenced i*n writing by and between the parties.
D. In the event City terminates under subsections (A) or (B) of this section, the
following shall apply: Upon City's delivery of the referenced notice to Vendor, Vendor 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 notice of termination, Vendor
shall submit a statement showing in detail the goods and/or services satisfactorily performed
under this Agreement to the date of termination. City shall then pay Vendor that portion of the
charges, if undisputed. The parties agree that Vendor is not entitled to compensation for services
it would have performed under the remaining term of the Agreement except as provided herein.
18.0 INDEMNIFICATION
Vendor shall defend (at the option of City), indemnify, and hold City, its 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 of, or incident to,, concerning or resulting from the fault of Vendor,
or Vendor's agents, employees or subcontractors, in the performance of Vendor's obligations
under this Agreement, no matter how, or to whom, such loss may occur. Nothing herein shall be
deemed to limit the rights of City or Vendor (including, but not limited to the right to seek
contribution) against any third party who may be liable for an indemnified claim.
6
19.0 COMPLIANCE WITH LAWS, CHARTER AND ORDINANCES
A. Vendor, its agents, employees and subcontractors shall use best efforts to comply
with all applicable federal and state laws, the Charter and Ordinances of the City of Round Rock,
as amended, and with all applicable rules and regulations promulgated by local, state and
national boards, bureaus and agencies.
B. In accordance with Chapter 227 1, Texas Government Code, a governmental entity
may not enter into a contract with a company for goods and services unless the contract contains
written verification from the company that it: (1) does not boycott Israel; and (2) and will not
boycott Israel during the term of the contract. The signatory executing this Agreement on behalf
of Vendor verifies that Vendor does not boycott Israel and will not boycott Israel during the term
of this Agreement.
20.0 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
assign, sublet or transfer any interest in this Agreement without prior written authorization of the
other party.
21.0 NOTICES
All notices and other communications in connection with this Agreement shall be in
writing and shall be considered given as follows:
1. When delivered personally to the recipient's address as stated in this Agreement;
or
2. Three (3) days after being deposited in the United States mail, with postage
prepaid to the recipient's address as stated in this Agreement.
Notice to Vendor:
Green Dream International LLC
32 West 8'h Street, Suite 607
Erie, Pennsylvania 16501-
Notioce to City:
City Manager Stephan L. Sheets, City Attorney
221 East Main Street AND TO: 309 East Main Street
Round Rock, TX 78664 Round Rock, TX 78664
Nothing contained herein shall be construed to restrict the transmission of routine
communications between representatives of City and Vendor.
22.0 APPLICABLE LAW; ENFORCEMENT AND VENUE
This Agreement shall be enforceable in Round Rock, Texas, and 1*f 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.
23.0 EXCLUSIVE AGREEMENT
This document,, and all appended documents, constitutes the entire Agreement between
Vendor and City. 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.
24.0 DISPUTE RESOLUTION
City and Vendor hereby expressly agree that no claims or disputes between the parties
arising out of or relating to this Agreement or a breach thereof shall be decided by any arbitration
proceeding, including without limitation, any proceeding under the Federal Arbitration Act (9
USC Section I - 14) or any applicable state arbitration statute.
25.0 SEVERABILITY
The invalidity,illegall*ty, or unenforceabl*11*ty of any provision of this Agreement or the
occurrence of any event rendering any portion or provision of this Agreement void shall 1*n no
way affect the validity or enforceability of any other portion or provision of this Agreement. Any
void provision shall be deemed severed from this Agreement, and the balance of this Agreement
shall be construed and enforced as if this Agreement did not contain the particular portion or
provision held to be void. The parties further agree to 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 provisions of this section shall not prevent this entire Agreement from
being void should a provision which 1*s of the essence of this Agreement be determined void.
26.0 MISCELLANEOUS PROVISIONS
Standard of Care. Vendor represents that it employs trained, experienced and
competent persons to perform all of the services, responsibilities and duties specified herein and
that such services, responsibilities and duties shall be performed i*n a manner according to
generally accepted industry practices.
Tiimes of the Essence. Vendor understands and agrees that time i*s of the essence and
that any failure of Vendor to fulfill obligations for each portion of this Agreement within the
agreed ti eframes will constitute a material breach of this Agreement. Vendor shall 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 Vendor's failure to perform in these
circumstances, City may pursue any remedy available without waiver of any of Ci*ty's additional
legal rights or remedies.
8
Force Majeure. Neither City nor Vendor 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 defined herein. However, notice of such impediment or delay in performance must
be timely given, and all reasonable efforts undertaken to mitigate its effects.
Multiple Counterparts. This Agreement may be executed in multiple counterparts, any
one of which shall be considered an original of this document; and all of which, when taken
together, shall constitute one and the same instrument.
IN WITNESS WHEREOF, City and Vendor have executed this Agreement on the dates
indicated.
City of Round Rock, Texas
By:
Prin
Tith
Dat(
Attest:
40
By: _at7 Ka4t'--�w
Sara L. White, City Clerk
For City, p ved as to For
t:
By: L .0
.
Stephan L. Sheets, City Attorney
Green Dream International LLC
By:
Printed Name: Eman Radha
Title: Owner - Member
Date Signed:
9
July 16,2021
Exhibit "A"
:K TEXAS
City of Round Rock, Texas
Purchasing Division
221 East Main Street
Round Rock, Texas 78664-5299
www. rou n d rocktexas. qov
INVITATION FOR BID (IFB)
FLEXIBLE AGGREGATE MATERIALS
SOLICITATION NUMBER 21=014
MARCH 2O21
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
FLEXIBLE AGGREGATE MATERIALS
PART I
GENERAL REQUIREMENTS
1. PURPOSE: The City of Round Rock, herein after "the City" seeks a bid from firms experienced in providing
flexible aggregate materials.
2. BACKGROUND: The City has a need for flexible aggregate materials that comply with the Texas
Department of Transportation (TxDOT) specifications that is readily available on an as -needed basis for
delivery to the City or pick up at the Contractor's location.
3. SOLICITATION PACKET: This solicitation packet is comprised of the following -
4.
Description
Index
Part I — General Requirements
Page(s) 2-5
Part II — Definitions, Standard Terms and Conditions and
Insurance Requirements
Page 6
Part III — Supplemental Terms and Conditions
Page(s) 7-9
Part IV — Specifications
Page 10
Attachment A — Bid Sheet
Page 11
Attachment B — Reference Sheet
Page 12
AUTHORIZED PURCHASING CONTACT(S): For questions or clarification of specifications, you may
contact:
Allen Reich
Purchaser
Purchasing Division
City of Round Rock
Phone: 512-218-6682
E-mail: areich(a)-roundrocktexas.gov
Amanda Crowell
Purchasing Division
City of Round Rock
Phone: 512-218-5458
E-mail: acrowell(a�roundrocktexas.gov
The individual(s) listed above is/are the only authorized City contact(s) for this solicitation. The authorized
purchasing contact 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.
5. SCHEDULE OF EVENTS: It is the City 's intention to follow the solicitation timeline below.
EVENT
DATE
Solicitation released
March 11, 2021
Deadline for submission of questions
March 25, 2021 @ 5:00 PM, CST
City responses to questions or addendums
Approximately March 29, 2021 @ 5:00 PM,
CST
Deadline for submission of responses
April 1, 2021 @ 3:00 PM, CST
Page 2 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
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
Questions shall be submitted in writing to the "Authorized Purchasing Contact". 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
6. 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.
7.
8.
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.
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 your 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.
Page 3 of 12
City of Round Rock
Flexible Aggregate Materials
IFI3 21m014
Class/Item: 750m52 & 750m56
MARCH 2O21
Exhibit "A"
ci Attachment An. 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
disgualification. 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.
❑ Attachment Be. 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.
9. 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.
Be 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 Iong-term cost to the City to acquire the Respondents 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.
10. 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.
Be 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.
11. 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.
12. 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
Page 4 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
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/elf info form1295.htm
Page 5 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
PART II
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: The Respondent shall meet or exceed all insurance requirements set forth in Standard
Insurance Requirements. The City's Standard Insurance Requirements document can be viewed and
downloaded from the City's website at: https://www.roundrocktexas.gov/departments/purchasing/.
Page 6 of 12
City of Round Rock
Exhibit "A "
Flexible Aggregate Materials
IFB 21=014
Class/Item: 750-52 & 750-56
MARCH 2O21
PART III
SUPPLEMENTAL TERMS AND CONDITIONS
is AGREEMENT TERM: The terms of the awarded agreement shall include but not be limited to the
following:
A. The term of the Agreement shall begin from date of award and shall remain in full force for sixty (60)
months.
B. Upon expiration of the contract term, the Contractor agrees to hold over under the terms and conditions
of this agreement for such a period as is reasonably necessary to re -solicit and/or complete the project
up to 120 days.
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 flexible aggregate
materials as specified herein and have adequate organization, facilities, equipment, financial capability,
and personnel to ensure prompt and efficient service to the City.
B. Provide all labor, supplies and materials required to satisfactorily perform the services as specified
herein and own or acquire at no cost to the City all construction aids, appliances, and equipment
Respondent deems necessary and maintain sole responsibility for the maintenance and repair of
Respondent's vehicles, equipment, tools, and all associated costs. The City shall not be responsible for
any Respondent's tools, equipment, or materials lost or damaged during the performance of the
services specified herein;
C. 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. SAFETY: 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. Be held responsible for the safety of their employees and unsafe acts or conditions that may cause
injury or damage to any persons or property within and around the work site. In case of conflict, the
most stringent safety requirement shall govern;
C. 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.
4. WORKFORCE: Successful Respondent shall:
A. Ensure Respondent's employees perform the services in a timely, professional, and efficient manner.
B. Ensure Respondent's employees, while working on City property, wear a company uniform that clearly
identifies them as the Respondent's employee;
C. Employ all personnel for work in accordance with the requirements set forth by the United States
Department of Labor. The City reserves the right to verify citizenship or right to work in the United
States.
Page 7 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
5. PRICING: 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. PRICE INCREASE: Contract prices for flexible aggregate materials shall remain firm throughout the initial
twelve (12) month term of the contract. A price increase to the agreement may be considered on the
anniversary date of the Contract each year and shall be equal to the consumer price index for that year, but
at no time can the increase be greater than 5% for any single line item.
A. Consumer Price Index (CPI): Price adjustments will be made in accordance with the percentage
change in the U.S. Department of Labor Consumer Price Index (CPI-U) for all Urban Consumers. The
price adjustment rate will be determined by comparing the percentage difference between the CPI in
effect for the base year six-month average (January through June OR July through December); and
each (January through June OR July through December six month average) thereafter. The
percentage difference between those two CPI issues will be the price adjustment rate. No retroactive
contract price adjustments will be allowed. The Consumer Price Index (CPI) is found at the Bureau of
Labor Statistics, Consumer Price Index website: http://www.bls.gov/cpi/.
B. Procedure to Request Increase:
i. Mail the written price increase request with the rate detail comparison and comprehensive
calculation and any supporting documentation to the designated City Contract Specialist a minimum
of 45 days prior to the annual Contract anniversary date. The detailed written calculation will be
verified and confirmed. All written requests for increases must include the City of Round Rock
contract number, solicitation reference information and contact information for the authorized
representative requesting the increase. Price increase requests shall be sent by mail to:
City of Round Rock
Purchasing Department
Attn: Contract Specialist
221 East Main Street
Round Rock, TX 79664-5299
ii. Upon receipt of the request, the City reserves the right to either accept the escalation and make
change to the purchase order within 30 days of the request or negotiate with the Vendor or cancel
the agreement or purchase order if an agreement cannot be reached on the value of the increase.
7. PERFORMANCE REVIEW: The City reserves the right to review the awarded respondent(s) performance
at any time during the contract term.
8. 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 services delivered are not in full
compliance with the specifications. In the event the services are not performed to the satisfaction of the
City; the vendor shall agree to reperform services to specification at no additional cost to the City. If any
agreement or purchase order is cancelled for non -acceptance, the needed services may be purchased
elsewhere.
9. ORDER QUANTITY: The quantities shown on the solicitation are estimates only. No guarantee of any
minimum or maximum purchase is made or implied. The City will only order the services/goods needed to
satisfy requirements within budgetary constraints, which may be more or less than indicated.
10. PERMITS: 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.
Page 8 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
11. 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.
12. POST AWARD MEETING: The City and successful Respondent(s) may have a post award meeting to
discuss, but not be limited to the following:
A. The method to provide a smooth and orderly transition of services performed from the current
contractor.
B. Provide City contact(s) information for implementation of agreement.
C. Identify specific milestones, goals and strategies to meet objectives.
13. 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:
Brandon Rainer
Logistics Officer
Utilities & Environmental Services
Phone: 512-639-3046
E-mail: brainer(&roundrocktexas.gov
14. INTERLOCAL PURCHASING AGREEMENTS:
A. The City has entered into Interlocal Agreements with other Governmental agencies pursuant to the
Interlocal Cooperation Act, Chapter 791 of the Texas Government Code. The Contractor agrees to offer
the same price and terms and conditions to other eligible agencies that have an interlocal agreement
with the City.
B. The City does not accept any responsibility or liability for the purchases by other government agencies
through an interlocal cooperative agreement
Pale 9 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
PART IV
SPECIFICATIONS
1. PURPOSE: The City has a need for flexible aggregate materials for waterline maintenance and roadway
surface treatments.
2. MATERIAL SPECIFICATIONS: The City requires that materials shall be:
A. TxDOT flexible (unbound) base material
B. Item 247, Type A, Grade 2, Grade 5, and/or city/county base as requested.
C. Comply with TxDOT specifications within the following link https://ftp.txdot.gov/pub/txdot-
info/des/specs/specbook. pdf
D. Alternate products will not be considered.
3. SERVICE REQUIREMENTS: The Contractor shall -
A. Provide access to the pick-up location since the City will predominantly pick-up the material in a 12 yd3
dump truck.
B. At the City's request, deliver flexible aggregate materials to the following location:
901 Luther Peterson Place
Round Rock, Texas 78665
C. Delivery must take place during the City's regular business hours of 8:OOAM — 4:OOPM CST unless
otherwise agreed upon at the time the PO is issued.
4. CITY RESPONSIBILITIES: The City will -
A. Issue a formal City PO for the flexible aggregate materials requested.
B. Coordinate pick-up of materials in a City 12 yd dump truck, as needed.
C. Coordinate delivery with the Contractor, as needed.
D. Be responsible for inspecting delivered materials for conformance.
Page 10 of 12
City of Round Rock Exhibit "A"
Flexible Aggregate Materials
IFB 21-014
Class/Item: 750-52 & 750-56
MARCH 2O21
ATTACHMENT A
BID SHEET
1. ATTACHMENT A — BID SHEET is posted in Solicitation Documents for IFB 21-014 Flexible Aggregate
Materials 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
Section 5 — 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 11 of 12
Attacl&YA1tWt Mtheet
Flexible Aggregate Materials
IFB 21-014
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 21-014 Aggregate Materials. 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
Aggregate TxDOT Item 247, Type A, Grade 2 Tested Super Flex
1
Base.
5000
TONS
$12.06
$60,300.00
Delivered To: 910 Luther Peterson Place; Round Rock, Texas
78665
Aggregate TxDOT Item 247, Type A, Grade 2 Tested Super Flex
2
Base.
5000
TONS
$6.96
$34,800.00
Picked up at Contractor location.
Aggregate TxDOT Item 247, Type A, Grade 5: 3/8" - 7 Mesh, Type
3
F.
Delivered To: 910 Luther Peterson PI ce;
Roun R a d ock, Texas
5000
TONS
$15.74
$78,700.00
78665
Aggregate TxDOT Item 247, Type A, Grade 5: 3/8" - 7 Mesh, Type
4
F.
5000
TONS
$10.70
$53,500.00
Picked up at Contractor location.
$227,300.00
Total:
Green Dream International LLC
COMPANY NAME:
SIGNATURE OF AUTHORIZED REPRESENTATIVE: '
Varand Vartanian, President
PRINTED NAME:
PHONE NUMBER:
EMAIL ADDRESS:
814-616-7800
info pdicompany.coom
1 of 1
City of Round Rock
Flexible Aggregate Materials
11713 21-014
Class/Item: 750m52 & 750-56
MARCH 2O21
Exhibit "A"
ATTACHMENT B
REFERENCE SHEET
PLEASE COMPLETE AND RETURN THIS FORM WITH THE SOLICITATION RESPONSE
SOLICITATION NUMBER: IFB 21-014
RESPONDENT'S NAME: Green Dream International LLC
DATE: April 1, 2021
Provide the name, address, telephone number and E-MAIL of at least three (3) valid Mun41
icipal, 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 MICC an FT MCCOY
Name of Contact
rharles Hilt
Title of Contact
Functional POC
EaMaIll Address
char1es.a.hi1t.ci'9v@ma1*1. 1,819
Present Address
MICC - FT MCCOY BLDG 1108 SOUTH R ST
City, State, Zip Code
FORT MCCOY---WI 54656-5153
Telephone Number
( 608)388,m5209 Fax Number. ( )
2. Company's Name
Department of Purchasing and Contracting
Name of Contact
Felicia Baugh
Title of Contact
DWM Warehouse Supervisor
EnMaell Address
fmbaugh@dekalbcountyga.gov
Present Address
1300 Commen:,c Drive. 2 Flooro Decatur.
City, State, Zip Code
Georgia 30030
Telephone Number
( 7704414-2364 Fax Number: ( )
I Company's Name
RFP 11432 - SPANISH OAKS SUBSTATION Leander, TX
Name of Contact
Kelly Mikulin
Title of Contact
Category Manager
E=Mal*l Address
Ke11y.M1*ku1in@1cra.org
Present Address
Lower Colorado River Authority 3700 Lake Blvd
City, State, Zip Code
-Austin
Austin TX 78703
Telephone Number
( 512)578- 1582 Fax Number: ( )
FAILURE TO PROVIDE THE REQUIRED INFORMATION WITH THE SOLICITATION RESPONSE MAY
AUTOMATICALLY DISQUALIFY THE RESPONSE FROM CONSIDERATION FOR AWARD.
Page
12 of 12
ACC>REP� CERTIFICATE OF LIABILITY INSURANCE
FDATE(MM/DDNriY)
04/30/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Dana Hansen
NAME:
Brown & Brown Insurance Agency of Virginia, Inc.
ac No exe : (703) 361-3191 FAX No : (703) 361-5182
ki6
11220 Assett Loop Suite 304
E" AIL dhansen@bbdcmetro.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
Manassas VA 20109
FINSURERA: Selective Insurance Company of America
12572
INSURED
INSURER s ; Accident Fund Insurance Company of America
10166
GREEN DREAM INTERNATIONAL, LLC
INSURER C
32 W 8TH ST
INSURER D
SUITE 607
INSURER E
ERIE PA 16501-1338
INSURERF:
COVERAGES CERTIFICATE NUMBER: CL209960038 REVISION Nl1MBER�
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
INSD
VWD
POLICY NUMBER(MM/DD/YYYY)/YYYY
POLICY EFF
POLICY EXP
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR
S 2403171
09/28/2020
09/28/2021
EACH OCCURRENCE
$ 190009000
MAGE TO RENTED
PREMISES(Ea occurrence)
500,000
g
MED EXP (Any one person)
g 159000
PERSONAL & ADV INJURY
$ 190009000
GEN'LAGGREGATE
X
LIMIT APPLIES PER:
POLICY PRO- LOC
OTHER:
GENERAL AGGREGATE
$ 290009000
RPODUCTS -COMP/OP AGG
290009000JECT
$
$
A
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
X HIRED XNON-OWNED
AUTOS ONLY AUTOS ONLY
S 2403171
09/28/2020
09/28/2021
COMBINED SINGLE LIMIT
(Ea accident
$ 190009000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
A
X
UMBRELLA LIAB
EXCESS LIAR
X
OCCUR
CLAIMS -MADE
S 2403171
09/28/2020
09/28/2021
EACH OCCURRENCE
$ 290009000
AGGREGATE
$ 290009000
DED X RETENTION $ •00
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YYN
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WCV6202162
12/25/2020
12/25/202,
X SPER TATUTE ERH
E.L. EACH ACCIDENT
$ 190009000
E.L. DISEASE - EA EMPLOYEE
190009000
$
E.L. DISEASE -POLICY LIMIT
190009000
$
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Round Rock, TX Purchasing Division ACCORDANCE WITH THE POLICY PROVISIONS.
221 East Main Street
AUTHORIZED REPRESENTATIVE
Round Rock TX 78664 I � �woo
O 1988=2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF INTERESTED PARTIES FORM 1295
10fl
Complete Nos. i - 4 and 6 if there are interested parties, OFFICE USE ONLY
Complete Nos. 1, 21 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. 2021ew781424
Green Dream International LLC
Erie, PA United States Date Filed:
2
Name of governmental entity or state agency that is a party to the contract for which the form is 07/21/2021
being filed.
Purchases City of Round Rock Purchasing Office TX gate 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.
IFB 21-014
Flexible Aggregate Materials for the City of Round Rock.
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 Varand Vartanian ,and my date of birth is
My address is 32 W. 8th St. suite no 607 Erie PA 16501 USA
�9
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Erie County, State of PA , on the. 21 day of JU'Y 20 21
(month) (year)
Varand Vartanian /Presiden
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us version via.cettcwtia
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10fl
Complete Nos. i - 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos. i, 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. 2021-781424
Green Dream International LLC
Erie, PA United States Date Filed:
2
Name of governmental entity or state agency that is a party to the contract for which the form is 07/21/2021
being filed.
Purchases City of Round Rock Purchasing Office TX Date Acknowledged:
07/28/2021
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.
IFB 21-014
Flexible Aggregate Materials for the City of Round Rock.
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.
MX
6
UNSWORN DECLARATION
My name is ,and my date of birth is
My address is �1 - It
(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 via.cettaq8a