Contract - Austin Materials - 4/28/2016City of Round Rock, Texas Contract Forms
Standard Form of Agreement: Section 00500
City of Round Rock, Texas
® Standard Form of Agreement between
Owner and Contractor
AGREEMENT made as of the Jay of AM W{/ in the year 201.
BETWEEN the Owner: City of Round Rock, Texas (hereafter "Owner" or "City")
221 East Main Street
Round Rock, Texas 78664
and the Contractor 1 &444/ i J(-' L. L 6- ("Contractor")
C zc, We i N -re-X
'7 ?
The Project is described as: The Dell Diamond Parking Lot Pavement Repairs will
consist of various Full -Depth, and Minor, repairs; as well as
the application of an asphalt emulsion sealant over the
approximate 805,000 s.f. area. Likewise, an estimated 55,000
ft. of pavement markings and symbols will be refinished.
The Engineer is: City of Round Rock
For and in consideration of the mutual terms, conditions and covenants of this Agreement and all
accompanying documents between Owner and Contractor, the receipt and sufficiency of which are hereby
acknowledged, Owner and Contractor agree as follows:
ARTICLE I THE CONTRACT DOCUMENTS
The Contract Documents consist of this Agreement, Conditions of the Contract (General, Supplementary
and other Conditions), Drawings, Specifications, Addenda issued prior to execution of this Agreement, other
documents listed in this Agreement and Modifications issued after execution of this Agreement; these form the
Contract, and are as fully a part of the Contract as if attached to this Agreement or repeated herein. The Contract
represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations,
representations or agreements, either written or oral. An enumeration of the Contract Documents, other than
Modifications, appears in Article 7.
ARTICLE 2 THE WORK OF THIS CONTRACT
Contractor shall fully execute the Work described in the Contract Documents, except to the extent
specifically indicated in the Contract Documents to be the responsibility of others.
00500 8-2012 Page 1 of 5 Standard Form of Agreement
00196575
R-?,oIL —�3b3
ARTICLE 3 DATE OF COMMENCEMENT; DATE OF SUBSTANTIAL COMPLETION; DATE OF
FINAL COMPLETION
3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated
below or provision is made for the date to be fixed in a Notice to Proceed issued by Owner.
3.2 The Contract Time shall be measured from the date delineated in the Notice to Proceed.
3.3 Contractor shall commence Work within
from the date delineated in the Notice to Proceed.
Ten
(__LO ) calendar days
3.4 Contractor shall achieve Substantial Completion of the items of Work listed on Attachment A to this
Agreement no later than N/A ( N/A ) calendar days from issuance by Owner of
Notice to Proceed, and Contractor shall achieve Substantial Completion of the entire Work no later than
Thirty ( 30 ) calendar days from issuance by Owner of Notice to Proceed, subject to
adjustments of this Contract Time as provided in the Contract Documents.
3.5 If Contractor fails to achieve Substantial Completion of the Work (or any portion thereof) on or before the
date(s) specified for Substantial Completion in the Agreement, Contractor shall pay to Owner, as liquidated
damages, the sum of Five -hundred
and No/100 Dollars ($ 500.00 ) for each calendar day that Substantial Completion is delayed after the
date(s) specified for Substantial Completion. It is hereby agreed that the liquidated damages to which Owner is
entitled hereunder are a reasonable forecast of just compensation for the harm that would be caused by Contractor's
failure to achieve Substantial Completion of the Work (or any portion thereof) on or before the date(s) specified for
Substantial Completion in the Agreement. It is agreed that the harm that would be caused by such failure, which
includes loss of expected use of the Project areas, provision of alternative storage facilities and rescheduling of
moving and occupancy dates, is one that is incapable or very difficult of accurate estimation. It is hereby agreed that
if Substantial Completion of the Work (or any portion thereof) is not achieved on or before thirty (30) days after the
date(s) specified for Substantial Completion in the Agreement, the Owner shall have the option to either collect
liquidated damages as set forth herein or to thereafter rely on its remedies under the Contract Documents and at law
and in equity, including without limitation, the recovery of actual damages. The date(s) specified for Substantial
Completion of the Work (or any portion thereof) in the Agreement shall be subject to adjustment as provided in the
Contract Documents.
3.6 Contractor shall achieve Final Completion of the entire Work no later than Forty-five
(__45_ ) calendar days from issuance by Owner of Notice to Proceed.
ARTICLE 4 CONTRACT SUM
shall
4.2 The Contract Sum is based upon the following alternates which are described in the Contract Documents
and are hereby accepted by Owner:
AIIA
Page 2 of 5
ARTICLE 5 PAYMENTS
4 5.1 PROGRESS PAYMENTS
5.1.1 Based upon Applications for Payment submitted to Engineer and Owner by Contractor, and Certificates for
Payment issued by Engineer and not disputed by Owner and/or Owner's lender, Owner shall make progress
payments on account of the Contract Sum to Contractor as provided below, in Article 14 of the City of Round Rock
General Conditions, and elsewhere in the Contract Documents.
5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of
the month.
5.1.3 Provided that an Application for Payment is received by Engineer and Owner, and Engineer issues a
Certificate of Payment not later than the tenth (10th) day of a month, Owner shall make payment to Contractor not
later than the tenth (10th) day of the next month. If an Application for Payment is received by Engineer and Owner
after the application date fixed above, payment shall be made by Owner not later than one month after the Engineer
issues a Certificate for Payment.
5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by
Contractor in accordance with the Contract Documents. The schedule of values shall allocate the entire Contract
Sum among the various portions of the Work. The schedule of values shall be prepared in such form and supported
by such data to substantiate its accuracy as Engineer and Owner may require. This schedule, unless objected to by
Engineer or Owner, shall be used as a basis for reviewing Contractor's Applications for Payment.
5.1.5 Applications for Payment shall warrant the percentage of completion of each portion of the Work as of the
end of the period covered by the Application for Payment.
5.1.6 Subject to other provisions of the Contract Documents, the amount of each progress payment shall be
computed as provided in Article 14 of the City of Round Rock General Conditions.
5.1.7 Except with Owner's prior written approval, Contractor shall not make advance payments to suppliers for
materials or equipment which have not been delivered and stored at the site.
5.2 FINAL PAYMENT
5.2.1 Final payment, constituting the entire unpaid balance of the Contract Sum, shall be made by Owner to
Contractor when:
.1 Contractor has fully performed the Contract except for Contractor's responsibility to correct
Work, and to satisfy other requirements, if any, which extend beyond final payment; and
.2 a final Certificate for Payment has been issued by Engineer.
5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of
Engineer's final Certificate for Payment. In no event shall final payment be required to be made prior to thirty (30)
days after all Work on the Contract has been fully performed. Defects in the Work discovered prior to final payment
shall be treated as non -conforming Work and shall be corrected by Contractor prior to final payment, and shall not
be treated as warranty items.
ARTICLE 6 TERMINATION OR SUSPENSION
6.1 The Contract may be terminated by Owner or Contractor as provided in Article 15 of the City of Round
Rock General Conditions.
Page 3 of 5
6.2 The Work may be suspended by Owner as provided in Article 15 of the City of Round Rock General
Conditions.
ARTICLE 7 ENUMERATION OF CONTRACT DOCUMENTS
7.1 The Contract Documents, except for Modifications issued after execution of this Agreement, are
enumerated as follows:
7.1.1 The Agreement is this executed version of the City of Round Rock, Texas Standard Form of Agreement
between Owner and Contractor, as modified.
7.1.2 The General Conditions are the "City of Round Rock Contract Forms 00700," General Conditions, as
modified.
7.1.3 The Supplementary, Special, and other Conditions of the Contract are those contained in the Project
Manual dated March 2016
7.1.4 The Specifications are those contained in the Project Manual dated March 2016
7.1.5 The Drawings, if any, are those contained in the Project Manual dated March 2016
7.1.6 The Insurance & Construction Bond Forms of the Contract are those contained in the Project Manual dated
March 2016
7.1.7 The Notice to Bidders, Instructions to Bidders, Bid Form, and Addenda, if any, are those contained in the
Project Manual dated March 2016
7.1.8 If this Agreement covers construction involving federal funds, thereby requiring inclusion of mandated
contract clauses, such federally required clauses are those contained in the "City of Round Rock Contract Forms
03000," Federally Required Contract Clauses, as modified.
7.1.9 Other documents, if any, forming part of the Contract Documents are as follows:
N/A
ARTICLE 8 MISCELLANEOUS PROVISIONS
8.1 Where reference is made in this Agreement to a provision of any document, the reference refers to that
provision as amended or supplemented by other provisions of the Contract Documents.
8.2 Owner's representative is: Todd Keltgen
2008 Enterprise Drive, Round Rock, Tx - 78664
Office - (512) 218-5583
Toddkp,roundrocktexas.gov
8.3 Contractor's representative is: R rr.. , (',, , 0- r k
8.4 Neither Owner's nor Contractor's representative shall be changed without ten (10) days' written notice to
the other party.
8.5 Waiver of any breach of this Agreement shall not constitute waiver of any subsequent breach.
Page 4 of 5
8.6 Owner agrees to pay Contractor from available funds for satisfactory performance of this Agreement in
accordance with the bid or proposal submitted therefor, subject to proper additions and deductions, all as provided in
the General Conditions, Supplemental Conditions, and Special Conditions of this Agreement, and Owner agrees to
make payments on account thereof as provided therein. Lack of funds shall render this Agreement null and void to
the extent funds are not available. This Agreement is a commitment of City of Round Rock's current revenues only.
8.7 Although this Agreement is drawn by Owner, both parties hereto expressly agree and assert that, in the
event of any dispute over its meaning or application, this Agreement shall be interpreted reasonably and fairly, and
neither more strongly for nor against either party.
8.8 This Agreement shall be enforceable in Round Rock, Texas, and if legal action is necessary by either party
with respect to the enforcement of any or all of the terms or conditions herein, exclusive venue for same shall lie in
Williamson County, Texas. This Agreement shall be governed by and construed in accordance with the laws and
court decisions of the State of Texas.
8.9 Both parties hereby expressly agree that no claims or disputes between the parties arising out of or relating
to this Agreement or a breach thereof shall be decided by an arbitration proceeding, including without limitation,
any proceeding under the Federal Arbitration Act (9 USC Section 1-14) or any applicable state arbitration statute.
8.10 The parties, by execution of this Agreement, bind themselves, their heirs, successors, assigns, and legal
representatives for the full and faithful performance of the terms and provisions hereof.
This Agreement is entered into as of the day and year first written above and is executed in at least three (3)
original copies, of which one is to be delivered to Contractor, one to Engineer for use in the administration of the
Contract, and the remainder to Owner.
OWNER CONTRACTOR
CITY 'FSUN ROC ,TEXAS
Printed Name: Why, IV4 Printed Name: ` f�
Title Title: L-}gym—&K:, I t> E-t,�
Date Signed: ' l Date Signed: Ilk
ATTEST:
GSL
City Clerk
4FORCI APP OVE AS TO FORM:
& I sW�
y
Page 5 of 5
Bond No. 019055044
PERFORMANCE BOND
THE STATE OF TEXAS §
COUNTY OF WILLIAMSON
§ KNOW ALL BY THESE PRESENTS:
§
That Austin Materials, LLC of the City of Austin Coun of
Travis ' t
,and State of Texas , as Principal, and Liberty Mutual Insurance Company
authorized under the law of the State of Texas to act as surety on bonds for principals, are held
and firmly bound unto THE CITY OF ROUND ROCK, TEXAS, (Owner), in the penal sum of
Two Hundred Fifty Nine Thousand Three Hundred Thirty Seven and 50/100
Dollars ($ 259,337.50- _ ) for the payment whereof, well and truly to be made the said
Principal and Surety bind themselves, and their heirs, administrators, executors, successors and
assigns, jointly and severally, by these presents:
WHEREAS, the Principal has entered into a certain written Agreement with the Owner dated the
"2ii 'vl- day of �_1.�� 20LID to which the Agreement is
hereby referred to and made a part hereo of s fully and to the same extent as if copied at length
herein consisting of: Dell Diamond Parking Lot Pavement Repairs p g
(Name of the Project)
NOW, THEREFORE, THE CONDITIONS OF THIS OBLIGATION IS SUCH, that if the said
Principal shall faithfully perform said Agreement and shall, in all respects, duly and faithfully
observe and perform all and singular the covenants, conditions and agreements in and by said
Agreement, agreed and covenanted by the Principal to be observed and performed, including but
not limited to, the repair of any and all defects in said work occasioned by and resulting from
defects in materials furnished by or workmanship of, the Principal in performing the Work
covered by said Agreement and occurring within a period of twelve (I2) months from the date of
Final Completion and all other covenants and conditions, according to the true intent and
meaning of said Agreement and the Plans and Specifications hereto annexed, then this obligation
shall be void; otherwise to remain in full force and effect;
PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253,
Texas Government code, as amended, and all liabilities on this bond shall be determined in
accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at
length herein.
Page I
006I0 7-2009 Performance Bond
00090656
PERFORMANCE BOND (continued)
Surety, for value received, stipulates and agrees that no change, extension of time, alteration or
addition to the term of the Agreement, or to the Work performed thereunder, or the Plans,
Specifications, or drawings accompanying the same, shall in anywise affect its obligation on this
bond, and it does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the Agreement, or to the work to be performed thereunder.
IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument
this 2nd day of June 20 16
Austin Materials, LLC
Liberty Mutual Insurance Company
Principal
10
Surety
J=44 - r-- EF
Tina Davis, TX License #1356133
Printed Name
Printed Name
10 By.
y:
Ti'tl
Tltl : orney-in- act --
Address: 9020 N. Capital of Texas Hwy, Bldg. 2, Ste. 250
Address: TSS mouth Temple, Ste. 700
10 Austin, TX 78759
Salt Lake City, UT 84101
INResident Agent of Surety:
N/A
Signature
Printed Name
Street Address
10 City, State & Zip Code
0
Page 2
00610 7.2009 Performance Bond
00090656
Bond No. 019055044
PAYMENT BOND
THE STATE OF TEXAS §
§ KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF WILLIAMSON §
That Austin Materials, LLC of the City of Austin County of
Travis ,and State of Texas i ert Mutual Insurance
as Principal, and omPK M _
authorized under the laws of the State of Texas to act as Surety on Bonds for Principals, are held
and firmly bound unto THE CITY OF ROUND ROCK, (OWNER), and all subcontractors,
workers, laborers, mechanics and suppliers as their interest may appear, all of whom shall have
the right to sue upon this bond, in the penal sum of
Two Hundred Fifty Nine Thousand Three Hundred Thirty Seven 50/100 Dollars
259,337.50 for the payment whereof, well and truly be made the
said Principal and Surety bind themselves and their heirs, administrators, executors, successors,
and assigns, jointly and severally, by these presents:
WHEREAS, the Principal has entered into a certain written Agreement with the Owner, dated
the '24t— day of * rw , 20_k, to which Agreement is
hereby referred to and made a part hereof as fully and to the same extent as if copied at length
herein consisting of: Dell Diamond Parking Lot Pavement_ Repairs _
(Name of the Project)
)
iN NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said
Principal shall well and truly pay all subcontractors, workers, laborers, mechanics, and suppliers,
all monies to them owing by said Principals for subcontracts, work, labor, equipment, supplies
and materials done and furnished for the construction of the improvements of said Agreement,
IN then this obligation shall be and become null and void; otherwise to remain in full force and
effect.
PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253.
Texas Government code, as amended, and all liabilities on this bond shall be determined in
accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at
length herein.
Page 1
006201-2004 Payment Bond
00090656
PAYMENT BOND (continued)
Surety, for value received, stipulates and agrees that no change, extension of time, alteration or
addition to the terms of the Agreement, or to the Work performed thereunder, or the plans,
specifications or drawings accompanying the same shall in anywise affect it's obligation on this
bond, and it does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the contract, or to the work to be performed thereunder.
IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this Instrument
A this 2nd day of_ June .20 16
Austin Materials, LLC Liberty Mutual Insurance Company
Principal Surety
L A ►�V'� F Tina Davis, TX License No. 1356133
Printed Name Printed Name
By -
By
-
Tit � M V L �P<-mit ..�'T act
Address: �;, t; , -'-� flW Address: 15outh Temple, Ste. goo
u' TI to salt Lake City, UT 84101
Resident Agent of Surety:
N/A
Signature
Printed Name
Street Address
Page 2
00620 7-2009 Payment Bond
00040656
CERTIFICATE OF LIABILITY INSURANCE Date: 6/14/2016
TDI number required. Please refer to the
PRODUCER: Texas Dept of Insurance website: htto://www.tdl.state.tx.us/
Marsh USA. Inc.
1166 Avenue ofthe Americas
New York. NY 10036
Phone: 212-345-0000 E-mail.
INSURED:
Austin Materials. LLC
9020 N. Caoitai of Texas Highway. Suite 250
Austin. TX 78759
Phone: E-mail
THIS IS TO CERTIFY THAT the Insured named above is insured by the Companies listed above with respect to the business operations
hereinafter described, for the types of insurance and in accordance with the provisions of the standard policies used by the companies,
and further hereinafter described. Exceptions to the policies are noted below.
CO TYPE OF POLICY EFFECTIVE EXPIRATION T LIMITS
LTR INSURANCE NUMBER DATE DATE
GENERAL LIABILITY
A
AUTOMOBILE LIABILITY
A
GENERAL AGGREGATE
COMPANIES AFFORDING COVERAGE TDI
A
ACE American Insurance Company 42160
B
Indemnity Insurance Company of North America 5786
C
Berkshire Hathaway Specialty Insurance Company 79850
D
$ 1,000,000
THIS IS TO CERTIFY THAT the Insured named above is insured by the Companies listed above with respect to the business operations
hereinafter described, for the types of insurance and in accordance with the provisions of the standard policies used by the companies,
and further hereinafter described. Exceptions to the policies are noted below.
CO TYPE OF POLICY EFFECTIVE EXPIRATION T LIMITS
LTR INSURANCE NUMBER DATE DATE
GENERAL LIABILITY
A
AUTOMOBILE LIABILITY
A
GENERAL AGGREGATE
$ 4,000,000
HDOG274053 0331/2016 123112016 PRODUCTS-COMP/OPAGG.
$ 4,000,000
PERSONAL & ADV. INJURY
$ 2,000,000
EACH OCCURRENCE
$ 2,000,000
FIRE DAMAGE (Any one fire)
$ 1,000,000
MED. EXPENSE (Any one person)
$ 10,000
COMBINED SINGLE LIMIT
$ 5,000.000
ISA H0904091 03/31,'2016 12:3112016 BODILY INJURY (Per person)
$
EXCESS LIABILITY
C 42LIM0302383 03 31 2016
WORKERS' COMPENSATION
AND EMPLOYERS' LIABILITY
B WLRC4860190 03,31'2016
PROFESSIONAL LIABILITY
BUILDERS' RISK INSURANCE
OR INSTALLATION INSURANCE
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
$
EACH OCCURRENCE
$ 5,000,000
12;31,2016 AGGREGATE
$ 5,000,000
STATUTORY LIMITS
$ per statute
EACH ACCIDENT
$ 1,000,000
1231 '2016 DISEASE - POLICY LIMIT
$ 1,000,000
DISEASE - EACH EMPLOYEE
$ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS/EXCEPTIONS
The City of Round Rock Is named as additional insured with respect to all policies except 'Workers' Compensation and Employers'
Liability' and 'Professional Liability% Should any of the above described policies be cancelled or changed before the expiration date
thereof, the Issuing company will mail thirty (30) days written notice to the certificate holder named below.
CERTIFICATE HOLDER: City Manager SIGN F AG NT ICENSED IN STATE OF TEXAS
City of Round Rock
221 E. Main Street
Round Rock, Texas 78664
Typed Name: udy Mil -Marsh USA Inc
License ID: 14797
Page 1
00650 10-2010
00205796 Certificate of Liability Insurance
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ROUND ROCK TEXAS
TRANSPORTATION DEPARTMENT
April 5, 2016
Mayor
Alan McGraw
Mayor Pro -Tem
George White
Subject: Recommendation to Award — Dell Diamond Parking Lot
Councilmembers
Craig Morgan
Frank Leff ingwell
Will Peckham
Writ Baese
Kris Whitfield
City Manager
Laurie Hadley
City Attorney
Stephan L. Sheets
Dear Mr. McDowell,
On April 5, 2016 bids were opened for the above reference project. Five (5) responsive bid proposals
were submitted with total bid prices ranging from $259,337.50 to $515,270.00. Per the attached Bid
Tabulation, Austin Materials is the apparent low bidder.
Based upon my review of the Bid Tabulation, I recommend the City of Round Rock to accept the bid of
Austin Materials in the amount of $259,337.50
Sincerely,
Leah Collier, P.E.
Chief Transportation Engineer
Attachments: Bid Tabulation
CITY OF ROUND ROCK 2008 Enterprise Drive, Round Rock, Texas 78664
[P] 512.218.7044 • [F] 512.218.5536 • roundrocktexas.gov
CERTIFICATE OF INTERESTED PARTIES
FORM 1.295
l of 1
Complete Nos. 1- 4 and 6 if there are interested parties,
OFFICE USE ONLY
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
CERTIFICATION OF FILING
Certificate Number:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2016-39299
Austin Materials, LLC
Austin, TX United States
Date Filed:
04!1312016
2 Name of governmental entity or state agency that Is a party tot the contract for which the form is
being filed.
City of Round Rock
Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the goods or services to be provided under the contract.
Dell Diamond Seal
Asphalt paving, slurry seal and striping
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 AFFIDAVIT I swear, or affirm, under of perjury, that the above disclosure is true and correct.
"ry JENNIE JONES
Notary ID * 130516226
My Comirilaslon Expires
January 28, 2020
Signature of th rued agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said nit (7)13P—PQ this the � �4��} day of�,
20 _1 to to certify which, witness my hand and seal of office.
f ..i p T,)es Ohlr
Zignature of officer ad histering oath Printed name of officer administering oath Title of officer admini tering oath
r-umis proviueu ay i exas ttnics Commission www,elhics.state.tx.us Version V1.0.645
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-39299
Date Filed:
04/13/2016
Date Acknowledged:
04/22/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Austin Materials, LLC
Austin, TX United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
City of Round Rock
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the goods or services to be provided under the contract.
Dell Diamond Seal
Asphalt paving, slurry seal and striping
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 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www. ethics. state. tx.us Version V1.0.645