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Contract - Halff Associates - 9/10/2020STATE OF TEXAS § COUNTY OF WILLIAMSON § SUPPLEMENTAL CONTRACT NO.3 TO CONTRACT FOR ENGINEERING SERVICES FIRM: HALFF ASSOCIATES, INC. ("Engineer") ADDRESS: 9500 Amberglen Boulevard, Building F, Suite 125, Austin, TX 78729 PROJECT: Chisholm Valley Storm Drain Improvements — Area 3 This Supplemental Contract No. 3 to Contract for Engineering Services is made by and between the City of Round Rock, Texas, hereinafter called the "City" and Halff Associates, Inc., hereinafter called the "Engineer". WHEREAS, the City and Engineer executed a Contract for Engineering Services, hereinafter called the "Contract", on the 11 th day of July, 2019 for the Chisholm Valley Storm Drain Improvements — Area 3 Project in the amount of $131, 5 3 5.00; and WHEREAS, the City and Engineer executed Supplemental Contract No. 1 on the 7th day of February, 2020 to modify the provisions for the scope of services and to increase the compensation by $17,005.00 to a total of $148,540.00; and WHEREAS, the City and Engineer executed Supplemental Contract No. 2 on the 20th day of March, 2020 to modify the provisions for the scope of services and to increase the compensation by $41,360.00 to a total of $189,900.00; and WHEREAS, it has become necessary to amend the Contract to modify the provisions for the scope of services and to increase the compensation by $74,630.00 to a total of $264,530.00; NOW THEREFORE, premises considered, the City and the Engineer agree that said Contract is amended as follows: I. Article 2, Engineering Services and Exhibit B, Engineering Services shall be amended as set forth in the attached Addendum to Exhibit B. Exhibit C, Work Schedule shall be amended as set forth in the attached Addendum to Exhibit C . II. Article 41, Compensation and Exhibit D, Fee Schedule shall be amended by increasing by $74,630.00 the maximum amount payable under the Contract for a total of $264,530.00, as shown by the attached Addendum to Exhibit D. Supplemental Contract 0199.1928; 00452435 Rev.06/16 84275 R- Z92010-07052- IN WITNESS WHEREOF, the City and the Engineer have executed this Supplemental Contract in duplicate,, Supplemental Contract 0199.1928; 00452435 [signature pages follow] Rev.06/16 84275 2 HALFF ASSOCIATES, INC. By: r C.in�1 � tDirect�roF WuleQ(2eKSources Date Supplemental Contract Rev.06/ 1 0199.1928; 00452435 84275 CITY OF RO ND ROCK By: A IM I Craig Mo g n, Ma I r Date Supplemental Contract 0199.1928; 00452435 APP OVED AST FORM: Stepha L. Sheets, City Attorney Rev.06/16 84275 ADDENDUM TO EXHIBIT B Engineering Services 1. PROJECT PURPOSE The purpose of this supplemental to the Chisholm Valley Subdivision — Study Area 3 Improvements is for additional services to provide utility improvements, environmental permitting, bid phase services, construction phase services within Study Area 3. The utility improvements will consist of water and sewer improvements on Chisholm Valley Drive, Round Up Trail and Sagebrush Drive. Additionally, these utility improvements will include new service connections to replace service connections within in the limits of storm drain improvements. The storm drain and utility improvements require environmental permitting, which includes an estimate of Waters of the US near the outfall and TCEQ coordination for WPAP and SCS approval. In addition, the City has request bid phase and construction support services and is included in this supplemental. ay'-� � ` � ♦ f � ♦ t go ♦ i ,gas ♦� � � � 4 ♦ � l r" r ♦ I t i BUFFALO PASS + � ♦ ♦ s' . ♦ ,� s - = , s !♦, 10 p ♦El CP S • ♦ ♦ f� ♦ ' / CA / i�rl % = I Syr? is / 4 v Legend ' s Proposed inlet Proposed Pipe / ® Existing Inlet � Existing Pipe Supplemental 3 Area s � Project Area Figure 1. Study Area 3 Project Limits 2. SCOPE OF WORK The scope of work for the services to be provided under this additional work effort request includes the following tasks based on the task numbering in the original scope: Chasholm Palley — Stucv Area 3 Flood Mitigation Design Task 5: 100% Design Phase Submittal Task 8: Environmental Permitting Task 9 : Bid Phase Services Task 10: Construction Administration Services Task 51: 1QQ% Design Phase Submittal Upon the Ci*ty"s formal approval of the 60% Preli inary Engineering Design, Halff will proceed with 100% design efforts. The work product will require the improving the wastewater lines on Sagebrush Drive and the refinement of the utility and storm drain design on Sagebrush Drive including design plans and opinions of probable cost associated with the proposed improvements. • Submit conlillent responses and redll*ned plan sheets to CORK for concurrence to ensure that the 100% plan set fully addresses the city's comments. • Prepare I I "x 17" 100% design plans for the proposed wasterwater main on Sagebrush Drive to the intersection with Chisholm Valley Drive. • 10 Revise storm drain design on Sagebrush Drive to accommodate new wastewater design and to avoid disturbing the existing curb line. o Add new plan and profile sheets for Sagebrush Drive based on additional wastewater limits. 10 0 o Revise plan and profile sheets for Sagebrush Drive based on new utility and storm drain locations as directed by CORK o Revise storm drain lateral profile sheets for Sage Brush Drive • Update engineer's opinion of pro bable cost utilizing the revised design Task be, Environmental Permitting 801 Wetland Delineation and Jurisdictional Determination of Waters of the United -States and Permit Avoidance Documentation Consultant shall perform on -the -ground delineation within the pro40 ject area to identify the limits of Waters of the United States (WOTUS), including wetlands, as defined in the United States Army Corps of Engineers (USAGE) "Wetland Delineation Manual, Technical report Y-87-1" and the "Regional Supplement to the Corps of Engineers Wetland Delineation Manual: Atlantic and Gulf Coastal Plain Region (Version 2.0) and the 2020 Navigable Waters Protection Rule. A brief technical memorandum will be prepared documenting the results of the field investigation, and that the proposed project will be designed to avoid impacts to aquatic resources with the potential to be regulated as WOTUS by the USAGE. This documentation will be based on the preliminary jurisdictional opinion of Halff Associates, Inc. and a USAGE Approved Jurisdictional Determination (AJD) and/or Section 404 permit application is not included in i's scope. 2 802 Cultural Resources Desktop Review and THC Consultation Letter Halff shall perform a cultural resources literature review/archival research of the proposed project area including perflo ing preliminary research into historic and recent aerial photography, previously recorded archaeological or historical sites, and previous cultural resources surveys in or adjacent to the area to determine the potential for encountering significant cultural resources within thei project area. Findings of this nvestigation shall be documented along with letter for submission for review/concurrence by the Texas Historical Commission (THC). 8e3 TCEO Water Pollution Abatement Plan Permitting The Engineer shall prepare a Water Pollution Abatement Plan (WPAP) in compliance with the requirements of Title 30, Texas Administrative Code Chapter 213 related to the Edwards Aquifer. No new impervious cover is anticipated to be part of the Chisholm Valley Storm Drain Improvements Project, so no permanent Best Management Practices (BMPs) will be designed or installed. The tasks that are anticipated include: • Prepare a Geologic Assessment Request fori*nclusion with the WPAP • Prepare and finalize a drainage report for inclusion in the WPAP. • Prepare calculations, plan sheets, and details for temporary BMPs. Provide summary of all water quality measures for inclusion in the WPAP submission. • Finalize PS&E plans for inclusion in the WPAP submission. 804 TCEO Organized Sewage Collection System Plan Permitting The Engineer shall prepare an Organized Sewage Collection System Plan (SCS) in compliance with the requirements of Title 30, Texas Administrative Code Chapter 213 related to the Edwards Aquifer. No new impervious cover is anticipated to be part of the Chisholm Valley Storm Drain Improvements Project, so no permanent Best Management Practices (BMPs) will be designed or installed. The tasks that are anticipated are: • Prepare a Geologic Assessment Request for inclusion with the SCS • Prepare and finalize the SCS Engineering Design Report. • Prepare calculations, plan sheets, and details for temporary BMPs. Provide summary of all water quality measures for inclusion in the SCS submission. • Finalize PS&E plans for inclusion in both the SCS submission. Deliver-ables0., The Engineer shall submit to TCEQ a complete version of both the Wj,''P and SCS consisting of the following items: • General Information FoC -0587 including location maps and project description 10 Is • The Geologic Assessment Form (TCEQ-0585), including the GA performed by rd party consultant • Water Pollution Abatement Plan Application Form (TCEQ-0584), including information derived from final drainage report • Organized Sewage Collection System Plan (TCEQ-0582) 3 • Temporary Sto water Section (TCEQ-0602) including the temporary BMP plan • Core Data Form (TCEQIIIIIIIIIIIIIIIIII, 10400) � Geological Exception Request Exclusions/ASSUMDtions.i • USACE 404 Nationwide Permit (NW) will not require a Pre-Constructi*on Notification (PCN) • Based on conversations with the TCEQ it is assumed that a Geological Assessment will not be required considering this project does not include any new impervious cover. • Halff will not prepare the geologic assessment (GA) required as part of the WPAP and SCS submission • Permanent BMP design • Fees required for WPAP and SCS submission The SCS and WPAP will be submitted to TCEQ concurrently with the 100% plans and a 60-day review period is anticipated. Construction i*s prohibited until final approval is received. Task 9: Bid Phase Services This phase of the preproposal includes a scope of work to provide bid phase services for an anticipated 2 months for City procurement. OR • Halff will attend a pre -bid meeting to discuss the project with potential bidding contractors. • Halff will be available to assist City in responding to questions from contractors. The City will take the lead in responding to all questions with the Contractor. The basis of estimate for the associated fee assumes approximately (five) 5 questions. • Halff will assist City with addenda prenaration. The City willtake the lead on issuing the agenda. Halff will prepare written description, drawing revision, and design modification for agenda. The basis of estimate for the associated fee assumes two (2) addenda. Task 1Qe:Consl uction Phase Serv40 ices This proposal includes a scope of work to provide construction phase support services for the anticipated 10 months for the storm drain repairs. • Construction Observation - Halff will attend biIIIIIIIIIIIIIIIIII,weekly visits and monthly construction progress meetings at the site with City and Contractor. The City will lead the meetings and Halff will respond to questions. The bl*IIIIIIIIIIIIIIIIIIIWeekly visits will be observing the progress and the quality of work and attempt to determine in general if the work i*s proceeding in accordance with the Construction Contract Documents. Halff assumes that daily inspection will be conducted by the assigned City Inspector. This scope assumes 20 site visits by one person where a maximum often (10) of the site visits will be attended by an engineer and the remaining by an engineer in training. • Submittal Reviews — Halff will provide a list of shopd rawings/submittals (Submittals Log) required to be turned in by the contractor based on the 100% plans and standards. Halff 4 will be responsible for review and approval of all shop drawings or submittals of the project and will be distributed to Halff by the City. Shop drawings or submittals will be reviewed for general conformance with the plans and specifications. The City will be the primary point of contact and will monitor the progress of the contractor in sending and processing submittals to see that documentation is being processed in accordance with Contractor's 10 schedule. The basis of estimate for the associated fee assumes approximately 15 submittals. • Response to RFIs — Halff will respond to Contractor Request for Information (RFI), Engineer will review and respond and design drawings may be modified to address the issue and new design details will be prepared. This scope assumes 5 RFIs from the Contractor. The basis of estimate for the associated fee assumes approximately ten (10) RIFI"s from the contractor with approximately two (2) requiring revisions to the plans. • Substantial/Final Walkthrough — Halff will conduct, in company with the City and Contractor, a final review of the Project for conformance with the design concept of the Project and general compliance with the Construction Contract Documents. Prepare a list of deficiencies to be corrected by the Contractor before recommendation of final payment. • Record Drawings —Revise the construction drawings in accordance with the red lines 40 furnished by the City reflecting changes in the Project made during construction. Halff will provide one (1) pdf set of the "Record Drawings" to the City. • Engineer's Concurrence Letter - Prepare a letter of concurrence that the construction is acceptable and has been completed i*n general conformance with the contract documents. 5 ADDENDUM TO EXHIBIT C Work Schedule Halff Associated, Inc. (Halff) can collunence work on this project immediately after notice -to - proceed (NTP) is received from the City of Round Rock. Halff anticipates completing Work Authorization No. 3 following the most recent project schedule., • Task 5: 100% Design Phase Submittal — Aug. 31, 2020 to Oct. 30,2020 • Task 6: QA/QC — Aug. 31, 2020 to Oct. 30, 2020 • Task8'.*Environ ental — Nov. 2, 2020 to Feb. 26, 2021 • Task 94.0 Bid Phase Services — Feb. 1, 2021 to May 3, 2021 • Task 10.,* Construction Phase Services — May 17, 2021 to Mar. 18, 2022 ADDENDUM TO EXHIBIT D Fee Schedule Attached Behind This Page Hourly rates to be billed on a time and materials basis per the following Rate Schedule attached (behind this page): *Rates may be amended once between Nov. 1, 2018 and Nov. 1, 2019, not to exceed a 3%increase. Halff Associates, Inc. Printed 8/11/2020 Chisholm Valley Storm Drain 11-1-vrovements -Area 3 Supplemental Work Authorization #3 Exhibit D Fee Schedule Total Total Other TOTALS Task LaborHours LoadedLaborCost DirectCosts Subconsultants Task 1: Project Management 0 $0000 $0000 $0000 $0000 Task 2: Site Data Acquisition 0 $0,000 $0,900 $0000 $0,500 Task 3: Preliminary Engineering Design (30%) 0 $0000 $0000 $0000 $0,00 Task 4: 60% Design Phase Submittal 0 $0,00 $0000 $0000 $0000 Task 5: 100% Design Phase Submittal 186 $27,5154,00 $0000 $0,00 $27951100 Task 6: QA/QC 0 $0,600 $0000 $0000 $0,00 Task 7: Bluebonnet School 0 $0000 $0,800 $0000 $0000 Task 8: Environmental Permitting 153 $22,440e00 $0.800 $0,000 $22944OeOO Task 9: Bid Phase Services 26 $4929OeOO $0000 $0000 $49290.00 Task 10: Construction Phase Services 125 $20r385e00 $0000 $0,800 $20,385.00 SUPPLEMENTAL NO.3 TOTAL: 490 $ 741630e00 0 0 $ 74,630.00 SUPPLEMENTAL NO-.2 TOTAL: 269 $ 41,360.00 0 0 $ 41,360e00 SUPPLEMENTAL NO.1 TOTAL: 117 $ 179005e00 0 0 $ 179005e00 ORIGINAL CONTRACT TOTAL: 850 $ 1299360.00 29175 0 $ 131,535.00 REVISED CONTRACT TOTAL: 19726 :1$ 2629355.00 - - - ME 29175 0 $ 2649530000 Chisholm Valley Drainage Assessment - Exhibit D Page D1 of 1 Chisholm Valley Storm Drain improvements - Area 3 SUPPLEMENTAL WORK AUTHORIZATION #3 Fee Summary Details I. Halff Associates' Direct Labor: Project Manager 14.0 Hrs. @ $230,00 /Hr.= $ 31220 Senior Engineer (Eng. V) 86.0 Hrs. @ $200400 /Hr.= $ 17200 Mid Engineerg(En. IV) 84.0 Hrs. @ $160,00 /Hr.= $ 13440I Jr Engineer (Eng. III) 270.0 Hrs. @ $135-00 /Hr.= $ 361450 Jr Environmental Scientist 36.0 Hrs. @ $120.00 /Hr.= $ 4320 Survey/SUE Crew 0.0 Hrs. @ $155,00 /Hr.= $ - Survev/SUE Technician 0.0 Hrs. @ $95-00 /Hr.= $ RPLS 0.0 Hrs. rd) $175,00 /Hr.= $ - Clerical 0.0 Hrs. @ $80,00 /Hr.= $ - Total 490,0 Total = $ 741630 II. Expenses (ODC) Total = $O, 00 III. Assignment Amount = $ 741630 N Halff Associates, Inc. Printed 8/11/2020 Direct Labor Supplemental Work Authorization #3 rhichnlm Vallnv -qtnrm rlrain lmnrnvpmcantc _ Arna SURVEY/ SURVEY/ PROJECT TASK SR PE MID PE JR PE MID SUE SUE PM ENG. V ENG. IV ENG. III ENV CREW TECH RPLS CLERICAL TOTAL Labor Rate $230,00 $200.00 $160.00 $135.00 $120.00 $155.00 $95 C0 $175 00 $80 00 HOURS BUDGET Task 1: Project Management Subtotal Task 1 Task 2: Site Data Acquisition Subtotal Task 2 Task 3: Preliminary Engineering Design (30%) Subtotal Task 3 Task 4: 60% Design Phase Submittal Subtotal Task 4 Task 5: 100% Design Phase Submittal 5.2 Revise drainage design sheets 4 5 10 60 79 $11,620.00 52.1 Revise/Prepare utility design sheets 2 2 4 20 28 $4,200 00 5.2.3 Design new wasterwater line on Sagebrush 2 3 8 50 63 $9,090 00 5 3.1 Develop utility specifications and cost estimate 2 2 $270 00 5 5 Interdisciplinary Coordination/Review 2 2 5 5 14 $2,335.00 Subtotal Task 5 186 $27,515.00 Task 6: QA/QC Subtotal Task 6 Task 7: Bluebonnet School Subtotal Task 7 Task 8: Environmental Permitting; 8 1a WOTUS Field Delineation 1 8 9 $1,120 00 8 1b WOTUS Memorandum of findings 2 4 12 18 $2,540,00 8 2a THC Literature Review 1 12 13 $1,670.00 8.2b THC Consultation Letter 1 1 4 6 $870.00 8.3 TCEQ WPAP 4 29 24 57 $8,680 00 84 TCEQ SCS 4 22 24 1 50 $7,560.00 Subtotal Task 8 153 $22,440.00 Task 9: Bid Phase Services 91 Pre -bid meeting 4 4 8 $1,340 00 92 Respond to technical questions (assume 5) 4 4 8 $1,340 00 9 3 Assist with addenda preparation (assume 2) 4 6 10 $1,610.00 Subtotal Task 9 26 $4,290.00 Task 10: Construction Phase Services 10.1 Construction Observation (assume 20) 20 20 40 $6,700.00 10.2 Submittal Reviews (assume 15) 10 15 25 $4,025 00 103 Responses to RFI (assume 10) 10 10 20 $3,350.00 10.4 Substainal/Final Walkthrough 8 8 16 $2,680.00 10 5 Record Drawings 4 16 20 $2,960.00 106 Concurrence Letter 2 2 4 $670 00 Subtotal Task 10 125 $20,385.00 14 86 84 270 36 490 $74,630.00 Halff Associates, Inc Printed 8/11/2020 Other Direct Costs Summary Reproductions Price per copy Number of copies Cost Standard Copies (letter, legal) $0.10 0 11x17 $0.20 0 - 22 "x34"-- Mylar $2.00-- 0 - Delivery / Courier Price per trip Number of trip Courier $15 0 - 1 Traffic Control Days Certified Traffic Control $11000 0--- Materials and Supplies Document preparation: binding, materials, etc. 0.00 Travel outside Round Rock, Austin Price per mile Miles Cost Travel @ $0.58 per mile $0.580 0 $0,00 1 Total ODC Cost0 : $OMOO Halff Associates, Inc. Printed 8/11/2020 CERTIFICATE OF INTERESTED PARTIES FORM 1295 OR — ---------- --------------------- ------------------- --- NMI ------- - ---------------- . ..... ...... 1 of 2 Complete Nos. 1 - 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos, 1, 21 3, 5, and s if there are no interested parties,. -- -- --------- --- ------------------- --- --- --- --------- ---- ---- 'CERTIFICATION OF FILING --- ---------- --- - ----------- .. ............ . ........ --------- ------------------- 1 Name of business entity filing form, and the city, state and country of the business entity's place *Certificate Number: of business. 2020-661034 Halff Associates, Inc. Austin, TX. United States Date Filed: -- -------------------me governments enft''or state agency that is a party to t e contract for which the orm is ------------ -- ---- -------- --------------------- - - --------------- ---- --------------------- it - -- ----- �8/25/2020 being filed. City.of Round Rock Date Acknowledged.. ----------- 11.a. wo­ -- ---------* -- -------- -------- ----- -- 3 Provide the identification number used by the governmental entity or state agency to track or identity the contract, and provide a description' of the services, goods, -or other property to be provided under the contract. R.,2019-0289 Imp rovem.............. Engineering Services, Chi--- sholm Valley Storm Drain &U------- - --tility .... .. 4 --- -----ents ... . .... ------------ - ---------- N0.0 Nloomature of interest Name of Interested Party City, State, Country (place of business) 111111111 applicable) . . .. ............... . -- ---------- - -- ...... .... ----- ----- ........ .......... . ------------------ . ....(check Conttollin Intermedia .......... ------ Adams , Bobby Houston, TX United States X ............. . ------------- ..... . . . wm -------- --------- - - - -------------- Bargainer, Tim ---------------- Austin, TX United States X - -------------- . .......... ............. -- -------- ---- -- ------------ ------------------- Baker ,Jessica Richardson, TX United States ......... . ... ..... .. X NOWN. . ............. ............ i 0 -------- ------------------ --- --- - ---- Edwards , Mark - --------------- Richardson, TX United States ---------- --- - ------------- -- X --- ----- ------------- ---- --- ------- .. ............ -------------- Ickert, Andrew NO Fort Worth, TX United States X Jackson, Todd Austin, TX United States X --------------- ---------------- -- --------- - Kunz, Pat ---------- ---------- ------- - Richardson, TX United States -------- _01*0 11111 Mo ----------- - - ---------- W, X 11 --------------- . . . .......... ----------- ---- --- ------ Miller, Steven Austin, TX United States X ROHNN -ft ------- Moya, Mike -------------------- -- --------------- - ----------- Austin, TX United States X 41 0 --------- 0- . ......... N 4- ------- -------- ----- ---- -------- Murray, Menton ROM . ...... ------------ ------- --------- McAllen, TX United States N011M - - - S�N - --------------- - - . - - ----- - ---------- NO i . ---- — - --------------- --------------- -- - Sagel, Joseph ..... ------- ------ ------- --------------- Richardson, TX United States ----- - ----- M --------- NUMN - X ------ . Tanksley, Dan -------------------------------- ------------------ Richardson, TX United States X - ------- -- Zapalac, Russell: - ---- ------------------ .. ... . ... --------------------------------- ...... - ---------- --------------- --------------- - - - --------------- Austin, TX United States X ---- ----- --- --- ------ ------ ----- Fo'''rmt provided by Texas Ethics Commission www,,ethics.state.bc.us Version V 11*.' 3­a,6aaf7*d This Page is too large to OCR CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 2 I- N Complete Nos,, i - 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos, 1, 21 31 5, and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number: of business. 2020-661034 Halff Associates, Inc. Austin, 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 08/25/2020 being filed. City of Round Rock Date Acknowledged: 08/26/2020 g Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. R-2019-0289 Engineering Services, Chisholm Valley Storm Drain & Utility Improvements 4 Name of Interested PartyCity,State, Country of business) Nature of interest a licable PP Controlling Intermediary Adams ,Bobby Houston, TX United States X Bargainer, Tim Austin, TX United States X Baker ,Jessica Richardson, TX United States X Edwards , Mark Richardson, TX United States X Ickert, Andrew Fort Worth, TX United States X Jackson, Todd Austin, TX United States X Kunz, Pat Richardson, TX United States X Miller, Steven Austin, TX United States X Moya, Mike Austin, TX United States X Murray, Menton McAllen, TX United States X Sagel, Joseph Richardson, TX United States X Tanksley Dan Richardson, TX United States X Zapalac, Russell Austin, TX United States X Forms provided by Texas Ethics Commission www.ethics.state.txus Version Vl,1,3a6aaf7d CERTIFICATE OF INTERESTED PARTIES FORM 1295 2of2 Complete Nos, 1 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. 2020-661034 Halff Associates, Inc. Austin, 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 08/25/2020 being filed. City of Round Rock Date Acknowledged: 08/26/2020 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. R-2019-0289 Engineering Services, Chisholm Valley Storm Drain & Utility Improvements 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. ❑ 6 UNSWORN DECLARATION My name is ,and my date of birth is My address is - - I (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 Ax, us Version Vl,1,3a6aaf7d