HomeMy WebLinkAboutC2016-575 - 11/15/2016 - Approved 4S_ II
v? � SUPPLY AGREEMENT NO. 764
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i2 FIRE HYDRANTS
THIS Fire Hydrants Supply Agreement ("Agreement") is entered into by and
between the City of Corpus Christi, a Texas home-rule municipal corporation
("City") and HD Supply WaterWorks ("Supplier"), effective for all purposes upon
execution by the City Manager or the City Manager's designee ("City Manager").
WHEREAS, Supplier has bid to provide Fire Hydrants in response to Request for
Bid No. 126 ("RFB"), which RFB includes the required scope of work and all
specifications and which RFB and the Supplier's bid response are incorporated by
reference in this Agreement as Exhibits 1 and 2, respectively, as if each were fully
set out here in its entirety.
NOW, THEREFORE, City and Supplier agree as follows:
1. Scope. Supplier will provide Fire Hydrants in accordance with the attached
Scope of Work, as shown in Attachment A, the content of which is
incorporated by reference into this Agreement as if fully set out here in its
entirety. "Goods," "products", and "supplies", as used in this Agreement,
refer to and have the same meaning.
2. Term. This Agreement is for 12 months. This Agreement includes an option to
extend the term for up to two additional 12-month periods ("Option Period"),
provided, the parties do so prior to expiration of the original term or the then-
current Option Period. The decision to exercise the option to extend the term
of this Agreement is, at all times, within the sole discretion of the City and is
conditioned upon the prior written agreement of the Supplier and the City
Manager.
3. Compensation and Payment. The total value of this Agreement is not to
exceed $178,690.00, subject to approved extensions and changes. Payment
will be made for goods delivered and accepted by the City within 30 days
of acceptance,subject to receipt of an acceptable invoice. All pricing must
be in accordance with the attached Bid/Pricing Schedule, as shown in
Attachment B, the content of which is incorporated by reference into this
Agreement as if fully set out here in its entirety.
4. Contract Administrator. The Contract Administrator designated by the City is
responsible for approval of all phases of performance and operations under
this Agreement, including deductions for non-performance and
City of Corpus Christi Page 1 of 7
Supply Agreement Standard Form
2016-575
11/15/16
M2016-149 INDEXEDHD Supply WaterWorks
authorizations for payment. The City's Contract Administrator for this
Agreement is as follows:
Name Robert Presnell
Department Warehouse Stores
Phone 361-826-1750
Email RobertPR@cctexas.com
5. Insurance. Before performance can begin under this Agreement, the
Supplier must deliver a certificate of insurance ("COI"), as proof of the
required insurance coverages, to the City's Risk Manager and the Contract
Administrator. Additionally, the COI must state that the City will be given at
least 30 days' advance written notice of cancellation, material change in
coverage, or intent not to renew any of the policies. The City must be named
as an additional insured. The City Attorney must be given copies of all
insurance policies within 10 days of the City Manager's written request.
Insurance requirements are as stated in Attachment C, the content of which
is incorporated by reference into this Agreement as if fully set out here in its
entirety.
6. Purchase Release Order. For multiple-release purchases of products to be
provided by the Supplier over a period of time, the City will exercise its right
to specify time, place and quantity of products to be delivered in the
following manner: any City department or division may send to Supplier a
purchase release order signed by an authorized agent of the department or
division. The purchase release order must refer to this Agreement, and
products will remain with the Supplier until such time as the products are
delivered and accepted by the City.
7. Inspection and Acceptance. Any products that are delivered but not
accepted by the City must be corrected or replaced immediately at no
charge to the City. If immediate correction or replacement at no charge
cannot be made by the Supplier, a replacement product may be bought
by the City on the open market and any costs incurred, including additional
costs over the item's bid price, must be paid by the Supplier within 30 days of
receipt of City's invoice.
8. Warranty. The Supplier warrants that all products supplied under this
Agreement are new, quality items that are free from defects, fit for their
intended purpose, and of good material and workmanship. The Supplier
warrants that it has clear title to the products and that the products are free
of liens or encumbrances. In addition, the products purchased under this
Agreement shall be warranted by the Supplier or, if indicated in Attachment
City of Corpus Christi Page 2 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
D by the manufacturer, for the period stated in Attachment D. Attachment
D is attached to this Agreement and is incorporated by reference into this
Agreement as if fully set out here in its entirety.
9. Quality/Quantity Adjustments. Any quantities indicated on the Bid/Pricing
Schedule are estimates only and do not obligate the City to order or accept
more than the City's actual requirements nor do the estimates restrict the
City from ordering less than its actual needs during the term of the
Agreement and including any Option Period. Substitutions and deviations
from the City's product requirements or specifications are prohibited without
the prior written approval of the Contract Administrator
10. Non-Appropriation. The continuation of this Agreement after the close of
any fiscal year of the City,which fiscal year ends on September 30th annually,
is subject to appropriations and budget approval specifically covering this
Agreement as an expenditure in said budget, and it is within the sole
discretion of the City's City Council to determine whether or not to fund this
Agreement. The City does not represent that this budget item will be
adopted, as said determination is within the City Council's sole discretion
when adopting each budget.
11. Independent Contractor. Supplier will perform the work required by this
Agreement as an independent contractor and will furnish such products in
its own manner and method, and under no circumstances or conditions will
any agent, servant or employee of the Supplier be considered an employee
of the City.
12. Subcontractors. Supplier may use subcontractors in connection with the
work performed under this Agreement. When using subcontractors,
however, the Supplier must obtain prior written approval from the Contract
Administrator if the subcontractors were not named at the time of bid. In
using subcontractors, the Supplier is responsible for all their acts and omissions
to the same extent as if the subcontractor and its employees were
employees of the Supplier. All requirements set forth as part of this
Agreement, including the necessity of providing a COI in advance to the
City, are applicable to all subcontractors and their employees to the same
extent as if the Supplier and its employees had performed the work.
13. Amendments. This Agreement may be amended or modified only by written
change order signed by both parties. Change orders may be used to modify
quantities as deemed necessary by the City.
City of Corpus Christi Page 3 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
14. Waiver. No waiver by either party of any breach of any term or condition of
this Agreement waives any subsequent breach of the same.
15. Taxes. The Supplier covenants to pay payroll taxes, Medicare taxes, FICA
taxes, unemployment taxes and all other related taxes. Upon request, the
City Manager shall be provided proof of payment of these taxes within 15
days of such request.
16. Notice. Any notice required under this Agreement must be given by fax,
hand delivery, or certified mail, postage prepaid, and is deemed received
on the day faxed or hand-delivered or on the third day after postmark if sent
by certified mail. Notice must be sent as follows:
IF TO CITY:
City of Corpus Christi
Attn: Robert Presnell
Warehouse Store Keeper
1201 Leopard Street, Corpus Christi, TX 78401
361-826-3174
IF TO SUPPLIER:
HD Supply WaterWorks
Attn: Paul Rodriguez
Branch Manager
7425 Leopard Street, Corpus Christi, TX 78410
361-239-6544
17. SUPPLIER AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND THE
CITY OF CORPUS CHRISTI AND ITS OFFICERS, EMPLOYEES AND
AGENTS ("INDEMNITEES') FROM AND AGAINST ANY AND ALL
LIABILITY, LOSS, CLAIMS, DEMANDS, SUITS AND CAUSES OF ACTION
OF ANY NATURE WHATSOEVER ON ACCOUNT OF PERSONAL
INJURIES (INCLUDING DEATH AND WORKERS' COMPENSATION
CLAIMS), PROPERTY LOSS OR DAMAGE, OR ANY OTHER KIND OF
INJURY, LOSS, OR DAMAGE, INCLUDING ALL EXPENSES OF
LITIGATION, COURT COSTS, ATTORNEYS' FEES AND EXPERT WITNESS
FEES WHICH ARISE OR ARE CLAIMED TO ARISE OUT OF OR IN
CONNECTION WITH THIS AGREEEMENT OR THE PERFORMANCE OF
THIS AGREEMENT, REGARDLESS OF WHETHER THE INJURIES, DEATH
OR DAMAGES ARE CAUSED OR ARE CLAIMED TO BE CAUSED BY THE
City of Corpus Christi Page 4 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
CONCURRENT OR CONTRIBUTORY NEGLIGENCE OF INDEMNITEES,
BUT NOT IF BY THE SOLE NEGLIGENCE OF INDEMNITEES UNMIXED
WITH THE FAULT OF ANY OTHER PERSON. SUPPLIER MUST, AT ITS OWN
EXPENSE, INVESTIGATE ALL CLAIMS AND DEMANDS, ATTEND TO
THEIR SETTLEMENT OR OTHER DISPOSITION, DEFEND ALL ACTIONS
BASED THEREON WITH COUNSEL SATISFACTORY TO THE CITY
ATTORNEY, AND PAY ALL CHARGES OF ATTORNEYS AND ALL OTHER
COSTS AND EXPENSES OF ANY KIND ARISING FROM ANY SAID
LIABILITY, DAMAGE, LOSS, CLAIMS, DEMANDS, SUITS, OR ACTIONS.
THE INDEMNIFICATION OBLIGATIONS OF SUPPLIER UNDER THIS
SECTION SHALL SURVIVE THE EXPIRATION OR EARLIER TERMINATION
OF THIS AGREEMENT.
18. Termination.
(A) The City Manager may terminate this Agreement for Supplier's failure to
perform the work specified in this Agreement or to keep any required
insurance policies in force during the entire term of this Agreement. The
Contract Administrator must give the Supplier written notice of the breach
and set out a reasonable opportunity to cure. If the Supplier has not cured
within the cure period, the City Manager may terminate this Agreement
immediately thereafter.
(B) Alternatively, the City Manager may terminate this Agreement for
convenience upon 30 days advance written notice to the Supplier. The City
Manager may also terminate this Agreement upon 24 hours written notice to
the Supplier for failure to pay or provide proof of payment of taxes as set out
in this Agreement.
19. Assignment. No assignment of this Agreement by the Supplier, or of any
right or interest contained herein, is effective unless the City Manager first
gives written consent to such assignment. The performance of this
Agreement by the Supplier is of the essence of this Agreement, and the City
Manager's right to withhold consent to such assignment is within the sole
discretion of the City Manager on any ground whatsoever.
20. Severability. Each provision of this Agreement is considered to be severable
and, if, for any reason, any provision or part of this Agreement is determined
to be invalid and contrary to applicable law, such invalidity shall not impair
the operation of nor affect those portions of this Agreement that are valid,
City of Corpus Christi Page 5 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
but this Agreement shall be construed and enforced in all respects as if the
invalid or unenforceable provision or part had been omitted.
21. Order of Precedence. In the event of any conflicts or inconsistencies
between this Agreement, its attachments, and exhibits, such conflicts and
inconsistencies will be resolved by reference to the documents in the
following order of priority:
A. this Agreement and its attachments
B. the bid solicitation document, including addenda (Exhibit 1)
C. the Supplier's bid response (Exhibit 2)
22. Certificate of Interested Parties. Supplier agrees to comply with Texas
Government Code Section 2252.908, as it may be amended, and to
complete Form 1295 "Certificate of Interested Parties" as part of this
Agreement.
23. Governing Law. This Agreement is subject to all federal, State, and local laws,
rules, and regulations. The applicable law for any legal disputes arising out
of this Agreement is the law of the State of Texas, and such form and venue
for such disputes is the appropriate district, county, or justice court in and for
Nueces County, Texas.
24. Entire Agreement.This Agreement constitutes the entire agreement between
the parties concerning the subject matter of this Agreement and supersedes
all prior negotiations, arrangements, agreements and understandings, either
oral or written, between the parties.
(SIGNATURE PAGE FOLLOWS)
City of Corpus Christi Page 6 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
SUPPLIER /
Signature: 4 elk
Printed Name: Loren Miller
Title: District Manager
Date: 10 October 2016
CITY OF CORPUS CHRISTI
Signature: (Y\ ,i
Printed Name: c,
142.o 1 k-P, I T
Title:A7rucw,r
Date: t � ) I le / /co
SECRFTA
ATTEST:
REBECCA HUERTA
CITY SECRETARY
Attached and Incorporated by Reference:
Attachment A: Scope of Work
Attachment B: Bid/Pricing Schedule
Attachment C: Insurance Requirements
Attachment D: Warranty Requirements
Incorporated by Reference Only:
Exhibit 1: RFB No. 126
Exhibit 2: Supplier's Bid Response
City of Corpus Christi Page 7 of 7
Supply Agreement Standard Form
Approved as to Legal Form 7/1/16
ATTACHMENT A-SCOPE OF WORK
4.1 General Requirements/Background Information
The Contractor shall provide Fire Hydrants as outlined in this Scope of Work.
4.2 Scope of work
This Scope of Work describes fire hydrants and includes sections on type,
functional and performance requirements. These hydrants are to be used by the
City of Corpus Christ for new and replacement installations, for municipal water
distribution and fire service. These specifications describe fire hydrants and
include sections on type, functional and performance requirements. Hydrants
shall comply with specification AWWA C-502, with latest revisions. Hydrants shall
be of the traffic model type equipped with a safety flange or collar on both the
Hydrant barrel and stem.
4.3 Functional and Performance Requirements
1. Type of shutoff- The shutoff shall be of the compression type only.
2. Inlet connection - The inlet shall be ASA-A21 .11, with latest revision
mechanical joint for size six inch, Class 150, cast iron pipe. A complete set of
joint material shall be furnished with each hydrant.
3. Delivery classifications - Each hydrant shall have two-hose nozzles and one-
pumper nozzle. Nozzle shall be readily replaceable threaded or camlocked
into hydrant body.
4. Bury length - The hydrants shall be furnished in bury length as specified in
Attachment B, Bid Price Schedule.
5. Diameter (nominal inside) of hose and pumper nozzles -The hose nozzle shall
be two and one-half inches inside diameter and the pumper nozzle shall be
four inches inside diameter.
6. Hose and pumper nozzle threads - The hose nozzles shall have two and one-
half inch National Standard Thread (seven and one-half threads per inch).
The pumper nozzle shall have six thread per inch with an outside diameter of
4.658 inches, pitch diameter of 4.543 inches and a root diameter of 4.406
inches.
7. Harnessing lugs - None required.
8. Nozzle cap gaskets - Required.
9. Tapping of drain opening - Tapping of the drain opening for pipe thread is
not required.
10. Drain opening - Required.
11. Direction to open - The hydrants shall open left (counter clockwise).
12. Color of finish above ground line - That portion of the hydrant above the
ground line shall be painted chrome yellow.
13. Shape and size of the operating and cap nuts -The operating and cap nuts
shall be tapered pentagon one and one-fourth inch point to face at base
and one and one-eighth inch point to face at top of the nut.
14. Nozzle cap chains - Hydrants shall be furnished without nozzle cap chains.
15. Size of hydrant valves - The main valve opening shall not be less than five
and one-quarter inches inside diameter.
16. Valve facing - The main valve facing of the hydrant shall be rubber with 90
± one Durometer hardness. When the main valve lower washer and stem
nut are not an integral casting then the bottom stem threads shall be
protected with a ductile and/or bronze cap nut and a stainless steel and/or
bronze lock nut.
17. Barrel sections - The hydrant shall be made in two or more barrel sections
with flanges connecting the barrel to the elbow and to the packing plate.
18. Breakable coupling - Hydrants shall be equipped with a breakable coupling
on both the barrel section and the stem. These couplings shall be at least
two inches above the finished grade line. The coupling shall be designed so
that in case of traffic collision the barrel and stem collar will break before any
other part of the hydrant breaks.
19. Hydrant adjustment-The hydrants shall be designed as to permit its extension
without excavating after the hydrant is completely installed.
20. Breakable collars - Barrel and stem - Weakened steel or weakened cast iron
bolts that are used in the breakable barrel couplings will not be acceptable.
21 . Operating stem -Stems that have operating thread located in the waterway
shall be made of manganese bronze, everdure, or other high quality non-
corrodible metal. Stems that do not have operating threads located in the
waterway must be sealed by a packing gland or 0-ring seal located
between the stem threads and the waterway. Iron or steel stems shall be
constructed with a bronze sleeve extending through the packing gland or
0-ring seal area. The sleeve shall be of sufficient length to be in the packing
or 0-ring seal in both open and closed positions of the main valve. The
sleeve shall be secured to the steel stem so as to prevent water leakage
between the two when subjected to 300 pounds hydrostatic test pressure.
22. Drain valve mechanism - Drain valves operating through gravity are not
acceptable.
23. Operating stem nut - The operating stem nut shall be designed to prevent
seepage, rain or sleet and the accumulation of dust between the operating
nut and the hydrant top. The operating stem nut shall be made of bronze.
24. Fire hydrants having the threaded part of the stem at the hydrant top shall
be equipped with a packing gland or an 0-ring seat immediately below the
threaded section of the stem.
25. The valve seat ring shall not be made an integral part of the shoe. The valve
seat ring shall be bronze and shall thread into a bronze drain ring.
4.4 Data to be furnished by the contractor
1. The Contractor shall upon request furnish two sets of prints showing complete
details and dimensions of the hydrant.
2. The Contractor shall upon request furnish one certified copy of physical tests
of all metals used in the manufacture of the fire hydrant that is normally
manufactured and that will meet the requirements specified in the
Agreement.
3. The Contractor shall upon request furnish the City a certified letter of
compliance stating that their fire hydrant meet the requirements specified in
the Agreement.
0,11S. :
1S. y ATTACHMENT B- BID PRICE SCHEDULE
( 1/4
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7857
Response For Supplier: HD Supply WaterWorks
Event#: 126-0
Name: Fire Hydrants
Reference: 31212
Description: Twelve month supply agreement for Fire Hydrants with an option to extend for up to 2 additional twelve month
periods subject to the approval of the Supplier and the City Manager or designee.
Preview Date: Q&A Open Date: 05/07/2016 08:00:00 AM
Open Date: 05/07/2016 08:00:00 AM Q&A Close Date: 05/12/2016 05:00:00 PM
Close Date: 05/25%2016 11:00:00 AM Dispute Close Date:
Responded To: 6 Out of 6 Lines
Total Bid Amount: 178,690.00 USD
Question Responses
Question Answer Attachment
Please download the attachment titled RFB Fire Yes 2016 Annual Hydrant bid.pdf
Hydrant and complete all required documents,
and upload as an attachment.
Response Attachments
Attachment
medallion-2e879e7d.pdf
Line Responses
,,1
Event# 126-0: Fire Hydrants
Line 1: 3 Foot Bury Fire Hydrant
Item: 2324 HYDRANT FIRE 3'
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 20.0000 UOM: EA
Bid Quantity: 20.0000 Unit Price: 1,395.00000 Extended Price: 27,900.00
No Charge: No No Bid: No
Vendor Item: 605366M3CLMEDCC CLOW MED.3'0"BURY CC HYDRANT
Line 2: 3-1/2 Foot Bury Fire Hydrant
Item: 2325 HYDRANT FIRE 3 1/2
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 30.0000 UOM: EA
Bid Quantity: 30.0000 Unit Price: 1,425.00000 Extended Price: 42,750.00
No Charge: No No Bid: No
Vendor Item: 605426M3CLMEDCC CLOW MED.3'6"CC HYDRANT
Line 3: 4 Foot Bury Fire Hydrant
Item: 2326 HYDRANT FIRE 4'
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 30.0000 UOM: EA
Bid Quantity: 30.0000 Unit Price: 1,465.00000 Extended Price: 43,950.00
No Charge: No No Bid: No
Vendor Item: 605486M3CLMEDCC CLOW MED.4'0"CC HYDRANT
Line 4: 4-1/2 Foot Bury Fire Hydrant
Item: 2327 HYDRANT FIRE 4 1/2'
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 20.0000 UOM: EA
Event # 126-0: Fire Hydrants
Bid Quantity: 20.0000 Unit Price: 1,495.00000 Extended Price: 29,900.00
No Charge: No No Bid: No
Vendor Item: 605546M3CLMEDCC CLOW MED.4'6"CC HYDRANT
Line 5: 5 Foot Bury Fire Hydrant
Item: 2328 HYDRANT FIRE 5'
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 12.0000 UOM: EA
Bid Quantity: 12.0000 Unit Price: 1,545.00000 Extended Price: 18,540.00
No Charge: No No Bid: No
Vendor Item: 605606M3CLMEDCC CLOW MED. 5'0"CC HYDRANT
Line 6: 5-1/2 Foot Bury Fire Hydrant
Item: 2329 HYDRANT FIRE 5 1/2'
Commodity Code: 340-60 Hydrants,Fire(Including Accessories and Parts)
Quantity: 10.0000 UOM: EA
Bid Quantity: 10.0000 Unit Price: 1,565.00000 Extended Price: 15,650.00
No Charge: No No Bid: No
Vendor Item: 605666M3CLMEDCC CLOW MED.5'6"CC HYDRANT
ATTACHMENT C- INSURANCE REQUIREMENTS
NO INSURANCE REQUIRED FOR THIS AGREEMENT
ATTACHMENT C- BOND REQUIREMENTS
NO BOND REQUIRED FOR THIS AGREEMENT
ATTACHMENT D - WARRANTY
Clow Valve Co. 902 South 2nd Street Telephone:641 673-8611
Oskaloosa, IA 52577 Fax:641 673-8269
CLOW MEDALLIONTM HYDRANT
TEN YEAR LIMITED WARRANTY
Clow Valve Company warrants that its Clow Medallion Fire Hydrant will be free from
defects in material and workmanship under normal and customary use and maintenance
for a period of ten(10)years from the date of shipment, provided the hydrant is installed
and maintained according to Clow instructions, and applicable codes. The foregoing
warranty does not cover failure of any part or parts from external forces, including but
not limited to earthquake,vandalism,vehicular or other impact, application of excessive
torque to the operating mechanism or frost heave.
Should any Clow Valve Company part or parts fail to conform to the foregoing
warranty, Clow shall, upon prompt written notice thereof,repair or replace,F.O.B.point
of manufacture, such defective part or parts. Purchaser shall, if requested, return the
part or parts to Clow,transportation prepaid. Purchaser shall bear all responsibility and
expense incurred for removal,reinstallation and shipping in connection with any part
supplied under the foregoing warranty.
THE FOREGOING WARRANTY IS IN LIEU OF AND EXCLUDES ALL
OTHER WARRANTIES NOT EXPRESSLY SET FORTH HEREIN,WHETHER
EXPRESS OR IMPLIED BY OPERATION OF LAW OR OTHERWISE,
INCLUDING BUT NOT LIMITED TO ANY WARRANTIES OF
MERCHANTABILITY OR FITNESS. IN NO EVENT SHALL CLOW VALVE
COMPANY BE RESPONSIBLE OR LIABLE FOR ANY INCIDENTAL OR
CONSEQUENTIAL LOSSES,DAMAGES OR EXPENSES.
r, ,. .. .t .
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
loft
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
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2016-60354
HD Supply WaterWorks
Corpus Christi,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 05123/2016
being filed.
City Of Corpus Christi Date Ack owledge
_L`\l it
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.
RFB No. 126
Fire Hydrants
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
5 Check only if there is NO Interested Party.
X
6 AFI• ,t I swear,or"affir under penal„of per that the above disclosure is true and correct.
DEBBIE LEE MMITE
I
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It1y commission Expires
Wafter 24.2010 C
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Signature of 'thorized agent of contractl}t!q business entity
AFFIX NOTARY STAMP/SEAL ABOVE \
Sworn to and subscribed before me,by the said LAU. peeGflt,t/ ,this the a4 day of
20 ,to certify which,witness my hand and seal of office.
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Signature of officer admini ter g oath Printed name of officer admini ring a t Title of officer adminis ring oath r/
Forms provided by Texas Ethics ommission www.ethics.state.tx.us Version V1.0.1021
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