HomeMy WebLinkAboutC2017-199 - 7/18/2017 - Approved 011 P
v vikk SERVICE AGREEMENT NO. 1240
4vcci, oto
x852 _. Security Access Control Maintenance and:Repair
Services for Utilities Department
THIS Security Access Control Maintenance and Repair Services for Utilities
Department Service Agreement ("Agreement") is entered into by and between
the City of Corpus Christi, a Texas home-rule municipal corporation ("City") and
Total Protection Systems, Inc. ("Contractor"), effective upon execution by the
City Manager or the City Manager's designee ("City Manager").
WHEREAS, Contractor has bid to provide . Security Access Control
Maintenance and Repair Services for Utilities Department in response to
Request for Bid/Proposal No. 123 ("RFB/RFP"), which •RFB/RFP includes the
required scope :of work and all specifications and which RFB/RFP and
the Contractor's bid or proposal response, as applicable, 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 Contractor agree as follows:
1. Scope. Contractor will provide Security Access Control and Maintenance
and Repair Services for Utilities Department ("Services") 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, and in accordance with Exhibit 2.
2. Term. This Agreementis for 12 months, with performance commencing
upon the date of issuance of a notice to proceed from the Contract
Administrator'or Purchasing Division. This Agreement includes anoption 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
Contractor and the City Manager.
3. Compensation and Payment. The total value of this Agreement is not to
exceed $34,900.00, subject to approved extensions and changes.
Payment will .be made for Services completed 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,
City of Corpus Christi Page 1 of 8
2017-199
7/18/17
M2017-096
Total Protection Systems Inc.
INDEXED
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
authorizations for payment. The City's Contract Administrator for this
Agreement is as follows:
Name: Joanna Moreno
Department: Utilities Department
Phone: 361-826-1649
Email:joannam@cctexas.com
5. Insurance; Bonds.
(A) Before performance can begin under this Agreement, the Contractor
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.
(B) In the event a payment bond, a performance bond, or both, are
required of the Contractor to be provided to the City under this Agreement
. before performance can commence, the terms, conditions, and amounts
required in the bonds and appropriate surety information are as included in
the RFB/RFP or as may be added to Attachment C, and such content is
incorporated here in this Agreement by reference as if each bond's terms,
conditions, and amounts were fully set out here in its entirety.
6. Purchase Release Order. For multiple-release purchases of Services to be
provided by the Contractor over a period of time, the City will exercise its
right to specify time, place and quantity of Services to be delivered in the
following manner: any City department or division may send to Contractor
a purchase release order signed by an authorized agent of the department
or division. The purchase release order must refer to this Agreement, and
City of Corpus Christi Page 2 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
Services will not be rendered until the Contractor receives the signed
purchase release order.
7. Inspection and Acceptance. Any Services that are provided but not
accepted by the City must be corrected or re-worked immediately at no
charge to the City. If immediate correction or re-working at no charge
cannot be made by the Contractor, a replacement service may be
procured by the City on the open market and any costs incurred, including
'additional costs over the item's bid/proposal price, must be paid by the
Contractor within 30 days of receipt of City's invoice.
8. Warranty. The Contractor 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 Contractor
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 Contractor or, if indicated in
Attachment 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 Service 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. Contractor will perform the work required by this
Agreement as an independent contractor and will furnish such Services in
its own manner and method, and under no circumstances or conditions will
any agent, servant or employee of the Contractor be considered an
employee of the City.
City of Corpus Christi Page 3 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
12. Subcontractors. Contractor may use subcontractors in connection with the
work performed under this Agreement. When using subcontractors,
however, the Contractor must obtain prior written approval from the
Contract Administrator if the subcontractors were not named at the time of
bid or proposal, as applicable. In using subcontractors, the Contractor is
responsible for all their acts and omissions to the same extent as if the
subcontractor and its employees were employees of the Contractor. 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 Contractor
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.
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 Contractor 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: Joanna Moreno
Title: Contracts/Funds Administrator, Utilities Treatment
Address: 2726 Holly Rd. Corpus Christi, TX 78415
Fax: 361-826-1715
IF TO CONTRACTOR:
Total Protection Systems, Inc.
Attn: Linda L. Donnell
Title: C.E.O
Address: PO Box 270837
Fax:361-289-1688
City of Corpus Christi Page 4 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
17. CONTRACTOR 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 CONCURRENT OR CONTRIBUTORY
NEGLIGENCE OF INDEMNITEES, BUT NOT IF BY THE SOLE
NEGLIGENCE OF INDEMNITEES UNMIXED WITH THE FAULT OF ANY
OTHER PERSON. CONTRACTOR 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 CONTRACTOR UNDER THIS
SECTION SHALL SURVIVE THE EXPIRATION OR EARLIER
TERMINATION OF THIS AGREEMENT.
18. Termination.
(A) The City Manager may terminate this Agreement for Contractor'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 Contractor written
notice of the breach and set out a reasonable opportunity to cure. If the
Contractor has not cured within the cure period, the City Manager may
terminate this Agreement immediately thereafter.
City of Corpus Christi Page 5 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
(B) Alternatively, the City Manager may terminate this Agreement for
convenience upon 30 days advance written notice to the Contractor. The
City Manager may also terminate this Agreement upon 24 hours written
notice to the Contractor 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 Contractor, or of any
right or interest contained herein, is effective unless the City Manager first
gives written consent tb such assignment. The performance of thrs
Agreement by the Contractor 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, 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 Contractor's bid response (Exhibit 2)
22. Certificate of Interested Parties. Contractor 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
City of Corpus Christi Page 6 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
supersedes all prior negotiations, arrangements, agreements and
understandings, either oral or written, between the parties.
(SIGNATURE PAGE FOLLOWS)
City of Corpus Christi Page 7 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
CONTRACTOR
Signature: �� ,L- Pe -41-4 1/
Printed Name: Linda L Donnell
Title: C.E.O.
Date: 6/7/17
CITY OF CORPUS CHRISTI
Signature: 1-Y\
Printed Name: -e PA-sty-a._
Title: Pro c�._✓
Date: 7 - I8- / '7
ATTEST: , f
RE:ECCA HUERTA
CITY SECRETARY
Attached and Incorporated by Reference:
Attachment A: Scope of Work M20JCu, .
Attachment B: Bid/Pricing Schedule
Attachment C: Insurance/Bond Requirements 0 COUNC?L ...e .�. .
Attachment D: Warranty Requirements
SECRETAR
Incorporated by Reference Only:
Exhibit 1 : RFB/RFP No. NA
Exhibit 2: Contractor's Bid/Proposal Response
City of Corpus Christi Page 8 of 8
Service Agreement Standard Form
Approved as to Legal Form 7/1/16
��IIB Ids
0( ATTACHMENT A- SCOPE OF WORK
seaT:at/
1852
General Requirements/Background Information
The City has installed building access/security system for various facilities requiring controlled
access to the buildings. The Security System provides access control through card readers,
with intercoms and camera monitoring at some locations, and general area monitoring at the
front gate and parking lot at some locations.-
Contractor shall provide maintenance and/or repair for the building access/security system to
Water, Wastewater,Stormwater,and Gas divisions to include, access readers,gates,video
monitors,alarm panels, and any additional security hardware and supporting infrastructure for
the system.
Scopeof work
A. Service Requirements:.:
a. The Contractor must be available to provide services between the hours of 7:00
a.m.and 7:00 p.m., Monday through Friday; on an as needed basis.
b. The Contractor shall receive work order request(s) and return phone request within 1
hour of a call being placed by the Utilities Department.
c. The Contractor shall be on site within 4 hours of receipt of work order request(s).
d. The Contractor shall repair/correct the deficiency within 24-hours of arrival on site
and perform inspection to ensure operational functionality.
e. Service repairs shall include any and all issues that may arise with the Building
access/security system.
f. At time of completion.report back to the requester and provide the sourceof
failure.
g. All parts used for any repair shall be new and unused.
B. Service requests are to be accepted by the following authorized personnel:
a. Contract Administrator
b. Work Coordinator
c: ON Stevens Personnel
C. Contractor shall provide a quote for major repairs/servrce,defined as exceec ng
$1,000.00. Ail quotes shall include tabor,parts,travel and any other costs associated
with the work performed_
D. All repairs shall be completely documented by the Contractor.A copy of each work
order or '
repo>r Op wZil be provided to the personnel on site and shall include the
following:
a. Ste location
b. Description of the repr*!service
c. List of material replaced
d. Start time, end time, and total:hours.
Work Site and Conditions
The:work shall be performed at the following locations:
Location Address
1 Broadway WW Treatment Plant 945 Resaca . ... . 78402
2 - -Oso WW Treatment.Plant 501 Nile Dr. 7841.2 _
2 . :.. Greenwood.WW Treatment Plant 1541 Saratoga Blvd. 78415• .
'3 Allison WW Treatment Plant. 4101'Allison Rd. . 78410
4 Laguna WW Treatment Plant 201 Jester St. 78418
5 Whitecap WW Treatment Plant- 13500 Whitecap 78418
6 Pump Station 301 Kinney St./Power St. 78401
7 Pump Station 1218 N. Water 78407
8. Various WW Lift Stations City Wide
9 ' Utilities Building' 2726 Holly Rd. 78415
10 O.N.Stevens Water Treatment Plant 13101 Leopard St. 78410
11 Wesley Seal Dam County Rd. 365 78383
Sandia,TX
12 Choke Canyon Dam 150 South Park Road 78071
Three Rivers,TX
1.3 Gas.Building 4225.S. Port Ave. 78415
Contractor:Quality Control and Superintendence. .
The Contractor shall establish and maintain a complete Quality Control Program to assure that
the requirements of the Contract are provided as specified. The Contractor will.also provide
supervision of the work to insure it.complies with the contract requirements.
Usc� ATTACHMENT B-BID/PRICING SCHEDULE
IORo CITY OF CORPUS CHRISTI
BID FORM
_____,)
1852
1. Refer to Contract Terms and Conditions before completing bid.
2. Quote your best price, including freight, for each item.
3. In submitting this bid, Bidder certifies that the prices in this bid have been arrived at independently,
without consultation, communication, or agreement with any other Bidder or competitor, for the
purpose of restricting competition with regard to prices.
Invitation to quote, FOB Destination, Freight Included, on the following:
DESCRIPTION QTY UNIT UNIT PRICE PRICE TOTAL
Security Labor-Normal Working Hours
M-Th 8:OOAM-5:15PM, Fri 8:OOAM-2:45PM 200 HR $95.00 $19,000.00
Security Labor-After Hours
M-Th 5:16PM-7:59AM, Fri 2:46PM-1 1:59PM 10 HR $142.50 $1,425.00
IT/Program Labor- Normal Working Hours
M-Th 8:OOAM-5:15PM, Fri 8:OOAM-2:45PM 50 HR $115.00 $5,750.00
IT/Program Labor-After Hours 10 HR $172.50 $1,725.00
M-Th 5:16PM-7:59AM, Fri 2:46PM-1 1:59PM
Parts/Material 1 $7,000.00 $7,000.00 $7,000.00
TOTAL $34,900.00
COMPANY: Total Protection Systems, Inc.
NAME OF PERSON AUTHORIZED TO SIGN: Linda L Donnell
ADDRESS: PO Box 270837 CITY / STATE/ZIP CC. Tx. 78427-0837
PHONE: 289-2788 EMAIL: Id@totalprotection.com
FAX: 289-1688 DATE: 6/7/17
SIGNATURE: ,L'_,_rt L Pe , // . .0. TITLE: C.E.O.
THE CITY RESERVES THE RIGHT TO REJECT OR CANCEL ANY OR ALL BIDS. TO WAIVE ANY INFORMALITIES
OR IRREGULARITIES IN THE BIDS RECEIVED AND TO CANCEL OR POSTPONE THIS PROJECT UNTIL A LATER
DATE.
Page of
RFQ Revised 12.6.16
Attachment C-Insurance/Bond Requirements
CONTRACTOR'S LIABILITY INSURANCE
A. Contractor must not commence work under this contract until all insurance required has been obtained
and such insurance has been approved by the City. Contractor must not allow any subcontractor, to
commence work until all similarinsurance required of any subcontractor has been obtained.
B. Contractor must furnish to the City's Risk Manager and Contract Administrator one (1) copy of
Certificates of Insurance with applicable policy endorsements showing the following minimum coverage
by an insurance company(s) acceptable to the City's Risk Manager. The City must be listed as an
additional insured on the General liability and Auto Liability policies by endorsement, and a waiver of
subrogation endorsement is required on all applicable policies. Endorsements must be provided with
Certificate of Insurance. Project name and/or number must be listed in Description Box of Certificate of
Insurance.
TYPE OF INSURANCE MINIMUM INSURANCE COVERAGE
30-day advance written notice of Bodily Injury and Property Damage
cancellation, non-renewal, material change Per occurrence- aggregate
or termination required on all certificates
and policies.
COMMERCIAL GENERAL LIABILITY $1,000,000 Per Occurrence
including: $2,000,000 Aggregate
1. Commercial Broad Form
2. Premises—Operations
3. Products/Completed Operations
4. Contractual Liability
5. Independent Contractors
6. Personal Injury-Advertising Injury
AUTO LIABILITY(including) $1,000,000 Combined Single Limit
1. Owned
2. Hired and Non-Owned
3. Rented/Leased
WORKERS'S COMPENSATION Statutory and complies with Part II of this
(All States Endorsement if Company is not Exhibit.
domiciled in Texas)
Employers Liability $500,000/$500,000/$500,000
C. In the event of accidents of any kind related to this contract, Contractor must furnish the Risk Manager
with copies of all reports of any accidents within 10 days of the accident.
II. ADDITIONAL REQUIREMENTS
A. Applicable for paid employees, Contractor must obtain workers' compensation coverage through a
licensed insurance company.The coverage must be written on a policy and endorsements approved by the
Texas Department of Insurance. The workers' compensation coverage provided must be in statutory
amounts according to the Texas Department of Insurance, Division of Workers' Compensation. An All
States Endorsement shall be required if Contractor is not domiciled in the State of Texas.
B. Contractor shall obtain and maintain in full force and effect for the duration of this Contract, and any
extension hereof, at Contractor's sole expense, insurance coverage written on an occurrence basis by
companies authorized and admitted to do business in the State of Texas and with an A.M. Best's rating of
• no less than A-VII.
C. Contractor shall be required to submit renewal certificates of insurance throughout the term of this contract
and any extensions within 10 days of the policy expiration dates. All notices under this Exhibit shall be
given to City at the following address:
City of Corpus Christi
Attn: Risk Manager
P.O. Box 9277
Corpus Christi, TX 78469-9277
D. Contractor agrees that, with respect to the above required insurance, all insurance policies are to
contain or be endorsed to contain the following required provisions:
• List the City and its officers, officials, employees, and volunteers, as additional insureds by endorsement
with regard to operations, completed operations, and activities of or on behalf of the named insured
performed under contract with the City,with the exception of the workers' compensation policy;
• Provide for an endorsement that the "other insurance" clause shall not apply to the City of Corpus Christi
where the City is an additional insured shown on the policy;
• Workers' compensation and employers' liability policies will provide a waiver of subrogation in favor of
the City; and
• Provide thirty(30)calendar days advance written notice directly to City of any,cancellation,non-renewal,
material change or termination in coverage and not less than ten(10)calendar days advance written notice
for nonpayment of premium.
E. Within five(5) calendar days of a cancellation,non-renewal, material change or termination of coverage,
Contractor shall provide a replacement Certificate of Insurance and applicable endorsements to City. City
shall have the option to suspend Contractor's performance should there be a lapse in coverage at any time
during this contract. Failure to provide and to maintain the required insurance shall constitute a material
breach of this contract.
F. In addition to any other remedies the City may have upon Contractor's failure to provide and maintain any
insurance or policy endorsements to the extent and within the time herein required,the City shall have the
right to order Contractor to stop work hereunder, and/or withhold any payment(s) which become due to
Contractor hereunder until Contractor demonstrates compliance with the requirements hereof.
G. Nothing herein contained shall be construed as limiting in any way the extent to which Contractor maybe
held responsible for payments of damages to persons or property resulting from Contractor's or its
subcontractor's performance of the work covered under this contract.
H. It is agreed that Contractor's insurance shall be deemed primary and non-contributory with respect to any
insurance or self insurance carried by the City of Corpus Christi for liability arising out of operations
under this contract.
I. It is understood and agreed that the insurance required is in addition to and separate from any other
obligation contained in this contract.
2016 Insurance Requirements
Utilities
Security Access System
11/28/2016 my Risk Management
Attachment C: Bond Requirements
No bond requirements necessary for this service agreement; Section 5. (B) is null
for this Service Agreement.
•
Attachment D- Warranty Requirements
Warranty on all labor shall be 90 days or better. Warranty on materials shall
be 365 days or better.
. 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. 2017-220331
Total Protection Systems, Inc.
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 06/07/2017
being filed.
City of Corpus Christi Utilities Department Da Ac owledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the ontr ct,and provide a
description of the services,goods,or other property to be provided under the contract.
1240
Security Access Control Maintenance&Repair Service Agreement
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 AFFIDAVIT I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct.
*111'1"'
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��� CANDY LYNN_MARROU \' �. " f----)
My Commission Expires - `i ,
'�� December 22,201 S ,i ,/Q1
"r"' Signature of autho zir ed agent of con ra•ing business entity
AFFIX NOTARY STAMP/SEAL ABOVE (( '' {{
Sworn to and subscribed before me,by the said d.jL✓t 0 0 ii 1. DO rlfie!i ,this the C'I day of Ikri
20 1,7 ,to certify which,witness my hand and seal of office.
I,.ct. Ni (n�y M RMi u IfK/)/ tall
Signature Oofficer 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 V1.0.883