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2020-11-25 CC PACKETC AI.I IOU.A COUNTY CO.AI\IISSIONER9C COURT ✓All Agenda Items Properly Numbered V� Contracts Completed and Signed /k All 1295's Flagged for Acceptance (number of 1295's All Documents for Clerk Signature Flagged On this 2541day of Ar , 2020 a complete and accurate packet for 5jP,of % 'P'Ufiv..�e,� 2020 Commissioners Court Regular Session DZay Month was delivered from the Calhoun County Judge's office to the Calhoun County Clerk's Office. �2 & alhoun County Judge/Assistant AT ' ,- �� FILED& M NOV 2 5 2020 Ai ,,A aP00MAN CPU C RK,CALHOU COUNTY, TEXAS BY: COMMISSIONERSCOURTCHECKLIST/FORMS DEPUTY Commissioners' Court — November 25, 2020 CALHOUN COUNTY COMMISSIONERS) COURT REGULAR 2020 TERM NOVEMBER 25, 2020 BE IT REMEMBERED THAT ON NOVEMBER 25, 2020, THERE WAS BEGUN AND HOLDEN A REGULAR TERM OF COMMISSIONERS' COURT. I. CALL TO ORDER This meeting was called to order at 10:00 A.M by Judge Richard Meyer. 2. ROLL CALL THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Clyde Syma Gary Reese Anna Goodman Catherine Blevins County Judge Commissioner, Precinct #1 Commissioner, Precinct #2 Commissioner, Precinct #3 Commissioner, Precinct #4 County Clerk Deputy County Clerk 3. INVOCATION & PLEDGE OF ALLEGIANCE (AGENDA ITEM NO. 2 & 3) Invocation — Commissioner David Hall Pledge to US Flag & Texas Flag — Commissioner Gary Reese/Vern Lyssy Page 1 of 6 Commissioners' Court — November 25, 2020 4. General Discussion of Public matters and Public Participation. S. Hear report from Memorial Medical Center. Jason Anglin, MMC CEO, presented report. 6. Approve the minutes of the November 4, 2020 Regular Meeting, November 10 Regular Meeting and November 10, 2020 Special Meeting. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 7. Public Hearing on a Petition to Vacate Lots 51 and 52 of the Caracol Subdivision relative to the plat recorded in Volume Z, Page 712 of the Plat Records of Calhoun County, Texas, (GR) Terry Ruddick, Urban Engineering, presented Petition. Commenced: 10:10 a.m. Adjourned: 10:12 a.m. 8. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 8) To vacate lots 51 and 52 of the Caraco/ Subdivision relative to the plat the plat recorded in Volume Z, Page 712 of the Plat Records of Calhoun County, Texas. (GR) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 2 of 6 Commissioners' Court - November 25, 2020 9. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 9) To accept check for $434.37 from Jan&Alligators LLCfor the Green Lake Alligator Project and deposit it in the General Fund. (GR) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 10. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 10) To award the bids forDe/ivered Fue/Anna/Supp/y Contract Bid Number 2020.01 for the period beginninglanuary 1, 2021 and ending December 31, 2021. (RM) New Distributing Inc. awarded bid. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Commissioner Hall, Lyssy, Syma, Reese ABSTAINED: Judge Richard Meyer 11. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 11) To award the bids for Insecticides for Mosquito Contro/Annua/Supply Contract Bid Number 2021.02 for the period beginning January 1, 2021 and ending December31,2021. (RM) Award to all low bids with the exception of: Malathion - Adapco LLC Malathion EW - Veseris 4 star 45 day - Clark Mosquito Control Products Inc. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pd 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 3 of 6 Commissioners' Court - November 25, 2020 12. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 12) To award the bids for Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number2021.03 for the period beginninglanuary 1, 2021 and ending December 31, 2021, (RM) Award all low bids with the exception of: Bid #5 - Martin Marietta Materials, Inc. Bid #6 - Quality Hot Mix, Inc. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 13. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 13) To authorize Commissioner Lyssy to open a credit account with Bassco Services and to sign all necessary documents, (VL) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 14. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 14) To appoint Lanyine Sajous to the Calhoun County Library Board to replace Linda Brush and appoint Lily Kuo to replace Jason Chu (RM) Naomi Cruz, County Librarian, presented appointments. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 4 of 6 Commissioners' Court — November 25, 2020 15. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 15) To pre -approve expenditures by incumbent County or Precinct Officer(s) under Calhoun County's Policy of Compliance with LGC 130,908, (RM) Pass 16. ACCEPT REPORTS FROM THE FOLLOWING COUNTY OFFICES: 1. County Auditor — October 2020 2. County Treasurer — October 2020 RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 17. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 17) Onany necessary budget ad. ustmenis (RM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 18. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 18) To approve the use of the Bauer Community Center as an additional site for District Court on December 14 and 15, 2020. (RM) MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 5 of 6 Commissioners' Court — November 25, 2020 County RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Payroll RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pet 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Adjourned: _10.35 a.m. Page 6 of 6 AGENDA NOTICE OF MEETING-11/25/2020 AT--d . I�0 CLOCK-T—\_-M NOV 2 0 2020 Richard H. Meyer ANNA GOODr N RYXziz�Eavid County judge Hall, Commissioner, Precinct 1 Vern ]Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, November 25, 2020 at 10:00 a.m. in the Commissioners' Courtroorn in the County Courthouse at 211 S. Ann Street, Suite 104, Port ]Lavaca, Calhoun County, Texas. AGENDA The subject matter of such meeting is as follows: 1. Call meeting to order. 2. Invocation. 3. Pledges of Allegiance. 4. General Discussion of Public Matters and Public Participation. 5. Hear report from Memorial Medical Center. 6. Approve the minutes of the November 4, 2020 Regular Meeting, November 10, 2020 Regular Meeting and November 10, 2020 Special Meeting. 7. Public Hearing on a Petition to Vacate Lots 51 and 52 of the Caracol Subdivision relative to the plat recorded in Volume Z, Page 712 of the Plat Records of Calhoun County, Texas. (GR) 8. Consider and take necessary action to vacate lots 51 and 52 of the Caracol Subdivision relative to the plat recorded in Volume Z, Page 712 of the Plat Records of Calhoun County, Texas. (GR) 9. Consider and take necessary action to accept a check for $434.37 from Janik Alligators LLC for the Green Lake Alligator Project and deposit it in the General Fund. (GR) 10. Consider and take necessary action to award the bids for Delivered Fuel Annual Supply Contract Bid Number 2021.01 for the period beginning January 1, 2021 and ending December 31, 2021. (RM) Page 1 of 2 NOTICE OF MEETING—11/25/2020 11. Consider and take necessary action to award the bids for Insecticides for Mosquito Control Annual Supply Contract Bid Number 2021.02 for the period beginning January 1, 2021 and ending December 31, 2021. (RM) 12. Consider and take necessary action to award the bids for Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2021.03 for the period beginning January 1, 2021 and ending December 31, 2021. (RM) 13. Consider and take necessary action to authorize Commissioner Lyssy to open a credit account with Bassco Services and to sign all necessary documents. (VL) 14. Consider and take necessary action to appoint Lanyine Sajous to the Calhoun County Library Board to replace Linda Brush and appoint Lily Ko to replace Jason Chu. (RM) 15. Consider and take necessary action to pre -approve expenditures by incumbent County or Precinct Officer(s) under Calhoun County's Policy of Compliance with LGC 130.908. (RM) 16. Accept reports from the following County Office: i. County Auditor — October 2020 ii. County Treasurer — October 2020 17. Consider and take necessary action on any necessary budget adjustments. (RM) 18. Approval of bills and payroll. (RM) Richard Meyer, County Calhoun County, Texas A copy of this Notice has been placed on the outside bulletin board of the Calhoun County Courthouse, 211 South Ann Street, Port Lavaca, Texas, which is readily accessible to the general public at all times. This Notice shall remain posted continuously for at least 72 hours preceding the scheduled meeting time. For your convenience, you may visit the county's website at www,calhouncotx.org under "Commissioners' Court Agenda" for any official court postings. Page 2 of 2 PUBLIC HEARING—11/25/2020 ATWAj1CLOCFILED K M —O' NOV 2 0 2020 Richard H.MeyeT COUNTY EAV CALNOPJN COUNTY, TEXAS County judge BY: 9J DE bavid Hall, Commissioner, Precinct 1 Vern ]Lyssy, Commissioner, Precinct 2 Clyde Synna, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 NOTICE OF PUBLIC HEARING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, November 25, 2020 at 10:00 in the Commissioners' Courtroom in the County Courthouse, 211 S. Ann Street, Suite 104, Port Lavaca, Calhoun County, Texas. 1. NOTICE IS HEREBY GIVEN that the Calhoun County Commissioners' Court will hold a public hearing in the Commissioners' Courtroom, 211 S. Ann Street, in Port Lavaca, Texas, at 10:00 a.m. on a Petition to Vacate Lots 51 and 52 of the Caracol Subdivision relative to the plat recorded in Volume Z, Page 712 of the Plat Records of Calhoun County, Texas. The public shall have the right to be present and participate in such hearing. Richard Meyer, Calhoun County, A copy of this Notice has been placed on the outside bulletin board of the Calhoun County Courthouse, 211 South Ann Street, Port Lavaca, Texas, which is readily accessible to the general public at all times. This Notice shall remain posted continuously for at least 72 hours preceding the scheduled meeting time. For your convenience, you may visit the county's website at www.calhouncotx.orz under "Commissioners' Court Agenda' for any official court postings. Page 1 of 1 Richard ]H . Meyer County judge David Hall, Commissioner, Precinct 1 Vern ]Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 4, 2020, at 10:00 a.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Ann Street, Suite 104, Port ]Lavaca, Calhoun County, Texas. Attached are the true and correct minutes of the above referenced meeting. Richard Meyer, my Judge Calhoun County, Texas Anna Goodman, County Clerk FRI IL , �► Page 1 of 1 Commissioners' Court — November 04, 2020 CALHOUN COUNTY Y C®MMISSION ERS' C®U]L T REGULAR 2020 TERM § NOVEMBER 04, 2020 BE IT REMEMBERED THAT ON NOVEMBER 04, 2020, THERE WAS BEGUN AND HOLDEN A REGULAR TERM OF COMMISSIONERS' COURT. 1. CALL TO ORDER This meeting was called to order at 10:00 A.M by Judge Richard Meyer. 2. ROLL CALL THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Clyde Syma Gary Reese Anna Goodman Catherine Blevins County Judge Commissioner, Precinct #1 Commissioner, Precinct #2 Commissioner, Precinct #3 Commissioner, Precinct #4 County Clerk Deputy County Clerk 3. INVOCATION & PLEDGE OF ALLEGIANCE (AGENDA ITEM NO. 2 & 3) Invocation — Commissioner David Hall Pledge to US Flag & Texas Flag — Commissioner Gary Reese/Vern Lyssy Page 1 of 6 commissioners' court — November 04,2020 4. General Discussion of Public matters and Public Participation. S. Approve the minutes of the Emergency Meeting on September 18, 2020, the Regular Meeting on October 21, 2020 and the Emergency Meeting on October 22, 2020. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 6. CONSIDER AND TAKE NECESSARY ACTION (AGNEDA ITEM NO. 6) To authorize Sheriff Vickery to sell to the Point Comfort Police Department for $1.00 three (3j WaltherPPX.40-callberhandguns: Seria/numbersfor weapons are; FAS 9403, FAS 8407, and FAS 8428. (RMj RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 7. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 7) To allow Sheriff Vickery to clarify the donation process for Canine Office Lima. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct i AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 2 of 6 Commissioners' Court — November 04, 2020 8. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO.8) To acknowledge an increase in the Sheriffs Forfeited Properly Fund as follows. 2860-999-60580 Buy Money - $1,500.00 and 2860-999-53920 Miscellaneous - $1,200.00. (RM) RESULT: APPROVED [UNANIMOUS] MOVER: Venn Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 9. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO.9) To approve the attached equipment transfer from the County Treasurer's Office to the CountyAuditor, Library, ITDepartmentandlail. (RM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 10. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 10) To authorize the County Treasurer to open a line of credit with Turtle and Hughes for Courthouse Maintenance supplies RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 11, CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 11) To declare all items on the attached list as Surplus/Salvage and authorize theirdisposal, (RM) Rescind RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 3 of 6 Commissioners' Court — November 04, 2020 Motion made to have the agenda item corrected and re -submit to court. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 12. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 12) To declare all items on the attached list as Waste and authorize their disposal, Juvenile Probation RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 13. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 13) To transfer all items on the attached list from the Juvenile Probation Department to the County Library, (RM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 4 of 6 Commissioners' Court — November 04, 2020 14. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 14) To approve the guidelines for disposing of SurpluslSalvage items utilizing the sealed bid process and advertising in the newspaper. (RM) No action taken. Everett Wood to get with Vern Lyssy, Commissioner Pct 2 and they will put items up for auction online. 15. CONSIDER AND TAKE NECESSARY ACTION (AGNNDA ITEM NO. 15) To pre -approve expenditures byincumbentCounty or Precinct Officer(s) under Calhoun County's Policy of Compliance with tGC 130.908. (RN) Pass 16. Accept report from the following County Office: 1. County Treasurer —August 2020 RESULT. APPROVED [UNANIMOUS] MOVER: Clyde Syma, Commissioner Pct 3 SECONDER: Vern Lyssy, Commissioner Pet 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 17. Consider and take necessary action on any necessary budget adjustments. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 5 of 6 Commissioners' Court — November 04, 2020 18. Approval of bills and payroll. MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese County RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Adjourned: 10:33 a.m. Page 6 of 6 Richard H. Meyere County judge ][David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 10, 2020, at 2:00 p.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Ann Street, Suite 104, Port ]Lavaca, Calhoun County, Texas. Attached are the true and correct minutes of the above referenced meeting. Richard Meyer, Co(5np3f Judge Calhoun County, Texas Anna Goodman, County Clerk Page 1 of 1 Commissioners' Court — November 10, 2020 SPECIAL MEETING § NOVEMBER 10, 2020 BE IT REMEMBERED THAT ON NOVEMBER 10, 2020, THERE WAS BEGUN AND HOLDEN A REGULAR TERM OF COMMISSIONERS' COURT. 1. CALL TO ORDER This meeting was called to order at 2:00 P.M. by Judge Richard Meyer. 2. ROLL CALL THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Clyde Syma Gary Reese Anna Goodman Catherine Blevins County Judge Commissioner, Precinct #1 Commissioner, Precinct #2 Commissioner, Precinct #3 Commissioner, Precinct #4 County Clerk Deputy County Clerk 3. INVOCATION & PLEDGE OF ALLEGIANCE (AGENDA ITEM NO.2 & 3) Invocation — Commissioner David Hall Pledge to US Flag & Texas Flag — Commissioner Gary Reese/Vern Lyssy Page 1 of 5 Commissioners' Court— November 10, 2020 4. Canvass the results of the 2020 General Election Mary Oita, Elec[ronsAdministrator, reported the canvass results of the 2020 General Election RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Adjourned.- 2.10 p m. Page 2 of 5 Richard H. Meyer County judge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 10, 2020, at 10:00 a.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Ann Street, Suite 104, Port Lavaca, Calhoun County, Texas. Attached are the true and correct minutes of the above referenced meeting. c Richard Meyer, Cou Judge Calhoun County, Texas Anna Goodman, County Clerk Page 1 of 1 Commissioners' Court— November 10, 2020 REGULAR 2020 TERM § NOVEMBER 10, 2020 BE IT REMEMBERED THAT ON NOVEMBER 10, 2020, THERE WAS BEGUN AND HOLDEN A REGULAR TERM OF COMMISSIONERS' COURT. 1. CALL TO ORDER This meeting was called to order at 10:00 A.M by Judge Richard Meyer. 2. ROLL CALL THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Clyde Syma Gary Reese Anna Goodman Catherine Blevins CountyJudge Commissioner, Precinct #1 Commissioner, Precinct #2 Commissioner, Precinct #3 Commissioner, Precinct #4 County Clerk Deputy County Clerk 3. INVOCATION & PLEDGE OF ALLEGIANCE (AGENDA ITEM NO.2 & 3) Invocation — Commissioner David Hall Pledge to US Flag & Texas Flag — Commissioner Gary Reese/Vern Lyssy Pagel of 5 Commissioners' Court — November 10, 2020 4. General Discussion of Public matters and Public Participation. S. Approve the minutes of the October 28, 2020 meeting. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 6. CONSIDER AND TAKE NECESSARY ACTION (AGNEDA ITEM NO. 6) To approve the PreliminmyPlat ofCaracal Resubdivision No. 8, a rep/at of Lots 53, 54, and 55 of Caraco/Subdivision relative to the plat recorded In volume Z, Page 712 of the Plat Records of Calhoun County, Texas, (GR) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 7. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 7) To acceptpayment from the Texas General Land Office in the amount of $1,000 for Bilge Reclamation Facilities in Seadrift, Texasand place in funds in Precinct 4 R&B account 570-53510. (GR) RESULT: APPROVED [UNANIMOUS] MOVER: Clyde Syma, Commissioner Pct 3 SECONDER: Gary Reese, Commissioner Pd 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 2 of 5 i Commissioners' Court— November 10, 2020 8. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO.8) To declare a 1992 Ford 5610 Tractor (Inventory No. 23-0087, Serial No. BD16349) as Surplus/Salvage and authorize its use as a trade-in for a John Deere 5090E Utility Tractor, (CS) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pd 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 9. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO.9) To pre -approve expenditures by incumbent County or Precinct Officer(s) under Calhoun County-SPolicy ofCoiapliance with LGC130.908. (RM) Shoppa's Farm Supply Co - John Deere 5090E Utility Tractor - $47,109.06 RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 10. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 10) To accept the attached list of October 2020 donations to the Calhoun County Library. (RM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 3 of 5 Commissioners' Court — November 10, 2020 11. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 11) To declare the attached lists of items as Surplus/Salvage and authorize their removal from each departments inventory.• 1. Adult Probation Department 2. Calhoun County Library RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pot 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 12. CONSIDER AND TAKE NECESSARY ACTION (AGENDA ITEM NO. 12) To declare the attached lists of items as Waste and authorize their disposal., 1. Adult Probation Department 2 Calhoun County Detention Center 3, Calhoun CountyLibrary RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner PC 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 13. Accept reports from the following County Offices: 1. District Clerk- October 2020 2 Floodplain Administration - October 2020 3 ,justice of the Peace Pct1; Pct 2; Pct 4; Pct 5 - October 2020 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Page 4 of 5 Commissioners' Court —November 10, 2020 14. Consider and take necessary action on any necessary budget adjustments. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Clyde Syma, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese 15. Approval of bills and payroll. MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese County RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Payroll RESULT: MOVER: SECONDER: AYES: APPROVED [UNANIMOUS] David Hall, Commissioner Pct 1 Vern Lyssy, Commissioner Pct 2 Judge Meyer, Commissioner Hall, Lyssy, Syma, Reese Adjourned: 10:13 a.m. Page 5of5 #7 AT FILED K)� r 0LED'131- yy NOV 2 0pp 2p020 Richar l ]H[. Meyer COUNITY/ LERPIA 9181kr�%LINTY, TEXAS county judge BYY� (�'�) li oEP avid Hall, Commissioner, Precinct I Vern Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 NOTICE OF PUBLIC HEARING The Commissioners' Court of Calhoun County, Texas will sneer on Wednesday, November 25, 2020 at 10:00 in the Commissioners' Courtroom in the County Courthouse, 211 S. Ann Street, Suite 104, Port ]Lavaca, Calhoun County, Texas. 1. NOTICE IS HERESY GIVEN that the Calhoun County Commissioners' Court will hold a public hearing in the Commissioners' Courtroom, 211 S. Ann Street, in Port Lavaca, Texas, at 10:00 a.m. on a Petition to Vacate Lots 51 and 52 of the Caracol Subdivision relative to the plat recorded in Volume Z, Page 712 of the PIat Records of Calhoun County, Texas. The public shall have the right to be present and participate in such hearing. Richard Meyer, Calhoun County, A copy of this Notice has been placed on the outside bulletin board of the Calhoun County Courthouse, 211 South Ann Street, Port Lavaca, Texas, which is readily accessible to the general public at all times. This Notice shall remain posted continuously for at least 72 hours preceding the scheduled meeting time. For your convenience, you may visit the county's website at wmn_v.cz!houncolxgrg under "Commissioners' Court Agenda' for any official court postings. Page 1 of I AU8*1 Land Surveying+Aer6al Imaging 9lneei991 November 19, 2020 Gary Reese Calhoun County Commissioner Precinct #4 P.O. Box 177 Seadrift, TX 77983 RE: Caracol Lot 52R Dear Commissioner Reese, Please consider this letter as my request to have the following item placed on the November 25, 2020 Commissioner's Court agenda: Public Hearing regarding Petition to Vacate Lots 51 and 52, Carocol Subdivision. If I can provide additional information please do not hesitate to contact me. f rely, T. u dick, R.P.L.S. C.E.O. Victoria San Antonio Cuero 2004 N. Commerce 12661 Silicon Drive 104 E. French Street N. urbansurrveylrlg.com Victoria, TX 77901 San Antonio, TX 78249 Cuero, TX 77964 361-578-9837 210-267-8654 381-277-9061 Firm#: 10021100 Firm#: 10193843 Firm#: 10021101 Wc.V)vil�l�,V�U ...mgr'Q . �i.5 l A 0 Land Surveying+Aefoa9lmaging 81n..1991 PETITION TO VACATE Lots 51 and 52 Caracol Subdivision THE STATE OF TEXAS) THE COUNTY OF CALHOUN) KNOW ALL MEN BY THESE PRESENTS: That the undersigned being the designated agent of the owners of the property described as Lots 51 and 52, Caracol Subdivision according to the map or plat of said subdivision recorded in Volume Z, Page 721 of the Plat Records of Calhoun County, Texas, do hereby petition the Calhoun County Commissioner's Court to Vacate said Lots 51 and 52, Caracol Subdivision in accordance with Sections 206 and 207 of the Subdivision Regulations and Recreational Vehicle Park Regulations Adopted by Calhoun County Commissioner's Court on November 29, 2004 and amended on December 13, 2007. The property is proposed to be replatted in accordance with a plat submitted to the Calhoun County Commissioner's Court. The petition will be considered by the Calhoun County Commissioner's Court on November 18, 2020 at 10:00 am. 2004 N. Commerce Victoria, TX 77901 361-578-9837 (S23839 Reggie Tuck) Victoria San Antonio Cuero 2004 N. Commerce 12661 Silicon Drive 104 E. French Street Victoria, TX 77901 San Antonio, TX 78249 Cuero, TX 77964 urbansurveying.com 361-578-9837 210-287-8854 361-277-9061 Firm#: 10021100 Firm 4:10193843 Firm#: 10021101 jLq,J uQL1 #9 tea_ y'.7:Lfi RECEIPT LOG Date Receipt Numbers I Total Amount Person Delivered to Confirmed By l l I &k# 1354,1 1 0- 3d- . 37 PAY TO THE ORDER 4 Janik Alligators LLC 3244 CR410 Rd El Campo, TX 77437 979-543-5894 Prosperity Banic 1301 N Mechanic St El Campo TX 77437 13579 I �1 88-2265/1131 DATE v DOLLARS Void after 90 days # to #/o Agenda Item for Commissioners Court — Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Delivered Fuel Annual Supply Contract Bid Number 2021.01 for the period beginning January 1, 2021 and ending December 31, 2021. RE: Delivered Fuel Annual Supply Contract Bid Number 2021.01 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Two (2) bids were received: 1. New Distributing Co., Inc. 2. Oil Patch Petroleum, Inc. New Distributing Co., Inc.: Appears to have met specifications • Bid has all of the required forms and all of the forms have the required signatures. Oil Patch Petroleum, Inc.: Did not meet specifications • Bid was missing signatures on two (2) forms, the Affidavit and Form 1295. Affidavit was not signed by the authorized agent, but the form was notarized. Form 1295 was not signed. Note: Information on their bid form appeared to be written incorrectly or left off. This conclusion was made based upon the other amounts on their submitted bid. p z S 2 F m m W O G Z m m G1 a C 3 0 z f z n cf z m N O' a e m m ID N N y cm A C A N a m: o 3 g 0 0 D, a N- N � O T. Q � W ' 2 9- Vmi tmii pj A o �p o - Re { { 4 O m { { W C. T N N 3. A O a a IntoC p va 3 ; 3 7 3 dQ C V iU d N 3 C �O N N O 3 N N F+ m 3 0- W m O Q Z C va 3 p a N i to N Q N M F� W o w I-' N Calhoun County, Texas BID TABULATION -- Delivered Fuel Annual Supply Contract - Bid Number: 2021.01 For Period Beginning January 1, 2021 and Ending December 31, 2021 Bid Tabulation Information is taken from the vendors bid forms (typed as on the vendors bid forms) NEW DISTRIBUTING CO., INC. OIL PATCH PETROLEUM, INC. Appeared to have Met Specifications Did Not Meet Specifications -. Missing signatures on 2 Forms Returned all forms and all forms have the required signatures Affidavit and Form 1295 are not signed BRAND NAME: CITGO UNB BRAND NAME: CITGO ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** MARK-UP TEXAS STATE OSLTF- TEXAS TEXAS. TEXAS -. PER EXCISE LUST Federal Oil ENVIRONMENTAL FEE MARK-UP STATE OSLTF- - ENVIRONMENTAL FEE DEPARTMENT FUEL TYPE GALLON TAX FEE Spill Fee (Based on Number of Gallons Delivered) OTHER PER EXCISE LUST Federal Oil (Based FEES GALLON TAX FEE Spill Fee Gallons oenvered) s Delivered) OTHER FEES Precinct 1 Gasoline Less than 2,500 Gallons - Less than 2,500 Gallons = FuelTank(s) Location: 305 Henry Barberwav Unleaded $OS . $0.20 .001 .00193 $.0012 /gal. 2,500 Gallons but Less N/A $ $0.20 N/A $1.70 After Hours Call Out $75.- Port Lavaca TX 77979 87 Octane than 5,000 Gallons = .10 .00193 2,500 Gallons but Less Fueling Generator $75.- .0012/gal. than 5,000 Gallons = Less than 300 Gallons $75.- 1 1 $345 (no decimal on bid form) ** Gasoline Unleaded than 2,500 Gallons = Less than 2,500 Gallons = 93 Octane $ .15 $0.20 .001 .00193 012/gal [2500Gallons but Less N/A $ $0.20 N/A $1.70 After Hours Call Out$75.- Non -Ethanol 5,000 Gallons = .10 .00193 2,500 Gallons but Less Fueling Generator $75. See above ** 12/gal. than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Diesel Less than 2,500 Gallons = Less than 2,500 Gallons = Low Sulfur $ .09 $0.20 .001 .00214 $ .0012/gaL 2,500 Gallons but Less N/A $ $0.20 N/A $1.70 2,500 After Hours Call Out $75- (Clear Diesel) than 5,000 Gallons = .10 .00204 Gallons but Less Fueling Generator $75.- $.0012/gaL than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Precinct 2 Gasoline Less than 2,500 Gallons = Less than 2,500 Gallons = Fuel Tank(s)Location: 5812 FM 1090 Unleaded $.OS $0.20 .001 .00193 $.0012/gal. 2,500 Gallons but Less N/A $ $0.20 N/A $1.70 After Hours Call Out $75.- Port Lavaca TX 77979 87 Octane than 5,000 Gallons = .10 .00193 2,500 Gallons but Less Fueling Generator $75.- $.0012/gaL than 5,000 Gallons = to nv Less than 300 Gallons $75: Less than 2,500 Gallons= Less than 2,500 Gallons = Diesel $ .0012/gaL $1.70 After Hours Call Out $75. Low Sulfur $ .09 $0.20 .001 .00214 2,500 Gallons but Less I N/A 1 $ .10 $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75.- (Clear Diesel) than 5,000 Gallons = than 5,000 Gallons = Less than 300 Gallons $75.- $.0012/gaL av nc 1 Bid Tabulation -Delivered Fuel Annualsupply Contract -- Continued NEW DISTRIBUTING CO., INC. OIL PATCH PETROLEUM, INC. Appeared to have Met Specifications Did Not Meet Specifcat/ons - Missing Signatures on 2 Forms Returned all forms and all forms have the required signatures BRAND NAME: CITGO UNB Affidavit and Form 1295 are not signed ** 87 Octane Ethanol -Free is all we have available** BRAND NAME: CITGO ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** d TEXAS - MARK-UP STATE OSLTF- TEXAS TEXAS PER EXCISE LUST Federal Oil ENVIRONMENTAL FEE - MARK-UP STATE OSLTF- TEXAS DEPARTMENT FUEL TYPE GALLON TAX FEE (eased Numbed) OTHER PER. PER EXCISE LUST Federal Oil ENVIRONMENTAL FEE Precinct 3 Spill Fee' s Gallons Delivered) FEES TAX FEE Spill Fee , (Based an. Number of Gallons Delivered) uel Tank(s) Location: Gasoline Less than 2,500 Gallons = 46275tate Hwy 172 Unl d $.0012/gal. Less than 2,500 Gallons= Port Lavaca TX 77979 ea e 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but Less N/A $ .10 $0.20 N/A $1.70 (Olivia) than 5,000 Gallons = .00193 2,500 Gallons but Less $ .0012/gal. than 5,000 Gallons = ** Gasoline $3.45 Unleaded Less than 2,500 Gallons = 93 Octane $ $0.20 $ .0012/gal. Less than 2,500 Gallons = Non -Ethanol .15 .001 .00193 2,500 Gallons but Less N/A $ .10 $0.20 N/A $1.70 ** See above ** than 5,000 Gallons = .00193 2,500 Gallons but Less $ .0012/gal. than 5,000 Gallons = $3.45 Diesel Less than 2,500 Gallons = Low Sulfur $ $0.20 $ .0012/gal. Less than 2,500 Gallons = (Clear Diesel) .09 .001 .00214 2,500 Gallons but Less N/A. $ .SO $0.20 N/A $1.70 than 5,000 Gallons = .00204 2,500 Gallons but Less $.0012/gaL than 5,000 Gallons= $3.45 Precinct 4 (Port O'Connor) Lees Fuel Tank(s) Location: Gasoline than 2,500 Gallons = $ .0012/gal. Less than 2,500 Gallons = 93 Trevor Street (off of Hwy 185) Port Unleaded $ .OS $0.20 .001 .00193 2,500 Gallohs but Less N/A $1.70 O'Connor Tx 77982 87 Octane than 5,000 Gallons = $ .18 $0.20 N/A .o0193 2,500 Gallons but Less $.0012/gaL than 5,000 Gallons= $3.45 Diesel Less than 21500. Gallons= Low Sulfur $ $0.20 $ .0012/gal. Less than 2,500 Gallons = (Clear Diesel) .09 .001 .00214 2,500 Gallons but Less N/A $ .18 $0.20 N/A $1.70 than 5,000 Gallons = .00204 2,500 Gallons but Less $ .0012/gal. than 5,000 Gallons = OTHER FEES r Hours Call Out $75- ng Generator $75.- than 300 Gallons $75.- After Hours Call Out $75.- Fueling Generator $75 Less than 300 Gallons $75. After Hours Call Out $75. Fueling Generator $75.- Less than 300 Gallons $75. r Hours Call Out $75.- ng Generator $75 than 300 Gallons $75.- After Hours $75. Fueling Generator $75. Less than 300 Gallons $75.- Page 2 of 5 Bid Tabulation - Delivered Fuel Annual Supply Contract -- Continued NEW DISTRIBUTING CO., INC. Appeared to have Met specifications OIL PATCH PETROLEUM, INC. Returned ail forms and ail forms have the required signatures Did Not Meet specifications - Missing Signatures on 2 Forms BRAND NAME: CITGO UNB Affidavit and Form1295 are not signed ** 87 Octane Ethanol -Free is all we have available ** BRAND NAME: CITGO ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** TEXAS MARK-UP STATE TEXAS TEXAS OSLTF- ENVIRONMENTAL FEE MARK-UP STATE TEXAS PER EXCISE LUST FederalOil OSLTF- ENVIRONMENTAL FEE DEPARTMENT LUST GALLON TAX- (aasedonNumberof OTHER PER EXCISE, LUST Federal Oil FEE Spill Fee Gallons Delivered) FEES GALLON TAX P (eased on Number of FEE Spill Fee Gallons Delivered) OTHER FEES Precinct 4 tSeadrift) Less than 2,500 Gallons = Fuel Dallas s) Location; Gasoline Less than 2,500 Gallons = 104 E Dallas Unleaded $ .0012/gal. $ .08 $0.20 .001 .00193 2,500 Gallons but Less N/A $_(no amount on bid form) After Hours Call Out $75 Seadrift Tx 77983 87 Octane $ .10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. than 5,000 Gallons = $.0012 al. than 5,000 Gallons Less than 300 Gallons $75 ** Gasoline $_(no amount on bid form) Unleaded Less than 2,500 Gallons= $ .0012/gal. Less than 2,500 Gallons = 93 Octane $ .15 $0.20 .001 .00193 2,500 Gallons but Less $_(no amount on bid form) After Hours Call Out $75 than 5,000 Gallons Non -Ethanol N/A $ .10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. = ** See above ** $ .0012/gaL than 5,000 Gallons = Less than 300 Gallons $75 $_(no amount on bid form) Diesel Less than 2,500 Gallons= $ .0012/gal. Less than 2,500 Gallons = Low Sulfur $ .09 $0.20 .001 .00214 2,500 Gallons but Less $ 10 $_(no amount on bid form) After Hours Call Out $75 (Clear Diesel) than 5,000 Gallons = N/A (No Decimal $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75. on. bid form) than 5,000. Gallons = $ .0012/gaL Less than 300 Gallons $75 $_(no amount on bid form). Precinct 4 (Seadrift) Less than 2,500 Gallons =' Fuel Tank(s) Location: Gasoline $ .0012/gaLess than 2,500 Gallons = Unleaded L aae Harbor Road $ .08 $0.20 .001 .00193 N/A 2,500 Gallons but Less $_(no amount on bid form) After Hours Call Out $75 than 5,000 Gallons Seadrift Tx 77983 87 Octane $ .10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. = $ .0012/gaL than 5,000 Gallons = Less than 300 Gallons $75 $_(no amount on bid form) Diesel Less than 2,500 Gallons = $ .0012/gaL Less than 21500 Gallons = Low Sulfur $ .09 $0.20 .001 .00214 2,500 Gallons but Less $_(no amount on bid form) After Hours Call Out $75 (Clear Diesel). than 5,000 Gallons = N/A $ .10 $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75. $..0012/gaL than 5,000 Gallons = Less than 300 Gallons $75 $_(no amount on bid form) Page 3 of 5 Sid Tabulation -Delivered Fuelgnnual5upply Contract -- Continued NEW DISTRIBUTING CO., INC. Appeared to have Met Specifications Returned all forms and allforms have the required signatures BRAND NAME: CITGO UNS ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** TEXAS MARK-UP STATE OSLTF TEXAS DEPARTMENT PER EXCISE LUST Federal Oil ENVIRONMENTAL FEE FUEL TYPE GALLON 7AX (Based on Number of OTHER Skid Fuel Tank FEE Spill Fee' Gallons Delivered) FEES [Skid Location for Fuel Delivery: Within Close Proximity to the Calhoun County Diesel Courthouse Low Sulfur 211 S Ann st (Clear Diesel) Port Lavaca TX 77979 Generator Calhoun County Courthouse Diesel Generator Fuel Tank Location for Fuel Delivery: LOW Sulfur 211 S Ann Street Port Lavaca TX 77979 (Red Diesel) Generator - Calhoun County adult Detention Center (Jail) Diesel eneeratorpuel Tank Location for Fuel Delivery: Low Sulfur 92 W Live Oak Drt Lavaca TX 77979 (Red Diesel) Less than 2,500 Gallons = $.z2 $0.20 $:0012/gal. 001 .00214 2,500 Gallons but Less N/A than 5,000 Gallons = $ .0012/gal: Less than 2,500 Gallons = $ .22 NA .001 $ .0012/gal. .00214 2,500 Gallons. but Less than 5,000 Gallons = N/A $.0012/gaL Less than 2,500 Gallons = $ .22 NA $ .0012/gal. .001 .00214 2,500 Gallons but Less than 5,000 Gallons = N/A $.0012/gaL OIL PATCH PETROLEUM Did Not Meet Specifications - Missing INC. -� q Signatures on 2 Forms Affidavit and Form 1295 are not signed BRAND NAME: CITGO ** 90 Octane Non -Ethanol ** TEXAS MARK-UP STATE' TEXAS bSLTF - PER EXCISE , LUST ENVIRONMENTAL FEE Federal Oil GALLON TAX FEE Based on Number of ;Spill Fee Gallons Delivered) OTHER FEES $ 12 Less than 21500 Gallons = (No Decimal $0.20 N/A on bid form) $1.70 .00204 2,500 Gallons but Less After Hours Call Out $75. than 5,000 Gallons = Fueling Generator $75. $3.45 Less than 300 Gallons $75. Less than 2,500 Gallons = $ .2350 NA .00100 $1.70 .00214 2,500 Gallons but Less After Hours Call Out $75.- than 5,000 Gallons = Fueling Generator $75.- $3.45 Less than 300 Gallons $75.- Less than 2,500 Gallons = ' (the " " .2350 NA .00100 $1.70 are on their bid formHoursCall .00214 2,500 Gallons but Less AfterOut $75.- than5,000 Gallons = Fueling Generator $75: $3.45 Less than. 300 Gallons $75. Page 4 of 5 Bid Tabulation -Delivered Fuel Annual Supply Contract -- Continued NEW DISTRIBUTING CO., INC. Appeared to have Met specifications Returned all forms and all forms have the required signatures BRAND NAME: CITGO UNB ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** .TEXAS TEXAS MARK-UP STATE OSLTF - ENVIRONMENTAL FEE PER EXCISE LUST Federal Oil (eased on Number of OTHER DEPARTMENT FUELTYPE GALLON TAX. FEE - SpillFee Gallons Delivered) FEES. Generator EMS Central Station Diesel Generator Fuel Tank Location for Fuel Delivery: Low Sulfur 705 Henry Barber Way (Red Diesel) Port Lavaca TX 77979 Generator EMS South Station Diesel Generator Fuel Tank Location for Fuel Delivery: Low Sulfur 5084 State Hwy 185 E (Red Diesel) ieadrift TX 77983 Generator Memorial Medical Center (Hospital) Diesel Generator Fuel Tank(s) Location for Fuel Low Sulfur Delivery: (Red Diesel) 815 N Virginia Street Port Lavaca TX 77979 Generator Memorial Medical Clinic Diesel Generator Fuel Tank Location for Fuel Delivery: Low Sulfur 1016 N Virginia Street (Red Diesel) Port Lavaca TX 77979 $ .22 $ .22 $.09 $ .22 Less than 2,500 Gallons = $ .0012/gal. NA .001 .00214 2,500 Gallons but Less than 5,000 Gallons = 1$.0012/gal. NA 1 .001 1 .00214 NA 1 .001 1 .00214 NA 1 .001 1 .00214 ass than 2,500 Gallons = .0012/gal. 500 Gallons but Less tan 5,000 Gallons = .0012/gal. Less than 2,500 Gallons = $ .0012/gal. 2,500 Gallons but Less than 5,000 Gallons = P .0012/gal. ass than 2,500 Gallons = .0012/gal. 500 Gallons but Less tan 5,000 Gallons = .0012/gal OIL PATCH PETROLEUM, INC. Did Not Meet specifications . Missing signatures on 2 Forms Affidavit and Form 1295 are not signed BRAND NAME: CITGO ** 90 Octane Non -Ethanol ** TEXAS MARK-UP STATE OSLTF- TEXAS ENVIRONMENTAL FEE - PER. EXCISE LUST Federal Oil „(Based on Number of GALLON TAX FEE Spill Fee - Gallons Delivered) OTHER FEES Less than 2,500 Gallons= After Hours Call Out $75: N/A $ .2350 NA .00100 .00214 $1.70 Fueling equipment 2,500 Gallons but Less Generator $75.- than 5,000 Gallons = $3.451 Less than 300 Gallons $75.- Less than 2,500 Gallons After Hours Call N/A $ .2350 I NA I.00l00l .00214 I2,50n 5 all Gall t Less $3.45IFueling ss than 300 Gallons $75. I I jLess $1.70 After HRS Call Out $75. Gallons N/A $.2350 NA p01001 .00214 2500alLess eGenerator n5l Galons lus $3.4ILs than 300 Less than 2,500 Gallons= After Hours Call Out $75.- N/A $ .2350 NA .00100 .00214 $1.70 Fueling Generator $75: 2,500 Gallons but Less ILess than 300 Gallons (no than 5,000 Gallons = $3.45 1amount on bid form) Texas Environmental Fee - Petroleum Products Delivery Fees : Less than 2,500 Gallons Delivered = $1.70 Fee Per Delivery / 2,500 Gallons but less than 5,000 Gallons = $3.45 Fee Per Delivery OSLTF - Federal Oil Spill Fee: Gas E10 - $0.001929 / Diesel - $0.002143 Page 5 of 5 Mae Belle Cassel From: peggy.hall@calhouncotx.org (peggy hall) <peggy.hall@calhouncotx.org> Sent: Tuesday, November 17, 2020 3:38 PM To: MaeBelle.Cassel@calhouncotx.org; Richard H Meyer Cc: Cindy Mueller, Sara.Rodriguez@calhouncotx.org; David Hall; angela.torres@calhouncotx.org; Vern Lyssy; Lesa Jurek; Clyde Syma; Lynette Adame; Gary Reese; april.townsend@calhouncotx.org Subject: Agenda Item for Court Nov 25, 2020 Attachments: Agenda - Award Bids for 2021 Delivered Fuel - Bid No. 2021.01 - Commissioners Court Nov 25 2020.pdf Mae Belle, RE: Delivered Fuel Annual Supply Contract Bid Number 2021.01 Please put the attached on Commissioners Court Agenda for November 25, 2020 I will bring you the hard copy for the packet. Peggy Aall Assistant Auditor Calhoun County 202 S. Ann St., Ste B Port Lavaca, TX 77979 Phone: 361-553-4610 Fax: 361-553-4614 Calhoun County Texas Agenda Item for Commissioners Court — Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Delivered Fuel Annual Supply Contract Bid Number 2021.01 for the period beginning January 1, 2021 and ending December 31, 2021. RE: Delivered Fuel Annual Supply Contract Bid Number 2021.01 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Two (2) bids were received: 1. New Distributing Co., Inc. 2. Oil Patch Petroleum, Inc. New Distributing Co., Inc.: Appears to have met specifications • Bid has all of the required forms and all of the forms have the required signatures. Oil Patch Petroleum, Inc.: Did not meet specifications • Bid was missing signatures on two (2) forms, the Affidavit and Form 1295. Affidavit was not signed by the authorized agent, but the form was notarized. Form 1295 was not signed. Note: Information on their bid form appeared to be written incorrectly or left off. This conclusion was made based upon the other amounts on their submitted bid. o z � m D O ti 2 A m m W. A D O y m m 2 O A 3 0 Z Z n � n � M m _ n 0 Z 0 m a. 3 C O p~ �' C Z Q m N m O m m N F (' G m m N j Nm PI N a n m e c d y 5 3'E 0 0 a; c vKm, e;,i 0... N i. C A C'. A � w m a> m gym, N e-.a e- _ JQ W N ^d^ ei C CL W m C o a 2 L °+ on 3 o' v a i 3 n M A N O N tr ~ m N L m CL 'T O 3 n 0 3 r+ m CL m 7 C m .+ C 7 M C S ^W C Calhoun County, Texas BID TABULATION -- Delivered Fuel Annual Supply Contract - Bid Number: 2021.01 For Period Beginning January 1, 2021 and Ending December 31, 2021 Rid Tabulation Information is taken from the vendors bid forms (typed as on the vendors bid forms) NEW DISTRIBUTING CO., INC. OIL PATCH PETROLEUM, INC. Appeared to have Met Specifications Did Not Meet Specifications - Missing Signatures on 2 Forms Returned all forms and all forms have the required signatures BRAND NAME: CITGO UNB Affidavit and Form 1295 are not signed ** 87 Octane Ethanol -Free is all we have available ** BRAND NAME: CITGO ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** TEXAS MARK-UP STATE TEXAS TEXAS OSLTF - ENVIRONMENTAL FEE MARK-UP STATE TEXAS PER EXCISE LUST FederalOil�- OSLTF- ENVIRONMENTAL FEE DEPARTMENT FUELTYPE - (BasedonNumberof OTHER. PER. EXCISE LUST Federal Oil GALLON TAX FEE ' Spill Fee Gallons Delivered) FEES GALLON TAX p (Based on Nombed) FEE Spill Fee Gallons Delivered) OTHER FEES r of Precinct 1 Less than 2,500 Gallons = Fuel Tank(s) Location: Gasoline Less than 2,500 Gallons = Unleaded $ .0012/gal. aor Henry Barber way $ .08 $0.20 .001 .00193 2,500 Gallons but Less N/A $1.70 After Hours Call Out $75.' wort Lavaca TX 77979 87 Octane $.10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75: than 5,000 Gallons = $..0012/gal. than 5,000 Gallons = Less than 300 Gallons $75.- Gasoline $345(no decimal on bid form) Unleaded Less than 2,500 Gallons = $ .0012/gaL Less than 2,500 Gallons = 93 Octane $ .15 $0.20 .001 .00193 2,500 Gallons but Less N/A than 5,000 Gallons $1.70 After Hours Call Out $75.- Non -Ethanol $ .10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. = ** See above ** $,0012/gaL than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Diesel Less than 2,500 Gallons = $ .0012/gaL Less than 2,500 Gallons = Low Sulfur $ .09 $0:20 .001 .00214 2,500 Gallons but Less $1.70 After Hours Call Out $75- (Clear Diesel) N/A $.10 $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75: than 5,000 Gallons = $ .0012/gal. than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Precinct Less than 2,500 Gallons= 7uel Tank(s) Location: Gasoline $ .0012/gal. Less than 2,500 Gallons = Unleaded i812 FM 1090 $ .O8 $0.20 .001 .00193 2,500 Gallons but Less N/A $1.70 After Hours Call Out $75: -ort Lavaca TX 77979 87 Octane than 5,000 Gallons = $ •10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. $ .0012/gaL than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Diesel Less than 2,500 Gallons = $ .0012/gaL Less than 2,500 Gallons = Low Sulfur $ .09 $0.20 .001 .00214 N/A 2,500 Gallons but Less $1.70 After Hours Call Out $75. (Clear Diesel) lions $ .10 $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75.- than 5,000 Ga= $ .0012/gaL than 5,000 Gallons = Less than 300 Gallons $75.- $3.45 Page 1 of 5 Bid Tabulation -Delivered Fuel Annual Supply Contract -- Continued NEW DISTRIBUTING CO., INC. Appeared to have Met specifications Returned ali forms and aii forms have the required signatures BRAND NAME: CITGO UNB ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christ! ** TEXAS .. MARK-UP STATE OSLTF- TEXAS DEPARTMENT FUELTYPE PER EXCISE LUST Federal Oil ENVIRONMENTAL FEE (Based on Number of OTHER GALLON TAX. FEE Spill Fee' ' Gallons Delivered) , FEES Precinct 3 Fuel Tank(s) Location: Gasoline Less than 2,500 Gallons= 24627 state Hwy 172 Port Unleaded $ $.0012/gal .OS $0.20 .00193 Lavaca TX 77979 ,,,,,,,,_, 87 Octane .001 2,500 Gallons but Less N/A ** Gasoline Unleaded 93 Octane $ .15 $0.20 T.00100193 Non -Ethanol ** See above ** Diesel Low Sulfur $ .09 $0.20 .001 1 .00214 (Clear Diesel) Precinct 4 (Port O'Connor) Fuel Tank(s) Location: Gasoline 93 Trevor Street (Off of Hwy 185). Unleaded $.08 $0.20 .001 .00193 Port O'Connor TX 77982 87 Octane Diesel Low Sulfur $ .09 $0.20 .001 .00214 (Clear Diesel) than 5,000 Gallons = $ .0012/gal. Less than 2,500 Gallons = $ .0012/gal. 2,500 Gallons but Less than 5,000 Gallons = $ .0012/gaL Less than 2,500 Gallons = $ .0012/gaL 2,500 Gallons but Less than 5,000 Gallons = $.0012/gal. .ess than 2,500 Gallons = (.0012/gaL !,500 Gallons but Less han 5,000 Gallons = .0012/gaL OIL PATCH PETROLEUM, INC. Did Not Meet specifications - Missing signatures on 2 Forms .Affidavit and Form 1295 are not signed BRAND NAME: CITGO ** 90 Octane Non -Ethanol ** TEXAS.: MARK-UP STATE OSLTF- TEXAS PER. EXCISE. LUST Federal Oil ENVIRONMENTAL FEE GALLON TAX. FEE .Spill Fee (Based on Number of - Gallons Delivered) OTHER FEES Less than 2,500 Gallons =. $ .10 $0.20 $1.70 After Hours Call Out $75- N/A .00193 2,500 Gallons but Less Fueling Generator $75: than 5,000 Gallons = Less than 300Gallons $75.- N/A ! $ .10 I $0.20 I N/A I .00193 N/A $.10 $1020 N/A . 00204 $18N. 0.20 1 N/A 1 .00193 ess than 2,500 Gallons = '0012/gaL ,500 Gallons but Less N/A $ .18 $0.20 N/A . 00204 lan 5,000 Gallons = .0012/gaL Less than 2,500 Gallons = $1.70 After Hours Call Out $75: 2,500 Gallons but Less Fueling Generator $75 han 5,000 Gallons = Less than 300 Gallons $75. ;s than 2,500 Gallons = 70 After Hours Call Out $75. 00 Gallons but Less Fueling Generator $75: n 5,00( Gallons = Less than 300 Gallons $75. than 2,500 Gallons= ) After Hours Call Out $75.- ) Gallons but Less Fueling Generator $75 5,000 Gallons = Less than 300 Gallons $75: :s than 2,500 Gallons = 70 After Hours $75. 00 Gallons but Less Fueling Generator $75. n 5,000 Gallons = Less than 300 Gallons $75.- Page 2 of 5 Bid Tabulation - Delivered Fuel Annual Supply Contract -- Continued NEW DISTRIBUTING CO., INC. OIL PATCH PETROLEUM, INC. Appeared to have Met Specifications Did Not Meet Specifications - Missing Signatures on 1 Forms Returned all forms and ail forms have the required signatures Affidavit and Form 1295 are not signed BRAND NAME: CITGO UNB BRAND NAME: CITGO ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** TEXAS TEXAS TEXAS TEXAS - -. MARK-UP STATE - OSLTF- ENVIRONMENTAL FEE MARK-UP STATE OSLTF- ENVIRONMENTAL FEE PER EXCISE LUST Federal Oil (Based on Number of OTHER PER EXCISE LUST Federal Oil (Based an. Number of DEPARTMENT FUEL TYPE GALLON TAX.- FEE Spill Fee GallonsDelivered)FEES. GALLON TAX. FEE Spill Fee Gallons Delivered) OTHER FEES Precinct 4 (Seadrift) Gasoline Less than 2,500 Gallons = Less than 2,500 Gallons= Fuel Tank(s)Loca[ion: Unleaded $08 .. $020 .001 .00193 $.0012/gal. 2,500 Gallons but Less N/A $ $0.20 N/A $_( no amount on bid form) 2,500 After Hours Call Out $75 104E Dallas .10 .00193 Gallons but Less Fueling Generator $75. Seadrift TX 77983 87 Octane than 5,000 Gallons = than 5,000 Gallons = Less than 300 Gallons $75 $.0012/gaL $_(no amount on bid form) **Gasoline Less than 2,500 Gallons= Less than 2,500 Gallons= Unleaded $ .0012/gaL $_(no amounton bid form) After Hours Call Out $75 93 Octane $ .15 $0.20 .001 .00193 2,500 Gallons but Less N/A $ .10 $0.20 N/A .00193 2,500 Gallons but Less Fueling Generator $75. Non -Ethanol than 5,000 Gallons = than 5,000 Gallons = Less than 300 Gallons $75 ** See above ** $ .0012/gal. $_(no amount on bid form) Less than 2,500 Gallons = Less than 2,500 Gallons = Diesel $.0012/gal. $10 $_(no amounton bid form) After Hours Call Out $75 Low Sulfur $ .09 $0.20 .001 .00214 2,500 Gallons but Less N/A (No Decimal $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75. (Clear Diesel) than 5,000 Gallons = on bid form) than 5,000 Gallons = Less than 300 Gallons $75 $ .0012/gaL $_(noamount on bid form) Precinct 4 (Seadrift) Gasoline Less than 2,500 Gallons = Less than 2,500 Gallons = Fuel Tank(s) Location: Unleaded $ .OS $0.20 .001 .00193 $ .0012/gaL 2,500 Gallons but Less N/A $.10 $ 0.20 N /A $_(no amount on bid form) 2,500 After Hours Call Out $75 448 Harbor Road .00193 Gallons but Less Fueling Generator $75. Seadrift TX 77983 87 Octane than 5,000 Gallons =. than 5,000 Gallons = Less than 300 Gallons $75 $ .0012/gaL no $_( .amount on bid form) Less than 2,500 Gallons = Less than 2,500 Gallons = Diesel $.0012/gaL $_(no amount on bid form) After Hours Call Out $75 Low Sulfur $ .09 $0.20 .001 .00214 2,500 Gallons but Less N/A $ .10 $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75. (Clear Diesel) than 5,000 Gallons = than 5,000 Gallons = Less than 300 Gallons $75 $.0012/gaL $_(no amount on bid form) Page 3 of 5 Bid Tabulation -Delivered Fuel Annual Supply Contract -- Continued DEPARTMENT - FUELTVPF Skid Fuel Tank ;kid Location for Fuel Delivery: Diesel Vithin Close Proximity to the Calhoun County :ourthouse Low Sulfur 11 S Ann St (Clear Diesel) ort Lavaca TX 77979 Generator Calhoun County Courthouse Diesel Generator Fuel Tank Location for Fuel Delivery: I Low Sulfur 211 S Ann street (Red Diesel) Port Lavaca TX 77979 Generator - Calhoun County Adult Detention Center (Jail) Geneerator Fuel Tank Location for Fuel Deli% 302 W Live Oak Port Lavaca TX 77979 Diesel Low Sulfur (Red Diesel) NEW DISTRIBUTING CO., INC. Appeared to have Met Specifications Returned all forms and all forms have the required signatures BRAND NAME: CITGO UNB ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** TEXAS TEXAS MARK-UP STATE OSLTF ENVIRONMENTAL. FEE PER EXCISE LUST Federal Oil (Based on Number of OTHER GALLON TAX FEE -Spill Fee Gallons Delivered) FFPS $ .22 $ .22 $ .22 $0.20 1 .001 1 .00214 NA 1 .001 1 .00214 NA 1 .001 1 .00214 OIL PATCH PETROLEUM, INC. Did Not Meet Specifications - Missing Signatures on 2 Forms Affidavit and Form 1295 are not signed BRAND NAME: CITGO **90 Octane Non -Ethanol** TEXAS TEXAS MARK-UP STATE OSLTF- -ENVIRONMENTAL FEE - PER EXCISE LUST Federal Oil ..;(Based on. Numberof GALLON TAX FEE Spill Fee Gallons Delivered) OTHER FEES -ss than 2,500 Gallons = Less than 2,500 Gallons = .0012/gal. $ 12 Less t 500 Gallons but Less Hours Call Out $75. N/A (No Decimal $0.20 N/A .00204 2,500 Gallons but Less Fueling Generator $75. ian 5,000 Gallons = on bid form) than 5,000 Gallons = .0012/gal. ILAfter ess than 300 Gallons $75. Less than 2,500 Gallons = $.00 Less than 2,500 Gallons = Gallons :han Gallons but lions s N/A :han 5,000 Gallons = $1.70 $ .2350 NA .00100 .o0214 2,500 Gallons but Less AfterHoursCallOut$75.- Fueling Generator $75.- i .0012/gaL than 5,000 Gallons = Less than 300 Gallons $75: $3.45 .ess than 2,500 Gallons = III .0012/gaL Less than 2,500 Gallons = " " (the "" are on their bid '.,500 Gallons but Less N/A han 5,000 Gallons = $1.70 $ .2350 NA .00100 .00214 2,500 Gallons but Less form)H After Hours Call Out $75.- .0012/gaL than 5,000 Gallons = Fueling Generator $75.- $3.45 .Less than 300 Gallons $75. Page 4 of 5 Bid Tabulation - Delivered Fuel Annual Supply Contract -- Continued NEW DISTRIBUTING CO., INC. OIL PATCH PETROLEUM, INC. Appeared to have Met Specifications Did Not Meet Specifications -. Missing. Signatures on 2 Forms Returned all forms and all forms have the required signatures Affidavit and Form 1295 are not signed BRAND NAME: CITGO UNB BRAND NAME: CITGO ** 87 Octane Ethanol -Free is all we have available ** ** Pricing basis will be Citgo unbranded Corpus Christi ** ** 90 Octane Non -Ethanol ** TEXAS TEXAS TEXAS TEXAS .MARK-UP STATE OSLTF-, ENVIRONMENTAL FEE MARK-UP STATE .OSLTF- ENVIRONMENTAL FEE - _ PER EXCISE LUST Federal Oil (Based on Number of OTHER PER. EXCISE . LUST Federal Oil- (Based on Number of - DEPARTMENT - 'FUELTYPE GALLON TAX. FEE _Spill Fee Gallons Delivered) FEES. GALLON. TAX. FEE ;Spill Fee Gallons Delivered) 'OTHER FEES - Generator Less than 2,500 Gallons= EMS Central Station Diesel $ .0012/gal. Less than 2,500 Gallons= After Hours Call Out $75.- Low Sulfur $ .22 NA .001 .00214 2,500 Gallons but Less N/A $ NA $1.70 Fueling equipment Generator Fuel Tank Location for Fuel Delivery: .2350 .00100 .00214 2,500 2,500 Gallons but Less Generator $75.- 705Henry Barber way (Red Diesel) than 5,000 Gallons = than 5,000 Gallons = $3.45 Less than 300 Gallons $75.- Port Lavaca TX 77979 $ .0012/gal. Generator Less than 2,500 Gallons = EMS South Station Diesel $ .0012/gal. Less than 2,500 Gallons = After Hours Call Out $75. Generator Fuel Tank Location for Fuel Delivery: Low Sulfur $ .22 NA .001 .00214 2,500 Gallons but Less N/A / $ .2350 NA .00100 .00214 2,500 2,500 Gallons but Less Fueling Generator $75. 6084 State Hwy 185 E (Red Diesel) than 5,000 Gallons = than 5,000 Gallons=$3.45 Less than 300 Gallons $75. Seadrift TX 77983 $.0012/gaL Generator Memorial Medical Center Less than 2,500 Gallons = (Hospital). Diesel $ .0012/gaL Less than 2,500 Gallons = $1.70 After HRS Call Out $75. Low Sulfur $ .09 NA .001 .00214 2,500 Gallons but Less N/A $ .2350 NA .00100 .00214 Fueling Generator $75: Generator Fuel Tank(s) Location for Fuel (Red Diesel) than 5,000 Gallons = 2,500 Gallons but Less Less than 300 Gallons 75: Delivery: $ .0012/gaL than 5,000 Gallons = $3.45 815 N Virginia Street Port Lavaca. TX 77979 Generator Less than 2,500 Gallons= Memorial Medical Clinic Diesel $.0012/gaL Less than 2,500 Gallons= After Hours Call Out $75: Low Sulfur $ .22 NA .001 .00214 2,500 Gallons but Less N/A $ NA $1.70 Fueling Generator $75.- Generator Fuel Tank Location for Fuel Delivery: (Red Diesel) than 5,000 Gallons = .2350 .00100 .00214 2,500 Gallons but Less Less than 300 Gallons (no 1016 N Virginia Street $ than 5,000 Gallons = $3.45 amount on bid form) Port Lavaca TX 77979 .0012/gal. Texas Environmental Fee - Petroleum Products Delivery Fees : Less than 2,500 Gallons Delivered = $1.70 Fee Per Delivery / 2,500 Gallons but less than 5,000 Gallons = $3.45 Fee Per Delivery OSLTF - Federal Oil Spill Fee: Gas E10 - $0.001929 / Diesel - $0.002143 Page s of s NEW DISTRIBUTING CO., INC. DELIVERED FUEL ANNUAL SUPPLY CONTRACT BID NUMBER: 2021.01 BEGINNING JANUARY 1, 2021 AND ENDING DECEMBER 31, 2021 CALHOUN COUNTY, TEXAS Annual Supply Contract for Delivered Fuel Beginning January 1, 2021 and Ending December 31, 2021 Bid Number: 2021.01 New Distributing Co., Inc. 4102 US Hwy. 59 N. Victoria, TX 77905 • Please type or print in ink. If handwritten, must be legible. • White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the bidder to provide up to the amount bid at the bid terms and conditions stated herein. Acceptance of the successful bid shall only obligate Calhoun County to purchase some of the items from that bidder. Calhoun County reserves the right to require any successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid packet, in its entirety, will be the binding contract between Calhoun County and the successful bidder. • SEE SPECIFICATIONS FOR DELIVERED FUEL AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • Estimated quantities are not guaranteed for the year. Amounts will vary by need. • ALL Transportation Costs and Other Fees must be included in the bid mark-up or clearly stated on the bid • FOB Calhoun County • Delivery in 24 hours from receipt of order. • Calhoun County is Exempt from all Federal Excise Taxes and Sales Tax (county, city and state sales tax). • Calhoun County is Not Exempt from: Texas State Excise Tax on Gasoline and Clear Diesel Page 1 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued Method or Source (provide copy) that will be used throughout the bid period:OPIS Victoria Citgo Unbranded OTHER FEES NOT INCLUDED IN MARK-UP If not applicable!or included in mark-up, Mark NA Texas List Any other Mark -Up Texas Environmental Fee(s)AND OSLTF - ' Fee (Based on Amount of Fee(Is): Per State LUST Federal pil Number of Gallons Ex: After HourIs Call: Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) Out Service Fee Less than 2,500 Gasoline Gallons= Precinct 1 Unleaded $.0012/ga1. Fuel Tank(s) Location: 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but N/A 305 Henry Barber Way Brand Name: Less than 5,000 Port Lavaca TX 77979 Citgo UNB Gallons= $ .0012/gal. Gasoline Less than 2,500 **87 Octane Unleaded Gallons= Ethanol -Free is $•0012/qa1. all we have 93 Octane $ .15 $0.20 001 .00193 2,500 Gallons but N/A available** Non -Ethanol Less than 5,000 **Pricing basis will Brand Name: Gallons= be Citgo unbranded Corpus Christi us Citgo UNB $ •0012/gal. Less than 2,500 Diesel Gallons = Low Sulfur $ .0012/gal. (Clear Diesel) $ •09 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= $ .0012/gal. Gasoline Less than 2,500 Precinct 2 Unleaded Gallons= $.0012/gal. Fuel Tank(s) Location: 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but N/A 5812 FM 1090 Brand Name: Less than 5,000 Port Lavaca TX 77979 Citgo UNB Gallons= $.0012/gal Less than 2,500 Diesel Gallons = Low Sulfur $.0012/gal. (Clear Diesel) $ .09 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= $ .0012/gal. Page 2 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP If not applicable or included in mark-up, Mark NA Texas Kist Any Other Mark -Up Texas Environmental Fee(s) AND OSLTF - Fee (Based on Amount of Feels)' Per State LUST Federal Oil. Number of Gallons Ex: After Hours Call Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) out service Fee Less than 2,500 Precinct 3 Gasoline Gallons= Fuel Tank(s) Location: Unleaded $.0012/gal. 24627 State Hwy 172 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but N/A Port Lavaca TX 77979 Brand Name: Less than 5,000 (Precinct3 is in Olivia) Citgo UNB Gallons= $ .0012/gal Gasoline Less than 2,500 **87 Octane Unleaded Gallons= $ .0012/gal. Ethanol -Free is all we have 93 Octane $ .15 $0.20 .001 .00193 2,500 Gallons but N/A available' Non -Ethanol Less than 5,000 **Pricing basis will be Brand Name: Gallons= Citgo unbranded Citgo UNB $.0012/ga1. Corpus Christi** Less than 2,500 Diesel Gallons= Low Sulfur $ .0012/gal. (Clear Diesel) $ .09 $0.20 .001 .00214 1$.0012/cj 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= 1. Precinct 4 Gasoline Less than 2,500 Gallons= (Port O'Connor) Unleaded 5.0012/ga1. Fuel Tank(s) Location: 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but N/A 93 Trevor Street Brand Name: Less than 5,000 (Off of Hwy185) 77982 Citgo Gallons= $ Port O'Connor TX .0012/gal. Less than 2,500 Diesel Gallons= Low Sulfur $.0012/gal. (Clear Diesel) $ .09 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= $ .0012/gal. Page 3 of 7 Invitation to Bid Form -Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP if not applicable or included in mark-up, Mark NA Texas List Any Other Environmental ' Feels) AND . Mark -Up Texas OSLTF - Fee (Based on Amount of Feels); Per State LUST ' Federal Oil Number of Gallons Ex: After Hours Call Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) Out Service Fee Less than 2,500 Precinct 4 Gasoline Gallons= (Seadrift) Unleaded $.0012/gal. Fuel Tank(s) Location: 87 Octane $ •08 $0.20 .001 .00193 2,500 Gallons but N/A 104 E Dallas Brand Name: Less than 5,000 Seadrift TX77983 Citgo UNB Gallons= $.0012/gal. Gasoline Less than 2,500 **87 Octane Unleaded Gallons= $.0012/gal. Ethanol -Free is 93 Octane $ 15 $0.20 .001 .00193 2,500 Gallons but N/A all we have Non -Ethanol Less than 5,000 available** Brand Name: Gallons= "Pricing basis will be Citgo unbranded Citgo UNB 0012/ al. $ g Corpus Christi" Less than 2,500 Diesel Gallons= Low Sulfur $.0012/gal. (Clear Diesel) $ •09 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= $.0012/ga1. Less than 2,500 Precinct 4 Gasoline Gallons= (Seadrift) Unleaded $.0012/gal. Fuel Tank(s) Location: 87 Octane $ .08 $0.20 .001 .00193 2,500 Gallons but N/A 448 Harabor Road Brand Name: Less than 5,000 Seadrift TX77983 Citgo UNB $� G0012/9 al. Less than 2,500 Diesel Gallons= Low Sulfur $.0012/gal. (Clear Diesel) $ •09 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons= $ .0012/gal. Page 4 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP If not'; applicable or included -in mark-up, Mark NA Texas List Any Other Mark -Up Texas Environmental Fees) ANR OSLTF - Fee (Based on Amount of Feels), Per State LUST Federal Oil Number of Gallons Ex: After Hours Call Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) Out Service Fee Skid Fuel Tank Less than 2,500 Skid Location for Fuel Diesel Gallons= Delivery: Low Sulfur $•0012/gal. Within Close Proximity (Clear Diesel) $ •22 $0.20 .001 .00214 2,500 Gallons but N/A to the Calhoun County Brand Name: Less than 5,000 Courthouse Citgo UNB Gallons= zll s Ann street $.0012/gal. Port Lavaca TX 77979 Generator - Calhoun County Diesel Less Gallon =2,500 Gallons = Courthouse tow Sulfur $.0012/ga1. Generator Fuel Tank (Red Diesel) $ •22 NA .001 .00214 2,500 Gallons but N/A Location for Fuel Brand Name: Less than5,000 Delivery: Cit o UNB g Gallons= $ .0012/gal. 211 S Ann Street Port Lavaca TX 77979 Generator - Calhoun County Less than 2,500 Adult Detention Diesel Gallons= Low Sulfur $.0012/gal. Center (JAIL) (Red Diesel) $ •22 NA .001 .00214 2,500 Gallons but N/A Generator Fuel Tank Brand Name: Less than5,000 Location for Fuel Citgo UNB Gallons= Delivery: $.0012/gal. 302 W Live Oak Port Lavaca TX 77979 Page 5 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP If not applicable or included in mark-up, Mark NA Texas ListAnyOther Mark -Up Texas Environmental Feels) AN01 ,OSLTF - Fee (Based on Amount of Fees) Per State LUST ' , Federal Oil Number of Gallons Ex: AfterHours Call Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) out Service Fee Generator - EMS Central Station Less than 2,500 (Emergency Diesel Gallons= Low Sulfur $.0012/gal. Management (Red Diesel) $ .22 NA .001 .00214 2,500 Gallons but N/A Services) Brand Name: Less than5,000 Generator Fuel Tank Citgo UNB Gallons= $.0012/gal. Location for Fuel Delivery: 705 Henry Barber Way Port Lavaca TX 77979 Generator - EMS South Station Less than 2,500 (Emergency Diesel Gallons= Low Sulfur $.0012/gal. Management (Red Diesel) $ -22 NA .001 .00214 2,500 Gallons but N/A Services Brand Name: Less than 5,000 Generator Fuel Tank Citgo UNB Gallons= $.0012/gal. Location for Fuel Delivery: 6084 State Hwy 185 E Seadrift TX 77983 Page 6 of 7 Invitation to Bid Form -Annual Supply Contractfor Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP If not applicable or included in mark-up, Mark NA Texas List Any Other Environmental Feels)ANd Mark -Up Texas OSLTF- Fee (Based on Amount of Fee(s); Per State LUST Federal Oil Number of Gallons Ex: After Hours Call Department Fuel Type Gallon Excise TaX FEE Spill Fee Delivered) out Service Fee Generator - Memorial Less than 2,500 Medical Center Diesel Gallons= Low Sulfur $•0012/gal. (Hospital)ITank (Red Diesel) $ •09 NA .001 .00214 2,500Gallons but N/A Generator Brand Name: Less than 5,000 Location for Fuel Cltgo UNB Gallons 0012/ al Delivery: $. 815 N Virginia Street Port Lavaca TX 77979 Generator - Memorial Diesel Less than 2,500 Gallons= Medical Clinic Low Sulfur $.0012/ga1. Generator Fuel Tank (Red Diesel) $ .22 NA .001 .00214 2,500 Gallons but N/A Location for Fuel Brand Name: Less than 5,000 Delivery: Citgo UNB Gallons0012/ al. $� 1016 N Virginia Street Port Lavaca TX 77979 The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Intivitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 11 /3/2020 Authorized Signature & Title: Printed Name & Title of Authorized Signature: Vice President Devin New - Vice President Phone Number: (361) 575-1981 Email: devin@newdistributing.com REMARKS: Page 7 of 7 11/3/2020 Customized OPIS City Rack Report far T C'us aJlrind,zond OPIS a;af9° j Ra(clik RQpa fit war'f�x VICTORIA/PLACEDO, TX 2020-11-03 10:00:18 EST **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS CBOB ETHANOL(10%) PRICES** 9.0 RVP Move Terms Unl Move Mid Move Pre Move Date Time 76-Mot b 125-3 127.08 + 1.27 142.27 + 1.27 175,18 + 1.27 11/02 18:00 Citgo b 1-10 127.09 + 1.18 142.75 + 1.18 174.57 + 1.19 11/02 18:00 Shell -Mot b 125-3 127.22 + 1.27 144.44 + 1.27 178.87 + 1,27 11/02 18;00 Valero b 1-10 127.40 + 1.40 143.10 + 1.40 175.80 + .90 11/02 18:00 .Mao u 1-10 127.44 -+ 1.49 142.60 + 1.50 174.92 + 1.50 11/02 18:00 PSX b 1-10 127.49 + 1.80 142.64 + 1.80 174.96 + 1.80 11/02 18:00 XOM b 125-3 127.49 + 1.90 144.71 + 1.90 178.13 + 1.91 11/02 19:00 Cenex b 1-10 129.65 + 2.59 -- -- -- -- -- -- -- -- 11/02 18:00 LOW RACK 127.08 142.27 174.57 HIGH RACK 129.65 144.71 178.87 RACK AVG 127.61 143.22 176.06 OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 109.94 -- -- 113.77 BRD LOW RACK 127.08 142.27 174.57 BRD HI6H RACK 129.65 144.71 178.87 BRD RACK AVG 127.63 143.32 176.25 UBD LOW RACK 127.44 142.60 174.92 UBD HIGH RACK 127.44 142.60 174.92 UBD RACK AVG 127.44 142.60 174.92 CONT AVG-11/03 127.61 143.22 176.06 CONT LOW-11/03 127.08 142.27 174.57 CONT HIGH-11/03 129.65 144.71 178.87 VICTORIA, TX LOW RETAIL 163.02 AVG RETAIL 170.44 LOW RETAIL EX -TAX 124.26 AVG RETAIL EX -TAX 131.68 VICTORIA/PLACEDO, TX 2020-11-03 10:00:18 EST **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS ULTRA LOW SULFUR LED DISTILLATE PRICES** Move Terms No.2 Move No.1 Move Pre Move Date Time Motiva b 125-3 117.73 + 2.68 -- -- -- -- -- -- -- -- 11/02 18:00 Valero b 1-10 118.20 + 2.95 -- -- -- -- -- -- -- -- 11/02 18:00 76-Mot b 125-3 118.22 + 2.67 -- -- -- -- -- -- -- -- 11/02 18:00 Shell -Mot b 125-3 118.22 + 2.67 -- -- -- -- -- -- -- -- 11/02 18:00 PSX b 1-10 118.31 + 2.60 -- -- -- -- -- -- -- -- 11/02 18:00 Citgo b 1-10 118.53 + 2.97 -- -- -- -- -- -- -- -- 11/02 18:00 Citgo u 1-10 118,53 + 2.97 -- -- -- -- -- -- -- -- 11/02 18:00 Cenex b 1-10 119.88 + 2.53 -- -- -- -- -- -- -- -- 11/02 18:00 LOW RACK 117.73 -- -- -- -- HIGH RACK 119.88 -- -- -- -- RACK AVG 118.45 -- -- -- -- OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 112.17 -- -- -- -- BRD LOW RACK 117.73 -- -- -- -- BRD HIGH RACK 119.88 -- -- -- -- BRD RACK AVG 118.44 -- -- -- -- UBD LOW RACK 118.53 -- -- -- -- UBD HIGH RACK 118.53 -- -- -- -- UBD RACK AVG 118.53 -- -- -- -- CONT AVG-11/03 118.45 -- -- -- -- CONT LOW-11/03 117.73 -- -- -- -- CONT HIGH-11/03 119.88 -- -- -- -- https:/lwebracks.opisnet.com/Default.aspx 112 11/3/2020 Customized OPTS City Rack Report for ME VICTORIA/PLACEDO, TX 2020-11-03 10:00:18 EST **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS ULTRA LOW SULFUR RED DYE LED DISTILLATE PRICES** No.2 No.1 Pre Move Terms RD Move RD Move RD Move Date Time Citgo b 1-10 118.93 + 2.97 -- -- -- -- -- -- -- -- 11/02 18:00 Citgo u 1-10 118.93 + 2.97 -- -- -- -- -- -- -- -- 11/02 18:00 PSX b 1-10 119.32 + 2.60 -- -- -- -- -- -- -- -- 11/02 18:00 Cenex b 1-10 120.28 + 2.53 -- -- -- -- -- -- -- -- 11/02 18:00 LOW RACK 118.93 -- -- -- -- HIGH RACK 120.28 -- -- -- -- RACK AVG 119.37 -- -- -- -- OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 112.52 -- -- -- -- BRD LOW RACK 118.93 -- -- -- -- BRD HIGH RACK 120.28 -- -- -- -- BRD RACK AVG 119.51 -- -- -- -- UBD LOW RACK 118.93 -- -- -- -- UBD HIGH RACK 118.93 -- -- -- -- UBD RACK AVG 118.93 -- -- -- -- CONT AVG-11/03 119.37 -- -- -- -- CONT LOW-11/03 118.93 -- -- -- -- CONT HIGH-11/03 120.28 -- -- -- -- VICTORIA/PLACEDO, TX 2020-11-03 10:00:18 EST **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS WHOLESALE 05 SME BIODIESEL PRICES** ULS2 ULS2D Move Terms LED LED Date Time Motiva b 125-3 117.73 -- -- 11/02 18:00 Valero b 1-10 118.20 -- -- 11/02 18:00 76-Mot b 125-3 113.22 -- -- 11/02 18:00 Shell -Mot b 125-3 118.22 -- -- 11/02 18:00 PSX b 1-10 118.31 -- -- 11/02 18:00 Citgo b 1-10 118.53 118.93 11/02 18:00 Citgo u 1-10 118-53 ,118i93% 11/02 18:00 XOM- b 125-3 120.4 -- -- 11/02 19:00 LOW RACK 117.73 118.93 HIGH RACK 120.44 118.93 RACK AVG 118.52 118.93 BRD LOW RACK 117.73 118.93 BRD HIGH RACK 120.44 118.93 BRD RACK AVG 118.52 118.93 URD LOW RACK 118.53 118.93 UBD HIGH RACK 118.53 118.93 UBD RACK AVG 118.53 118.93 CONT AVG-11/03 118.52 118.93 CONT LOW-11/03 117.73 118.93 CONT HIGH-11/03 120.44 118.93 Copyright, oil Price Information Service https://webracks.opisnet.com/Default.aspx 2/2 STATE OF TEXAS 0 AFFIDAVIT COUNTY OF CALHOUN 0 The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Davin New known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Name of Bidder (Company) New Address Phone Number Fax Number Affiant Devin New - Vice President Printed Name and Title of Affiant Co., Inc. PO Box 1247 Victoria, TX 77902 575-1981 (361)575-2602 Email Address devin@newdistributing.com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this 3rd day of JOHNNA KETHAN + Notary ID #132030531 .' N My Commission Expires May 29, 2023 November 120 20 Public in and for lkhai t County, Texas CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-685621 New Distributing Co., Inc. Victoria, TX United States Date Filed: 11/03/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021.01 Fuel Delivery 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary New, Devin Victoria, TX United States X New, Jon Victoria, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION ��tt My name is rDCVtr" rv�� and my date of birth is My address is ENE—NINE&N 9 I declare under penalty of perjury that the foregoing is true and correct. Executed in V i Oro CMA- County, State of '—RVK04 , on the iv' day of dotyw0¢I1- , 20 24 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aafld PLILL9LE'T'TA UOIS19A sn•xl'algls•so!gla•AmNw uoiss!wwoO sagl3 SW9j Aq PaPIAwd sw1o:j (1ue�eloeO) Alpe ssaulsnq 6upo2aluoo;o lua6e pszuoglog to aJnleuBiS (Je96) (yluow) 6Z' to Aep agl uoto alelS 'Alunoo ui palnoax3 loailoo pug anll si 6wo6aaol agl lggl Alnflad to Al!guad iapun aaeloap I (�jlunoo) (apoo diz) (aleis) (klo) (laa�ls) ' s! ssalppg An si gUlq to alep Aw pue ' si awau AW NOIIVMV1030 NMOMSNI 9 ❑ 'AYed Palsalalul ON s! a1ag11! 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Named Insured and Address: NEW DISTRIBUTING CO INC PO BOX 1247 VICTORIA TX 77902 9" s Policy No. Account No , Item 2. Policy Period: (Mo. Day Yr.) From 04-01-2020 to 04-01-2021 12:01 A.M., standard time at the address of the named insured as stated herein. The named insured is: Corporation Business of named insured is: Item3. $15,000,000 Occurrence Limit Item4. $15,000,000 Aggregate Limit Item 5. As Billed Annual Premium CERTIFIED ACTS OF Item 6. Schedule of Underlying Insurance Policies. TERRORISM PREMIUM: $1,255 Type of Insurance Limits of Liability Per Occurrence Aggregate Insurer - Federated unless otherwise indicated. GENERAL LIABILITY ®Commercial General Liability $1,a00,00 $2,000,00 Businessowners Dwelling Dwelling AUTO LIABILITY XQ Business Auto $1,000,00 Auto Dealers Coverage Form Businessowners Personal Auto OTHER UNDERLYING INSURANCE ❑ Equipment Dealers Stock Floater, Coverage B - Property of Others ■ Garagekeepers Legal Liability - Building Pae1of2 CU-F-1 (01-17) :§ t Transaction Effective Date:04-01-2020 Insured Copy EMPLOYERS LIABILITY Limits of Liability Employers Liability State Fund Selfinsured Work Comp Endorsement(s) attached hereto: See Schedule of Forms and Endorsements Attached MUTUALS - PARTICIPATION CLAUSE WITHOUT CONTINGENT LIABILITY: No Contingent Liability: This policy is nonassessable. The policyholder is a member of the Company and shall participate, to the extent and upon the conditions fixed and determined by the Board of Directors in accordance with the provisions of law, in the distribution of dividends so fixed and determined. MUTUAL - MEMBERSHIP AND VOTING NOTICE: -- -The-insured is notified that -by virtueofthis-policy, he or she is -a member of the Federated Mutual --Insurance Company of Owatonna, Minnesota, and is entitled to vote either in person or by proxy at any and all meetings of said Company. The Annual Meetings are held in its. Home Office. in Owatonna,.. Minnesota, on the third Tuesday of April in each year at ten o'clock A.M. In Witness Whereof, the Company has caused this policy to be executed and attested. 1 �I SECRETARY PRESIDENT This policy consists of: (1) this Declarations; (2) the Schedule of Forms and Endorsements, if attached; and (3) all forms and endorsements listed on this Declarations or, if attached, the Schedule of Forms and Endorsements. Page 2 of 2 CU-F-1 (01-17) Transaction Effective Date:04-01-2020 CONFLICT OF INTEREST OUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire Is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section Is a misdemeanor. !J Name of vendor who has a business relationship with local governmental entity. New Distributing z Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Calhoun County Texas Name of Officer 4J Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yes ®No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? F1 Yes ® No 6 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. s ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 �. A r .,..r ° 11 /3/2020 u o Signatr r do uslness with the governmental entity Data Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a tluee-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a —d) of this certification. Devin New - Vice President Name and Title of Authorized Agent Signature of Authorized Agent 11 /3/2020 I am unable to certify to the above statements. My explanation is attached. Date Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require thatthe language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, New Distributing certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.SS..C. § 3801 at seq., apply to this certification and disclosure, if any. Signature of Contractor's Authorized Official Devin New - Vice President Printed Name and Title of Contractor's Authorized Official 11 /3/2020 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing N/A b. grant N/Ab. initial award N/A b. material change c, cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f, loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter _ Prime Subawardee Name and Address of Prime: Tier_, if Known: N/A N/A Congressional District, if known: Con ressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: N/A N/A CFDA Number, ifapplicable: 8. Federal Action Number, if known: 9. Award Amount, ifknown: N/A N/A $ 10. a. Name and Address of Lobbying Registrant b. individuals Performing Services (including address ii (f individual, last nante, first name, Ml): rlifferen(fi»nr No. IOa) (last name, first name, Ml): N/A N/A 11. Information requested through this form is authorized by title 31 U.S.C, section 1352. This Signature:�..✓1 disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Deyln New by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Vice President U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: (361) 575-1981 Date:11/3/2020 inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) Devin New Representative �.1a,' : 1 it 1 1,11t� �; the undersigned representative of New Distributing (hereafter referred to as Company) being an Company or Business Name. adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle f, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in. Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means o for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signature of Representative Devin New - Vice President Print Name& Title 11/3/2020 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001(3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ 1 certify that is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) I certify that New Distributing is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Devin New - Vice President Printed Name and Title of Authorized Agent 11/3/2020 Date R' I'll,� ' �D, • - D e (0 IKI Please Type If handwritten, must be in ink and legible Vendor's Name: New Address: 4102 US Hwy. 59 N. Victoria, TX 77905 Remittance Address: PO Box 1247 Victoria, TX 77902 Telephone: (361)575-1981 Fax: (361)575-2602 Email: devin@newdistributing.com Email(s) to send Bid Information: devin@newdistributing.com AND jnew@newdistributing.com Signature of Authorized Representative: � Printed name of Authorized Rep: Devin New ORDER - CONTACT INFORMATION Order Contact Name & Title: Devin New -Vice President / Terry Foster - Order Contact Telephone: (361) 575-1981 Order Contact Fax: N/A Order Contact Email: orders@newdistributing.com w-9 Request for Taxpayer Give Form to the Fonn (Rev. October 2018) Identification Number and Certification requester. Do not Depadment of the Treasury send to the IRS. Internal Revenua Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank. NEW DISTRIBUTING CO., INC. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to o� following seven boxes, certain entities, not Individuals; see o. o ❑ IndlVldual/sole proprietor or ❑ C Corporation 0 S Corporation ❑ Partnership ❑ Trust/estate Instructions on page 3): c single -member U_C Exempt payee code (If any) ao j�,"wo ❑ Limited liability company. Enter the tax classification(C=C corporation, S=S corporation, P=Partnership)► `o Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC If the LLC Is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC Is co de (if any) Q. Q. another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, &single-memberLLC that Is disregarded from the owner should check the appropriate box for the tax ciasslocatlon of Its owner. y ❑ Other (sea Instructions)► (AppNes loaccouMs mafnleN,edwlaMe the a4J N 6 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optlonall w P.O. BOX 1247 6 city, state, and ZIP code VICTORIA, TX 77902 7 Ust account number(s) here (optional) NW. 11 Taxpayer Identification Number TIN Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid ( social security number backup withholding. For individuals, this is generally your social security number (Sate): However, fora resident alien, sole proprietor, or disregarded entity, see the Instructions for Part I, later, For other FM _ m ~� entities, it Is your employer Identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note; if the account is in more than one name, see the Instructions for line 1. Also see What Name and I Employer Identification number Number To Give the Requester for guidelines on whose number to enter. 1. The number shown on this form is my correct taxpayer Identification number (or I am waiting fora number to be issued to me); and 2. 1 am not 6ubjectto backup withholding because; (a) I am exemptfrom backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S, citizen or other U.S, person (defined below); and 4. The FATCA code(s) entered on this form (If any) Indicating that I am exempt from FATCA reporting Is correct. Certification Instructions. You most cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. lid" Signature of �n�y Here U.S. person �t / Date► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.ka.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identl8catlon number (FIN) which may be your social security number (SSN), Individual taxpayer Identificatlon number #TIN), adoption taxpayer Identification number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an information return. Examples of Information returns Include, but are not limited to, the following. • Form 1099-INT Qnterest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-M)SC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-8 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S, person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cal. No. 10231X Form W-9 (Rev.10-2013) OIL PATCH PETROLEUM, INC. DELIVERED FUEL ANNUAL SUPPLY CONTRACT BID NUMBER: 2021.01 BEGINNING JANUARY 1, 2021 AND ENDING DECEMBER 31, 2021 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM Annual Supply Contract for Delivered Fuel Beginning January 1, 2021 and Ending December 31, 2021 Bid Number: 2021.01 ErPIRM RUN S,Y i �. • Please type or print in ink. If handwritten, must be legible. • White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the bidder to provide up to the amount bid at the bid terms and conditions stated herein. Acceptance of the successful bid shall only obligate Calhoun County to purchase some of the items from that bidder. Calhoun County reserves the right to require any successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid packet, in its entirety, will be the binding contract between Calhoun County and the successful bidder. • SEE SPECIFICATIONS FOR DELIVERED FUEL AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • Estimated quantities are not guaranteed for the year. Amounts will vary by need. • ALL Transportation Costs and Other Fees must be included in the bid mark-up or clearly stated on the bid • FOB Calhoun County • Delivery in 24 hours from receipt of order. • Calhoun County is Exempt from all Federal Excise Taxes and Sales Tax (county, city and state sales tax). • Calhoun County is Not Exempt from: Texas State Excise Tax on Gasoline and Clear Diesel Page 1 of 7 Invitation to Bid Form -Annual Supply Contract for Delivered Fuel --Continued Method or Source (provide copy) that will be used throughout the bid period: cU OTHER FEES NOT -INCLUDED IN MARK=UP If not.applicable or,included in mark-up, Mark NA Texas List Any Other Mark -Up Texas ' Environmental Fee(s)AND osLTF- 'Fee,(Basedon Amount ofFee(s)-, Per State LUST" Federal Oil'` Number of Gallons 'Ex: AfterHours Call: Department Fuel Type Gallon Excise Tax . FEE Spill Fee Delivered). Outservne. Fee i Gasoline Less than 2,500 r� Precinct y Gallons= Fuel Tank(s) Location: Unleaded $ 87 Octane $ /� $0.20 iVif = OD/q-5 2,500 Gallons but s. Henry Barber Way Port Lavaca TX 77979 Port B nd Name: f. Less than 5,000 Lc1a— Gallons = ,./`�•�� $ Gasoline Less than 2,500� Unleaded UNNoon--Eth Octanenol /6 �A �rg3 Gallons= 0 $ $0.20 2,500 Gallons but II Brand Name: Less than 5,000 Gallons= ' c $ 3.q6' 44Y-1 Diesel Less than 2,500 a� Gallons= d Low Sulfur .16 hd A ' $ I.10 p-esw (Clear Diesel) $ $0.20 2,500 Gallons but 7 ,- Brand Name: Less than 51000 14 �d-V-'d�"i '3 Gallons- )D Gasoline Less than 2,500 4""f aLte Precinct 2 Unleaded Gallons= $ $3 Fuel Tank(s) Location: 87 Octane $ ` �U $0.20 AJ1k , OOI q3 2,500 Gallons but 5812 FM 1090 Bran, e. Less than 5,000 Port Lavaca TX 77979 Gallons= ,44,d-�t�u $ 3.40 � 5: Less than 2,500 ak-terttr5 Cat- vuj- Diesel Gallons= 41s- Low Sulfur I U d1JA G0A&q $ 00 Ft;m4p�tra� J (Clear Diesel) $ $0.20 • 2,500 Gallons but Brand Name: Less than 5,000 G1— Galllo2ons= 1q/I $ --] -16 Gt&#"V* 3 - for mr Qor Page 2 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP . . If no4.applicable or incYuded in mark-up; Mark NA, 'Texas Ljst Any Other. Mark-Up Texas Environmental Fee(s) AND,,,, OSLTF- Fee(Basetlon ,Amount of Feels) Per State LUST ' Federatoil 'Numberof;Gallons Ex''AfterHours CaU Department Fuel Type Gallon Excise Tax FEE'? 'spill Fee Delivered) :Out' Service6ee Precinct 3 Gasoline Less than 2,500 Vitt Gallons= Fuel Tank(s) Location: Unleaded $ ' jU $0.20 q1A 2 I-VII R3 $ d� 2,500 Gallons but Q J 24627 State Hwy 172 87 Octane �. Port Lavaca TX 77979 Br nd Name: Less than 5,000"J Gallons =4 /'2+ (Precinct 3 is in Olivia) V $ . Gasoline Less than 2,500 Unleaded Gallons- /.10 4�17r,• . 4U,A Octane $ $0.20 N/I{ s 10063 $ 2,500 Gallons but t Non -Ethanol Less than 5,000 Brr� nndd NNname: sall�,�s=, �RJ7� v Ci6- Diesel Less than 2,500 aftrakj,�; Low Sulfur Gallons= (Clear Diesel) fU $ $0.20 uJj} bUaU`f 2,500 Gallons but Br ndName: Less than 5,000 Gallons ,� $ 3, Lj,44 V�i'le j-L5ty ' 4. k*,V)S,- P "(jo��os Precinct4 Gasoline Less than 2,500 ' L c" (Port O'Connor) Unleaded Gallon s= Fuel Tank(s)Location: 93 Trevor 87 Octane $ `�� $0.20 OU ({} ,6V(g3 2,500 Gallons but ✓ � Street (Off of Hwy Br n Less than 5,000 Port O'Connoror TX 77982 Gallons $yyo�u Diesel Less than 2,500 Gallons= ry Low Sulfur rf p0,;04 $ 1.,19 4 (Clear Diesel) $ $0.20 2,500Gallons but p¢ Bland Less n 5,000 is Jt Gallons Gallons = $3.4 9rir i; Im Page 3 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued DTFER FEES NOT INCLUDED IN 11 MARK-UP If not applicable orincluded in mark-up, MarkNA TeXas List Any Other ;. Mark -Up Texas Environmental Fees) AND ` . OSLTF - Fee (Based on Amount of FeQ(s)' Per State LUST; .federal Oil; -NumperofGaIlion s Ex:AfterHoursCa.))' Department Fuel Type Gallon Excise Tax 'FEE,,,' SpilhFee. Delivered) outservice Fee ' Precinct Gasoline Less than 2,500 Gallons= (Seadrift) Unleaded @® l��Q �v/ 6 $ Fuel Tank(s) Location: 87 Octane $ $0.20 i Gallons but ° 104 E Dallas BrAnd Name: Less t Less than 5,000 Seadrift TX77983 Gallons= $aro Gasoline Less than 2,500 Unleaded Gallons= atox Octane $ e $0.20 �" �(((� 00® q3 2,500 Gallons but Non -Ethanol Less than 5,000 Brppd Name: Gallons= =�� 5 Diesel Less than 2,500 Gallons= Low Sulfur $ (Clear Diesel) $ i ® $0.20 rqj/} ° 2,500 Gallons but Bra dName: Less than5,000 Gallons = $ Precinct Gasoline Less than 2,500 Gallons= (Seadrift) Unleaded $ $0.20 $ 2,500 Gallons but Fuel Tank(s) Location: 87 Octane 448 Harabor Road B//r���nd Name: Less than5,000 Seadrift TX77983 Gallons= Diesel Less than 2,500 Gallons= Low Sulfur ` I"�) /yes-�y! $ (Clear Diesel) $ $0.20 a vim'"' 1 2,500 Gallons but Bra d Name: Less than5,000 Gallons= �G Page 4 of 7 Ma Invitation to Bid Form -Annual Supply Contract for Delivered Fuel --Continued OTHER FEES NOT INCLUDED IN MARK-UP If not=appliaaple,or included in mark-up, Mark NA Texas., List Any, Other Mark -Up Texas OSLTF - Erivironmental' Fee(s) AND. Per State LUST' Faderal ol(` Fee (Based on Number of Gallons ' Amount offee(s),- Ex: After Hours.Cell; Department Fuel Type Gallon Excise Tax. FEE.""; Spru.Fee,' Delivered) ' Outservice.Fee i Skid Fuel Tank Skid Location for Fuel Diesel Less than 2,500 Delivery: Low Sulfur Gallons - $ (Clear Diesel) +� $ �� $0.20 �. � UIJ 2,500 Gallons but _ � • tWithin Calhoun to the Calhoun County County Courthouse B nd Name: Less than 5,000 Y�t""� 211 S Ann Street $ aln� Port Lavaca TX 77979U� Generator- Calhoun County Diesel Less than 2,500 Galt.r7 7 Courthouse Low Sulfur dv'0D e t,6314 $ ( �fjj Generator Fuel Tank (Red Diesel) ���i $ ' �" NA 2,500 Gallons but Location for Fuel and Name: Less than 5,000 Delivery: Gallons= 211 S Ann Street $ .W3 Port Lavaca TX 77979 �� PI Generator - Calhoun County Adult Detention Diesel I,� Less than zsoo Gallons-�°;•' Center (JAIL) Low Sulfur (Red Diesel) �L11� $ ° �J NA Wl� .Up1 $ I•Ib 2,500 Gallons but -. Generator Fuel Tank B and Name: Less than 5,000 Location for Fuel Gal Ions = Delivery: $ 3.46 302 W Live Oak Port Lavaca TX 77979 Ova el(pr M Page 5 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK-UP If not applicable or included in mark-up,, Mark NA' ` Texas List Any Other Mark -Up Texas Environmental Fee(s)AND , Per State OSLTF - Fee (Based on . Amount of Fee(s)'. LUST °Federal Oil Number of Gallons 'EX: After Hours Call,: Department Fuel Type Gallon Excise Tax FEE Spill Fee Delivered) Out Service Fee Generator - EMS Central Station Less than 2,500 DIE - (Emergency Gallons= Management Low Sulf ulfur $.a NA r �fG+p 2,500Gallons but (Red Diesel) „/,al� Services) g nd Name: Less than 5,000,//Q Gallons = Generator Fuel Tank Location for Fuel 22 Delivery: 705 Henry Barber Way Port Lavaca TX 77979 Generator - EMS'{°� South Station (Emergency Diesel Less than 2,500 Gallons= ✓ Low Sulfur p(0U $ 110 Management (Red Diesel) $'�✓y NA 0 _yfk O® 2,500 Gallons but Services) IlAarld Name: Less than 5,000 Generator Fuel Tank LZIL Gallons= „e Location for Fuel $ H Delivery:✓ 7 . 6084 State Hwy 185E Seadrift TX 77983 Page 6 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN MARK -Up If not applicable or included in mark-up, Mark NA "Texas List Any OthEp Mark -Up Texas Environmental Fee(s),AND OSLTF ,- Fee (Based on Amount of Feels) Per State "LUST F,ederai.O11 Number of Gallons Ex:I After Hours Call Department Fuel Type Gallon Excise Tax FEE ,Spill Fee Delivered) Out Service Fee Generator - HAAs C� Memorial Less than 2,500 Medical Centex Diesel Gallons= (Hospital) Low Sulfur Low $ 1•� Diesel) $ eO NA a�1D(J 2,S00Gallonsbut I Generator Fuel Tank Name: Less than 5,000 Location for Fuel Delivery: r� Gallops �� 815 N Virginia Street Port Lavaca TX 77979 _41- Generator - rid Memorial Diesel Less than 2,500 RR _ Medical Clinic Low Sulfur 001U0 poa14 Gallon = S "4�44 Generator Fuel Tank (Red Diesel) $ °a`�� . NA 2,500 Gallons but - Location for Fuel B�3nd Name: Less than 5,000 Delivery: /°A�lsi) �-'�`" Gal�ns, $� ARA, 1016 N Virginia Street �Ivj Port Lavaca TX 77979 The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Intivitation to Bid packet and fully understands and has followed ail requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: /0 A1a-6?4J 0 Authorized Signature & Title: Printed Name & Title of Authoriizedd Signature: Phone Numbers/_(573""T:JC1U REMARKS: wIfLafiL w /tom Ema11:v_��-(2ULP-mm,urn Page 7 of 7 10121/2020 hops://dataconnect.dtn.com/energy/view/energy!mailbox/datacannecUinbax/prinLdo?rand-172687&key=201059C5400732444068857C... CITGO PETROLEUtd The following Price Quotations are effective for the Date/Time noted below and will remain in effect Unless otherwise notified, Prices are posted gross and do not Include taxes. 1% discount -net 10 days given on Invoice. If you do not receive price changes every working day, please notify DTN at 1-800-779-5779, TX, CORPUS CHRISTI 10/21/20 18:00 CI-87UNL-CONV-4001 .0505- 1.5234 TX, CORPUS CHRISTI 10/21/20 18:00 CI-87UNL-ETH-12800 .0381- 1.2354 TX, CORPUS CHRISTI 10/21/20 18:00 CI-89MID-ETH-12820 .0392- 1.3970-� TX, CORPUS CHRISTI 10/21/20 18:00 CI-90GAS-CONY-4105 .0382- L 53844 TX, CORPUS CHRISTI 10/21/20 18:00 CI-935NL-ETH-12850 .0382- 1.6596-" TX, CORPUS CHRISTI 10/21/20 18:00 UB-87UNL-ETH-12800 .0404- 1,2332 "-�69 TX, CORPUS CHRISTI 10/21/20 18:00 UB-89MID-ETH-12820 .040S- :1.3847-- TX., CORPUS CHRISTI 10/21/20 18:00 UB-935NL-ETH-12850 .0404- 1.6979- TX, CORPUS CHRISTI 10/21/20 18:00 CI-ULS-85%-14805 .0344- 1.1400 - I, GP1 TX, CORPUS CHRISTI 10/21/20 18:00 CI-ULS-DTXBS%-14315 .0344- 1.2520 TX, CORPUS CHRISTI 10/21/20 19:00 CI-ULS-DYB5%-14905 .0344- 1.1440 TX, CORPUS CHRISTI 10/21/20 18:00 CI-ULS-TX85%-14305 ,0344- 1.1480- TX, CORPUS CHRISTI 10/21/20 18:00 UB-TXLEDDYD-13757 .0344- 1.1520 TX, CORPUS CHRISTI 10/21/20 18:00 U0-ULS-65%-14805 .0344- 1.1400, (,n TX, CORPUS CHRISTI 10/21/20 18:00 UB-ULS-DTX85%-14315 .0344- 1,1520-Vb TX, CORPUS CHRISTI 10/21/20 18:00 US-ULS-DYB5%-14905 .0344- 1.1440-Y r TX, CORPUS CHRISTI 10121/20 18:00 UB-ULS-TX85%-14305 .0344- 1.1480- L TX,. CORPUS CHRISTI 10/21/20 18:00 US-ULSD T)(LED-13758 .0344- 1,1480 TX, SAN ANTONIO 10/21/20 18:00 US-87UNL-ETH-12800 .0451- 1.2806 " l; TX, SAN ANTONIO 10/22/20 18:00 UB-89MID-ETH-12820 .0451- 1.4321- ./ TX, SAN ANTONIO 10/21/20 18100 UB-935NL-ETH-12850 .0451- 1.7604 ^ fff TX, SAN ANTONIO 10/21/20 18:00 UB-ULSD-13900 .0331- 12406 TX, SAN ANTONIO 10/21/20 18:00 UB-ULSD-DYD-13903 .0331- 1.. 2446- TX, SAN ANTONIO 10/22/20 18:00 UR-ULSD-TXLED-13753 10331- 1.250fi- TX, SAN ANTONIO 10/21/20 18:00 UB-ULSDDTXLED-137S5 .0331- 1.2546- TX, VICTORIA 10/21/20 18:00 UB-87UNL-ETH-12800 .0451- 1,3567- TX, VICTORIA 10/21/20 18:00 UH-89MID-ETH-12820 .0451- 1.5082y2� TX, VICTORIA 10/21/20 18:00 UB-935NL-ETH-12850 ,0452- 1.8314- TX, VICTORIA 10/21/20 18:00 US-ULS-DTX85%-14315 .0343- 1.1963 TX, VICTORIA 10121/20 18;00 US-ULS-TXBS%-14305 .0343- 1.1923 TX, VICTORIA 10/21/20 18:00 UB-ULSD-TXLED-13753 - .0343- 1.1923 TX, VICTORIA 10/21/20 18:00 UB-ULSDDTXLED-13755 .0343- 1,1963_�, hops:l/dalaconnect,dtn.rom/energylview/energylmailbox(dataconnectllnbox/printdo?rand=1726B7&hey=201059C5400732444068857C5E0916872E50 1 /1 STATE OF TEXAS {} COUNTY OF CALHOUN {} AFFIDAVIT The undersigned certifies that the bid prices contained in this bid have been: carefully checked and are submitted as correct and final and If bid is accepted, agrees to furnish any ana/or all items upon which prices are offered, at the price(s) and upon the conditions contained In the Specifications and General Conditions, BEFORE ME, the undersigned authority, on this day personally appeared } f ,t) '_v (D known to me to be the person whose name is subscribed to the following, who, upon oath says; I am the Manager; Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or Individual has not prepared this Bid in collusion with any other Bidder. i further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County_ in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Afflant -Printed Name and Title of Afflant Name of Bidder (Company) Address) 6q PhoneNumber fax Number 6� �71-5-4 3fr' Email Address V (EJVfZt A,Q,6LLP0-40,hN.+rz,kt SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, an oath; states that the facts contained In the above are true and correct, this A '') day of I �- L, r I t e" 2N . NORA VERA s Notary public, suite of Texas "V`�iG�l l� �t •'+a� '�'• "' comm. Expires t2-to•2020 , Notary 10 104803a6 Notary Public in and for - f t.cr re q County, Texas CERTIFICATE OF INTERESTED PARTIES FORM 1295 l ofl 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: 2020-682192 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. CALHOUN COUNTY PORT LAVACA, TX United States Date Filed: 10/2312020 2 Name of governmental entity or state agency that is a party to the. contract for which the form is being filed. OIL PATCH PETROLEUM, INC 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 services, goods, or other property to be provided under the contract. 2021.01 FUEL 4 Name of Interested Parry City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. X 6 UNSWORN DECLARATION ® M name is and my date of birth is w��.�M�� ySHA x':3 Y�a �'i Wc Myaddressr,�". ill ..�lnm aiY(St Ow WWx9m, I declare under penalty of perjury that the foregoing is true and correct. �� Executed in ��i County, State of �l , on the ja�day of Va , 20W. (month) (year) a a+ Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d swve tas�tivvvv) E f jOLp�� �'1'NYS tY'fttE9ppLF�eEs Ito AUTNOt .®, oe ba end9?Lsd, ; " st4teRoeN on R72 94�?�I352 , CONFLICT OF INTEREST QUESTIONNAIRE FORAM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.R. 23, 84th Leg., Regular Session. OFFICELISEONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a), By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name who has a busin s relationship with local governmental entity. /Avendor 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated ❑ completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) -3J Name of local government officer about whom the information is being disclosed. Name of Officer 41 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. " A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yesus,j No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes L No 5 Describe each employment or business relationship thatthe vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 L 1AW y /- M--Jt , /U ou -A ago - Signature f vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with, obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a - d) of this certification. 1&41IV /`TUGcJ� - 0 i AI.�d&/Z �U'dA'aiUC%D Name and Title of Authorized A ent Date 061 Sign lure of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all fliers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, &e 7 Q1CA 100 rtifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions f 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Printed Name and Title of Contractors Avthori; /0-AA-A0140 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 loruuouc Emmert 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type; a. contract a. bid/offer/application a. initial filing b. grant _ b. initial award _ b. material change c, cooperative agreement c. post -award d. loan For material change only; c. loan guarantee Year quarter f, loan insurance Date of last report 4. Name and Address of Reporting Entity; 5. Jl18e rHing Entity in No.4 is Subawardee, Prime Subawardee me d Address of Prime: Tier_, if Known: a. Name and Address of Lobbyi. (if individual, last ditme, first name, 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who falls to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such Federal Use Only CFDA Number, ifopplicable: 9. Award Amount, differentfrmn No. IOa) (last name, first name, MI): Signature: Print Name: (_ /AJ0f i Title: Af �(��� Telephone No.a/ s-Date: Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) the undersigned representative of ���� Representative 60'i. You/ T /?»�GuaL i LiIC (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. 'Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. ��14_te Signature of Representative Prim & Title /u- 2) 2 •,2CJ-1 & Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ I certify that ��is a "Nonresident Bidder" of Texas (Company Name) as fi ed in Governme t Code §2252.001 and our principal place of business is rn . (City and State) XI I certify thatio'd UC-cyiVmp� AO — is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. ( !ac,4 Signature of Authorized Agent �c�� 1tY41� 666 — ®d at"uzj Printed Name and Title of Authorized Agent Date Please Type If handwritten, must be in ink and legible Vendor's Name: Address: Remittance Address: i U S /J jVq Aj Pa 2�v-(e�LA",L & 2 AFL, `-k 40o Telephone: �5 -73" A1aJ 6U Fax: 3�1— j 73- A/3OX Email: ViG7�ZiA�UItF�i4TCF�11�712CJL�tzNc,CLout Email(s) to send Bid Information: t'/!-AVi Ar Af3byk- Signature of Authorized Representative: Printed name of Authorized Rep: Z4,-j y Order Contact Name & Title: Order Contact Telephone: 5t e �%611 -� 13 6 Order Contact Fax: 6641 "V L `"�5c5 a Order Contact Email: �/d7IJP-WA ® Request for Taxpayer Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to wwuv.frs.gov/Fami for instructions and the latest information. f Name (as shown on your income tax return). Name Is required on this line; do not leave this line blank. OIL PATCH PETROLEUM INC. 2 Business name/disregarded entity name, If different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entities, not individuals; see a Instructions on page 3): o ❑ Individual/sole proprietor or ❑� C Corporation ❑ S Corporation ❑ Partnership ❑ TmWestate c single -member LLC Exempt payee code (if any) Q. 0 Z ' ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► `0 a Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting m LLC If the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code if an ( y) it another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ❑ Other (see instructions)► &,It-ro.... n m I.Med..Wd• Me asJ N 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optional) w 1526 N PADRE ISLAND DR CALHOUN COUNTY m 202 S ANN ST, PORT LAVACA, TX 77979 6 City, state, and ZIP code CORPUS CHRISTI, TX 78408.2349 361-553-4610 FAX 361-553-4614 7 List account numbers) here (optional) WE Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid social security number backup withholding. For individuals, this is generally your social security number (SSN). However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other _ m _ entities, It Is your employer Identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification number Number To Give the Requester for guidelines on whose number to enter. r, 00%_ e . , � Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are4t required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. oryrr Signature of Here I U.S.personl General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to wwvvJns.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) Date► 10-1:91a- otoav • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-V (Rev. 10-20181 #11 Agenda Item for Commissioners Court - Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Insecticides for Mosquito Control Annual Supply Contract Bid Number 2021.02 for the period beginning January 1, 2021 and ending December 31, 2021. A& win - 14 PA - 0 4S* 45- k RE: Insecticides for Mosquito Control Annual Supply Contract Bid Number 2021.02 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Four (4) bids were received: 1. ADAPCO, LLC 2. CLARKE MOSQUITO CONTROL PRODUCTS, INC. 3. RENTOKIL NORTH AMERICA, INC. dba TARGET SPECIALTY PRODUCTS 4. ES OPCO USA, LLC dba VESERIS (Vendor's bids are attached.) EV�i /EW all bids to determine the vendors that meet Appeared to Have Met Specifications: 1. ADAPCO, LLC 2. CLARKE MOSQUITO CONTROL PRODUCTS, INC. 3. ES OPCO USA, LLC dba VESERIS Did Not meet specifications: 1. Rentokil North America, Inc. dba Target Specialty Products • Bid was not signed • Affidavit was not notarized by a notary. The affidavit has an attorney's signature and the attorney's stamp. NOTE?, ids for the following (page 1 of 3):I 1. Malathion 2. Malathion EW No bids on the following, 1. 4-8 ULV !Fourstar Sustained Release 45 Day Microbial Briquets (page 3 of 3). Please review all 3 bids on this insecticide to determine the action Commissioners Court will take on the bids received for this insecticide. Q m d H Q A d A n 5 a 9. Z O. D m D O A m O N C y 2 O rr- a N o z^ n m 1 � C � n n x D O m G m A A z 9 os o C 2 r y � N YI A { z 2 { { A C 'm^ m'.� 'mn a v' Ito 3 m m m m Vf VI IA IA � dM . 4 Z O D c D Z { { =4 N Am o A 0 vN 3 Vmi N.. W b N � m m R, { { { { m N O N � 9 { { { { N C N O N Vmi Vmi lmlf T N � M { { { { no- N vm, m vm, { vmi {{ tmi� vmi C b O O b a r � d a A..6 m m m N ' L S m N x C Vmi Vmi N Vmf- (� o - m m CL N N y..N �..3 ;m Nom Emlm w ... m m C 7 c � o .mn ei C (D W � N 3 3 H � a r d Q m n C 3 O N W N 7 CL m 3 y � c a _ C M H O1 C � vy O v n 70 n 0 4 M '! C 6 n m m rt W W C 1 fl C. N C O N F+ 6 a m m m CL N O O A N m C 1 3 fD OC. G W a �**** In the event of Ine Bids, thewinning - .bid is determined per the Texas Local I Tie Bide are Calhoun County, Texas .Government Code 262.027(b). . Highlighted In Pink ........... . BID TABULATION - INSECTICIDES FOR MOSQUITO CONTROL ANNUAL SUPPLY CONTRACT, BID NUMBER: 2021.02 - ALL PRECINCTS For Period Beginning JANUARY 12021 and Ending 31, 2021 Bids that APPEAR TO BE LOW BIDS are Highlighted in Yellow CLARKE MOSQUITO CONTROL RENTOKIL NORTH AMERICA, INC. ES OPCO USA LLC BID ITEM UNIT ADAPCO LLC PRODUCTS INC dba TARGET SPECIALTY PRODUCTS dba VESERIS MaxPar G2-60. MaxPar G2-60 equivalent to BVA 13 - see bid Mineral Oil BVA 13 ULV Oil or Callpar SON BVA 13 Diluent Oil page 5 (2) Did not meet specifications: Did not sign Bid and 5 Gallon Pail $40.95 No Bid Affidavit was not notarized $46.25 No Bid SO Gallon Drum $409:50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized $372.00 $350.00 55 Gallon Drum $450.45 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized $409.00 $385.00 275 Gallon Tote $2,282.50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was notnotarized 2,131.75 $1,925.00 Fyfanon ULV Fyfanon ULV MALATHION Active Ingredients: Malathion 96.5% Active Ingredients: Malathion 96.5% Tie Bids - Award determined by drawing in Commissioners Court 2 x 2.5 Gallon Case No Bid No Bid No Bid No Bid 5 Gallon Pail $325.25 No Bid No Bid ' $325.25 55 Gallon Drum $3,464.45 No Bid No Bid $3,464A5 260 Gallon Tote $15,446.60 No Bid No Bid $15,446.60 Fyfanon EW Malathion SEC Fyfanon EW MALATHION EW Active Ingredients: Malathion 40.9% Active Ingredients: Malathion 57% Active Ingredients: Malathion 40.9% Tie Bids -Award determined by drawing 2 x 2.5 Gallon Case ° $261.90 No Bid Did not meet specifications: Did not sign Bid and Affidavit was $261.90 in Commissioners Court not notarized 225.00 30 Gallon Drum $1,538.10 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,350.00 ` $1,538.10 r PermaSease 30-30 Biomist 30+30 ** Permanone 30-30 & Perm-X UL 30-30 ** Masterl-ine Kontrol 30-30 Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; 30-30 ULV Piperonyl Butoxide 30.0% Piperonyl butoxide 30.0% Piperonyl Butoxide 30.0% Piperonyl Butoxide 30.0% ** Perm-X UL 30-30 ** 2 x 2.5 Gallon Case $299.85 $325.00 Did not meet specifications: Did not sign Bid and Affidavit was notnotarized 305.00 $289.65 ** Permanone 30-30 ** 5 Gallon Pail No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 295.00 No Bid ** Permanone 30-30 ** 30 Gallon Drum $1,799.10 $1,950.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,770.00 $1,582.50 ** Perm-x UL 30-30 ** 55 Gallon Drum No Bid $3,575.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 3,300.00 $2,915.00 275 Gallon Tote $16,491.75 $17,875.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized16,225.00 $14,162.50 **Permanone 30-30** Bid Tabulation -- Insecticides for Mosquito Control Annual Supply Contract, Bid Number.., 2021.02 -- Continued CLARKE MOSQUITO CONTROL RENTOKIL NORTH AMERICA, INC. ES OPCO USA LLC BID ITEM UNIT ADAPCO LLC PRODUCTS INC dba TARGET SPECIALTY PRODUCTS dba VESERIS ** Permanone 31-66 & Perm-X UL 31-66 ** Perm-X UL31-66 Active Ingredients: Permethrin 31.28%; Active Ingredients: Permethrin 31%; 31-66 ULV Piperonyl Butoxide 66% Piperonyl Butoxide 66% ** Permanone 31-66 ** 4 x 1 Gallon Case No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 376.00 No Bid 2 x 2.5 Gallon Case No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 470.00 $480.00 ** Perm-X UL 31-66 ** 30 Gallon Drum No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 2,820.00 $2,$$0•00 ** Permanone 31-66 ** ** Permanone 31-66 a'* 275 Gallon Tote No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 25,850.00 $26,400.00 PermaSease 31-67 MasterLlne Kontrol 31-67 Active Ingredients: Permethrin 31.15%; Active Ingredients: Permethrin 31.15%; 31-67 ULV Piperonyl Butoxide 66.85% Piperonyl Butoxide 66.85% 4 x 1 Gallon Case No Bid No Bid No Bid No Bid 2 x 2.5 Gallon Case $433.45 No Bid No Bid $430.00 30 Gallon Drum $2,609.40 No Bid No Bid $2,580.00 275 Gallon Tote $23,919.50 No Bid No Bid $23,650.00 PermaSease 4-4 Biomist 4+4 Perm-X UL 4-4 MasterLine Kontrol 4-4 Active Ingredients: Permethrin 4.6%; Active Ingredients: Premethrin 4%; Active Ingredients: Permethrin 4%; Active Ingredients: Permethrin 4.6%; 4-4 ULV Piperonyl butoxide 4.6% Piperonyl Butoxide 4% Piperonyl Butoxide 4% Piperonyl Butoxide 4.6% 2 x 2.5 Gallon Case $87.45 $100.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 109.06 $82.50 30 Gallon Drum No Bid $600.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 552.35 $495.00 55 Gallon Drum $961.95 $1,100.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,009.40 $1,650.00 275 Gallon Tote $4,809.75 $5,500.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 4,671,88 $4,537.50 4-8 ULV -- Permanone RTU NO BIDS due to Vendor not meeting Active Ingredients: Permethrin 3.98%; specifications Piperonyl Butoxide 8.48% 2 x 2.5 Gallon Case No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 185.70 No Bid 30 Gallon Tote No Bid No Bid Did not meet specifications:. Did not sign Bid and Affidavit was not notarized 1,110.00 No Bid 55 Gallon Drum No Bid No Bid No Bid No Bid 275 Gallon Tote No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 9,762.50 No Bid Page 2 of 3 Bid Tabulation -- Insecticides for Mosquito Control Annual Supply Contract, Bid Number.' 2021.02 -- Continued BID ITEM UNIT ADAPCO LLC CLARKE MOSQUITO CONTROL PRODUCTS INC RENTOKIL NORTH AMERICA, INC. dba TARGET SPECIALTY PRODUCTS ES OPCO USA LLC dba VESERIS Altosid 30 Day Briquets ALTOSID 30 DAY BRIQUETS Active Ingredients: (S)-Methoprene 8.62% Altosid 30 Day Briquets Active Ingredients: (S)-Methoprene 8.62% Altosid 30 Day Briquets Active Ingredients: (S)-Methoprene 8.62% 400 Per Case No Bid $480.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized ueo.oD $476.00 ALTOSID XR EXTENDED RESIDUAL BRIQUETS - Altosid XR Briquets Altosid XR Briquets Active Ingredients: (5)-Methoprene 2.1% Altosid XR Briquets Active Ingredients: (S)-Methoprene 2.1% Altosid XR Briquets Active Ingredients: (S)-Methoprene 2.1% 220 Per CASE No Bid $759.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 759.00 $752.40 DELTAGARD or Equivalent Deltagard ULV Active Ingredients: Deltamethrin 2.0% DeltaGard Active Ingredients: Deltamethrin 2.0% 2 x 2.5 Gallon Case $981.00 No Bid Did not meet specifications: Did not sign Bid and Affidavit was no notarized 1060.00 No Bid 30 Gallon Drum $5,740.80 No Bid Ditl not meet specifications: Did not sign Bid and Affidavit was not notarized 6210.00 No Bid 250 Gallon Drum(Tote) $47,262.50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 51000.00 No Bid Fourstar 45/90/180 Day Briquets Microabial Briquets Active Ingredients: Bacillus sphaericus FOURSTAR SUSTAINED RELEASE 45 DAY MICROBIAL BRIQUETS Summit B.t.i. Equivalent to Fourstar 45 Day *Alternate not exact substitute: Vectomax WSP (800 WSP/case) Active Ingredients: Bacillus sphoericus 2352, Serotype H5a5b, Strain ABTS 1743 Technical Powder (670 BSITU/mg) 7.5% 2362, Serotype H5a5b, Strain AML614 fermentation solids, spores and insecticidal toxins 6%; Bacillus thuringiensis subspecies israelensis Strain BMP 144 fermentation solids, spores and insecticidal toxins 1% Summit B.t.f. Briquets Equivalent to Foursta r 45 Day Briquets see bid page 5 (1) Active Ingredients: Bacillius thuringiensis subspecies israelensis solids, spores and insecticidal toxins 10.31%' Briquets * Alternate: Vectomax WSP - 30 Day --- 100 Per Case $82.50 800 WSP/Case = "ALTERNATE., 800 WSP/Case $1,299.00 a4=$324.75 per 200 45 Day --- 800 Per Case $1,299.00 45 Day --- 200 Per Case $282.67 No Bid No Bid FOURSTAR SUSTAINED RELEASE 90 DAY MICROBIAL BRIQUETS 90 Day --- 200 Per Case No Bid $469.33 No Bid No Bid FOURSTAR SUSTAINED RELEASE 180 DAY MICROBIAL BRIQUETS 180 Day --- 200 Per Case No Bid $733.33 No Bid No Bid Page 3 of 3 Mae Belle Cassel From: peggy.hall@calhouncotx.org (peggy hall) <peggy.hall@calhouncotx.org> Sent: Tuesday, November 17, 2020 3:44 PM To: MaeBelle.Cassel@calhouncotx.org; Richard H Meyer Cc: Cindy Mueller; Sara.Rodriguez@calhouncotx.org; David Hall; angela.torres@calhouncotx.org; Vern Lyssy; Lesa Jurek; Clyde Syma; Lynette Adame; Gary Reese; april.townsend@calhouncotx.org Subject: Agenda Item for Court Nov 25, 2020 Attachments: Agenda - Award Bids for 2021 Insecticides for Mosquito Control - Bid No. 2021.02 for Court Nov 25 2020.pdf Mae Belle, Re: Insecticides for Mosquito Control Bid Number 2021.02 Please put the attached on Commissioners Court Agenda for November 25, 2020 1 will bring you a hard copy for the packet. Peggy 3lall Assistant Auditor Calhoun County 202 S. Ann St., Ste B Port Lavaca, TX 77979 Phone: 361-553-4610 Fax: 361-553-4614 Calhoun County Texas Agenda Item for Commissioners Court — Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Insecticides for Mosquito Control Annual Supply Contract Bid Number 2021.02 for the period beginning January 1, 2021 and ending December 31, 2021. RE: Insecticides for Mosquito Control Annual Supply Contract Bid Number 2021.02 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Four (4) bids were received: 1. ADAPCO, LLC 2. CLARKE MOSQUITO CONTROL PRODUCTS, INC. 3. RENTOKIL NORTH AMERICA, INC. dba TARGET SPECIALTY PRODUCTS 4. ES OPCO USA, LLC dba VESERIS Vendor's bids are attached.) FEVIEW all bids to determine the vendors that meet specifications Appeared to Have Met Specifications: 1. ADAPCO, LLC 2. CLARKE MOSQUITO CONTROL PRODUCTS, INC. 3. ES OPCO USA, LLC dba VESERIS Did Not meet specifications: 1. Rentokil North America, Inc. dba Target Specialty Products • Bid was not signed • Affidavit was not notarized by a notary. The affidavit has an attorney's signature and the attorney's stamp. NOTEtie bids for the following (page 1 of 3):1 1. Malathion 2. Malathion EW No bids on the following; 1. 4-8 ULV Fourstar Sustained Release 45 Day Microbial Briquets (page 3 of 3 Please review all 3 bids on this insecticide to determine the action Commissioners Court will take on the bids received for this insecticide. Q M c A v n D d N G O d z C D O m OD 5g A O C m s n 9 O m P R g N N y 2 O �. n n n ^ _ A A O a O O C 2 r Cl N A N m 0 2 m m m N m Q o m a a t < < < d Np d m m m m m _. m 3 3 < < < < N p N N N n 9 w M. sus, < wvmi tmi+ c p N m A d 3$ o d � r 9 � � vmi vmi vmi �, m aS,c H O n N N d G < < < w N w w ffap1 3 NN A M. N < < < (y N N Vmf d-'d n... =. O d -.. go <. vm, oO� ao.. o N N m Vi Vmi gyp. W O' c rt O 3 O A C 1 r Q m O N n 0 3 .a N c m 7 Q N C 7 (D Q S O M, � c p Q e a M fD �' m O N 3 3 C DO N r 3 C o+ n O 3 hiO _ N 3 3 a—)Q 7 C Q S. ' DO C v n n 3 M 1M d m :+ � W N Q N Z o � N r a fD N N F+ N r**" In the event of & Bids, ttie w1nnin6 - Bids that bid is determined per the Texas Local Tie Bids are I -APPEAR TO BE LOW BIDS are .Government Code 262.027(b). . Highlighted In Pink Calhoun County, Texas I I Highlighted in Yellow BID TABULATION - INSECTICIDES FOR MOSQUITO CONTROL ANNUAL SUPPLY CONTRACT, BID NUMBER: 2021.02 - ALL PRECINCTS For Period Beginning JANUARY 1 2021 and Ending DECEMBER 31, 2021 CLARKE MOSQUITO CONTROL RENTOKIL NORTH AMERICA, INC. ES OPCO USA LLC BID ITEM UNIT ADAPCO LLC PRODUCTS INC dba TARGET SPECIALTY PRODUCTS dba VESERIS MaxPar G2-60 MaxPar G2-60 equivalent to BVA 13 - see bid Mineral Oil BVA 13 ULV Oil or Callpar 80N BVA 13 Diluent Oil page 5 (2) Did not meet specifications: Did not sign Bid and 5 Gallon Pail $40.95 No Bid Affidavit was not notarized $46.25 No Bid 50 Gallon Drum $409.50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized $372.00 $350.00 55 Gallon Drum $450.45 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized $409.00 $385.00' 275 Gallon Tote $2,282.50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 2,131.75 $1,925.00 Fyfanon ULV Fyfanon ULV MALATHION Active Ingredients: Malathion 96.5% Active Ingredients: Malathion 96.5% 2 x 2.5 Gallon Case No Bid No Bid No Bid Tie Bids - Award determined by drawing in Commissioners Court 5 Gallon Pail $325.25 No Bid $325.25 55 Gallon Drum $3,464.45 No Bid LNoBid $3,464.45 260 Gallon Tote $15,446.60 No BidL $15,446.66 Fyfanon EW Malathion 5EC Fyfanon EW. MALATHION EW Active Ingredients: Malathion 40.9% Active Ingredients: Malathion 57% Active Ingredients: Malathion 40.9% 2 X 2.5 Gallon Case - $261.90 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 225.0o `$261.90 Tie Bids -Award determined by drawing in Commissioners Court Did not meet specifications: Did not sign Bid and Affidavit was 30 Gallon Drum $1,538.10 No Bid not notarized 1,350.00 $1,538.10 - PermaSease 30-30. Biomist 30+30 **Permanone 30-30 & Perm-XUL 30-30 ** MasterLine Kontrol 30-30 Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; Active Ingredients: Permethrin 30.0%; 30-30 ULV Piperonyl Butoxide 30.0% Piperonyl butoxide 30.0% Piperonyl Butoxide 30.0% Piperonyl Butoxide 30.0% 2 x 2.5 Gallon Case $299.85 $325.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 305.00 $289.65 **Perm-XUL30-30** ** Permanone 30-30 ** 5 Gallon Pail No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 295.00 No Bid **Permanone30-30** 30 Gallon Drum $1,799.10 $1,950.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,770.00 $1,582.50. 55 Gallon Drum No Bid $3,575.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 3,300.00 $2,915.00 ** Perm-X UL 30-30 ** ** ** Permanone 30-30 275 Gallon Tote $16,491.75 $17,875.00 Did not meet specifications: Did not si gn Bid and Affidavit was not notarized 16,225.00 ' $14,162.50- aevamr Bid Tabulation -- Insecticides for Mosquito Control Annual Supply Contract, Bid Number.' 2021.02 -- Continued CLARKE MOSQUITO CONTROL RENTOKIL NORTH AMERICA, INC. ES OPCO USA LLC BID ITEM UNIT ADAPCO LLC PRODUCTS INC dba TARGET SPECIALTY PRODUCTS dba VESERIS ** Permanone 31-66 & Perm-X UL 31-66 ** Perm-X UL 31-66 31-66 ULV .Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66% Active Ingredients: Permethrin 31%; Piperonyl Butoxide 66% 4 x I Gallon Case No Bid No Bid Did not meetspecifications: Did not sign Bid and Affidavit was not notarized 376.00 No Bid ** Permanone 31-66 ** 2 x 25 Gallon Case . No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 470.00 $480.00 ** ** Perm-X UL 31-66 30 Gallon Drum No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 2,820.00 $2,880.00 ** Permanone 31-66 ** 275 Gallon Tote No Bid No Bid Did not meetspecifications: Did not sign Bid and Affidavit was not notarized 25,850.00 $26,400.00 ** Permanone 31-66 ** PermaSease 31-67 MasterLlne Kontrol.31-67 31-67 ULV Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon Case No Bid No Bid No Bid No Bid 2 x 2.5 Gallon Case $433.45 No Bid No Bid $430.00 30 Gallon Drum $2,609.40 No Bid No Bid $2,580.00. 275 Gallon Tote $23,919.50 No Bid No Bid $23,650.00 PermaSease 4-4 Biomist 4+4 Perm-X UL 4-4 Masterl-ine Kontrol 4-4 Active Ingredients: Permethrin 4.6%; Active Ingredients: Premethrin 4%; Active Ingredients: Permethrin 4%; Active Ingredients: Permethrin 4.6%; 4-4 ULV Piperonyl butoxide 4.6% Piperonyl Butoxide 4% Piperonyl Butoxide 4% Piperonyl Butoxide 4.6% 2 x 2.5 Gallon Case $87.45 $100.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 109.06 $82.50 30 Gallon Drum No Bid $600.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 552.35 $495.00 55 Gallon Drum $96195 $1,100.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,009.40 $1,650.00 275 Gallon Tote $4,809.75 $5,500.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 4,671.88 $4,537.50` 4-8 ULV -- Permanone RTU NO BIDS due to Vendor not meeting Active Ingredients: Permethrin 3.98%; specifications Piperonyl Butoxide 8.48% 2 x 2.5 Gallon Case No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 185.70 No Bid 30. Gallon Tote No Bid No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 1,110.00 No Bid 55 Gallon Drum No Bid No Bid No Bid No Bid 275 Gallon Tote No Bid NO Bid Did not meet specifications: Did not sign Bid and Affidavit was no notarized 9,762.50 No Bid Page 2 of 3 Bid Tabulation -- Insecticides for Mosquito Control Annual Supply Contract Bid Number.- 2021.02 -- Continued CLARKE MOSQUITO CONTROL RENTOKIL NORTH AMERICA, INC. ES OPCO USA LLC BID ITEM UNIT ` ' ADAPCO LLC PRODUCTS INC dba TARGET SPECIALTY PRODUCTS dba VESERIS Altosid 30 Day Briquets ALTOSID 30 DAY BRIQUETS Active Ingredients: Altosid 30 Day Briquets Altosid 30 Day Briquets (S)-Methoprene 8.62% Active Ingredients: (S)-Methoprene 8.62% Active Ingredients: (S)-Methoprene 8.62% 400 Per Case No Bid $480.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 480.00 $476.00 ALTOSID XR EXTENDED RESIDUAL BRIQUETS - Altosid Altosid XR Briquets Altosid XR Briquets Altosid XR Briquets XR Briquets Active Ingredients: Active Ingredients: Active Ingredients: (5)-Methoprene 2.1% (S)-Methoprene 2.1% (S)-Methoprene.2.1% 220 Per Case No Bid $759.00 Did not meet specifications: Did not sign Bid and Affidavit was not notarized 759.00 $752.40 Deltagard ULV DeltaGard DELTAGARD or Equivalent Active Ingredients: Deltamethrin 2.0% Active Ingredients: Deltamethrin 2.0% 2 X 2.5 Gallon Case $981:00 No Bid Did not meet specifications: Did not sign Bid and Affidavit was. not notarized 1 oao.00 No Bid 30 Gallon Drum $5,740.80 No Bid Did not meetspecifcatians:Oid not sign Bid and Affitlavit was mmnotarized 6210.00 No Bid 250 Gallon Drum(Tote) $47,262.50 No Bid Did not meet specifications: Did not sign Bid and Affidavit was not notarized 51000.00 No Bid Fourstar 45/90/180 Day Briquets Microabial Briquets Active Ingredients: Bacillus sphaericus 2362, Serotype H5a5b, Strain AML614 Summit B.t.L Briquets *Alternate not exact substitute: fermentation solids, spores and Equivalent to Fourstar 45 Day Briquets FOURSTAR SUSTAINED Vectomax WSP (800 WSP/case) insecticidal toxins 6%; Bacillus see bid page 5 (1) RELEASE 45 DAY MICROBIAL Active Ingredients: Bacillus sphaericus thuringiensis subspecies israelensis Active Ingredients: Bacillius thuringiensis 2362, Serotype H5a5b, Strain ABTS 1743 Strain BMP 144 fermentation solids, subspecies israelensis solids, spores and BRIQUETS Technical Powder (670 BSITU/mg) 75% spores and insecticidal toxins 1% insecticidal toxins 10.31% Summit B.t.i. Equivalent to Fourstar 45 Doy Briquets 30 Day --- 100 Per Case $82.50 * Alternate: Vectomax WSP - - 800 WSP/case = *ALTERNATE., 800 WSP/Case $1,299.00:4=$324.75 per 200 45Day --- 800 Per Case $1,299.00 45 Day --- 200 Per Case $282.67 No Bid No Bid FOURSTAR SUSTAINED RELEASE 90 DAY MICROBIAL BRIQUETS 90 Day --- 200 Per Case No Bid $469.33 No Bid No Bid FOURSTAR SUSTAINED RELEASE 280 DAY MICROBIAL BRIQUETS 180 Day --- 200 Per Case No Bid $733.33 No Bid No Bid Page 3 of 3 INSECTICIDES FOR MOSQUITO CONTROL ANNUAL SUPPLY CONTRACT Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.02 Vendor's Name & Address ADAPCO LLC; 550 Aero Ln, Sanford, FL 32771 • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the vendor to provide up to the amount bid at the bid terms and conditions stated herein. Calhoun County reserves the right to require the successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS Mineral Oil - BVA Mosquito Larvicide Oil BVA 13 ULV oil or Calpar 8ON nst Name of Mineral of 5 Gallon Pail $ 40.95 /per 5 Gallon Pail 50 Gallon Drum $ 409.50 /per 50 Gallon Drum 55 Gallon Drum $ 450.45 /per 55 Gallon Drum 275 Gallon Tote $ 2,282,50 /per 275 Gallon Tote Page 1 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED Malathion Fyfanon IJLV +—List Insecticide Name Active Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ No Bid /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ 325.25 /per 5 Gallon Pail 55 Gallon Drum $ 3,464.45 /per 55 Gallon Drum 260 Gallon Tote $ 15,446.60 /per 260 Gallon Tote Malathion EW Fyfanon EW � list Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ 261.90 /per Case (Case = 2x2.5 Gal lugs) 30 Gallon Drum $ 1,538.10 /per 30 Gallon Drum 30-30 ULV Perrna5ease 30-30 , List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 299,85 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ No Bid /per 5 Gallon Pail 30 Gallon Drum $ 1,799.10 /per 30 Gallon Drum 55 Gallon Drum $ No Bid /per 55 Gallon Drum 275 Gallon Tote $ 16,491,75 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED 31-66 U'LV NO Bid �-- List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ /per Case (Case = 4x1 Gal lugs) 2 x 2.5 Gallon $ /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ /per 30 Gallon Drum 275 Gallon Tote $ /per 275 Gallon Tote 31-67 ULV PermaSease 31-67 -- List Insecticide Name Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ NO Bid /per Case (Case = 4x1 Gal lugs) 2 x 2.5 Gallon $ 433.45 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 2,609.40 /per 30 Gallon Drum 275 Gallon Tote $ 23,919.50 /per 275 Gallon Tote 4-4 U....LV PermaSease 4-4 .-- List Insecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 87.45 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ NO Bid /per 30 Gallon Tote 55 Gallon Drum $ 961,95 /per 55 Gallon Drum 275 Gallon Tote $ 4,809.75 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED 4-8 ULV No Bid List Insecticide Name Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ /per Case (Case = 2x2.5 Gal Jugs) 30 Galion Tote $ /per 30 Gallon Tote 55 Gallon Drum $ /per 55 Gallon Drum 275 Gallon Tote $ /per 275 Gallon Tote Altosid 30 Day Briquets OR Equivalent No Bid List Insecticide Name Active Ingredients: (5) Methoprene 8.62% 400 Per Case $ /percase Altosid XR Extended Residual Briquets OR Equivalent No Bid List Insecticide Name Active Ingredients: (5) Methoprene 2.1% 220 Per Case $ /per case DeltaGard OR Equivalent Deltagard ULV List Insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ 981.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 5,740.80 /per 30 Gallon Drum 250 Gallon Tote $ 47,262.60/per 250 Gallon Tote Page 4 of 5 Invitation To Bid Form -Annual Supply ContractforinsecticidesforMosquito Control -- CONTINUED FourStar Sustained Release 45/90/180 Day Microbial Briquets I Alternate not exact substitute: Vectomax VV�'P (800 WSP/case) List Insecticlde Name IOR Equivalent sa r m :.. __ I —"-I Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecies israelensis 1% 45 Day ----- 200 Per Case $ 1,299.00 /per case 90 Day ----- 200 Per Case $ /per case 180 Day-----200 Per Case $ /per case The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: November 4, 2020 Authorized Signature & Title: VP and Secretary Printed Name & Title of Authorized Signature: Jason Trumbetta, Vice President and Secretary Phone Number: (407) 328-6519 Email: bids(cbmyadapco.com Exceptions and/or Variations from Specifications and/or additional Notes: Please see attached Specimen Page 5 of 5 STATE OF TEXAS Florida {} AFFIDAVIT C'Cal INT.X.OF-CALFIOUN {} Seminole County The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Jason Trumbetta known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant Jas Trumbetta ADAPCO Vice President and Secretary_ Printed Name and Title of Affiant Name of Bidder (Company) ADAPCO LIC Address 550 Aero Ln, Sanford. Fl, 32771 Phone Number (407) 328-6519 or (800) 367--0659 Fax Number Email Address bids@myadapco.com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this 4th day of November , 20 20 �,.Pa oW. Notary Publi6 Stal9 oY Floritla X Kathryn A RiJ96011 ,s, .. o` Afy Q�.owF Miftw do 46�33i xtr Expire 1210YIZO-Er Notary in and for Seminole County, TexasFlorida 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 Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2020-686163 ADAPCO, LLC SANFORD, FL United States Date Filed: 11104/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County, TX 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 services, goods, or other property to be provided under the contract. 2021.02 Insecticides for Mosquito Control 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary Azelis Americas, LLC Westport, CT United States X 5 Check only if there is NO Interested Party. El 6 UNSWORN DECLARATION f My name is Jason Trumbetta and my date of birth is My address is 550 Aero Ln. Sanford FL 32.771 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Seminole County, State of Florida , on the 4th day of November, 2020 (month) (year) Signatur of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-686163 ADAPCO,LLC SANFORD, FL United States Date Filed: 11/04/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County, TX Date Acknowledged: 12/17/2020 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. 2021.02 Insecticides for Mosquito Control 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Azelis Americas, LLC Westport, CT United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is and my date of birth Is My address is 1 , (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of , on the _day of , 20_ (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d Page 1 of 2 CERTIFICATE OF LIABILITY INSURANCE GATE I11/1.5 5/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center NAME: Willis Towers Watson Northeast, Inc. £ka Willis of New York, Inc. PHONE 1-877-945-7376 FAX 1-868-967-2378 c/o 26 Century Blvd C No E#: A/C Na: P.O. Box 305191 E-MAIL cextificatesOwillis.com BORES Nashville, IN 372305191 USA I ,,,,,, INSURED Adapco, LLC Specialty Professional Products, LLC 550 Aero Lane Sanford, FL 32771 COVERAGES CERTIFICATE NUMBER - XL Insurance America Inc Commerce & Industry Insurance RFVISION NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDL SO SUBR WD POUCYNUMBER POLICYEFF MWDD/YYYY POLICY UP MM/OO LIMITS �( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE�X OCCUR DAMA ET RENTED PREMISES Es occunence $ 100,000 MED EXP (Any one person) $ 5,000 A - '.. 11/14/2019 11/14/2020 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X PRO-JECT ❑ LOC POLICY D PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accident. $ 1,000,000 �( BODILY INJURY (Par person) $ ANYAUTO B OWNED SCHEDULED AUTOSONLY AUTOS ,'4"r�� 11/15/201911/15/2020 !� BODILY INJURY (Per accident) $ per--iAYDAMAGE Per accitlent $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMSRELLAUAJB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ e WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE Y/N OFFICERIMEMBEREXCLUDE07 No (Mantlatory In Ni NIA 1 'r. '!p xd E :yy. 11/15/2019 11/15/2020 PER OTH- X STATUTE ER TTE E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000, 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ 1, 000,000 B Automobile Liability Any MA Auto c" J,kT cm'kvL.s'l..1 i N 11/15/2019 11/15/2020 Combined Single Lind $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe allached if more space is required) Mosquito Control Chemical Distribution SEE ATTACHED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �'+ Evidence of Coverage ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and lo. o e registered marks of ACORD t;. MW ,��" BATCR:14seo99 AGENCY CUSTOMER ID: LOC #: AC"I? ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Northeast, Inc. as Willis of New York, Inc. Adapco, LLC Specialty Professional Products, LLC 550 Aero Lane POLICY NUMBER See Page 1 Sanford, FL 32771 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORD IN OVERAGE Commerce & Industry Insurance Company `4 F, POLICY NUMBER ��� EFF DATE: 11/15/2019 EXP DATE: 11/15/2020 , -�'� �P �``' tl'az wi TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation & EL Each Accident $1,000,000 Employers Liability EL Disease -Each Emp $1,000,000 Per Statute EL Disease -Policy Lmt $1,000,000 ACORD 101 (20081011 n 20OR ACORD CORPORATION_ All rinhfR reeervad_ The ACORD name and logo are registered marks of ACORD Svp ". BATCH: 1458099 C *. �... KC CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Cede, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Date Received vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense If the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. ADAPCO, LI..0 L. 2 R Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Calhoun Co, TX Mosquito Control Director Name of Officer AJ Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Elyse LD No B. is the vendor receiving or likely to receive taxable income, other than Investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? E]Yes FIND 6 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government off leer serves as an officer or director, or holds an ownership interest of one percent or more. Sales and Distribution of Mosquito Control Chernicals, Equipment and Surveiiliance Tools 6 ElCheck this box If the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signature of v �Ii r doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/3012015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification, d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Jason Trumbetta, Vice President and Secretary '11/04/2020 Name and Title of Authorized Agent Date Sig 4 re of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subreciplents shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S,C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, ADAPCO LLC , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signature ontractor's Authorizee-d O 1 Jason Trumbetta, Vice President and Secretary Printed Name and Title of Contractor's Authorized Official November 4, 2020 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract NSA a. bid/offer/application a. initial filing _ b. grant _ b. initial award _ b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Prime _ Subawardee Name and Address of Prime: Tier , if Known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicable: 8. Federal Action Number, if known: 9. Award Amount, ifknown: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first narne, MI): df/erentfrom No. I0q) (last name, first name, MI): 11. Information requested through this form is N/A authorized by title 31 U.S.C. section 1352. This Signature: ,,�,.!_,_.__ disclosure of lobbying activities is a material --— representation of fact upon which reliance was placed Print Name: a On Trumbetta by the tier above when this transaction was made or > entered into. This disclosure is required pursuant to 31 Title: VP and Secretary U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: (407) 328-6519 Date:11/04/2020 inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 Jason Trumbetta the undersigned representative of Representative ADAPCO LLC (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant, to 2270.001, Texas Government Code: 1. 'Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signal�of Representative Jason Trumbetta, Vice President and Secretary Print Name & Title November 4, 2020 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. 9 1 certify that ADAPCO LLC is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is 550 Aero Ln., Sanford FL 32771 (City and Stare) Please note your dedicated Technical Sales Representative resides in TX. Colton Cooper 110 Piney Pathway Magnolia, TX 77364 ❑ 1 certify that (Company Name) defined in Government Code §2252.001. Signature of,horized Agent Jason Trumbetta Printed Name and Title of Authorized Agent November 4 2020 Date is a "Resident Bidder" of Texas as Please Type If handwritten, must be in ink and legible Vendor's Name: ADAPCO, LL.0 Address: 550 Aero Ln. Sanford FL 32771 Remittance Address: PO Box 931574 Telephone: Fax: Atlanta, GA 31193-1574 328-6519 or (800) 367-0659 Email: bids@myadapco.com Email(s) to send Bid Information: bids@myadapco.com Signature of Authorized Representative: Printed name name of Authorized Rep: Jason Trumbetta ORDER - CONTACT INFORMATION Order Contact Name & Title: Joy Edwards Order Contact Telephone: (877)250-6508 Order Contact Fax: n/a Order Contact Email: ordersCa7myadapco.com W-9 Request for Taxpayer Give Farm (Rev. October 2018) Identification Number and Certification Form to the requester. ®o not Depanment of the Treasury Intamel Revenue Service ► Go to ww e.1mgmillib mW9 for instructions and the latest information. send to the IRS. t Name (as shown on your interne tax return). Name is required an this line: do not IeaJe this line blank. A®APC® LLC 2 Business name/disregarded entity, name, If different from above .— �. m 3 Check appropriate box forfederal tax classification of the person whose name Is entered online 1. Check only one of the 4 Exemptions (Codes epplyonly to b following seven bones, certain enti0es, not Individuals; see a c Individuaysoie proprietor or p p ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Tmstsestate Instructions an page a): ®s single -member LLC Exempt payee coda (if any) co � � ❑ Umited liability company. Enter the in classification (C=C corporation, S=5 corporation, P=Partnership)► Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting s LLC If the LLC is classified as a single -member LLC that is disregarded from the owner untess the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code Of any) w is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other(a" instruotiorrs)► 4Y+ovesmxcw,rm.•enlmnea•urelem•asJ 6 Address (number, street, and apt. suke no) see inWWcw om. or Requesters name and address (options m N SSO AePO Lane 6 City, state, and ZIP code Sankind FL 32771-6342 7 List account numbers) here (optlonall Number tinter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions far Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account Is in more than one name, see the Instructions for line 1. Also see What Name and Number To Give the Requesterfor guidelines on whose number to enter. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form Of any) indicating that I am exempt from FATCA reporting is correct Certification instructions. You must cross out item 2 above if you have been noted by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Pad II, later. signature AJU.S. person► Data 1.r 'l..n General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and Its instructions, such as legislation enacted after they were published, go to www.frs-gov/FomiW9. Purpose of Form An individual or entity (Forth W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) • Form 109" (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Farm 1099-C (canceled debt) • Form 1099-A(acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN you might be subject to backup withholding. Sse What Is backup withholding, later. Cat. No. 10231X Form W-9 (Rev.10-2018) � ♦. 1 '-• 1. • • �- - •- 1 ■ . CALHOUN COUNTY, TEXAS ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.02 Vendor's Name & Address Clarke Mosquito Control Products, Inc 675 Sidwell Ct St. Charles, IL 60174 • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the vendor to provide up to the amount bid at the bid terms and conditions stated herein. Calhoun County reserves the right to require the successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS Mineral Oil - BVA Mosquito Larvicide Oil , List Name of Mineral Oil 5 Gallon Pail $ NO BID /per 5 Gallon Pail 50 Gallon Drum $ NO BID /per 50 Gallon Drum 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote Page 1 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED Malathion --List Insecticide Name Active Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ NO BID /per 5 Gallon Pail 55 Gallon Drum $ NO BID /per 55 Gallon Drum 260 Gallon Tote $ NO BID /per 260 Gallon Tote - Malathion EW f-List Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum 30-30 ULV Biomist 30+30 List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 325.00 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ NO BID /per 5 Gallon Pail 30 Gallon Drum $ 1,950.00 /per 30 Gallon Drum 55 Gallon Drum $ 3,575.00 /per 55 Gallon Drum 275 Gallon Tote $ 17,875.00 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form - Annual supply Contract far Insecticides for Mosquito Control -- CONTINUED 31-66 ULV Biomist 31+66 List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ NO BID /per Case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote 31-67 ULV List Insecticide Name Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ NO BID /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote 4-4 ULV Biomist 4+4 List Insecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 100.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ 600.00 /per 30 Gallon Tote 55 Gallon Drum $ 1,100.00 /per 55 Gallon Drum 275 Gallon Tote $ 5,500.00 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED 4-8 ULV List Insecticide Name Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ NO BID /per 30 Gallon Tote 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote Altosid 30 Day Briquets OR Equivalent Altosid 30 Day Briquets List Insecticide Name Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ 480.00 /per case Altosid XR Extended Residual Briquets OR Equivalent Altosid xR Briquets , List insecticide Name Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ 759.00 /percase DeltaGard OR Equivalent , List Insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum 250 Gallon Tote $ NO BID /per 250 Gallon Tote Page 4 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED FourStar Sustained Release 45/90/180 Day Microbial Briquets DR Equivalent Fourstar 45/90/180 Day Briquets List Insecticide Name Ingredients: Bacillus sphaericus 6%; subspecies 45 Day ----- 200 Per Case $ 282.67 /per case 90 Day ----- 200 Per Case $ 469.33 /per case 180 Day-----200 Per Case $ 733.33 /per case The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: .J012, • ,2r O a C Authorized Signature & Title: Printed Name & Title of Authorized Signature: Karen Larson, VP Product Innovation & Government Affairs Phone Number: 800-323-5727 Email: customercare@clarke.com Exceptions and/or Variations from Specifications and/or additional Notes: N Page 5 of 5 I Z.1-i A/0 i C� STATE OF TVXd {} AFFIDAVIT COUNTY OF CALHOGN {} ILAd6 The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Karen Larson known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant Karen Larson, VP Product Innovation & Government Affairs Printed Name and Title of Affiant Name of Bidder (Company) Clarke Mosquito Control Products, Inc Address 675 Sidwell Ct, St. Charles, IL 60174 Phone Number 800-323-5727 Fax Number 630-443-3070 Email Address customercare(oclame.com SWORN TO AND SUBSCRIBED BEFORE ME by the abov/e� `Affiant, who, on oath, states that the facts contained in the above are true and correct, this _,2�qL day of I \i i(i f.1')thtiK 20 . OFFICIAL SEAL r( f q Z ? MARIANN CUMBO I fLL- , i . /If7/L NOTARY PUBLIC- STATE OFILLINOIS Notary Public in and for j�1 i)!'iQ County, Teas- MY COMMISSION EXPIRES:04103122 wa,, CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-683638 Clarke Mosquito Control Products St Charles, IL United States Date Filed: 10/28/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021.02 mosquito control products 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECL RATION ,.. My name is • .y3�A 1'- .t 'i and my date of birth is R IA r My address is 3"f "' z N Sy x .. 1 declare under penalltyy f perjury that the foregoing is true and correct. 1\ i�l� -County, State of e \ y t! � ' ", �. Executed in � ty, , on th da of � 20 `� (month) (year) -Signature of 6Abrized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d 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 Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2020-683638 Clarke Mosquito Control Products St Charles, IL United States Date Filed: 10/28/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County Date Acknowledged: 12/17/2020 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. 2021.02 mosquito control products 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECLARATION My name is and my date of birth is My address is , (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 I exas ttnics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 11/2/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poltcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsementlsl. Binational Midwest Limited Jackson Boulevard IL 60604 INSURED Clarke Mosquito Control Products, Inc. Clarke Environmental Mosquito Management, Inc. 675 Sidwell Court St. Charles IL 60174 COVERAGES NUMBER: REVISION THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEtRi ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OFINSURANCE ADDLSUBR POLICYNUMBER POLICY EFF IMMIDDIYYYYI POLICY EXP flMMIDDfYYY)r)LIMITS B tXCOMMERCIAL GENERAL LIABILITY CLAIMS-MADE1XI OCCUR r- '`+'i+.» 11/1/2019 3/1/2021EACHOCCURRENCE $1,000,000 PREMIETOREN 0PREMISES Eaoccunence $300,000 MED EXP (Any one person) $ 25,000 ution Legal Liability PERSONAL &ADV INJURY $1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICV[y] ECT �LDG GENERAL AGGREGATE $2.000,000 PRODUCTS-COMP/OP AGG $2.000,000 pollution Legal Liab COMBINED SINGLE LIMIT Ea accident $1,000,000 $1,000,000 OTHER: 11/1/2019 3/1/2021 C. AUTOMOBILE LIABILITY 1 .0 *: X ANY AUTO - t �:. ,. ,. BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS I BODILY INJURY Per accident) 8 X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ -I �'' B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 11/1/2019 3/1/2021 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000.000 DIED I RETENTION$ $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? NIA § `E;� 'e`.9 p53f i 5?y7 11/1/2020 11/1/2020 3/1/2021 3/1/2021 X PER OTH& STATUTE ER E.L. EACH ACCIDENT $1.000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Pollution Legal Liability includes coverage for Third Party On -site, Third Party Off -site, Hostile Fire and Building Equipment, Products Pollution, Contractors Pollution and Transportation Cargo. Calhoun County is included as additional insured under General Liability, on a primary and non-contributory basis, when agreed in a written contract, subject to policy terms, conditions and exclusions. Calhoun County 211 S Ann St, Suite 301 Port Lavaca TX 77979 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. rW4 V 1Stltl-ZU15 AwHU CUKYUKAT IUN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176,001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. Avendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. !J Name of vendor who has a business relationship with local governmental entity. Clarke Mosquito Control Products, Inc z El Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4J Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? FlYes F-1 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? E]Yes FIND 6 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signattre of vendor dqtlg business with the governmental entity Da e Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Karen Larson, VPVP, Product Innovation & Gov't Affairs Name and Title of Authorized Agent Signature o Authorized Agent CiC - a;? Date I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid orwill be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require thatthe language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Clarke Mosquito Control Product§ Inc The Contractor, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature of Co tractor's Authorized Official Karen Larson, VP, Product Innovation & Gov't Affairs Printed Name and Title of Contractor's Authorized Official C ..� qr Date Approved by OMB - N/A 0348-0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant _ b, initial award _ b. material change c, cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 Is Subarardee, Enter Prime _ Subawardee . Name and Address of Prime: Tier_, if Known: N/A Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicable: 8. Federal Action Number, ifknown: 9. Award Amount, ifknown: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last tame, fnshmme, MI): differentfrom •am No. IOa) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. 1352. This Signature: V, section t_ disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Karen Larson by. the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: VP, Product Innovation & Gov't Affairs U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: 800-323-5727 Date: Inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty ofnot less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) • 1 • CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, Karen Larson the undersigned representative of Representative Clarke Mosquito Control Products, Inc (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly awned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signatu'r6 of Repres tative Karen Larson, VP, Product Innovation & Gov't Affairs Print !//N�yame & Title J - r 2 q, i,W,50 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. 12 1 certify that Clarke Mosquito Control Products, Inc is.a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code§2252.001 and our principal place of business is St. Charles. IL (City and state) ❑ 1 certify that is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of A�d Agent Karen Larson Printed Name and Title of Authorized Agent Date Please Type If handwritten, must be in ink and legible Vendor's Name: Clarke Mosquito Control Products, Inc Address: 675 Sidwell Ct St Charles, IL 60174 Remittance Address: 16277 Collections Center Drive Chicago, IL 60693 Telephone: 800-323-5727 Fax: 630-443-3070 Email: customercare@clarke.com Email(s) to send Bid Information: customercare@clarke.com; dcarroll@clarke.com Signature of Authorized Representative: Printed name of Authorized Rep: Karen Larson ORDER - CONTACT INFORMATION Order Contact Name & Title: Doug Carroll Order Contact Telephone: 817-600-5353 Order Contact Fax: 630-443-3070 Order Contact Email: dcarroll@clarke.com; customercare@clarke.com I - Request for 'Taxpayer Give Form to the (Rev, October 2018) Identification Number and Certification requester. Do not "apartment of the Treasury send to the IRS. Internal Revenue Service ► Go to warmira.ilovlFormW8 for instructions and the latest information. t Name (as shown on your Income tax return). Name is requlred on Clarke Mosquito Control Products, Inc. 2 Business name/disregarded entity name, If different from above 3 Check appropriate box for federal tax classification of the person whose name Is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not Individuals; see a Instructions on page 3): o 0 Individual/sole proprietor or FAD Corporation D S Corporation d Partnership Trustleslate single -member LLD Exempt payee code (if any) [] Limited liability company. Enter the tax dasslilcatlen (C=C corporation, B=6 corporation, P=Pannalship) r o Note: Check the appropriate box In the line above for the tax classification of the single-mernber owner. Do not check Exemption from FATCA reporting is LLD If the LLD Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the U.0 Is codo (If any) a E another LLC that Is not disregarded iron the owner for U.S. federal tax purposes. Otherwise, a single -member L LG that -._..__ ...... Is disregarded from the owner should check the appropriate box for the tax classification of Its owner, Othor(sealnstructlonay 1rManev a unamornmhm Iswe meus; gr s Address (number street, and apt or suite no.)Se6 instructions. Requester's name and address (optional) g± 675 Sidwell Court e City, state, antl ZIP code St. Charles, IL 60174 TList account number(s)here optldnafj • — Taxpayer Identification Number (TIN) _ Enter your TIN In the appropriate box. The TW provided must match the name given on lino 1 to avoid suclai ancur_I_ty numtear ;T J bacltup withholding, For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other - - entitles, It is your employer identification number (EIN). If you do not have a number, see How to gef a ITM TIN, later. or _ _ _ Note If the account is In more than one name, sae the instructions for line 1. Also sea What Name and p yer Identification number - ern IoI Number To Give the Requester for guidelines on whose number to enter, 1. The number shown on this form is my correct taxpayer Identification number (or, I am waiting for a number to be Issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and S. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions, You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions for Part II, later, Tarr I Signature of Here U.S. person ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its Instructions, such as legislation enacted after they were published,. go to www.1rs,gov1FormW9. Purpose of Form An individual or entity (Form W-9 requester) who Is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of Information returns include, but are not limited to, the following. • Form 1099-INT (Interest earned or paid) "ate► ';?011S d • Form 1099-CIV (dividends, including those from stocks or mutual funds) • Form 1099-MISO (various types of Income, prizes, awards, or gross proceeds) • Form 1099.5 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form '1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tultion) • Form 1099•C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN. If you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later, Cat. No. 10231X - Form W-g (Rev. 10-2018) RENTOKIL NORTH AMERICA, INC. dba TARGET SPECIALTY PRODUCTS ANNUAL SUPPLY CONTRACT Beginning January 1, 2021 and Ending December 31, 2021 ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.02 Vendor's Name & Address Rentokil North America, Inc DBA Target Specialty Products 11730 Airline Highway Baton Rouge, Lousiana 70817 • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the vendor to provide up to the amount bid at the bid terms and conditions stated herein. Calhoun County reserves the right to require the successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS Mineral Oil - BVA Mosquito Larvicide Oil BVA-13 Diluent Oil usrPeme of rtnme a on 5 Gallon Paii $ 46.25 /per 5 Gallon Pail 50 Gallon Drum $ 372.00 /per 50 Gallon Drum 55 Gallon Drum $ 409.00 /per 55 Gallon Drum 275 Galion Tote $ 2,131.75 /per 275 Gallon Tote Page 1 of 5 Invitation To Bid Form -Annual Supply Contract for insecticides for Mosquito Control —CONTINUED Malathlon N/A List Insecticide Name Active Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ NO BID /per 5 Gallon Pail 55 Gallon Drum $ NO BID /per 55 Galion Drum 260 Gallon Tote $ NO BID /per 260 Gallon Tote Malathion EW Malathion 5EC - List Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ 225.00 /per Case (Case = 2x2,5 Gal Jugs) 30 Gallon Drum $ 1,350.00 /per 30 Gallon Drum Permanone 30-30 (5 gal, 30 gal, and 275 gal), Perm-X UL 30-30 (2x2.5 gal and 55 gal) 30-30 ULV List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 305.00 /per Case (Case = 2x2.5 Gal lugs) 5 Gallon Pail $ 295.00 /per 5 Gallon Pail 30 Gallon Drum $ 1,770.00 /per 30 Gallon Drum 55 Gallon Drum $ 3,300.00 /per 55 Gallon Drum 275 Gallon Tote $ 16,225.00 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid form -Annual Supply Contract for lnsecdcides for Mosquito Control --CONTINUED Permanone 31-66 (41 gal, 30 gal, and 275 gal), Perm-X UL 31-66 (2x2.5 gal) 31.66 ULV List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ 376.00 /per Case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $470.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $2,820.00 /per 30 Gallon Drum 275 Gallon Tote $ 25,850.00 /per 275 Gallon Tote 31-67 ULV N/A List Insecticide Name Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85°% 4 x 1 Gallon $ NO BID /per case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) NO BID 30 Gallon Drum $ /per 30 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote 4-4 ULV Perm-X UL 4-4 List Insecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $109.06 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ 552.35 /per 30 Gallon Tote 55 Gallon Drum $ 1,009.40 /per 55 Gallon Drum 275 Gallon Tote $ 4,671.88 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides far Mosquito Control -- CC71VTINUED 4-8 ULV Permzarione RTU ,— List Insecticide Name Active Ingredients: Permethrin 3.98%; Plperonyl 8utoxide 8.48% ^� 2 x 2.5 Gallon $ 105.70 /per Case (Case = 2x2.5 Gal lugs) 30 Gallon Tote $ 1,110.00 /per 30 Gallon Tote 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ 9,762250 /per 275 Gallon Tate Altosid 30 Day Briquets OR Equivalent Altosid 30-Day Briquets List Insecticide Name Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ 450.00 /per case Altosid XR Extended Residual Briquets OR Equivalent Altosid XR Briquets ..- List Insecticide Name Active Ingredients: (S)Methoprene 2.1% 220 Per Case $ 759.00 /per case DeltaGard OR Equivalent DeltaGard .- List Insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $1,060.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 6,210.00 /per 30 Gallon Drum i_ 250 Gallon Tote $ 51,000.00 /per 250 Gallon Tote Page 4 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticidesfor Mosquito Control -- CONTINUED FourStar Sustained Release 45/90/180 Day Microbial Briquets N/A a List Insecticide Name 6%; Bacillus 45 Day ----- 200 Per Case $ NO BID /per case 90 Day ----- 200 Per Case $ NO BID /per case 180Day ----- 200PerCase $NOBID /per case The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 11 /9/2020 Authorized Signature & Title: Printed Name &'ritle of Authorized signature: Crystal Salter Vector Customer Service Representive 225-241-5670 (Crystal) OR 318-254-3330(Patrlck) Crystal.Salter@target-speciaity.com & Patrick.Sutton@target-specialty.com Phone Number: Email: Exceptions and/or Variations from Specifications and/or additional Notes: Page 5 of 5 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared crystal Salter known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. /� rx n/I 1 /i Affiant Crystal Salter, Vector Customer Service Representive Printed Name and Title of Affiant Name of Bidder (Company) Rentokil North America, Inc DBA Target Specialty Products Address 1225 N. Post Oak Road, Houston, TX 77055 Phone Number 225-241-5670(Crystal)OR316-254-3330(Patrick) Fax Number Email Address SWORN TO AND SUBSCRIBED BEFORE tE by the above Affiant, y ho, on oath, states that the facts contained in the ^ G above are true and correct, this day of /u :q ,lunuliilr„!, :s Public in and for i Comes East Baton Rouge Pariah owj CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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: 2020-687710 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Target Specialty Products Houston, LA United States Date Filed: 11/09/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021.02 Annual Supply Contract for Insecticides for Mosquito Control 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Myers, John Reading, PA United States X Gelling, Bruce Reading, PA United States X Coyle, Jason Reading, PA United States X Helt, David Santa Fe Springs, CA United X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION JhMihl Nichols John Michael HI My name is ,and my date of birth is � My address is 1225 N. Post Oak Rd. Houston TX 77055 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Harris county, state of Texas on the 9th day of November2020 (month) (year) Signature of authorized agent of contracting business entity (Declarant) I-orms provioect Dy I exas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer riahtsto the certificate holder in lieu of such endorspmenffst PRODUCER Edgewood Partners Insurance Center 200 Glenridge Point Parkway Suite 400 Atlanta GA 30342 INSURED Rentokil North America, Inc. DBA Target Specialty Products (REN210) 15415 Marquardt Avenue Santa Fe Springs CA 90670 COVERAGES CERTIFICATE NUMBERt+§ai"�.',J§-'"9-,Zi, u'�` wcfnslnu eu lsnnco. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTM F' I . - OMEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILNSR TR TYPE OF INSURANCE ADDL INSID SUBR POLICY NUMBER POLICY EFF MMIDOM'W POLICYEXP MMIDDIYYYYl LIMITS A X COMMERCIALGENERAL LIABILITY CLAIMS -MADE OCCUR _ S 1 " - ., _.n.. 10/1/2020 10/1/2021 EACH OCCURRENCE $5,000,000 AMAGE TORE -RENTED PREMISES Ea occurrence $5,000,000 MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $5,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY jEGGT [X] rx] LOC OTHER: GENERALAGGREGATE $5,000,000 PRODUCTS-COMP/OP AGG $5,000,000 $ D D AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED ONLY AUTOS ONLY 1){ Yni€a 10/1/2020 70/1/2020 10/1/2021 10/1/2021 COMBINED SINGLE LIMIT Ea accident $2,000,000 X BODILY INJURY (Per person) $ 1AUTOS BODILY INJURY (Per accident) $ PROPERTY -DAMAGE Per axident $ B X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE r: - 10/1/2020 10/7/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $5.000,000 DED I X I RETENTION$ $ E SATION AND EMPLOY RS'LIASILIITY V/N ANYPROFFICE IMEMBRIPARTUDED?ECUTIVE (Mandatory InN REXCLUDED'! (fyes,doryln NH) Dyes, IPTIONantler DESCRIPTION OF OPERATIONS below N/A �'' e... y,ew- 10/1/2020 10/1/2020 10/1/2021 10/1/2021 X STATUTE ERH E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE - EA EMPLOYEE $2,000,000 E.L. DISEASE -POLICY LIMIT $2,000,000 A C Ermm& Omissions Liability Come/Client Coverage Ir'� �t M� J"T' z fJ:4iL�' IN, 10/1/2020 10/1/2020 10/1/2021 10/1/2021 Each lncidenVAgg Each Occurrence 5,000,000 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5 ACORD CORPORATION_ All rinht t ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.H. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. Crystal Salter/ Target Specialty Products 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information Is being disclosed. N/A Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? F1 Yes © No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? F]Yes ® No 5 Describe each employment or business relationship thatthe vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership Interest of one percent or more. No Employment or Business relationship exisit with any Local Government Officer 6 ElCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signa ure of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11130/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Crystal Salter, Vector Customer Service Representive Name and Title of Authorized Agent cAt Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. tcz u Date Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying; in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, Target Specialty Products certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. CSignature 01 Contractor's Authorized Official Crystal Salter Vector Customer Service Representive Printed Name and Title of Contractor's Authorized Official 11/9/2020 Date Approved by OMB Disclosure of Lobbying Activities 0349-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Type of Federal Action: 2. 3taWs of Federal Action. 3. Report Type; [NIA'y; contract gram a. bid/otfer/application N/A b. initial award a. initial filing N/A b, material change a cooperative agreement c, pose -award d. loan e. loan guarantee For material change only: f. loan insurance year quarter Date of last report____.._ 4. Name and Address of Reporting Enthyt "-- A. YiReporting Entity in No.41s Subawardee, Entcr e Prime Subawardee Name and Address of Prime: Tler__, if Known: N/A N/A Con essionalDistrict;Ifknows: Congressional iflmown: 6. Federal Department/Agency 7. Federal Program Name/Description; N/a CFDA Number, lfapplicable: N/A S. Federal Action Number, Vibi,wn: ---__ 9. Award N/A $ N/A b. individuals Performing Services (including address if 10. A. Name and Address of Lobbying Registrant (if individual, last name, fawt name, AM.- dierent from No. Jou) (last name, first name, MIJ: N/A N/A ��_w.., 11. Ynformation eequested through this — form is authorized by title 31 U.S.C. section 1352. This Slgnature: disclosure of lobbying activities is a material _C representation of fact upon which reliance was placed Print Name:Crystal Salter by the tier above when this transaction was made or entered Into. This disclosure Is required pursuant to 31 Title: Vector Customer Service Representative U.S.C. 1352. This information will be reported to the Congress sernknunally, and will be available for public Telephone No.t225-241-5670 Date. 11/9/2020 inspection. Any person who fails to file the required "" disclosure shall be subject to a civil penalty of not less than $10,000 and not more then $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction R �^ Standard Form - LLL (Rev. 7.97) Crvstal Salter Representative • Ire ��. �i �i /i�ri ;1 �i the undersigned representative of Rentokil North America, Inc DBA Target Specially Products , (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. 'Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company' means o for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signature of�tepresentative Crystal Salter, Vector Customer Service Representive Print Name & Title 11/9/2020 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ 1 certify that is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) I certify that Target specialty Products is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Crystal Salter, Vector Customer Service Representive Printed Name and Title of Authorized Agent 11 /9/2020 Date Please Type If handwritten, must be in ink and legible Vendor's Name: Rentokil North America, Inc DBA Target Specialty Products Address: 1225 N. Post Oak Road, Houston, TX 77055 Remittance Address: PO Box 14084 Reading, PA 19612-3848 Telephone: 713-249-2076 Fax: Email: Patrick.sutton@target-specialty.com or crystal.salter@target-Specialty.com Email(s) to send Bid Information: Patrick.sutton@target-specialty.com crystal.salter@target-Specialty.com mike. nichols@target-specialty.com Signature of Authorized Representative: Printed name of Authorized Rep: Crystal Salter, Vector Customer Service Representive ORDER ® CONTACT INFORMATION Order Contact Name & Title: Jeff Bastian, Houston Service Center Manager Order Contact Telephone: 1-800-901-9746 Or 713-682-4411 Order Contact Fax: 713-682-4374 Order Contact Email: Jeffery.13astian@target-specialty.com Form w-9 Request for Taxpayer Give Form to the (Rev. December Treas Identification Number and Certification requester. o not Department of the Treasury Send to the IRS, IRS, ne Interpol Revenue Service I Name (as shown on your Income tax return). Name Is required on this Ifn%do not leave this line blank. Rentokil North America, Inc. N 2 Business name{disregarded entity name, If different from above Tar et Specialty Products 3 Check appropriate box for federal tax classification: check only one of the following seven boxes: 4 Exemptions leads$ apply only to o rn ❑ Individual/sole proprietor or C Corporation ❑ S Corporation ❑ Partnership ❑ TrusVestate certain entities, not Individuals; see instructions on page 3): m e a o o single -member LLC Limited liabilitycompany. Enter the tax classification C=C corporation, S=S corporalion, P= artnershi ► ❑ p y ( p p p) Exempt payee code (if any) 5 a p Note. For single -member LLC that is disregarded, do not check LLC; Check the appropriate box in the line above for Exemption from FATCA reporting � w s n of the the tax classification of the single -member owner. code (If any) — c a` o ❑Other (see instructions)► — (nppues io„aovni, ma;m•rmuwi;me nw us} !� _ 5 Address (number, street, and apt. or suite no.) Requester's name and address (optional) a PO Box 14084 N m 6 City, state, and ZIP code Reading, PA 19612 7 List account number(s) here (optional) " Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number _J backup withholding. For individuals, this is generally your social security number (page However, for a resident alien, sole proprietor, or disregarded entity, see the Par{ I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see Ilow to get a TIN on page 3. or Note. If the account Is In more than one name, see the Instructions for line 1 and the chart on page 4 for Employer identiricatian numberT^� guidelines on whose number to enter. of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not requires to sign the certification, but you must provide your correct TIN. See the Instructions on page 3. Signature of Her Here I U.S. person ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN). Individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to most on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funs) • Form 1099-MISC (various types of income, prizes, awards. or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) Date► 01/21/2020 • Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099 A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U,S. person (Including a resident alien), to provide. your correct l'IN, It you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What Is backup withholding? on page 2. By signing the filled -out form, you: 1. Cattily that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U.S. exempt payee_ If applicable, you are also certifying that as a U.S. person, your allocable share of any pat nership income from a U.S. trade or business is not subject to the withholding lox on foreign partners' share of effectively connected Income, and 4. Certify that FATCA cadets) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further Information. Cat. IJo, 102M Form VII (Rev. 12-2014) E 1 1 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.02 Vendor's Name & Address U�ta Locw� 11:S $PCO USO t_L.0 b8o VeSeif�� I 1�e,w'ka Pe CON N�� 01 J -4 So l oorcp,,� C T� yg0g • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • This is a bid form only and does not represent an order for a purchase by Calhoun County. • Acceptance of the successful bid shall obligate the vendor to provide up to the amount bid at the bid terms and conditions stated herein. Calhoun County reserves the right to require the successful bidder to enter a separate written contract containing the terms herein and other reasonable conditions. The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS Mineral Oil - BVA Mosquito Larvicide Oil V' 1 x PAP, U — 60 —Iist Name of Mineral Oil 5 Gallon Pail $ A /per 5 Gallon Pail 50 Gallon Drum $ 3 S� , Q /per 50 Gallon Drum 55 Gallon Drum $ 385. 00 /per 55 Gallon Drum 275 Gallon Tote $ 1, G a-5 /per 275 Gallon Tote Page 1 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED Malathion -\proA) L Y List Insecticide Name Active Ingredients: Malathion 96.5%; Oth r 3.5% 2 x 2.5 Gallon $ N /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ �,�II m a /per 5 Gallon Pail 55 Gallon Drum $ 3 `f wi , H 5 /per 55 Gallon Drum 260 Gallon Tote $ l s ``t� , 0 /per 260 Gallon Tote Malathion EW TA ry CVV F—List Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ to 0 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 5M. 10 /per 30 Gallon Drum 30-30 U LV YY1 Y4 Oea L . N -e �j V I 30-30 — List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ agq, b , j /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ N 19 /per 5 Gallon Pail 30 Gallon Drum $ 15 g9, , 5 () /per 30 Gallon Drum 55 Gallon Drum $ �2 q 15. oo /per55 Gallon Drum 275 Gallon Tote $%0 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form -Annual Supply Contract for lnsecticidesforMosquito Control — CONTINUED 31-66 ULV Pe g m - X W- 3' - (D —List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ N 6 /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $ i f b ®. Q D /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ gg(�, Qo /per 30 Gallon Drum 275 Gallon Tote $ y 00. 00 /per 275 Gallon Tote 31-67 ULV s 4 n 3 — List Insecticide Name Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ M P /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $ 9 30 , Q C7 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ cz s So. 00 /per 30 Gallon Drum 275 Gallon Tote $ aj 6 5 0. DO /per 275 Gallon Tote 4-4 ULV '1 - List Insecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ D U , 5 Q /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ L1 9 5. 00 /per 30 Gallon Tote 55 Gallon Drum $ 11t 5 Q , 00 /per 55 Gallon Drum 275 Gallon Tote $ Ll r „5 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED 4-8 ULV List Insecticide Name Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ NA /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ r4 q /per 30 Gallon Tote 55 Gallon Drum $ N A /per 55 Gallon Drum 275 Gallon Tote $ /per 275 Gallon Tote Altosid 30 Day Briquets OR Equivalent F List Insecticide Name Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ L1 7 6. 00 77 /per case 4 445,4^ q4,MX, 5 r ply p.N Altosid XR Extended Residual Briquets OR Equivalent List Insecticide Name Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ -4 52 AQ /percase �6 �'�i ��� '` � f lCw. DeltaGard OR Equivalent F List Insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ ),I !i /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ m /per 30 Gallon Drum 250 Gallon Tote $ At /per 250 Gallon Tote Page 4 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED FourStar Sustained Release 45/90/180 Day Microbial Briquets Is (A w, �., T r g , a. �e-IS ®R E - List Insecticide Name _; -f Q I Active Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecig israelensis 1% 30 bra 100 Pelt case S d - 5 0 /PPt cwSP 45 Day ----- 200 Per Case $ N i4 /per case 90 Day ----- 200 Per Case $ A /per case 180 Day ----- 200 Per Case $ "Aj /v ✓4 /percase The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: D C) c' .;,,2 0, Authorized Signature & Title: Printed Name & Title of Authorized Signature: Phone Number: 10 — 1) tP Email: K e t h m k A A s( Ve SQR f S. Co Exceptions and/or Variations from Specifications and/or additional Notes:C1) S u to w, f 811 tJ r; %tie? S eaulVAlevl 4,) BU P 13 , V,Sro<:4tn r-6 () poor - 9.5 Q1/IA �3 MAI6e SDS Re✓�e�� r✓tA e `%f 07 v'I C9­(7 NPe�S rip, e w f 0'F S e0�,VbrleV45 .�h ewe A 5 A Se cp D IJ Page 5 of 5 STATE OF TEXAS (} AFFIDAVIT COUNTY OFCALHOUN U The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared - Q r-f k L • H w iq S known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business r to any fficial, employee, or agent of Calhoun County prior to the official opening of this Bid. /f Affiant II I 1 9L. Nm✓iS kU'c Ue�gli OPr w',sl Printed Name and Title of Affiant Name of Bidder (Company) V eSe Address L 0Ci4l -- `I O-Z mc— erIf L ArA? Co RtA f 0 L:ST, . T � ulU0 Phone Number Cc: 3& -agq- 613 - ®1w (3 -20 3 -Oy Fax Number II '' nn Email Address �i P; t � e � a a S l` JP j e R 1,J` , Co M SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this A �*\ day of d ,C k-O)W—1( , 20,11,10 . �MELISSAA.WEEKS 't" °{R6 Notary Public, State of Texas yp !; `!; •:�H Comm. Expires 02-16.2021 "nADO'� Notary 1[) 131007952 Notary Public in and for V-\M f ( � County, Texas CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of1 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. 2020-683738 Veseris Austin , TX United States Date Filed: 10/28/2020 2 Name of governmental entity or state agency that is a parry to the contract for which the form is being filed. Calhoun County, Texas 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 services, goods, or other property to be provided under the contract. 2021.02 Insecticides for Mosquito Control, January 1, 2021 thru December 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Gibbs, Doug Houston, TX United States X Theriot, Mark Corpus Christi, TX United States X Haas, Keith Houston, TX United States X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION My name is 12,i '(' L 18 ki and my date of birth is gm • a` �'ti ,. VERMIN- My address Is y.. "„ .a cXP". r. .11z�,., .. .� z..... -. a. (street) (city); V ' -' (state) (zip code) (country) I declare under of perjury that the foregoing is true and correct. Ipenalty D Executed in it It) rf r .S County, State f TFx,9 .s . on the o»� a day of OC I1 20Q_. (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3aflaaf7d DATE (MWDDNYYY) 1/22/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer riohts to the certificate holder in lieu of such cndomementrsl. PRODUCER Arthur J. Gallagher Risk Management Services, Inc. 2345 Grand Blvd., Suite 400 Kansas City MO 64108 INSURED ES OPCO USA LLC 10800 Pecan Park Blvd. Bldg. 1, Suite 300 Austin TX 78750 THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPEOFINSURANCE AODL SUER POLICYNUMBER MM/UDYEFF MPOppYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY Cl-AIMS-MADE OCCUR �.'{tl�J I' m 9 710 12/31/2019 12/31/2020 EACHOCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea accunence $250,000 MED EXP (Any one person) $ 25,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jRT ® LOC OTHER: GENERALAGGREGATE $2,000,000 PRODUCTS-COMP/OPAGO $2,000,000 Pollution $1,000,000 B AUTOMOBILE LIABILITY ANY AUTO OWNED ASCHEDULED AUTOS ONLY UTOS HIRED X NON -OWNED AUTOS ONLV AUTOS ONLY 12/31/2019 12/31/2020 COMBINED SINGLE LIMIT Ee accident $1,000,000 X BODILY INJURY (Par person) $ SDOILY INJURY (Per acciden) $ X PROPERTYDAMAGE fpieaccident $ C X UMBRELLALIAS EXCESS LIAB X OCCUR CLAIMS -MADE SI - 12/31/2019 12/31/2020 EACHOCCURRENCE $10,000,000 AGGREGATE $10,000,000 DED I I RETENTION$ Pollution $Included D WORKERS COMPENSATION ANDEMPLOYERS'LIABIDTY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ (Mandatory In NH) If yyes, describe under DESCRIPTION OF OPERATIONSbel. NIA °''" d& a_-w 12/31/2019 12(31/2020 X I STATUTE ERH E.L. EACH ACCIOEM $1,000,000OFFICER/MEMBEREXCLUDEDT E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000000 E Excess Liability I y °j M1 12/31/2019 12/31/2020 Each Occurrence 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached N more space is required) Evidence of Insurance Coverage for ES Opco USA, LLC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ES Opco USA LLC 3075 Highland Parkway, Suite 200 Downers Grove IL 60515 ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. N 2 Checkthis box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. N lA Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. N� A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? E]Yes FIND B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes E-1 No 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 1 v 6 LiCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signature of vendor doing business Qith the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Name and Title of Authorized Agent 36// 2�L Signature of Authorized Agent A Oc4 2NO Date I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed ) by 31, U.S.C)). § 1352 (as amended by the Lobbying Disclosure Act of 1995). % The Contractor, P A L. as aS , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provis' ns of 31 U.S.C. § 38seq., apply to this certification and disclosure, if any. tia10 Ig ature of ContralIctor's Authorized OfOfficial�jL Printed Name and Title of�Contractor's Authorize o2c4 20.,20 Date Approved by OMB 0348-0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application l filing b. grant b. initial award rial change c. cooperative agreement c. post -award d. I an Forange only: Alast e.I guarantee insurance Yeauarter f. Datrt 4. Name ind Akddress of Reporting Entity: J 5. if Repor ing Entity in No. I Pri a Subawardee Name an Address of Prime: Tier , if Know 6.Feder4IjDepartment/Agehey: 1 1 7. Federal CFDA Num or, ifapplicable: 8. Fede a I Action Number, ifkno n: 9. Award mount, if known: '1 10. a. N e and Address of Lobbyin egistrant b. Individlials Performing Services hchrding address iJ' (iflnrli dual, lastname, first name, M - differentfi- inNo. 10a) (last non e, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such Federal Use Only Signature: I Print Name: �i L Title: e W144 Telephone No.:'413-2o3-b43% Date: c2 Qcf xpo Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, 4: 4 h L • rs W 5 the undersigned representative of Representative V e'P2 k.s (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those enti ies or business associations that exist to make a profit. A C ') / SiJJ ature off Represenitative A L �l2i�Il Yaa:I jt Print Name & Title �5 ©C4 ,� DSO Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ I certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. (Company Name) is a "Nonresident Bidder" of Texas as defined in Government Code §2252.001 and our principal place of business is (City and State) Cal' I certify that �2 6e g , � is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. re of Authorized IAgent o I C �. ECG u s Y w b l: C Ile if �e G. A �1 se Name and Title of Authorized Agent �?g 0c 20,20 Date VENDOR AND ORDER INFORMATION Please Type if handwritten, must be in ink and legible Vendor's Name: l/ e,5 2 K i s Address: � , rJ D J-06A1 JjRe6s: Je5er2:5, r-(0o Wlcd P yNe C®t(�LIS CI�r S4� 7X 48N0g Remittance Address: t S O® C o LAS h 1_-1-- G [rl Telephone: I- O D O- q OO - 9 o 00� Fax: Email: I- (o©67+013� Email(s) to send Bid Information: K e i ( .. h as .5 I-' Ue 5 e 12 ; ,S . CD,�_ .r Signature of Authorized Representative: Printed name of Authorized Rep: � 2 :,+ L L . 11 a a 5 ORDER — CONTACT INFORMATION_ MAY* I �eK;Of Order Contact Name & Title: Order Contact Telephone: Order Contact Fax: Order Contact Email: ke:4 k L- . 413- 203- NfCO UArciC, 4pr95, Oy 3( i i I<e;qk. kaAS ✓eseR;s. Caws 12)S,Ce� e. Request for Taxpayer Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not �� Send to Rite IRS. m ► Go to www.im.gov/FormWS for instructions and the latest Information. 1 Name (as shown on your Income lax return). Name Is required on this line; do not leave this line blank. ES OPCO USA LLC 2 Business namaldisregarded entity arms. if different from above Veseris a S Check appropriate box for federal tax classifcation of the person whose name is entered an line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not Individuals; an a c [d] Individualllsole proprietor or 0 0Corpara0on ❑SCorporation ❑ Partnership ❑Twsusstato Instructions on page 3): 6 airgle-mamher LLC Exempt payed code of any) r u limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► `a Note: Check the appropriate box in the line above for the tax classification of the singla-member owner. Do not check Exemption from FATCA receding e w 'G a LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is is from for pods ( IP any) a 0 another LLC that not disregarded the ownar U.S. federal tax purposes. Otherwise, a single -member LLC that Is disregarded from the owner should check the appropriate box for the tax classification of its owner Other (a" Instructions) ► Nrr.W+ro•ttmmronwmYnN•uuu. m•us a Address (number. street, and apt. or suite no.) See Instructions. Requester's name and address (optional) 10800 Pecan Park Blvd #300 e City. state, and TIP cad, Austin TX 78750 7 Usl account numbers) here (oplionot) Tax aver Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid I social aeeur ty number i backup withholding. For proprietor, or this this is generally your social security number (Baru). However, far a _ m resident alien, sole proprietor, or disregarded entity, see She Instructions for Pad I, later. For ether entities, It is your employer Identification number (EIN), If you do not have a number, see How to get a TIN, later. or Note: If the account Is in more than one name, see the instructions for line 1. Also see What Name and jEmployarichertiff tlon number Number To Give the Requester for guidelines on whose number to enter. u 1. The number shown on this Porto Is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or ib)1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contdbut ons to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provde your correct TIN. Sea the instructions for Pan It, later. steel Signature of Here I U.S.oarsmb, A e Dater ;t/110>P?Nn General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments, For the latest Information about developments related to Form W-9 and Its instructions, such as legislation enacted after they were published, go to www.1rs.gov/FonnW9. Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), individual taxpayer Identification number (]TIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report an an information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099 C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only it you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not retum Form W9 to the requester with a TIN, you might be subject to backup withholding, See What is backup withholding, later Cat. No 10231X Form W9(Rev 10-20181 #12 Agenda Item for Commissioners Court — Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2021.03 for the period beginning January 1, 2021 and ending December 31, 2021. RE: Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2021.03 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Ten (10) bids were received: 1. BLADES GROUP, LLC 2. CLEVELAND ASPHALT PRODUCTS, INC. 3. JOHNNIE R. GRESHAM OPERATING, INC. 4. MARTIN MARIETTA MATERIALS, INC. 5. MARTIN PRODUCTS SALES, LLC dba MARTIN ASPHALT COMPANY 6. K-C LEASE SERVICE INC. dba MATAGORDA CONSTRUCTION & MATERIALS 7. MIDTEX MATERIALS, LLC 8. QUALITY HOT MIX, INC. 9. VULCAN MATERIALS COMPANY dba VULCAN CONSTRUCTION MATERIALS, LLC 10. WALLER COUNTY ASPHALT, INC. Vendor's bids are attached. REVIEW all bids to determine the vendors that meet vecificationsJ ALL TEN (10) BIDS APPEAR TO MEET SPECIFICATIONS NOT a tie:bids for the following (page 4 off 1. Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) 2. Bid Item #6; Item 302, Type PB, Grade 4 (Pre -Coated Rock) No bids on the following Bid Item #4: Item 275, Cement Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) (See Bid - page 7 of 10) Please review both bids for: Unit by the Ton to determine the low bid that meets specifications (See page 2 of the Specifications — attached for your review) Baseline Price for Fuel Adjustment on Delivery Price on November 9, 2020 = $2.132 SPECIFICATIONS FOR ROAD MATERIALS AND ASPHALTS, OIL AND EMULSIONS BY ORDER of the Commissioners Court of Calhoun County, Texas, sealed bids will be received for Road Materials and Asphalts, Oils and Emulsions as needed by the Road and Bridge Precincts. See Contact, Billing and Location Information for Calhoun County Precincts for complete information and location on each Calhoun County Road and Bridge Precinct. DEADLINE FOR SEALED BID SUBMISSION IS 2:00 PM, Tuesday, November 10, 2020 SUBMISSION OF SEALED BIDS Sealed bid shall be submitted to: Richard H. Meyer, County Judge Calhoun County Courthouse 211 S. Ann St., Suite 301 Port Lavaca, TX 77979 The outside of the 9 x 12 or larger envelope must be clearly marked: Sealed Bid 2021.03 — Road Materials and Asphalts, Oils and Emulsions If you send your bid by UPS, FedEx, or other delivery service, the outside of this envelope must be clearly marked: Sealed Bid 2021.03 — Road Materials and Asphalts, Oils and Emulsions BID TERM The bid shall be in effect for a period of twelve (12) months beginning January 1, 2021 and ending December 31, 2021. BID INFORMATION/REQUIREMENTS To submit a valid bid, read the entire Invitation to Bid Packet for all required information that must be included and all required forms that must be filled out, signed and dated and returned. Calhoun County is always very conscious and extremely appreciative of the time and effort you have expended to submit a bid. If you will not be submitting a bid, we would appreciate you indicating on your "NO BID" response any requirements of this bid request which may have influenced your decision to "NO BID". Calhoun County is not responsible for errors if the bid forms are handwritten. It is recommended that all information submitted by the vendor on the bid forms be typed. If handwritten, must be in ink and legible. White out is not acceptable. Page 1 of 8 Materials shall meet or exceed "Texas Department of Transportation Current Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges" and/or Calhoun County requirements. ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch to Dust Bid Item #2: Item 247, Type A Limestone, Grade 2 [1 % Inch] Bid Item #3: Item 247, Type A Limestone, Grade 3 [1 % Inch] Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb. Bag (on Pallets) Bid Item #5 Item 302, Type PB, Grade 3 (Pre -Coated Rock) Bid Item #6 Item 302, Type PB, Grade 4 (Pre- Coated Rock) Bid Item #7 Item 302, Type PE, Grade 3 (Pre -Coated Rock), *Material Source out of Bid Item #8 Item 302, Type PE, Grade 4 (Pre -Coated Rock), *Material Source out of Bid Item #9 Item 302, Type E, Grade 5, Ice Rock (Non Coated Limestone Only) Bid Item #10 Item 330, Type D (Pre -Mix Limestone) Bid Item #11 Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) The material will be used to construct a base course, a surface course, a level -up course, pothole repair, or any combination of these courses of the types and grade using a cold -mixed material consisting of native limestone rock asphalt (LRA) aggregate, fluxing material, water. LRA Mixture -Furnish LRA according to DMS-9210, "Limestone Rock Asphalt (LRA)", Item 330 D per the Surface Aggregate Classification plans as set forth by TXDOT Standard Specifications for Construction and Maintenance of Highways, Streets, and Bridges 2014. No material will be accepted that has been blended and stored on the producer's pad for more than 24 hours prior to loading and shipment. Bid Item #12 Item 334, Type D, Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.21MF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Bid Item #13 Item 432 Riprap, Section 2.3 Stone Riprap, 12" Limestone ASPHALTS, OILS & EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14 Primer Oil Bid Item #15 RC-250 —Temperature must be no lower than 1400 Bid Item #16 CRS-2 —Temperature must be no lower than 1500 and no higher than 1800 Vendor may bid any or all material(s) for any location. Vendor must be able to furnish bid items under terms of these specifications and general conditions if vendor is awarded a bid. Calhoun County is EXEMPT from all Sales Tax (county, city and state sales tax) and all Federal Excise Taxes, if applicable. Page 2 of 8 Pump and hoses, if applicable, are to be furnished by the vendor at no extra charge or shall be included in the bid. Demurrage charges, if applicable, stated separately from the bid price of the material will increase the amount of the bid price for the material. Materials bid must be broken down into price per unit and delivery price. A fuel adjustment will be allowed on the delivery price only as fluctuations in diesel prices occur as listed on http://www.eia.gov/petroleum/gasdie eel using the Gulf Coast Region. The baseline price will be the price on this site on November 9, 2020 rounded to the nearest one - hundredth and thereafter the index will be adjusted and documented on Monday of each week after bids are accepted. The allowable fuel adjustment will be calculated by subtracting the baseline price from the posted price (for the Monday immediately prior to the delivery date of the material), and if the difference is less than 5 cents no adjustment will be allowed; 5 cents to 9 cents a 1% adjustment to the delivery price per unit; 10 cents to 14 cents a 2% adjustment to the delivery price per unit; 15 to 19 cents a 3% adjustment to the delivery price per unit; 20 to 24 cents a 4% adjustment to the delivery price per unit and so on. A 1% adiustment will be made on the delivery price for every 5 cent increase or decrease from the baseline price. Vendor must include a copy of the document from the EIA.GOV website that was used to determine delivery price when invoicing Calhoun County. Vendor will be required to deliver to all jobsites in Calhoun County as directed by the Commissioner of applicable Calhoun County Precinct. Jobsite can be road, field location or stockpile at designated Calhoun County locations. Miles from pit to stockpile and/orjobsite will be shortest legal route. Delivery shall be FOB Destination to designated Calhoun County Precinct stockpile orjobsites. Materials shall be ordered in quantities as determined by each Calhoun County Commissioner. Calhoun County Precincts will put out needed signs and barricades for traffic control. Calhoun County Precincts will accept the number of trucks necessary to do a job on a most cost efficient basis, which could require various numbers of trucks. Any Vendor traveling on Calhoun County roads will not exceed its legal gross weight. Each load shall be weighed on a certified public scale. Truck and trailer shall be weighed empty at least once on each job run, or when a change is made due to changing truck, trailer, or other. Cost of weighing shall be paid by the hauler. Driver shall get a material company ticket from pit or location when loading. A copy of the scale weight ticket, material company ticket and Page 3 of 8 company delivery ticket shall be given to the Calhoun County employee at the jobsite when load is inspected and dumped. Calhoun County Precincts will supervise the dumping of loads and a Calhoun County employee will sign the delivery ticket. The Calhoun County Precinct must receive a copy of the signed delivery ticket. Calhoun County shall have the right to pull sample loaded truck(s) to a certified scale of Calhoun County's choice for loaded weight, unload truck(s) and take empty weight on same scale to verify weights. Calhoun County shall pay for the weighing. Calhoun County legally accepts the materials after it is unloaded and approved by the Calhoun County Commissioner of said precinct. Any exceptions and or variations from the specifications in this bid document must be indicated on the bid form or on a separate attachment to the bid and labeled as such. Exceptions taken and/or variations made to the specifications and listed on the vendor's bid or separate attachment may void the bid. The request for a bid on a material does not guarantee that Calhoun County will purchase this material during the bid period. Calhoun County does not guarantee to purchase any minimum or maximum quantities. The materials will only be ordered as needed. When required, all materials ordered will be delivered to the Calhoun County Precinct within 24 hours from time of order. In the event the vendor is unable to deliver the materials(s) ordered within 24 hours from time of order, Calhoun County reserves the right to cancel the order and re -order the said material(s) from the vendor which submitted the next lowest bid that met specifications and can deliver within 24 hours from time of order. Calhoun County shall not incur any penalties, fees and/or other charges when cancelling an order. Vendor shall be required to notify Calhoun County in the event of unforeseen delay arising in the delivery of an order. In the event an order will not arrive at the Calhoun County Precinct at the designated time, Calhoun County shall have the right to cancel the order or refuse acceptance of the order. Calhoun County shall not be accessed any penalties, fees and/or other costs due to this cancellation or refusal. Calhoun County or the vendor have the right to cancel the delivery of a material(s) at any time due to weather, road conditions and/or machinery breakdown. No penalties, fees and/or other charges will be billed to Calhoun County if the delivery of a material(s) is cancelled by Calhoun County or the vendor due to weather, road conditions and/or machinery breakdown. The County reserves the right to refuse any order delivered for not being in compliance with the specifications, general conditions and/or the "Hazardous Communications Act", commonly known as the "Texas Right to Know Act". The vendor, at the vendor's cost, shall immediately remove the material(s) from the Calhoun County Precinct that are deemed unsatisfactory, and are not in compliance with the specifications, general conditions and/or do not meet State and/or Federal Regulations. No Page 4 of 8 penalties, fees, and/or other charges will be billed to Calhoun County for the removal of the material(s) from the Calhoun County Precinct. Safety Data Sheets and Placards, if applicable, must be furnished at the time of delivery as specified by State and/or Federal Regulations. Calhoun County reserves the right to conduct random sampling of pre -qualified materials for testing and to perform random audits of test reports. Calhoun County representatives may sample materials from the manufacturing plant, terminal, shipping container and any other source they deem necessary to insure reliability of the materials. If testing will be performed through a third party, the vendor will be required to allow the third party access to the facilities in order to acquire samples for testing. Regardless of results of any material(s) test required by Calhoun County, all costs incurred for such tests shall be paid for by the vendor. Specifications are not being met if materials are not delivered at the required temperatures. The award of a bid will be voided if specifications, general conditions and/or instructions within this Invitation to Bid Packet are not followed. The bid would then be awarded to the vendor which submitted the next lowest bid that met specifications and all requirements of the Invitation to Bid Packet. All Calhoun County Precincts handle their own orders; therefore invoices shall be billed to each Calhoun County Precinct separately. All invoices must be billed to Calhoun County to the attention of the Calhoun County Commissioner and Precinct ordering the material(s). Bid item number and material description, as stated on the bid form, awarded material bid price per unit and delivery price must appear on all invoices in order to be considered for payment. No other charges, including pump, hoses, special fees or after hour delivery fees, may be added to the awarded bid price per unit and delivery price when invoiced unless these charges were noted on the bid form or separate attachment and awarded as such. Invoices shall be free from sales tax (county, city or state sales tax) and federal excise taxes, if applicable. Invoices shall include a copy of the document from the EIA.GOV website that was used to calculate the increase or decrease in the delivery charge. Invoices shall include a copy of the delivery ticket that shows confirmation of delivery. It is understood that Calhoun County Commissioners Court reserves the right to accept or reject any and/or all bids for any/or all materials and/or services covered in this bid request and to waive informalities or defects in bids, or to accept such bids as it shall deem to be most advantageous and in the best interest of Calhoun County. Page 5 of 8 Calhoun County Commissioners have the right to reject at any time any material that is undesirable for either road orjobsite location. Calhoun County will evaluate and award bid based on lowest and best bid meeting specifications and all requirements of the Invitation to Bid Packet. "Lowest and best" means a bid or offer providing the best value considering associated direct and indirect costs, including transport, maintenance, reliability, life cycle, warranties and customer service after a sale. Calhoun County reserves the right to accept and/or reject any/all of the options bid as it deems to be in the best interest of Calhoun County. Although the cost of materials(s) to be provided is an essential part of the bid, Calhoun County is not obligated to award a bid (contract) on the sole basis of cost but will award to the vendor considered to be the best value to the Calhoun County. The bid award shall be based on, but not necessarily limited to, the following factors: • Unit price • Extended price (and other charges, if any) • Special needs and requirements of Calhoun County • Delivery • Compliance in returning and/or including all required forms • Results of testing samples (if required by Calhoun County) • Calhoun County's experience with materials bid • Vendors past performance record with Calhoun County If bids are awarded, award information will be emailed and/or mailed to all vendors that submitted a bid regardless if the vendor was awarded a bid or not. Calhoun County Commissioners Court and the County Auditor's office work diligently to get this information to the vendors as soon as possible. To obtain results, or if you have any questions, please contact Peggy Hall, Calhoun County Assistant Auditor, 202 S. Ann St., Suite B, Port Lavaca, Texas 77979, or by phone or email, (361) 553-4610, peggy.hall@calhouncotx.org. As time permits, bid awards will be posted on Calhoun County's website, www.calhouncotx.org, under Bid Notices and Results. Once bids are awarded by Calhoun County Commissioners Court, this bid packet in its entirety will be the working contract between Calhoun County and the successful bidder for the period designated. Calhoun County or the vendor may cancel this contract at any time for any reason, provided a written notice is given. Should there be a change in ownership or management, the bid (contract) shall be cancelled unless a mutual agreement is reached with the new owner or manager to continue the bid (contract) with its present provisions and prices. Vendor understands that Calhoun County is a government entity subject to Texas State and Federal public information statues. Vendor hereby waives any obligation to the release to the public of any documents submitted in accordance with the bid. Page 6 of 8 No person has the authority to verbally alter these specifications or any information within the Invitation to Bid packet. Any changes will be made in writing (Addendum approved by Calhoun County Commissioners Court) and mailed and or emailed to each vendor that received a bid packet. All disputes or protests will be held in Calhoun County, Texas. INSURANCE REQUIREMENTS The awarded bidder must furnish, at their own expense, certificates of insurance or other acceptable evidence from a reputable insurance company or companies acceptable to Calhoun County, licensed to write insurance in the State of Texas showing the contractor (bidder) is covered by insurance within the following minimum limits of liability: • Statutory Workers' Compensation and Employer's Liability Insurance ($1,000,000 or greater) with a Waiver of Subrogation in favor of Calhoun County. • General Liability including Product Liability Insurance ($100,000/$3,000,000 or greater) • Auto Insurance ($100,000 BIPP/$300,000 BIPO/$100,000 PD or greater) Coverage shall apply on an occurrence basis. In the event any work is sublet, the contractor (bidder) shall require each subcontractor similarly to provide the same coverage and shall acquire evidence of such coverage of the subcontractor. The policy(s) shall be on the commercial general liability form and shall include coverage for acts of independent contractors. Calhoun County shall be covered as an additional insured under the policy(s). The certificates of insurance furnished to Calhoun County shall contain a provision that coverage under such policies shall not be cancelled or materially changed unless at least a 30 days prior written notice has been given to Calhoun County. Calhoun County's receipt of or failure to object to any insurance certificates or policies submitted by the awarded bidder does not release or diminish in any manner the liability or obligations of the awarded bidder or subcontractor or constitute a waiver of any of the insurance requirements for the bid. Replacement certificates of liability of insurance evidencing continuation of such coverage and naming, by policy endorsement, Calhoun County as an additional insured, shall be furnished to the County Auditor's office prior to the expiration of the current policies. Should the awarded bidder at any time neglect, refuse to provide, or cancel the insurance required, Calhoun County shall have the right to terminate the bid and/or pursue any remedy available by law. The insurance coverage requirements in this bid will in no way be construed as limiting the scope of indemnification. Page 7 of 8 REQUIRED INFORMATION/FORMS TO BE RETURNED WITH INVITIATION TO BID • Invitation to Bid Form (page 1-8) • Affidavit • Certificate of Interested Parties, Form 1295 — Must return when submitting your bid • Certificate of Current Liability Insurance — Return a copy of your current Certificate of Liability Insurance with your bid. This will provide proof that you carry at least the minimum required coverage. Once the bids are awarded, the bidder that is awarded a bid must provide a Certificate of Liability Insurance that reflects that Calhoun County (certificate holder) is an additional insured on general liability subject to the conditions of the additional insured. • Conflict of Interest Questionnaire, Form CIQ— Every bidder doing business with Calhoun County or seeking to do business with Calhoun County must complete Box 1 and sign and date in Box 7. Whether or not a conflict exists determines the other information to include on the form. • Certificate Regarding Debarment & Suspension and Other Responsibility Matters • Certification Regarding Lobbying • Disclosure of Lobbying Activities — If Not Applicable, bidder must mark NA, and sign and date • House Bill 89 Verification • Residence Certification • Vendor and Order Information Form • W-9 Page 8 of 8 F v c^ .0 m A C D r.z :4 m x 3 D m �� 3 a z z mr m 2 z Rn o z g z = 3 v ~'a 3 A Z O z C z D Q y m O m A A z 0 D D A O C m 2 A 3 G <_ p 9 C m m m y D n D Ain p n O z z n y N D 3 y. v a n O m `Q m ti O.v A C N A m. O O m z D n r r D y C H z G) m !P n z z n n A a G Y1 A OM vmi w tmii wvmi vmi tmn 3 m m m m m m m m m m m m a G < < (m/1 (m/1 N lm/1 VI V1 VI IA N � 3. Im (m/1 Im/. (m/1 (m/1 VI (A VI Vmf N M ^? 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C Q rt m m N O a N C S W CALHOUN COUNTY, TEXAS BID TABULATION ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT, BID NUMBER: 2021.03 For the Period Beginning January 1, 2021 and Ending December 31, 2021 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE: $2.132 on November 9, 2020 Tie Bids: The winning bid is determined per Texas Local Government Code 262.027(b). ROAD MATERIALS If two responsiblebldders submit the lowest andbest bid, the commissionerscourt shall decide between the two by drawine lots in a mannarnrescdhad by the cnuntv.ludn Bid Item #1: Limestone-3/4 Inch to Dust .LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct Ton $6.00 $21.50 $27.50 24 tons Precinct 4-P Ton $6.00 $21.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons. Precinct 1 Ton $5.50 $24.00 $29.50 Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction & Materials Precinct 2 Ton $5.50 $24.00 $29.50. Belly 25 tons Precinct 3 Ton $5.50 $24.00 $29.50. Belly 25 tons Precinct4-P Ton 1 $5.50 1 $24.50 1 $30.00 1 Belly 25 tons Precinct 4-5 Ton $5.50 $24.00 $29.50 Belly 25 tons Precinct 1 Ton $6.00 $24.00 $30.00 24 MidTex Materials, LLC (Bid has error on Precinct 4-S) Precinct 2 Ton $6.00. $24.00 $30.00 24 Precinct 3 Ton $6.00 524.00 $30,00 24 Precinct4-P Ton $6.00 $26.00 $32.00 24 Precinct4-S Ton $6.00 $6.00 (Bid has $6.00) $30.00 (Bid has$30) 24 Precinct 1 Ton $4.97 $26.48 $31.45 N/A Johnnie R. Gresham Operating, Inc. Precinct Ton $4.97` $26.48 ,$31.45 N/A Precinct 3 Ton $4.97 $26.48 $31.45 - N/A Precinct 4-P Ton 1 $4.97 $26.48 $31.45 N/A Precinct 4-S Tan 1 $4.97 $26.48 $31.45 N/A Page 1 of 10 Bid Item#2: ITEM 247, TYPE A LIMESTONE, GRADE 2 [13/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIESARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct 3 Ton $6.00 $21.50 24 tons Precinct 4-P Ton $6.00 $21.50 .27.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons Precinct 1 Ton $5.00 $24.00 $29.00. Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction St Materials Precinct Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct 3 Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct 4-P Ton $5.00 $24.50 $29.50 Belly 25 tons Precinct 4-S Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct 1 Ton $6.00 $24.00 $30.00 24 MidTex Materials, LLC Precinct 2 Ton $6.00 $24.00 $30.00 24 Precinct 3 Ton $6.00 $24.00 $30.00 24 Precinct 4-1) Ton $6.00 $26.00 $32.00 24 Precinct 4-S Ton $6.00 $24.00 $30.00 24 Precinct 1 Ton $4.47 $26.48 $30.95 N/A Johnnie R. Gresham Operating, Inc. Precinct Ton $4.47 $26.48 $30.95 N/A Precinct .Ton $4.47 $26.48 $30.95 N/A Precinct 4-P Ton $4.47 $26.48 $30.95 N/A Precinct4-S Ton $4.47 $26.48 $30.95 N/A Precinct 1 Ton $23.50 $14.00 $37.50 24 tons Martin Marietta Materials, Inc. *VIA GREGORY RAIL YARD* *Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $23.50 $14.25 $37.75 24 tons Precinct 3 Ton $23.50 $15.96 $39.46 24 tons Precinct4-P Ton $23.50 $15.96 $39.46 24tons Precinct4-S Ton $23.50 1 $13.80 1 $37.30 1 24 tons Precinct 1 Ton $22.50 $19.00 $41.50 22 tons Vulcan Materials Company dba Vulcan Construction Materials, LLC Precinct 2 Ton $22.50 $20.00 $42.50 22 tons Precinct 3 Ton $22.50 $21.50 $44.00 22 tons Precinct4-P Ton $22.50 $21.50 $44.00 22 tons Precinct 4-S Ton $22.50_ $19.00 $41.50 22 tons Page 2 of 10 Bid Item #3: ITEM 247, TYPE A LIMESTONE, GRADE 3 [13/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct 3 Ton$6.00 $21.50 $27.50 24 tons Precinct 4-P Ton $6.00 $21.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons Precinct 1 Ton $6.00 $24.00 $30.00 24 MidTex Materials, LLC Precinct 2 Ton $6.00 $24.00 $30.00 24 Precinct Ton $6.00 $24.00 $30.00 24 Precinct 4-P, Ton $6.00 $26.00 $32.00 24 Precinct 4-S Ton $6.00 $24.00 $30.00 24 Precinct 1 Ton $4.47 $26.48 $30.95 N/A Johnnie R. Gresham Operating, Inc. Precinct 2 Ton $4.47 $26.48 $30.95 N/A Precinct 3 Ton $4.47 $26.48 $30.95 N/A Precinct 4-P Ton $4.47 $26.48 $30.95 N/A Precinct 4-S Ton $4.47 $26.48 $30.95 N/A Precinct 1 Ton $22.50 $19.00 $41.50 22 tons Vulcan Materials Company dba Vulcan Constructions Materials, LLC , Precinct 2 Ton $22.50 $20.00 $42.50 22 tons Precinct 3 Ton $22.50 $21.50 $44.00 22 tons Precinct4-P Ton $2250 $21.50 $44.00 22tons Precinct4-S Ton $22.50 $19.00 $41.50 22tons Bid Item #4: ITEM 275, CEMENT 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed), 275.2-1, Hydraulic Cement Type 1, 47 lb Bag (cost per Pallet) List # of 47 lb Bags on a Pallet LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1, 2, 3, Ton 4-P&4-S NO BIDS RECEIVED _ of 47 L6 Bags on Pallet Page 3 of 10 Bid Item #5: Item 302,`Type PB, Grade 3 (Pre -Coated Rock) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND. REMARKS, IF ANY Precinct 1 Ton $23.39 $38.61 $62.00 '' 24 tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY* " Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $23.70 $38.30 $62.00 24 tons Precinct 3 Ton $21.18 $40.82 $62.00 24 tons Precinct4-P Ton $20.71 1 $41.29 1 $62.00 24 tons Precinct 4-S Ton $23.07 $38.93 $62.00 24 tons Precinct 1 Ton $53.00 $9.00 $62.00 24 tons Quality Hot Mix, Inc. *NOTE' ALL DELIVERIES ARE IN. END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED&. PROVIDED IF AVAILABLE. Precinct Ton $53.00 $9.00 $62.00 24 tons Precinct 3 Ton $53.00 $9.00 $62.00 24 tons Precinct 4-P Ton 1 $53.00 $9.00 $62.00 :`1 24 tons Precinct 4-S I Ton 1 $53.00 $9.00 $62.00 1 24 tons Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF. ANY Precinct 1 Ton $23.39 $38.61 $62.00 24 tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY* ` Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED,4NCLUDED WITH THEIR BID Precinct Ton $23.70 $38.30 $62.00 24 tons Precinct 3 Ton $21.18 $40.82 $62.00 24 tons. Precinct4-P Ton $20.71 $41.29 $62.00 24 tons Precinct4-S Ton $23.07 $38.93 $62.00 24tons Precinct s Ton $53.00 $9.00 $62.00 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $53.00 $9.00 $62.00 24tons Precinct 3 Ton $53.00 $9.00 $62.00 ` 24 tons Precinct 4-P Ton 1 $53.00 1 $9.00 $62.00 1 24tons Precinct 4-S I Ton $53.00 $9.00 $62.00 24 tons Page 4 of 10 Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material source out of LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $22.50 $37.98 $60.48 24 tons Vulcan Materials Company Precinct 2 Ton $22.50 1 $38.75 $61.25 24 tons dba Vulcan Construction Precinct Ton $22.50 $40.30 $62.80 24 tons Materials, LLC Precinct 4-P Ton $22.50 $38.75 $61.25 24 tons * MATERIAL SOURCE OUT OF DABNEY(UVALDE)" Precinct 4-S Ton $22.50 $38.75 $61.25 24tons Precinct 1 Ton $27.91 $38.61. $66.52 24tons. Martin Marietta Materials, Inc. Precinct Ton $29.18 $38.30 $67.48 24 tons * MATERIAL SOURCE OUT OF UVALDE' *VIA BLACK SPUR QUARRY* Precinct 3 Ton $28.40 $40.82 $69.22 24 tons *Page8 of Bid, under Exceptions and/or Variations from Specifications and/or additional Precinct 4-P Ton 1 $27.93 1 $41.29 1 $69.22 1 24 tons notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING -NO LETTER WAS Precinct4-S Ton $27.59 $38.93 $66.52 24tons ATTACHED/INCLUDEDWITH THEIR BID Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Materialsource out of LOCATION Unit. MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF. ANY Precinct 1 Ton $23.50 $37.98 $61.48 24 tons Vulcan Materials' Company Precinct Ton $23.50 $38.75 $62.25 24tons dba Vulcan Construction. Precinct 3 Ton $23.50 $40.30 $63.80 24 tons Materials, LLC Precinct4-P Ton $23.50 $38.75 $62.25 24 tons *MATERIAL SOURCE OUT OF. DABNEY (UVALDE)* Precinct 4-S Ton $23.50 $38.75 $62.25 24 tons Precinct I Ton $27.91 $38.61 $66.52 24 tons Martin Marietta Materials, Inc. Precinct Ton $29.18 $38.30 $67.48 24 tons * MATERIAL SOURCE OUT OF UVALDE Precinct 3 Ton $28.40 $40.82 $69.22 24 tons *Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additonal Precinct 4-P Ton $v.93 $41.29 $69.22 24tons notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS Precinct 4-S Ton $27s59 $38.93 $66.52 24tons ATTACHED/INCLUDED WITH THEIR BID Page 5 of 10 Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER ` BIDDER AND REMARKS, IF ANY Precinct 1 Ton $15.50 $24.00 $39.50 Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction and Materials Precinct 2 Ton $15.50 $24.00 $39.50 Belly 25 tons Precinct 3 Ton 1 $15.50 $24.00 1 $39.50 1 Belly 25 tons Precinct4-P Ton $15.50 $24.50 $40.00 Belly 25tons Precinct 4-S Ton $15.50 $24.00 $39.50 Belly 25 tons Precinct 1 Ton $26.50 $23.50 $50.00 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERES CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $26.50 $23.50 $50.00 24 tons Precinct 3 Ton $26.50 $23.50 $50.00 24 tons Precinct4-P Tone $26.50 $23:50 $50.00 24tons Precinct 4-S Ton $26.50 $23.50 $50.00 24tons Bid Item#10: ITEM 330, TYPE D;(PRE-MIX LIMESTONE) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $10.50 $26.48 $36.98 N/A Johnnie R. Gresham Operating, Inc. - Precinct - Ton ' $10.50 $26.48 $36.98 N/A Precinct 3 1 Ton 1 $10.50 1 $26.48 1 $36.98 1 N/A Precinct4-P Ton $10.50 $26.48 $36.98 N/A Precinct 4-S - Ton $10.50 $26.48 $36.98 N/A Precinct 1 Ton ' $40.50 $37.98 $78.48 24tons Vulcan Materials Companydba Vulcan Construction Materials, LLC *LIMESTONE ROCK ASPHALT Precinct 2 .Ton $40.50 $38.75 $79.25 24tons Precinct 3 Ton $40.50 $40.30 $80.80 24 tons Precinct 4-P Ton $40.50 $38.75 $79.25 24 tons Precinct4-S Ton F $40.50 $38.75 $79.25 24tons Precinct 1 Ton $46.00 $38.61 $84.61 24tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY *Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING -.NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $46.00 $38.30 $84.30 24 tons Precinct 3 Ton $46.00 $40.82 $86.82 24 tons Precinct 4-P Ton $46.00 $41.29 $87.29 24 tons Precinct4-S Ton $46.00 $38.93 $84.93 24tons Page 6 of 10 Bid Item #11: ITEM 330 D, POTHOLE REPAIR, LIMESTONE ROCK ASPHALT (LRA) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct Ton $46.50 $37.98 $84.48 24 tons Yard3 No Bid 50 lb Bag No Bid Precinct 2 Ton $46.50 $38.75 $85.25 24 tons Yard3 No Bid 50 Ib Bag No Bid Vulcan Materials Companydba Precinct 3 Ton $46.50 $40.30 $86.80 24 tons Yard No Bid Vulcan Construction 50 lb Bag No Bid Materials, LLC * D PLUS MIX Precinct4-P Ton $46.50 $38.75 $85.25 24 tons Yard No Bid 50 lb Bag No Bid Precinct4-S. Ton $46.50 $38.75 $85.25 24tons Yard No Bid 50 lb Bag No Bid Precinct 1 Ton $58.77. $39.18 $97.95 24 Tons Yard $65.23 $43.49 $108.72 22 Cu Yds 50 lb Bag $12.00 $12.00 62 Bags = 1 Pallet Precinct 2 Ton $57.32 $38.22 $95.54 24 Tons Yard3 $67.64 $45.10 $112.74 22CuYds 50 Ib Bag $12.00 - $12.00 62 Bags = 1 Pallet Precinct 3 Ton $64.75 $43.17 $107.92 24 Tons Yard3 ' $76.41 $50.94 $127.35 22 Cu Yds Blades Group, LLC 50lbBag $12.00 - $12.00 62Bags =.... . 1 Pallet Precinct4-P .Ton $64.24 $42.82 $107.06 24 Tons Yard $75.80 $50.53 $126.33 22 Cu Yds 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Precinct 4-S Ton $62.28 $41.52 $103.80 24 Tons Yard $73.49 $48.99 $122.48 22 Cu Yds 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Page 7 of 10 Bid Item #12: ITEM 334, TYPE D, HOT MIX COLD LAID ASPHALT CONCRETE PAVEMENT LOCATION Unit. MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $75.00. $9.00 $84.00 25 tons Quality Hot Mix, Inc. 'NOTE' ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED& PROVIDED IF AVAILABLE. Precinct 2 Ton $75.00 $9.00 $84.00 25 tons Precinct 3 Ton $75.00 $9.00 $84.00 25 tons Precinct 4-P Ton $75.00 $9.00 $84.00 25 tons Precinct 4-S Ton $75.00 t$9.00 $84.00 25 tons Precinct 1 Ton $85.00 $30.59 $115.59 25 TONS DELIVERED Waller County Asphalt, Inc. ' BID IS FOR HIGH PERFORMANCE ASPPM GRADE IV', Precinct 2 Ton $85.00 $31.51 $116.51 25 TONS Precinct 3 Ton $85.00 $27.83 $112.83 25 TONS Precinct 4-P Ton 1 $85.00 1 $35.19 1 $120.19 1 25 TONS Precinct4-S Ton 1 $85.00 1 $34.96 1 $119.96 1 25 TONS. Bid Item #13: ITEM 432, Riprap, Section 2.3 Stone Riprap,12" Limestone LOCATION Unit. MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND. REMARKS, IF. ANY Precinct l Ton $17.33 $34.13 $51.46 N/A Johnnie R. Gresham Operating, Inc. Precinct 1 Ton $17.33 $34.13 $51.46 N/A Precinct 3 1 Ton 1 $17.33 1 $34.13 1 $51.46 1 N/A Precinct4-P Ton $17.33 $34.13 $51.46 N/A Precinct4-S Ton $17.33 $34.13 $51.46 N/A Precinct 1 Ton $26.00 $50.00 $76.00 24 MidTex.Materials, LLC Precinct 2 Ton $26.00 $50.00 $76.00 24 Precinct 3 .Ton $26.00 $50.00 $76.00 24 Precinct 4-P Ton 1 $26.00 $52.00 1 $78.00 1 24 Precinct4-S Ton $26.00 $50.00 $76.00 24 Precinct 1 Ton $40.00 $45.00 $85.00 22 tons Vulcan Materials Company dba Vulcan Construction Materials, LLC Precinct 2 Ton $40.00 $45.00 $85.00 22 tons Precinct 3 Ton $40.00 $50.00 $90.00 22 tons Precinct 4-P Ton $40.00 $47.00 $87.00 22 tons Precinct 4-S I Ton $40.00 1 $45.00 $85.00 22 tons Page 8 of 10 ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $2.00 $0.20 $2.20 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $2.00 $0.20 $2.20 After 2 Free Hours Cleveland Asphalt Products, Inc. • PRICE BASED ON MINIMUM FULL LOAD OF $80.00 Per Hour. 5000 GALLONS, FOR SMALLER QUANTITIES Precinct 3 1 Gallon $2.00 1 $0.20 $2.20 After 2 Free Hours PLEASE CALL 800-334-0177. DILUTED MATERIALCANNOT.BE RETURNED $80.00 Per Hour FOR CREDIT. Precinct 4-P Gallon $2.00 $0.20 $2.20 After 2 Free Hours $80.00 Per Hour Precinct4-S Gallon. $2.00 $0.20 $2.20 After 2Free :Hours $70.00 Per Hour Precinct 1 Gallon $2.65 $0.19 $2.84 After 2 Free Hours $70.00 Per Hour Precinct 2 Gallon $2.65 $0.19 $2.84 After 2 Free Hours Martin Products Sales, LLC dba $70.00 Per Hour Precinct 3 Gallon $2.65 1 $0.17 $2.82 After 2 Free Hours Martin Asphalt Company *.MC-30* $70.00 Per Hour * 5,000 GAL MINIMUM Precinct 4-P Gallon $2.65 $0.21 $2.86 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $2.65 $0.21 $2.86 After 2 Free Hours Page 9 of 10 Bid Item#15: RC-250 LOCATION .Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER. AND REMARKS, IF ANY $70.00 Per Hour Precinct 1 Gallon: $2.55 $0.19 2.74 After 2 Free Hours $70.00 Per Hour Precinct 2 Gallon $2.55 $0.19 2.74 After 2 Free Hours Martin Products Sales, LLC $70.00 Per Hour dba Precinct 3 Gallon $2.55 $0.17 2.72 After 2 Free Hours Martin Asphalt Company $70.00 Per Hour * 5000 GALLON MINIMUM Precinct 4-P Gallon $2.55 $0.21 2.76 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $2.55 $0.21 2.76 After 2 Free Hours $80.00 Per Hour Precinct 1 Gallon $2.75 $0.20 2.95 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $2.75 $0.20 2.95 After 2 Free Hours Cleveland Asphalt Products, Inc. *. PRICE BASED ON MINIMUM FULL LOAD OF $80.00 Per Hour 5000 GALLONS, FOR SMALLER QUANTITIES Precinct 3 Gallon $2.75 $0.20 2.95 After 2 Free Hours PLEASE CALL 800-334.0177. DILUTED MATERIAL CANNOT BE RETURNED $80.00 Per Hour Precinct 4-P Gallon $2.75 $0.20 2.95 After 2 Free Hours FOR CREDIT. $80.00 Per Hour Precinct4-S Gallon $2.75 $0.20 2.95 After 2 Free Hours Bid Item #16: CRS=2 LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $1.75 $0.20 $1,95 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $1.75 $0.20 $1.95 After 2 Free Hours Cleveland Asphalt Products, Inc. * PRICE BASED ON MINIMUM FULL LOAD OF $80.00 Per Hour 5000 GALLONS, FOR SMALLER QUANTITIES. Precinct 3 Gallo❑ $1.75 $0.20 $1.95 After 2 Free Hours PLEASE CALL 800-334-0177. DILUTED MATERIALCANNOTBE RETURNED $80.00 Per Hour Precinct 4-P Gallon $1.75 $0.20 $1.95 After 2 Free Hours FOR CREDIT. $80.00 Per Hour Precinct 4-S Gallon $1.75 $0.20 $1.95 After 2 Free Hours $70.00 Per Hour Precinct 1 Gallon $1.85 $0.19 $2.04 After 2 Free Hours $70.00 Per Hour Precinct 2 Gallon $1.85 $0.19 $2.04 After 2 Free Hours Martin Products Sales, LLC $70.00 Per Hour dba Precinct 3 Gallon $1.85 $0.17 $2.02 After 2 Free Hours Martin Asphalt Company $70.00 Per Hour * 5000 GALLON MINIMUM Precinct 4-P Gallon $1.85 $0.21 $2.06 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $1.85 $0.21 $2.06 lAfter 2 Free Hours Page 10 of 10 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE ON NOVEMBER 9, 2020 (See page 3 of the specifications) $2.132 www.eia.gov/petroleum/gasdiesel For ROAD MATERIALS ULlIII ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 eiaU.S. Energy Information Administration PETROLEUM & OTHER LIQUIDS OVERVIEW DATA ANALYSIS & PROJECTIONS '(' l./Q.�+e• n. `I rl (�P. GLOSSARY, FAQS> Weekly Retail Gasoline and Diesel Prices •, /nf Zv 2 v (Dollars per Galion, Including Tries). Nw _41 Ares Gulf Coast (PADD 3) v Period: Weekly v show Dam By:. e Product C Area Graph cm,� 90105/20 10/72120 10119120 10126/20 19/02720 11109120 haw Hlelory Gasoline -All Grades ❑ 1.9011 1.914 1.905 1.908 1.8621 1.823 1993.2020 All Grades- Conventional Ames 0 1.915 1.923 1.927 1.917 1.878 1.B41 1994.2020 All Grades- Reformulated Area ❑ 1.870 1.893 1.855 1.888 i.B261.783 1994-2020 Regular 0 1.827 _ 1.839 1.830 1.832 1.788 1.748 1992.2020 Conventonal Areas ❑ 1.848 1.856 1.859 1.848 1.810 1.773 1092.2020 Reformulated Areas ❑ 1.777 1.799 1.760 1.793 1.731 1.688 1994-2020 Mld9rade 0 2.199 2.212 2.203 2.211 - 2.167 2.124 1994.2020. Conventonal Ames ❑ 2.228 2.232 2.236 2.226 2.195 2.153 1994-2020 Reformulated Areas ❑ 2.150 2.176 2.143 _ PA78 2.117 2.072 1994.2020 Premium 0 2A67 2A83 2.479 2.485 2.437 2.400 1994.2on Conven8onal Areas 0 2.509 2.520 2.534 2.523 2.483 2.448 1994.2020 Reformulated Areas ❑ 2.406 2A30 2,400 2.429 2.371 2.329 1994-2020 Dim] (On -Highway) -All Type ❑ 2.141 2.148 2.143 2.146 2.131 2.132 1994.2020 Ultra Low sulfur (15 ppm and Under) 0 2.141 2.148 2.143 2,146 2A31 2.132 2007.2D20 Click on the mums key loan to Teem haw mdow uml series Into BMW, arm embed a Mad or map on yourwehase.. -No Data Reported;--NotAppllmbm; NA=NotAvallable; W=WlthtwldtomlddladwumofindWldual=panydata. Relems Dam: 111M020 Nest Remus Date; 1111612020 Agenda Item for Commissioners Court — Wednesday, November 25, 2020 Consider and take necessary action to award the bids for Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2021.03 for the period beginning January 1, 2021 and ending December 31, 2021. RE: Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2021.03 Period beginning January 1, 2021 and ending December 31, 2021 Bids were opened at 2:00 PM, Tuesday, November 10, 2020. Ten (10) bids were received: 1. BLADES GROUP, LLC 2. CLEVELAND ASPHALT PRODUCTS, INC. 3. JOHNNIER. GRESHAM OPERATING, INC. 4. MARTIN MARIETTA MATERIALS, INC. 5. MARTIN PRODUCTS SALES, LLC dba MARTIN ASPHALT COMPANY 6. K-C LEASE SERVICE INC. dba MATAGORDA CONSTRUCTION & MATERIALS 7. MIDTEX MATERIALS, LLC 8. QUALITY HOT MIX, INC. 9. VULCAN MATERIALS COMPANY dba VULCAN CONSTRUCTION MATERIALS, LLC 10. WALLER COUNTY ASPHALT, INC. Vendor's bids are attached.; FEVIEW all bids to determine the vendors that meet specifications. ALL TEN (10) BIDS APPEAR TO MEET SPECIFICATIONS —_ NOTE? [T bids for the following (page 4 of 10) 1. Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) 2. Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) iNo bids on the following Bid Item#4: Item 275, Cement Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) (See Bid - page 7 of 10) Please review both bids for: Unit by the Tonto determine the low bid that meets specifications (See page 2 of the Specifications — attached for your review) Baseline Price for Fuel Adjustment on Delivery Price on November 9, 2020 = $2.132 ,. k SPECIFICATIONS FOR ROAD MATERIALS AND ASPHALTS, OIL AND EMULSIONS BY ORDER of the Commissioners Court of Calhoun County, Texas, sealed bids will be received for Road Materials and Asphalts, Oils and Emulsions as needed by the Road and Bridge Precincts. See Contact, Billing and Location Information for Calhoun County Precincts for complete information and location on each Calhoun County Road and Bridge Precinct. DEADLINE FOR SEALED BID SUBMISSION IS 2:00 PM, Tuesday, November 10, 2020 SUBMISSION OF SEALED BIDS Sealed bid shall be submitted to: Richard H. Meyer, County Judge Calhoun County Courthouse 211 S. Ann St., Suite 301 Port Lavaca, TX 77979 The outside of the 9 x 12 or larger envelope must be clearly marked: Sealed Bid 2021.03 — Road Materials and Asphalts, Oils and Emulsions If you send your bid by UPS, Fed Ex, or other delivery service, the outside of this envelope must be clearly marked: Sealed Bid 2021.03 — Road Materials and Asphalts, Oils and Emulsions BID TERM The bid shall be in effect for a period of twelve (12) months beginning January 1, 2021 and ending December 31, 2021. BID INFORMATION/REQUIREMENTS To submit a valid bid, read the entire Invitation to Bid Packet for all required information that must be included and all required forms that must be filled out, signed and dated and returned. Calhoun County is always very conscious and extremely appreciative of the time and effort you have expended to submit a bid. If you will not be submitting a bid, we would appreciate you indicating on your "NO BID" response any requirements of this bid request which may have influenced your decision to "NO BID". Calhoun County is not responsible for errors if the bid forms are handwritten. It is recommended that all information submitted by the vendor on the bid forms be typed. If handwritten, must be in ink and legible. White out is not acceptable. Page 1 of 8 A Materials shall meet or exceed "Texas Department of Transportation Current Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges" and/or Calhoun County requirements. ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch to Dust Bid Item #2: Item 247, Type A Limestone, Grade 2 [1 % Inch] Bid Item #3: Item 247, Type A Limestone, Grade 3 [1 % Inch] Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb. Bag (on Pallets) Bid Item #5 Item 302, Type PB, Grade 3 (Pre -Coated Rock) Bid Item #6 Item 302, Type PB, Grade 4 (Pre- Coated Rock) Bid Item #7 Item 302, Type PE, Grade 3 (Pre -Coated Rock), *Material Source out of Bid Item #8 Item 302, Type PE, Grade 4 (Pre -Coated Rock), *Material Source out of Bid Item #9 Item 302, Type E, Grade 5, Ice Rock (Non Coated Limestone Only) Bid Item #10 Item 330, Type D (Pre -Mix Limestone) Bid Item #11 Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) The material will be used to construct a base course, a surface course, a level -up course, pothole repair, or any combination of these courses of the types and grade using a cold -mixed material consisting of native limestone rock asphalt (LRA) aggregate, fluxing material, water. LRA Mixture -Furnish LRA according to DMS-9210, "Limestone Rock Asphalt (LRA)", Item 330 D per the Surface Aggregate Classification plans as set forth by TXDOT Standard Specifications for Construction and Maintenance of Highways, Streets, and Bridges 2014. No material will be accepted that has been blended and stored on the producer's pad for more than 24 hours prior to loading and shipment. Bid Item #12 Item 334, Type D, Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.21MF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Bid Item #13 Item 432 Riprap, Section 2.3 Stone Riprap, 12" Limestone ASPHALTS. OILS & EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14 Primer Oil Bid Item #15 RC-250 —Temperature must be no lower than 1400 Bid Item #16 CRS-2 —Temperature must be no lower than 150' and no higher than 1800 Vendor may bid any or all material(s) for any location. Vendor must be able to furnish bid items under terms of these specifications and general conditions if vendor is awarded a bid. Calhoun County is EXEMPT from all Sales Tax (county, city and state sales tax) and all Federal Excise Taxes, if applicable. Page 2 of 8 Pump and hoses, if applicable, are to be furnished by the vendor at no extra charge or shall be included in the bid. Demurrage charges, if applicable, stated separately from the bid price of the material will increase the amount of the bid price for the material. Materials bid must be broken down into price per unit and delivery price. A fuel adjustment will be allowed on the delivery price only as fluctuations in diesel prices occur as listed on http://www.eia-gov/petroleum/gasdiesel using the Gulf Coast Region. The baseline price will be the price on this site on November 9, 2020 rounded to the nearest one - hundredth and thereafter the index will be adjusted and documented on Monday of each week after bids are accepted. The allowable fuel adjustment will be calculated by subtracting the baseline price from the posted price (for the Monday immediately prior to the delivery date of the material), and if the difference is less than 5 cents no adjustment will be allowed; 5 cents to 9 cents a 1% adjustment to the delivery price per unit; 10 cents to 14 cents a 2% adjustment to the delivery price per unit; 15 to 19 cents a 3% adjustment to the delivery price per unit; 20 to 24 cents a 4% adjustment to the delivery price per unit and so on. A 1% adiustment will be made on the delivery price for every 5 cent increase or decrease from the baseline price. Vendor must include a copy of the document from the EIA.GOV website that was used to determine delivery price when invoicing Calhoun County. Vendor will be required to deliver to all jobsites in Calhoun County as directed by the Commissioner of applicable Calhoun County Precinct. Jobsite can be road, field location or stockpile at designated Calhoun County locations. Miles from pit to stockpile and/orjobsite will be shortest legal route. Delivery shall be FOB Destination to designated Calhoun County Precinct stockpile orjobsites. Materials shall be ordered in quantities as determined by each Calhoun County Commissioner. Calhoun County Precincts will put out needed signs and barricades for traffic control. Calhoun County Precincts will accept the number of trucks necessary to do a job on a most cost efficient basis, which could require various numbers of trucks. Any Vendor traveling on Calhoun County roads will not exceed its legal gross weight. Each load shall be weighed on a certified public scale. Truck and trailer shall be weighed empty at least once on each job run, or when a change is made due to changing truck, trailer, or other. Cost of weighing shall be paid by the hauler. Driver shall get a material company ticket from pit or location when loading. A copy of the scale weight ticket, material company ticket and Page 3 of 8 company delivery ticket shall be given to the Calhoun County employee at the jobsite when load is inspected and dumped. Calhoun County Precincts will supervise the dumping of loads and a Calhoun County employee will sign the delivery ticket. The Calhoun County Precinct must receive a copy of the signed delivery ticket. Calhoun County shall have the right to pull sample loaded truck(s) to a certified scale of Calhoun County's choice for loaded weight, unload truck(s) and take empty weight on same scale to verify weights. Calhoun County shall pay for the weighing. Calhoun County legally accepts the materials after it is unloaded and approved by the Calhoun County Commissioner of said precinct. Any exceptions and or variations from the specifications in this bid document must be indicated on the bid form or on a separate attachment to the bid and labeled as such. Exceptions taken and/or variations made to the specifications and listed on the vendor's bid or separate attachment may void the bid. The request for a bid on a material does not guarantee that Calhoun County will purchase this material during the bid period. Calhoun County does not guarantee to purchase any minimum or maximum quantities. The materials will only be ordered as needed. When required, all materials ordered will be delivered to the Calhoun County Precinct within 24 hours from time of order. In the event the vendor is unable to deliver the materials(s) ordered within 24 hours from time of order, Calhoun County reserves the right to cancel the order and re -order the said material(s) from the vendor which submitted the next lowest bid that met specifications and can deliver within 24 hours from time of order. Calhoun County shall not incur any penalties, fees and/or other charges when cancelling an order. Vendor shall be required to notify Calhoun County in the event of unforeseen delay arising in the delivery of an order. In the event an order will not arrive at the Calhoun County Precinct at the designated time, Calhoun County shall have the right to cancel the order or refuse acceptance of the order. Calhoun County shall not be accessed any penalties, fees and/or other costs due to this cancellation or refusal. Calhoun County or the vendor have the right to cancel the delivery of a material(s) at any time due to weather, road conditions and/or machinery breakdown. No penalties, fees and/or other charges will be billed to Calhoun County if the delivery of a material(s) is cancelled by Calhoun County or the vendor due to weather, road conditions and/or machinery breakdown. The County reserves the right to refuse any order delivered for not being in compliance with the specifications, general conditions and/or the "Hazardous Communications Act", commonly known as the "Texas Right to Know Act". The vendor, at the vendor's cost, shall immediately remove the material(s) from the Calhoun County Precinct that are deemed unsatisfactory, and are not in compliance with the specifications, general conditions and/or do not meet State and/or Federal Regulations. No Page 4 of 8 penalties, fees, and/or other charges will be billed to Calhoun County for the removal of the material(s) from the Calhoun County Precinct. Safety Data Sheets and Placards, if applicable, must be furnished at the time of delivery as specified by State and/or Federal Regulations. Calhoun County reserves the right to conduct random sampling of pre -qualified materials for testing and to perform random audits of test reports. Calhoun County representatives may sample materials from the manufacturing plant, terminal, shipping container and any other source they deem necessary to insure reliability of the materials. If testing will be performed through a third party, the vendor will be required to allow the third party access to the facilities in order to acquire samples for testing. Regardless of results of any material(s) test required by Calhoun County, all costs incurred for such tests shall be paid for by the vendor. Specifications are not being met if materials are not delivered at the required temperatures. The award of a bid will be voided if specifications, general conditions and/or instructions within this Invitation to Bid Packet are not followed. The bid would then be awarded to the vendor which submitted the next lowest bid that met specifications and all requirements of the Invitation to Bid Packet. All Calhoun County Precincts handle their own orders; therefore invoices shall be billed to each Calhoun County Precinct separately. All invoices must be billed to Calhoun County to the attention of the Calhoun County Commissioner and Precinct ordering the material(s). Bid item number and material description, as stated on the bid form, awarded material bid price per unit and delivery price must appear on all invoices in order to be considered for payment. No other charges, including pump, hoses, special fees or after hour delivery fees, may be added to the awarded bid price per unit and delivery price when invoiced unless these charges were noted on the bid form or separate attachment and awarded as such. Invoices shall be free from sales tax (county, city or state sales tax) and federal excise taxes, if applicable. Invoices shall include a copy of the document from the EIA.GOV website that was used to calculate the increase or decrease in the delivery charge. Invoices shall include a copy of the delivery ticket that shows confirmation of delivery. It is understood that Calhoun County Commissioners Court reserves the right to accept or reject any and/or all bids for any/or all materials and/or services covered in this bid request and to waive informalities or defects in bids, or to accept such bids as it shall deem to be most advantageous and in the best interest of Calhoun County. Page 5 of 8 x Calhoun County Commissioners have the right to reject at any time any material that is undesirable for either road or jobsite location. Calhoun County will evaluate and award bid based on lowest and best bid meeting specifications and all requirements of the Invitation to Bid Packet. "Lowest and best" means a bid or offer providing the best value considering associated direct and indirect costs, including transport, maintenance, reliability, life cycle, warranties and customer service after a sale. Calhoun County reserves the right to accept and/or reject any/all of the options bid as it deems to be in the best interest of Calhoun County. Although the cost of materials(s) to be provided is an essential part of the bid, Calhoun County is not obligated to award a bid (contract) on the sole basis of cost but will award to the vendor considered to be the best value to the Calhoun County. The bid award shall be based on, but not necessarily limited to, the following factors: • Unit price • Extended price (and other charges, if any) • Special needs and requirements of Calhoun County • Delivery • Compliance in returning and/or including all required forms • Results of testing samples (if required by Calhoun County) • Calhoun County's experience with materials bid • Vendor's past performance record with Calhoun County If bids are awarded, award information will be emailed and/or mailed to all vendors that submitted a bid regardless if the vendor was awarded a bid or not. Calhoun County Commissioners Court and the County Auditor's office work diligently to get this information to the vendors as soon as possible. To obtain results, or if you have any questions, please contact Peggy Hall, Calhoun County Assistant Auditor, 202 S. Ann St., Suite B, Port Lavaca, Texas 77979, or by phone or email, (361) 553-4610, peggy.hall@calhouncotx.org. As time permits, bid awards will be posted on Calhoun County's website, www.calhouncotx.org, under Bid Notices and Results. Once bids are awarded by Calhoun County Commissioners Court, this bid packet in its entirety will be the working contract between Calhoun County and the successful bidder for the period designated. Calhoun County or the vendor may cancel this contract at any time for any reason, provided a written notice is given. Should there be a change in ownership or management, the bid (contract) shall be cancelled unless a mutual agreement is reached with the new owner or manager to continue the bid (contract) with its present provisions and prices. Vendor understands that Calhoun County is a government entity subject to Texas State and Federal public information statues. Vendor hereby waives any obligation to the release to the public of any documents submitted in accordance with the bid. Page 6 of 8 No person has the authority to verbally alter these specifications or any information within the Invitation to Bid packet. Any changes will be made in writing (Addendum approved by Calhoun County Commissioners Court) and mailed and or emailed to each vendor that received a bid packet. All disputes or protests will be held in Calhoun County, Texas. INSURANCE REQUIREMENTS The awarded bidder must furnish, at their own expense, certificates of insurance or other acceptable evidence from a reputable insurance company or companies acceptable to Calhoun County, licensed to write insurance in the State of Texas showing the contractor (bidder) is covered by insurance within the following minimum limits of liability: • Statutory Workers' Compensation and Employer's Liability Insurance ($1,000,000 or greater) with a Waiver of Subrogation in favor of Calhoun County. • General Liability including Product Liability Insurance ($100,000/$3,000,000 or greater) • Auto Insurance ($100,000 BIPP/$300,000 BIPO/$100,000 PD or greater) Coverage shall apply on an occurrence basis. In the event any work is sublet, the contractor (bidder) shall require each subcontractor similarly to provide the same coverage and shall acquire evidence of such coverage of the subcontractor. The policy(s) shall be on the commercial general liability form and shall include coverage for acts of independent contractors. Calhoun County shall be covered as an additional insured under the policy(s). The certificates of insurance furnished to Calhoun County shall contain a provision that coverage under such policies shall not be cancelled or materially changed unless at least a 30 days prior written notice has been given to Calhoun County. Calhoun County's receipt of or failure to object to any insurance certificates or policies submitted by the awarded bidder does not release or diminish in any manner the liability or obligations of the awarded bidder or subcontractor or constitute a waiver of any of the insurance requirements for the bid. Replacement certificates of liability of insurance evidencing continuation of such coverage and naming, by policy endorsement, Calhoun County as an additional insured, shall be furnished to the County Auditor's office prior to the expiration of the current policies. Should the awarded bidder at any time neglect, refuse to provide, or cancel the insurance required, Calhoun County shall have the right to terminate the bid and/or pursue any remedy available by law. The insurance coverage requirements in this bid will in no way be construed as limiting the scope of indemnification. Page 7 of 8 REQUIRED INFORMATION/FORMS TO BE RETURNED WITH INVITIATION TO BID • Invitation to Bid Form (page 1-8) • Affidavit • Certificate of Interested Parties, Form 1295 — Must return when submitting your bid • Certificate of Current Liability Insurance — Return a copy of your current Certificate of Liability Insurance with your bid. This will provide proof that you carry at least the minimum required coverage. Once the bids are awarded, the bidder that is awarded a bid must provide a Certificate of Liability Insurance that reflects that Calhoun County (certificate holder) is an additional insured on general liability subject to the conditions of the additional insured. • Conflict of Interest Questionnaire, Form CIQ— Every bidder doing business with Calhoun County or seeking to do business with Calhoun County must complete Box 1 and sign and date in Box 7. Whether or not a conflict exists determines the other information to include on the form. • Certificate Regarding Debarment & Suspension and Other Responsibility Matters • Certification Regarding Lobbying • Disclosure of Lobbying Activities — If Not Applicable, bidder must mark NA, and sign and date • House Bill 89 Verification • Residence Certification • Vendor and Order Information Form • W-9 Page 8 of 8 Z3 x 3 y 9 3 z Z GI D O D m Z A D A yC A 3 A< C A inlO� S K z m D 9 m AG G nom >V D a n S C n n r z z y N 3 3 ti O^ n D O v m D C N A m C C Z r A m ti z A Ro Z n G1 i G D � rr n m A a G N T T m m m N C N V1 !A VI N m lm/1 lmll VI V1 N a ?. � N m VI m N N N N m m v{mi Vmf v<mi v<mi N d n N H O In vi vmi tmii � � vmi m b !^ m m m m ? 0 . vmi vmi vmi vmi V{mf A C O n N N O 9 ri N Vmi Vmi tT/� tm/f N Vmi Vmi (m/� Vmf < p, pj i DeF N Vi V1 lmA N C' P N i �. V1 Vf Vf IA tm/1 Vmi Imn N Vmi VTi d. � � W O ' - N A N N VI N Vf lm/1 N N VI Vmf y. A m m m m m m m m m m O VI V1 N VI V1 (m/1 (m/1 Vml VI {m/1 b -n ;a 0 0 V m m 0. W m. QQ 3 N 3 N m 0 3 S � 01 .0 �n O N y� N `01 a) CL 3 m C 3 ; o. dq O) C D n 3 0 3 3 ra d a y (D '0 (J4i .a N N O G N 0 N rt ) M W Z C 3 a N O N 1-A 0 {s L ! CALHOUN COUNTY, TEXAS BID TABULATION ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT, BID NUMBER: 2021.03 For the Period Beginning January 1, 2021 and Ending December31, 2021 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE: $2.132 on November 9, 2020 Tie Bids: The winning bid is determined per Texas Local Government Code 262.027(b). ROAD MATERIALS If two responsible bidders submit the lowest and best bid, the commissioners court shall decide between the two by drawine lots in a. manner nrescrihed by ♦he r,n,nty h,dan Bid Item #1: Limestone-3/4 Inch to Dust LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND. REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. 'NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct 3 Ton $6.00 $21.50 $27.50 24 tons Precinct 4-P Ton 1 $6.00 $21.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons Precinct 1 Ton $5.50 $24.00 $29.50 Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction & Materials Precinct 2 Ton $5.50 $24.00 $29.50 Belly 25 tons Precinct 3 Ton $5.50 $24.00 $29.50 Belly 25 tons Precinct 4-P Ton $5.50 1 $24.50 1 $30.00 1 Belly 25 tons Precinct 4-S Ton $5.50 $24.00 $29.50 Belly 25 tons Precinct 1 Ton $6.00 $24.00 $30.00 24 MicITex Materials, LLC (Bid has error an Precinct 4-S) Precinct 2 Ton $6.00 $24.00 $30.00 24 Precinct 3 ron $6.00 $z4.00 $30.00 24 Precinct 4-P- Ton _ $6.00 - - $26.00 $32.00 24 Precinct4-S Ton $6.00 $6.00 (Bid has $6.00) $30.00 (Bid has $30) 24 Precinct 1 Ton $4.97 $26.48 $31.45 N/A Johnnie R. Gresham Operating, Inc. Precinct 2 Ton $4.97 $26.48 $31.45 N/A Precinct 3 Ton $4.97 $26.48 $31.45 N/A Precinct4-P Ton 1 $4.97 $26.48 $31.45 1 N/A Precinct 4-S Ton $4.97 $26.48 $31.45 N/A Page 1 of 10 Bid Item#2: ITEM 247, TYPE A LIMESTONE, GRADE 2 [13/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct Ton $6.00 $21.50 $27.50 24 tons Precinct 4-P Ton $6.00 $21.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons Precinct 1 Ton $5.00 $24.00 $29.00 Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction & Materials Precinct Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct 3 Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct 4-P Ton $5.00 $24.50 $29.50 Belly 25 tons Precinct 4-S Ton $5.00 $24.00 $29.00 Belly 25 tons Precinct Ton $6.00 $24.00 $30.00 24 MiclTex Materials, LLC Precinct Ton $6.00 $24.00 $30.00 24 Precinct 3 Ton $6.00 $24.00 $30.00 24 Precinct 4-P Ton $6.00 $26.00 $32.00 24 Precinct 4-S Ton $6.00 $24.00 $30.00 24 Precinct 1 Ton $4.47 $26.48 $30.95 N/A Johnnie R. Gresham Operating, Inc. Precinct 2 Ton $4.47 $26.48 $30.95 N/A Precinct 3 Ton $4.47 $26.48 $30.95 N/A Precinct 4-P Ton $4.47 $26.48 $30.95 N/A Precinct4-S Ton $4.47 $26.48 $30.95 N/A Precinct 1 Ton $23.50 $14.00 $37.50 24 tons Martin Marietta Materials, Inc. *VIA GREGORY RAIL YARD* *Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHEDLETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct Ton $23.50 $14.25 $37.75 24 tons Precinct 3 Ton $23.50 $15.96 $39.46 24 tons Precinct4-P Ton $23.50 $15.96 $39.46 24 tons Precinct4-S I Ton $23.50 1 $13.80 $37.30 24 tons Precinct 1 Ton $2250 $19.00 $41.50 22 tons Vulcan Materials Company dba Vulcan Construction Materials, LLC Precinct 2 Ton $22.50 $20.00 $42.50 22 tons Precinct 3 Ton $22.50 $21.50 $44.00 22 tons Precinct4-P Ton $22.50 $21.50 $44.00 22 tons Precinct4-S Ton $22.50 $19.00 $41.50 22 tons Page 2 of 10 Bid Item#3: ITEM 247, TYPE A LIMESTONE, GRADE 3 [13/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $6.00 $21.50 $27.50 24 tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $6.00 $21.50 $27.50 24 tons Precinct 3 Ton $6.00 $21.50 $27.50 24 tons Precinct 4-P Ton $6.00 $21.50 $27.50 24 tons Precinct 4-S Ton $6.00 $21.50 $27.50 24 tons Precinct 1 Ton $6.00. $24.00 $30.00 24 MidTex Materials, LLC. Precinct 2 Ton $6.00 $24.00 $30.00 24 Precinct Ton $6.00 $24.00 $30.00 24 Precinct 4-P Ton $6.00 $26.00 $32.00 24 Precinct4-S Ton $6.00 $24.00 $30.00 24 Precinct 1 Ton $4.47 $26.48 $30.95 N/A Johnnie R. Gresham Operating, Inc. Precinct 2 Ton $4.47 $26.48 $30.95 N/A Precinct 3 Ton $4.47 $26.48 $30.95 N/A Precinct4-P Ton $4.47 $26.48 $30.95 N/A Precinct4-S Ton $4.47 $26.48 $30.95 N/A Precinct 1 Ton $22.50 $19.00 $41.50 22 tons Vulcan Materials Company dba Vulcan Constructions Materials, LLC Precinct 2 Ton $22.50 $20.00 $42.50 22 tons Precinct 3 Ton $22.50 $21.50 $44.00 22 tons Precinct 4-P Ton $22.50 $21.50 $44.00 22 tons Precinct 4-5 Ton $22.50 $19.00 $41.50 22 tons Bid Item #4: ITEM 275, CEMENT 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) - 275.2-1, Hydraulic Cement Type 1, 47 lb Bag (cost per Pallet) List # of 47 Ib Bags on a Pallet LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1, 2, 3, Ton 4-P & 4-S NO BIDS RECEIVED Bags bn Pallet Page 3 of 10 Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $23.39 $38.61 $62.00 24 tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY* * Page 8 of Bid; under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING -NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $23.70 $38.30 $62.00 24tons Precinct 3 Ton $21.18 $40.82 $62.00 24tons Precinct4-P Ton $20.71 $41.29 $62.00 24tons Precinct4-S Ton $23.07 $38.93 $62.00 24 tons Precinct 1 Ton $53.00 $9.00 $62.00 24 tons Quality Hot Mix, Inc. *NOTE*. ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED &.PROVIDED IF AVAILABLE. - Precinct 2 Ton $53.00 $9.00 $62.00 24 tons Precinct Ton $53.00 $9.00 $62.00 24tons ,Precinct 4-P Ton $53.00 $9.00 _. $62.00 24 tons Precinct 4-S Ton $53.00. $9.00 $62.00 24 tons Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF. ANY Precinct 1 Ton $23.39 $38.61 $62.00 ' 24 tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY* ' Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $23.70 $38.30 $62.00 24 tons Precinct 3 Ton $21.18 $40.82 $62.00 24tons Precinct4-P Ton $20.71 $41.29 $62.00 -. `. 24tons PrecincY4-S Tan $23.07 $38.93 $62.00 24tons Precinct 1 .Ton $53.00 $9.00 $62.00 24tons Quality Hot Mix, Inc. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 2 Ton $53.00 $9.00 $62.00 24tons Precinct3 Ton $53.00 $9.00 $62.00 24 tons Precinct 4-P Ton $53.00 $9.00 $62.00 24tons Precinct 4-S I Ton 1 $53.00 1 $9.00 1 $62.00 24tons Page 4 of 10 Bid Item#7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER .AND REMARKS, IF ANY Precinct 1 Ton $22.50 $37.98 $60.48 24 tons Vulcan Materials Company dba Vulcan Construction Materials, LLC * MATERIAL SOURCE OUT OF DABNEY(UVALDE) Precinct 2 Ton $22.50 $38.75 $61.25 24 tons Precinct 3 Ton $22.50 $40.30 $62.80 24 tons Precinct 4-P Ton $22.50 $38.75 $61.25 24 tons Precinct4-S Ton $22.50 $38.75 $61.25 24 tons Precinct 1 Ton $27.91 $38.61 $66.52 24 tons Martin Marietta Materials, Inc. w MATERIAL SOURCE OUT OF UVALDE *VIA BLACK SPUR QUARRY* *Page 8 of Bid, under Exceptions and/or Variations from Specifications and/or additional notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING - NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $29.18 $38.30 $67.48 24 tons Precinct 3 Ton $28.40 $40.82 $69.22 24 tons Precinct 4-P Ton 1 $27.93 1 $41.29 1 $69.22 1 24 tons Precinct4-S Ton $27.59 $38.93 $66.52 24 tons Bid item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material source out of LOCATION Unit MATERIAL DELIVERY TOTALMINIMUM LOAD/ORDER `BIDDER AND REMARKS, IF ANY Precinct 1 Ton $23.50 $37.98 $61.48 24 tons Vulcan Materials Company dba Vulcan Construction Materials, LLC *MATERIAL SOURCE OUT OF DABNEY (UVALDE)* Precinct 2 Ton $23.50 $38.75 $62.25 24 tons Precinct 3 Ton $23.50 $40.30 $63.80 24 tons. Precinct4-P Ton $23.50 $38.75 $62.25 24 tons Precinct 4-S Ton $23.50 $38.75 $62.25 24 tons Precinct 1 Ton $27.91 $38.61 $66.52 24 tons Martin Marietta Materials, Inc. * MATERIAL SOURCE OUT OF UVALDE *Page 8 of Bid, under Exceptions. and/or Variations from Specifications and/or additonal notes: SEE ATTACHED LETTER REGARDING MATERIAL TESTING • NO LETTER WAS ATTACHED/INCLUDED WITH THEIR BID Precinct 2 Ton $29.18 $38.30 $67.48 24 tons Precinct 3 Ton $28.40 $40.82 $69.22 24tons Precinct4-P I Ton 1 $27.93 1 $41.29 1 $69.22 1 24 tons Precinct 4-S Ton $27.59 $38.93 $66.52 24 tons Page 5 of 10 Bid Item#9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) LOCATION Unit. MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $15.50. $24.00. ' $39.50 Belly 25 tons K-C Lease Service, Inc. dba Matagorda Construction and Materials Precinct 2 Ton $15.50 $24.00 $39.50 Belly 25 tons Precinct 3 Ton $15.50 $24.00 $39.50 Belly 25 tons Precinct4-P Ton $15.50 $24.50 $40.00 Belly 25tons Precinct 4-S. Ton $15.50 $24.00 $39.50 Belly 25 tons Precinct 1 Ton $26.50 $23.50 $50.00 24 tons Quality Hot Mix, Inc. 'NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERES CAN BE REQUESTED& PROVIDED IFAVAILABLE. Precinct 2 Ton $26.50 $23.50 $50.00 24 tons Precinct 3 Ton $26.50 $23.50 $50.00 24 tons Precinct 4-P. Ton $26.50 $23.50 $50.00 24 tons Precinct 4-S I Ton 1 $26.50 1 $23.50 1 $50.00 1 24 tons Bid Item #10: ITEM 330, TYPE D (PRE -MIX LIMESTONE) LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $10.50 $26.48 $36.98 N/A Johnnie R. Gresham I Operating, Inc. Precinct 2 Ton $10.50 ' $26.48 $36.98 N/A Precinct 3 1 Ton 1 $10.50 1 $26.48 1 $36.98 1 N/A Precinct 4-P Ton $10.50 $26.48 $36.98 N/A Precinct4-S Ton $10.50 $26.48 $36.98 N/A Precinct 1 Ton $40.50 $37.98 $78.48 24 tons Vulcan Materials Companydba Vulcan Construction Materials, LLC *LIMESTONE ROCK ASPHALT* Precinct 2 Ton $40.50 $38.75 $79.25 24 tons Precinct 3 Ton $40.50 $40.30 $80.80 24 tons, Precinct 4-P Ton $40.50 $38.75 $79.25 24 tons Precinct 4-S .Ton $40.50 $38.75 $79.25 24 tons Precinct 1 Ton $46.00 $38.61 $84.61 24 tons Martin Marietta Materials, Inc. *VIA BLACK SPUR QUARRY *Page 8of Bid, under Exceptions and/or Variationsfrom Specifications and/or additional notes: SEE ATTACHED LETTER REGARDINGMATERIAL TESTING - NO LETTER WAS ATTACHEopNcwDEDWITH THEIR BID Precinct 2 Ton $46.00 $38.30 $84.30 24 tons Precinct Ton $46.00 $40.82 $86.82 24 tons Precinct4-P Ton $46.00 $41.29 $87.29 24 tons Precinct 4-S I Ton 1 $46.00 i $38.93 i $84.93 24 tons Page 6 of 10 Bid Item #11: ITEM 330'D, POTHOLEREPAIR, LIMESTONE ROCK ASPHALT (LRA) LOCATION Unit. MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $46.50 $37.98 $84.48 24 tons Yard3 No Bid 50 lb Bag No Bid Precinct 2 Ton $46.50 $38.75 $85.25 24 tons Yard No Bid 50 lb Bag No Bid ' Vulcan MaterialsCompany dba Precinct 3 Ton $46.50 $40.30 $86.80 24 tons Yard No Bid Vulcan Construction Materials, LLC 50 lb Bag No Bid *DPLUS MIX" Precinct4-P Ton $46.50 $38.75 $85.25 24 tons Yard No Bid 50 lb Bag No Bid Precinct 4-S. Ton $46.50 ,$38.75 $85.25 24 tons Yard3 No Bid 50 lb Bag No Bid Precinct Ton $58.77 $39.18 $97.95 24 Tons Yard $65.23 $43.49 $108.72 22 Cu Yds 50 lb Bag $12.00. $12.00 62 Bags = 1 Pallet Precinct 2 Ton $57.32 $38.22 $95.54 24 Tons Yard $67.64 $45.10 $112.74 22 Cu Yds 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Precinct 3 Ton $64.75 $43.17 $107.92 24 Tons Yard3 $76.41 $50.94 $127.35 22 Cu Yds Blades Group, LLC 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Precinct4-P Ton $64.24 $42.82 $107.06 24 Tons Yard $75.80 $50.53 $126.33 22 Cu Yds 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Precinct 4-S Ton $62.28 $41.52 $103.80 24 Tons Yard 3. $73.49 $48.99 $122.48 22 Cu Yds 50 lb Bag $12.00 - $12.00 62 Bags = 1 Pallet Page 7 of 10 Bid Item #12: ITEM 334, TYPE D, HOT MIX COLD LAID ASPHALT CONCRETE PAVEMENT LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF. ANY Precinct Ton $75.00 $9.00 $84.00 25 tons Quality Hot Mix, Inc.. *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED& PROVIDEDIF AVAILABLE. Precinct 2 Ton $75.00 $9.00 $84.00 25 tons Precinct 3 Ton $75.00 $9.00 $84.00 25 tons Precinct 4-P Ton $75.00 $9.00 $84.00 1 25 tons Precinct 4-S' Ton $75.00 $9.00 $84.00 25 tons Precinct 1 Ton $85.00 $30.59 $115.59 25 TONS DELIVERED Waller County Asphalt, Inc. * BID IS FOR HIGH PERFORMANCE ASPPM GRADE IV* Precinct 2 Ton $85.00 $31.51 $116.51 25 TONS Precinct 3 Ton $85.00 $27.83 $112.83 25 TONS Precinct 4-P Ton $85.00 $35.19 1 $120.19 25 TONS Precinct 4-S Ton $85.00 $34.96 $119.96 25 TONS Bid Item #13: ITEM 432, Riprap, Section 2.3 Stone Riprap,12" Limestone LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $17.33 $34.13 $51.46 N/A Johnnie R. Gresham Operating, Inca Precinct Ton $17.33 $34.13 $51.46 N/A. Precinct Ton $17.33 $34.13 $51.46 N/A Precinct 4-P Ton $17.33 1 $34.13 $51.46 N/A Precinct4-S Ton $17.33 $34.13 $51.46 N/A Precinct 1 -Ton $26.00 $50.00 $76.00 24 MidTex Materials, LLC Precinct Ton $26.00 $50.00 $76.00 24 Precinct 3 Ton $26.00 $50.00 $76.00 24 PreciInd 4-P Ton $26.00 $52.00 $78.00 24 Precinct4-S Ton $26.00 $50.00 $76.00 24 Precinct 1 Ton $40.00 $45.00 $85.00 22tons Vulcan Materials Company dba Vulcan Construction Materials, LLC Precinct 2 Ton $40.00 $45.00 $85.00 22 tons Precinct 3 Ton $40.00 $50.00 $90.00 22 tons Precinct 4-P Ton $40.00 $47.00 $87.00 22 tons Precinct 4-S -- Ton $40.00 $45.00 $85.00 22 tons Page 8 of 10 ASPHALTS. OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $2.00 $0.20 $2.20 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $2.00 $0.20 $2.20 After 2 Free Hours Cleveland Asphalt Products, Inc. * PRICE BASED ON MINIMUM FULL LOAD OF $80.00 Per Hour SOOO GALLONS, FOR SMALLER QUANTITIES Precinct 3 Gallon $2.00 1 $0.20 $2.20 After 2 Free Hours PLEASE CALL 800-334-0177.. DILUTED MATERIAL CANNOT. BE RETURNED $80.00 Per Hour FOR CREDIT. Precinct 4-P Gallon $2.00 $0.20 $2.20 After 2 Free Hours $80.00 Per Hour Precinct 4-S Gallon $2.00 $0.20 $2.20 After 2 Free Hours $70.00 Per Hour Precinct 1 Gallon $2.65 $0.19 $2.84 After 2 Free Hours $70.00 Per Hour Precinct 2 Gallon $2.65 $0.19 $2.84 After 2 Free Hours Martin Products Sales, LLC dba $70.00 Per Hour Precinct 3 - Gallon $2.65 1 $0.17 $2.82 After 2 Free Hours Martin Asphalt Company * MC-30 * $70.00 Per Hour * 5,000 GAL MINIMUM Precinct 4-P Gallon $2.65 $0.21 $2.86 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $2.65 $0.21 $2.86 After 2 Free Hours Page 9of10 ,1 Bid Item #15: RC-250 LOCATION .Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $70.00 Per Hour Precinct 1 Gallon $2.55 $0.19 2.74 After.2 Free Hours $70.00 Per Hour Precinct 2 Gallon $2.55 $0.19 2.74 After 2 Free Hours Martin Products Sales, LLC dba $70.00 Per Hour Precinct 3 Gallon $2.55 $0.17 2.72 After 2 Free Hours Martin Asphalt Company $70.00 Per Hour * 5000 GALLON MINIMUM Precinct 4-P Gallon $2.55 $0.21 2.76 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $2.55 $0.21 2.76 After 2 Free Hours $80.00 Per Hour Precinct 1 Gallon $2.75 $0.20 2.95 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $2.75 $0.20 2.95 After 2 Free Hours Cleveland Asphalt Products, Inc. * PRICE BASED ON MINIMUM FULL LOAD OF $80.00 Per Hour 5000 GALLONS, FOR SMALLER QUANTITIES Precinct 3 Gallon $2.75 $0.20 2.95 After 2 Free Hours PLEASE CALL 800-334-0177. DILUTED MATERIAL CANNOT BE RETURNED $80.00 Per Hour FOR CREDIT:. Precinct 4-P Gallon $2.75 $0.20 2.95 After 2 Free Hours $80.00 Per Hour Precinct 4-S Gallon $2.75 $0.20 2.95 After 2 Free Hours Bid Item #16: CRS-2 LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE. BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $1.75 $0.20 $1.95 After 2 Free Hours $80.00 Per Hour Precinct 2 Gallon $1.75 -$0.20 $1.95 After 2 Free Hours Cleveland Asphalt Products, Inc. *. PRICE BASED ON. MINIMUM FULL LOAD OF $80.00 Per Hour 5000 GALLONS, FOR SMALLER QUANTITIES Precinct 3 Gallon $1.75 $0.20 $1.95 After 2 Free Hours PLEASE CALL 800-334-0177. DILUTED MATERIAL CANNOT BE RETURNED $80.00 Per Hour FOR CREDIT. Precinct 4-P Gallon $1.75 $0.20 $1.95 After 2 Free Hours $80.00 Per Hour Precinct 4-S Gallon $1.75 $0.20 $1.95 After 2 Free Hours $70.00 Per Hour Precinct 1 Gallon $1.85 $0.19 $2.04 After 2 Free Hours $70.00 Per Hour Precinct 2 Gallon $1.85 $0.19 $2.04 After 2 Free Hours Martin Products Sales, LLC $70.00 Per Hour dba Precinct 3 Gallon $1.85 $0.17 $2.02 After 2 Free Hours Martin Asphalt Company $70.00 Per Hour * 5000 GALLON MINIMUM Precinct 4-P Gallon $1.85 $0.21 $2.06 After 2 Free Hours $70.00 Per Hour Precinct 4-S Gallon $1.85 $0.21 $2.06 After 2 Free Hours Page 10 of 10 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE ON NOVEMBER 9, 2020 (See page 3 of the specifications) $2.132 www.eia.gov/petroleum/gasdiesel For ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 etaUS.EnergyInformation Administration PETROLEUM & OTHER LIQUIDS y^ OVERVIEW < . DATA ANALYSIS& PROJECTIONS / Base l t n Pi 1 re GP✓ GLOSSARY FADS, Weekly Retail Gasoline and Diesel Prices A� Z (Dollars per Gallon, Including Taxes) NOV -11 Area: Gulf Coast (PADD 3) v Period: Weekly v ShewDab By: Q Product C Area View Olckan the mumkey loon to loam how tosawnload series Into Excel, or to embed a chart or map on yourwebsae. rte. -=No Data Repod;-=NmAPPImble; NA_NotAwilable; W=V Mheb to avoid disclosure ofIndNldual company date. Release Deb: 1119/2020 Next Release Dab: 11116/2020 r �� �, ■ 1.■ WE ASPHALTS, OILS AND EMULSIONS /_1►1►'llk1�.�1�I71�'I�LiI>t a,", e w Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY,TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name &Address ,,{ '3 KV\ -3 • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. -The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. Page 1 of 8 n Invitation To Rid Form -Annual Supply ConU'act jor Road Materials and Aspholts, Oils and Emulslons -- CONTINUED Bid Item #3: Item 247, Type A Limestone, Grade 3 (13/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE 1 { I Precinct 1 = Tan ! ! Precinct 2 { Ton { ; Precinct 3 1 Ton I I I i Precinct4-P Ton , Precinct 4S I Ton { { 1 1 Remarks: Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 Ib Bag (Cost per Pallet) List # of 47 lb Bags on a Pallet Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ! Precinct 1 Ton I { I { 1 ! �iof 471b1 1 i I 1 1 i { Bags on Pallet Precinct 2 i Ton 1 1 1 I _ of 47 lb i flags on Pallet Precinct 3 Ton of 47 lb ! ! ! ! Bags on Pallet ! Precinct4-PTon I ! „_of471b 1 Bags on Pallet i ! I 1 i Precinct4-S ; Ton i , t _of471b! I flags on Pallet I I I Remarks: Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #5: Item 302, Type PS, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 Ton i Precinct 2 { Ton i I I Precinct 3 i Ton I Precinct4-P Ton i I i Precinct4-5 i Ton i Remarks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY =TOTALLOAD/ORDER I ' ' Precinct 1 i Ton ! I f Precinct 2 I Ton _ Precinct j Ton i I Precinct4-PTon Precinct 4-S ; Ton i Remarks: Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 i Ton i i i I Precinct 2 i Ton i I Precinct 3 Ton I i i i I Precinct4-P I Ton I i i S i Precinct4-S I Ton Remarks: Page 3 of 8 I Invitation To Bid Form -Annual Supply Contract for Road Materlols and Asphalts, Oils and FmuWons -- CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL Precinct 1 ; Ton I Precinct 2 I Ton Precinct 3 I Ton ' 1 Precinct4-P 1 Ton 1 ; I i I [Precinct 4-S I Ton 1 1 1 Remarks: MINIMUM Bid Item #9: Item 302, Type E, Grade S, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE Precinct 1 I Ton I I I I 1 1 E I Precinct ' Ton 1 1 1 1 Precinct 3 I Ton I I I I I I I Precinct4-P 1 Ton Precinct 4-5 ` Ton i I Remarks: Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 Ton i 1 1 I. Precinct 1 Ton I I I 1 1 I Precinct 3 1 Ton I I I 1 Precinct4-P I Ton 1 I i Precinct4-S I Ton I i i I 1 1 Remarks: Page 4 of 8 Invitation To Bid Form - Annual5uppty Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item 415, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton 'bq I 1c2 \ Yarda 3-3 �'\�J .� 1 I � � 3. -1) t 1)1 -)� C. &6 1 50lbBag 1 �r�.®� It.1r� �G ,®�O�• �� \\ . Precinct 2 Ton , oL� I� ,� E .� "�'o.� S Yard' ��> la� _i� 1 i.. 0� l� ���•, I°A I -:�. 6.- .tea I 50 lb Bag I a I ... 1 Q Precinct 3 I Ton b ,Z J I $ �•� ,\1 q� !� Q�i • 1'�. i �.� o'°�� I Yard' 6A �Sa.A \.A 15\�AI.3� 1.33Cu� 50lb Bag i — ' Precinct4-P Ton , \13,71 all. i Yard' 5G.3.3 1 �'a. 1 SO lb Bag 1� 0 1 b' Precinct4-5 ! Ton II\i•.O ',� U "a� IS ��. J ri I� j G ISO Yard' 4 j� c1\(� ig °3\cb .`, ` 1s \S ` ..), `� i . I SO lb Bag S `�, I Iy !a•� Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 IMF Table x5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 1 Ton i I I I Precinct 1 Ton-71 , Precinct I Ton I I 4-P 1 Ton 4-S 1 Ton Page 5 of 8 Invitation To Bid Fort?) -Annual Supply Contract far Road Materials and Asphalts, Offs and Emulsions -- CONTINUED Item #13: Item 432, Riprap, Section 2.3 Stone Riprap,12" Limestone Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL i i I i i I i I i i Precinct 1 I Ton I Precinct 2 Ton I I I I Precinct 3 ; Ton r r I Precinct4-P I Ton ! I I ! ! Precinct4-S ; Ton I ! I ASPHALTS. OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item#14: Primer oil Price per gallon / delivery price to County f LOCATION Unit MATERIAL I Precinct 1 I Gallon i I I Precinct I Gallon ! I Precinct I Gallon I I I r I ! Precinct4-P! Gallon I I Precinct4-S ! Gallon i I I (Remarks: e and/or Jobsite MINIMUM LOAD/ORDER DELIVERY I TOTAL I DEMURRAGE I$ Per Hour After r (_ Free Flours : I I$ Per Hour After I_ Free Hours I 1 ;$ Per Hour After I Free Hours r I I I I$ Per Hour After Free Hours i I !$. Per Hour After I Free Hours Page 6 of 8 a Invitation To Bid Farm -Annual Supply Con tract jor Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I ;$__Per Hour After Precinct 1 Gallon ,m-Free (lours J$ Per Hour After Precinct 2 1 Gallon I 1 _ Free Hours I { { I I I Per Hour After Precinct 3 ; Gallon �_ Free Hours 1 I I I I$ Per Hour After i Precinct4-P; Gallon I � I I Free Hours I I I 1 1 1$Per Hour After Precinct4-SGallon I I ' i Free Hours Re ma rks: Bid item #16: CRS-2 Temperature must be no lower than 1501 and no higher than 1801 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE Per Hour After Precinct i Gallon ! I {_Free Hours I!$ Per Hour After Precinct Gallon 1 3 1 1_ Free Hours I I i is Per Hour After Precinct I Gallon I I i I r Free Hours I I I I$ Per How' After Precinct4-P' Gallon Free Hours i I E I I '$ Per How After Precinct 4-S I Gallon I I I I_ Free Hours Remarks: Be sure to complete next page (page 8) Page 7 of 8 In vitation To Bid Form - Annual5upply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed ail requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: \ ci ` � b" c _0 Authorized Signature & lr\4ti) kitaeu�o-a Type Name & Title of Authorized Signature: 1 � Dow's Z` rjpj r ej A11oVZ-rW Pr+�su� DI(lel Phone Number: o11ril-3`6--Mo\A Email; Td�crei®Y�1 CUG'feClS06\'�k;Lvm Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEXAS 0 AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and Gen-eral Conditions. BEFORE ME, the undersigned authority, on this day personally appeared 1 P�KYS ftSj \�o�'i known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or tg-� ' ' I, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant -L Printed Name and Title of Affiant Name of Bidder (Company) 18 C." k,;�' btvE S+1(t'` �i1`-\c •-� Address �3 Vn my Phone Number g 3C?.. 4�`I� • �\ r Fax Number Email Address SWORN TO AND SUBSCRIBED BEFORE ME by the above Apffiant, who, on oath, states that the facts contained in the above are true and correct, this'�1"�-) day of Q 20 . M ierof texas7/202467-6 Notary Public in and for L y County, Texas CERTIFICATE OF INTERESTED PARTIES FORM 1,295 1of1 Complete Nos. 1- A an(I 6 if there are interested parties. Complete Nos. 1, 2, 3, S, and 6 if there are no interested parties. OFFICE USE ONLY CERTIFICATION OF (FILING, Certificate Number: 2020-679648 Date Filed: 10/16/2020 Date Acknowledged: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Blades Group, LLC UVALDE, TX United ;;,fates 2 amr. o governmental entity or state agency that Is a party to t no contract for which the form Is being filed. Calhoun County 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. 2021.03 Road Materials & Asphalts Bid/Contract 4��^���� Name of Interested party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 15 Check only if there is No Interested party. I.-1 6 UNSWORN DECLARATION WT,My name is 0 maS _ � t 6`1 _ ��, and my date -off biirrth is My address is 3�'nm�"�133 _. )iJ , \✓� ,l�i�d� (street) (city) (stMot (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. n ' t-c. Executed in U �J A` ._County, State of , on the _\1 day of _�t 2:p�13 i (month) (year) �-"- Signature�thodzed-agenref contl�g business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.,3a6aaf7d p W„eker s ppJ13Pn L4Wl e r II I I lu P g Berkshire HathBwa Nnrf OAFMI c II ly a kt tv Y I I eN GUARD C..',;Ii" 4nmpanics iJ p NtL PuIiSY It,(brn,i:tlOn VrtLln led tnsurad ana trolling Address :aaLp<r. R ].3aY ILi1:N L10: Y. RA ]eJGi'ii3� R Federal EL 4Plbyrtr'e PC AJJitimlol Namcs of AlsurOd '. Nts it pofl lbihllbAS oil Pti-A (Llj SCO E,e,L Pae+l iTE 30. .Ilral— T: 'l.]p01 lCI�Op13030-0:/O:r10v]) Agency 1d1111 .¢ IM(L' 111t a6ElCv 1!4 .pu9l dip tri,ve R]:hoanr, w/ 1an �i Afe,., Cade: NlPpvf]p in.'tmad L. ra tlsFiII4Y ,:e.t6C] F'em F 1 Y rblrt ti F .. :•/ 1, 2.121. 111.1 W, kn:11-1'. I, 11--1 s ne'rvp add.aa= 137 Cnvnrn9.• n. :'iW:1.:ri Ca:npone:t=Cni,fau,nnca'Vaet nnn n![h,zP'+I,cYa¢Ply:!o tn-'f/eil,erc'ComYanwl.%n r L.a f+ :I lha iulc::in9 xtncel: Ta+a[ I 4. 2n,VbiYiz Lta4i!rylesunncf - PazS Rv'm ei tFlf Fln!vry a9Pllte tb Wn,kn,awN o+:ha [tn[az Yl[1etl In 1pen jiih, T1,a in,tz ei p„r llalzl,ly urvd=.,'Fn:t T.:o a:u: 00aly Lijury ky AcclGYnt- N:M1 aY[laan!' $$OS.CC4 ebauy n;bry br cl.a..Y-eY:F YmP!eva• swa.mc I soaev !+J+:y try obaua'9P"w umrz soo,00c ! C. Utb<rsStee tn;urane9-nad iFme of lbp pbllua ago f:c eo 011'w'a except... ttel: Intpdn t ,<I3.n, and tNr glnkce eF Hvth O+Neu, Dl+la, 'NmNnpbn. and wyow�n9. o. nee Pamv n end:v three endmamenm and s Feaweep a.P [.L.n;nn eno+or,rt:rnn Pxa; - slhed„t. bf .e,.oe [4) P1.111UP T1*+1 mom Z11111114, tFari l..[h09rYnv,vm.:p16Y 1s't;minie b: C::r 1,11null I:tae[:I,cat,er. z, RY ap e'1tl +ztinJ Vlena, All reYu.rrtd,niv„m T:,en :s sukJ n.t tb ven'i[nhon any x!,dn5r dy avdl[. (layhnuad Cn d:, Y.hw ppyel kIt I IYP 4 t]l4 -- t 15 1 p lb 1 b 00 t i 9p". I u. i". A X.39 Pu4Vc syn.0 W lA e+ to. Pa iO>JPpa Eb. wwwJ d , J.. N Ij CD �^^ _ 4/ CL to 00 oo r 0 rj � ) / \ ® \ ■ \ \�� ! !�� \ � \ \ / } \�\.\�� \ \\ z 3 3 » / � C✓� w wt IQ� __.?� /\2 \§/\\/� 71 ; \ � \ � \ � § IS ƒ\} 2 \ \ « C R omz 0 9 a / « 2 y 5 0 \ r \ ƒ(J ((\� \\��\ 2(§ )� } >gr�} \\\�\ �} 9 4 w El tz Er CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1 -a) with a local governmental entity and the vendor meets requirements under Section 176,006(a). By law this questionnaire must be filed with the records administrator or the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section Is a misdorneanor. 11 Name of vendor whohasa business relationship with local governmental entity. IJ, &LU' T �-. —C ❑ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate,) 31 Name of local government officer about whoono the information is being disclosed. 8v �� Name of Officer IJ Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family rnernber of the officer receiving or likely to receive taxable Income, other than investment income, from the vendor? Yes i% No B. is the vendor receiving or likely to receive taxable income, other than investment income, front or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes Ej No 5 Describe each employment or business relationship thatthe vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section f 76.003(a)(2)(13), excluding gifts described in Section I76.003(a-1). 7 -- - AD Signature of vendor buss vernmental entity Date Form provided by Texas Ethics Commission www. ethics. state.ix. us Revised 11;3012015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective prinnaq participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred_ suspended, proposed for debanuent, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Havc not within a thrcc-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. c. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a - d) of this certification. \!1<O%INS &�1 N � mz. \ O - \ Name and Title of Authorized Agent Date Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for Influencing or attempting to Influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (Including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, %pLLC , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. ignature of Contractor's Authorized Official i �1dC�Ai ��IJ1a�1 �pJ�S'i�)txlE'A)� �Z Printed Name and Title of Contractor's Authorized Official \fit " t \o — DC) Date Approved by OMl3 0 0348.0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S,C. 1352 (See reverse for nublic burden disclosure) I. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing _ b. grant _ b. initial award b. material change C. cooperative agreement c. post -award d. loan For material change only; e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Prime _ Subawardee Name and Address of Prime: "Pier , if Known: Congressional District, if known: I i. i CoWi: ssimtal Distrletz if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ffapplicable: 8. Federal Action Number,lfknown: 9. Award Amount, if known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if fifindividual, last name,firwnante,M& diffcrent,j•omNo.10a) (Ills! name, first name, MI): tt. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: �---- _ disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name7M®MM. by the tier above when this transaction was made or p1 A entered into. This disclosure is required pursuant to 31 Title: Q�Nef'jki�lltav"s•Ci4 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.:1O Sib- "�0 Date: �^ inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than SM000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 OIN b rJ the undersigned representative of Representative aA 2 �4� 1--�— (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas, Pursuant to 2270.001, Texas Government Code.' 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, Inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for-prcflt sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signature of Representative Print Name & Title �1®-\b �a _ Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount, RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq„ as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec, 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident, (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ 1 certify that is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business Is (City and State) M/i certify that m is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. W Signatbre-dfAuthorized Agent ;0 v-%W T MSltj,Mc Printed Name and Title of Authorized Agent Date Please Type If handwritten, must be in ink and legible Vendor's Name: \ \f" '0-O b Q Q o \.,`^C ' Address: 13, � h \-\ yvPA a x -1S?®\ Remittance Address: S;o� R6 f�bo'j'-?- Telephone: S3®•- :).-1 % - Fax: %2Q)-sci\- \!& i:�`rj Email: keoy1V3' WS — Email(s) to send Bid Information: Signature of Authorized Printed name of Authorized Rep: Mrm�-s ORDER — CONTACT INFORMATION Order Contact Name & Title: Order Contact Telephone: o,AVY 3\ b - Vq b "A Order Contact Fax: S So - S M-yooa'A Order Contact Email: 3�O\v!1'r.3C OCKaSf 11R\, `� Request for Taxpayer Form ne H'Iv.rrtor2vta) Identification Number and Certification Give For in to the requester. Do not 9apartrnbntof n,5rraaslay send to'the IRS. 'oternul Revsnut; 3awica m Go to rvww.irs,govyfrormy/9 for instructions and the latest information. i NOme (as shown on your income tax retum). Marro Is raqulrad on till; IInO: Ito nbr leave thin line blank. BLADES GROUP, LLC. � 2 Bu hrr nflg1Pk115YHgrn ed HnL1Yy r11nC I dl'fefant fNm nbU\^E rn N _ J appropriate no ._ a Gie 4 a >rc mate box foe Fedcal W¢ rlas;Iflcaumn of the ,error, ernes, Hams, i^ cnro^cd online Clock only nab df the 4 Fxe+nrp�imly (eels apply only to O1 klboe.,x seven box J I c In erdlltnt, not individuals: yea i G I, s1w,,tiens on pogo, 3t 0 Inelividuel/role proprietor or 0 G Clorporatlon ❑ S Corpomilam Pnrmashlp L) nusu.stata m: single-m5mber LLC Exempt ell Qme M any) ^•o`g [✓ Limited liability company. udar thn lax classification (C=C mrporaiion, 8--s cerebration, Pzapadnatahlp) P _ P p Nbfe: 1-hock Oro appropriate box in the lino abr of the owner. oche .nick Exemption from FA'I'GA repxn'na the tax regaulad The HeC t weer- i t.1.0 if tlis LLC is clasEltied as a s1191em¢mbor LI. I. in'rt e; ails garda;i irarb the owner unless tfrfl owner of the LLC is fro r„'Ja (it anyj Q. i another LLC that le not disregurdad from the caner nor U.G. federal tax purposes uthei isa, a single-mcmuer LLC the la dsrugarded from the owner simuld t.Tenk the anpropture hex fee the tux clas>tticatlon pl its owner. ,y Otler less rPYLry'.UOny1P fA0.mrosm.,euo✓rrcf ragrb.h.!curplo µp.4.) D Address (number. sleet, and opt 0. Ultb no) Flea In5lructlaas. bill 3 FM 1403 0 Ciyq state, and ZIP rode UVALDE, TX 78801 7 Lis1 acecunt number(+)Bare (ap;ierral) Enter your I IN in the approprialo box. The IFIN provided must rnetch the name given on line 1 to avoid backup withholding. For inclividuals, this is yenerally your social security number (SSN). However, for a resident alien, sole proprietor, or star speeded entity, see the inshructions for Part I, later. For office entities, it is your employer identification number (FIN). if you do not have a number, see How to yet a TIN. later, Note: If the account is in more than one name, see the instructions for line 1. Also see What Afarnc and Number to Give the Requester for guidelines on whose number to enter. Under penalties of perjury, I celtry, that: -- - - - 1. The number shown on this form is my correct taxpayer identification number (or I am visiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I nave not been notified by the hncrnul Revenue SOMOO (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me. that I am no longer subject to backup withholding; and 3. 1 am a U.S. cliizon or ether U.S. person (defined below); and ?. 1"he FATCA coda(=) entered on this form (if any) indicating that I am oxenipt hum FATCA reporting is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that yet] are out, ently subject to backup withholding because you have failed to report all interest and dividends on your tax return, For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, GeNOWILLlena to an Individual retirement arrangement LRAI, and generally, payrnerne other Than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. anyrr 519110hire of f a Here U.S. person► r' "%, E " t �"f`"I�.s:.��.4, onto. �, �;2�J'j General instructions Suction references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-U and its instructions, such as legislation enacted after they were published, go to vvwvvJragov/FomuWg. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with file IRS must obtain your correct taxpayer identification number TIN) which relay be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identfication number (EIN), to report on an information return the amours pall to you, or other amount reportable on an Information relutn. Examples of information returns Include, but are no limited to, the following. • Form 1099-IP1T (interest earned or Fold) • Form 1099-HIV (dividends, including those from stocks or mutual funds) • Form'1009-KIISC (various types of income, prizes, awards, or gross proceeds) • Form 1009-10 (stock or mutual fund sales and ceatain other transacterrs by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and Ihird party notwork transactions) • Form 1098 (home mortgage merest), 1098-E (el loan interest), 1098-T (Luition) • Form 1099-C (canceled debt) • Form 1099^A (acquisition or abandonment of salcumd pl'operty) tlse Form W-9 only If you are a U.S, person (including a resident alien), to provide your correed TIN. If you no not return Form 11I-9 to the requester with a TIN,, you tnipht be subject to bactrup withholding. See What is backup withholding, taller. Gat, No. 1W.31x Plain W-91Rev. 10-'10181 CLEVELAND ASPHALT PRODUCTS, INC. ME ANNUAL SUPPLY CONTRACT Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name & Address Cleveland Asphalt Products, INC. Shepherd, Texas 77371 - Please Type. If handwritten, must be in ink and legible. White out is not acceptable. -The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch To Dust Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton NB NB NB NB I Precinct 2 Ton NB I I NB NB I NB Precinct 3 Ton I NB I NB NB NB Precinct4-P I Ton I NB I NB NB NB Precinct4-S Ton I NB I NB NB I NB Remarks: Bid Item #2: Item 247, Type A Limestone, Grade 2, [13/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 Ton I NB I I NB I NB I NB Precinct 2 I Ton I NB I NB I NB I NB I Precinct 3 Ton NB I I NB NB I I NB Precinct4-P I Ton NB I NB NB NB I Precinct 4-5 I Ton I NB i NB I NB I NB Remarks: Page 1 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I 1 I I Precinct 1 1 Ton I NB I NB I NB 1 I NB I Precinct 2 Ton NB i NB 1 NB I NB Precinct 3 I Ton NB I NB I NB NB NB NB Precinct 4-P ; Ton ' 1 I NB I NB NB i NB i NB i NB Precinct 4-S 1 Ton I I I I Remarks: Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Bag (Cost per Pallet) List It of 47 lb Bags on a Pallet Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton NB NEI NB NB of 47 lb 1 NB I NB NB i NB i Bags on Pallet I i i NB i NB NB NB 2 1 Ton I I I I I of471b 1NB j NB I i NB NB Bags on Pallet ' ' NB NB I NB NB 3 I To I of 47 lb NB 1 NB NB NB I Bags on Pallet I 1 I 4-P Ton NB NB NB NB _of47lb I NB NB I NB I NB j Bags on Pallet I 4-S ; Ton I NB NB NB NB _of471b NB NB I NB NB Bags on Pallet I I I I Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #S; Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton NB NB NB NB Precinct 2 1 Ton I NB NB NB NB ' i Precinct 3 1 Ton 1NB I NB NB I NB I I I Precinct4-P 1 Ton i NB I NB 1 NB I I NB I I Precinct4-S i Ton I NB I NB NB I ; NB Remarks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I ' Precinct 1 Ton NB I 1 NB 1 , NB I I NB Precinct 2 1 Ton I NB I NB NB NB Precinct Ton I I NB I NB I NB NB Precinct4-P 1 Ton ; NB i NB NB I NB I Precinct4-S I Ton I NB I 1 NB I NB 1 NB marks: d Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I NB I NB I NB I NB Precinct 1 Ton 1 I i 1 Precinct 2 1 Ton I NB NB NB NB I Precinct 3 1 Ton j NB NB NB I NB Precinct4-P 1 Ton NB NB NB 1 NB Precinct4-S Ton 1 NB NB I NB NB Remarks: Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED I Item #8a Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 I Ton NB NB I I I NB I I NB NB NB i NB i NB Precinct Ton 1 i Precinct Ton NB I NB i NB I i NB i I , Precinct4-P I Ton 1 NB NB 1 NB 1 NB I I NB Precinct 4-S ; Ton NB I I I NB I I NB Remarks: Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton I 1 NB 1 1 NB 1 NB 1 NB Precinct 2 ' Ton I NB 1 NB 1 NB 1 I NB Precinct 3 1 Ton NB NB I 1 NB 1 NB Precinct 1 Ton I NB 1 NB 1 NB i I NB I NB 1 NB 1 NB 1 NB Precinct 4-S I Ton I I I arks: Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 1 NB I i NB NB NB Precinct 1 Ton I Precinct 1 Ton I , 1 NB I I I NB I NB 1 NB 1 1 NB 1 NB 1 NB I NB Precinct 3 1 Ton I 1 I 1 Precinct4-P 1 Ton 1 NB 1 NB 1 NB 1 NB I 13recinct4-S Ton I NB I 1 NB 1 NB 1 NB arks: Page 4 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid item#11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton NB 1 NB I NB I NB Yard NB i NB INB NB 50lb Bag NB I NB I NB NB Precinct 2 1 Ton ; NB I NB 1 NB NB 1 Yard 1 NB I NB NB NB 1 50lb Bag NB NB NB NB I 1 Precinct 3 I Ton ; NB I NB I NB 1 I NB Yard' NB NB I NB I NB 50lb Bag 1 NB I NB I NB 1 NB Precinct4-P 1 Ton NB 1 NB NB NB 1 Yard I NB 1 NB 1 NB I NB ; 1 50 lb Bag 1 NB 1 NB 1 NB NB Precinct4-S 1 Ton NB 1 NB 1 NB 1 NB 1 Yard I NB 1 NB 1 NB 1 NB I 1 50lb Bag NB NB I NB NB Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton NB NB 1 NB 1 NB 1 I I Precinct 2 1 Ton 1 NB NB 1 NB 1 NB I Precinct 3 1 Ton I NB 1 NB NB I NB Precinct4-P 1 Ton 1 NB NB NB i NB Precinct4-S 1 Ton 1 NB NB 1 NB NB Remarks: Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #13: Item 432, Riprap, Section 2.3 Stone Rlprap, 12" Limestone Price per ton / delivery price to County Stockpile and/or Jobsite -1 MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 I Precinct 1 Ton NB NB NB 1 NB I Precinct2 1 Ton NB NB NB NB i I Precinct 3 I Ton I NB 1 NB I NB NB I I NB NB I NB NB Precinct 4-P 1 Ton I 1 I i 1 NB 1 NB 1 Precinct 4-S I Ton I I I NB 1 , NB ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid item'#14t Primer Oil Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I 1 i I I I I I is 80.00 Per Hour After 1 1 $2.00 1 $0.20 I $2.20 Precinct 1 1 Gallon 1 12 Free Hours I I I $ 80.00 Per Hour After 1 1 $2.00 1 $0.20 1 $2.20 1 Precinct 2 1 Gallon I 1 I 1 2 Free Hours 'i I 1$ 80.00 per Hour After I $2.00 Precinct Gallon 1 I 1 $0.20 1 I $2.20 1 2 Free Hours I I I i '$ 1 $2.00 $0.20 $2.20 80.00 1 Per Hour After Precinct4-P I Gallon I 1 1 1 2 Free Hours I I 1 1 I 1 I I $ 80.00 per Hour After $2.00 Precinct 4-S 1 Gallon I I $0.20 I 1 1 $2.20 1 1 2 Free Hours Remarks: Price based on minimum full load of 5000 gallons, for smaller quantities please call 800-334-0177. Diluted material can not be returned for credit. Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/orlobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I $2.75 $0.20 $2.95 I ;$ 80.00 Per HourAfter Precinct 1 Gallon I I ; 2 Free Hours I I ' 1 $2.75 I $0.20 1 $2.95 ;$$D�Q�Per Hour After Precinct 2 1 Gallon 1 1 ' 2 Free Hours I 1 1 $2.75 1 $0.20 $2.95 I I$ 80.00 Per Hour After Precinct 3 Gallon I I 1 12 Free Hours $2.75 1 $0.20 I Precinct 4-P I Gallon 1 $2.95 1$ 80.00 Per Hour After ;2 Free Hours 1 $2.75 1 $0.20 $2.95 1$ 80.00 Per Hour After Precinct 4-S I Gallon I 1 2 Free Hours Remarks: Price based on minimum full load of 5000 gallons, for smaller quantities please call 800-334-0177. Diluted material can not be returned for credit. Bid Item #16: CRS-2 Temperature must be no lower than 1500 and no higher than 1800 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I 1 I 1 1 1$ 80.00 Per Hour After Precinct Gallon $1.75 $0.20 1 $1.95 2 Free Hours 1 I $1.75 1 $0.20 1 $1.95 ;$ 80.00 Per Hour After Precinct 2 I Gallon 1 I 1 12 Free Hours I I I $1.75 1 $0.20 $1.95 $ 80 QQ Per Hour After Precinct Gallon 1 1? Free 1 1 $80.00 Per Hour After Precinct 4-P I Gallon I 1.75 $0.20 $1.95 1 2 Free Hours I I $ 80.00 Per Hour After $1.75 I $0.20 Precinct 4-S I Gallon 1 $1.95 1 2 Free Hours Remarks: Price based on minimum full load of 5000 gallons, for smaller quantities please call 800-334-0177. Diluted material can not be returned for credit. Be sure to complete next page (page 8) Page 7 of 8 invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 10/28/2020 Authorized Signature & Title: Type Name & Title of Authorized Signature: Clayton Moore, Sales Rep. Phone Number: 800-334-0177 Email: ccmcapco(cbmsn.com Exceptions and or Variations from Specifications and/or additional Notes: All prices based on minimum 5000 aallon load. For smaller quantities please call. Diluted loads can not be returned for credit. Page 8 of 8 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Clayton Moore known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. ffia� Clayton Moore, Sales Rep. Printed Name and Title of Affiant Name of Bidder (Company) Cleveland Asphalt Products INC Address PO Box 1449, Shepherd, Texas 77371 Phone Number 800-334-0177 Fax Number 936-628-6602 Email Address ccmcapco@msn.com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, thisZgl`* " day of October 120 20 . YP 9 AMIE FEARRINGTON C/✓ ��'""P +� STATE OF TEXAS Notary Public inandfor���` '? p°+ ID q t3133525-0 1 J � - vCOUnty, Texas 9�OF'�* My Comm. Expires 9D•31.2021 CERTIFICATE OF INTERESTED PARTIES FORM 1295 l of l 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: 2020-683858 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Cleveland Asphalt Products INC Shepherd, TX United States Date Filed: 10/28/2020 2 Name of governmental entity or state agency that is a parry to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. Bid Number 2021.03 Road Materials and Asphalts, Oils and Emulsions January 1, 2021 thru December 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. X 6 UNSWORN DECLARATION k°r�, via' t4 +ia 1 My name is Clayton Moore and my date of birth is 1 —+k � ; ;'.`-? My address is PO Box 1449 Shepherd TX , 77371 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in San Jacinto County, State of Texas , on the 28 day of October , 20 20 , (month) (year) Signature of authorize auuttho-ri`ze`d agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d DATE(MMIDD/YYYY) 11/4/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Nuninu, Bowen, Miclette & Britt Insurance Agency, LLC PHONE Heather Cameron FAX 1111 North Loop West, #400 IArC No Ezt1' 713-880-7100 IA/c Not: 71 Houston TX 77008 E-MAIL hcameron@bmbinc.com INSURED Cleveland Asphalt Products, Inc. P 0 Box1449 Shepherd TX 77371 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTE `"' "L Gv'"Y't dcEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER p POLICY NUMBER POLICY EFF YY MM/DD/YY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y V �y� P Rak.£ d ;7] .x.�,0 81112020 811/2021 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $300,000 MED EXP (Any one person) $ 25.000 PERSONAL & ADV INJURY $1,000,0D0 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT ❑ LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $2,000,000 COMBINED SINGLE LIMIT Ea accident $ $1 000 000 C OTHER: AUTOMOBILE LIABILITY %t ANYAUTO V VV1,190 �{ i ,M' p1 *' .2 8/1/2020 8I1/2021 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Peraocidenl $ A UMBRELLA LIAR X OCCUR Y N - NEWS 811/2020 0/1/2021 EACH OCCURRENCE $3,000,000 X AGGREGATE $3,000,000 EXCESS LIAB CLAIMS -MADE �`+ S DED RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY!' ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? NIA y "' {ars'so. 8/1/2020 8/1/2021 X PER OTH- STATUTE ER E.L. EACH ACCIDENT 1,000,0p0 1$$ E.L. DISEASE - EA EMPLOYE1,p00,000 (Mandatory In NH) If yes, tlescribe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The following policy provisions and/or endorsements form part of the policies of insurance represented by this certificate of insurance. The terms contained in the policies and/or endorsements supersede the representations made herein. Electronic copies of the policy provisions and/or endorsements listed below are available by emailing: certificates@bmbinc.com General Liability: Blanket additional insured Ongoing Operations per form #CG 2026 07 04 Blanket additional insured Completed Operations per form #CG2037 1001 Blanket waiver of subrogation per form #ECC-320-0712 See Attached... Calhoun County 211 S. Ann St. Suite 301 Port Lavaca TX 77979 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. @ 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: n ADDITIONAL REMARKS SCHEDUU4 Page 1 of 1 AGENCY Bowen, Miclette & Britt Insurance Agency, LLC NAMED INSURED Cleveland Asphalt Products, Inc. P O Box 1449 Shepherd TX 77371 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE primary/non-contributory per form #ECC-548-0317 additional insured perform #Q-ADLIN-B-0814 waiver of subrogation perform #Q-WAIVER-B-0814 primary/non-contributory per form # CA 04 49 11 16 s Compensation: waiver of subrogation per form #WC 42 03 04 B additional insured perform #EXS-200-0712 primary/non-contributory per form #EXS-200-0712 ACORD 101 (2008/01) V 2UU8 ACOKU CUKFUKAIIVN. All rights reserves. The ACORD name and logo are registered marks of ACORD n >7A4s � Policy Number ,,`tilt Cleveland Asphalt Products, Inc. Effective Date 08/01/2020 08/01/2021 Endorsement Number: 21 aommc Additional Insured Designated Person or Organization In consideration of an additional premium of $0, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name and Address of Additional Insured Persons or Organizations(s) As required by written contract. Information required to complete this Schedule, if not shown above, will be showm in the Declarations Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties, Inc., 2004 Policy Number • �MO 1 Cleveland Asphalt Products, Inc. Effective Date 0810112020 - 08101/2021 Endorsement Number:22 namrnur .-�. Additional Insured — Owners, Lessees or Contractors — Completed Operations This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ie and Address of Person or Organization: Blanket where required by written contract And Description of Completed Operations: Additional Premium: SO (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II— Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to Lability arising out of "your work" at the location designated and described in the schedule of this endorsement performed for that insured and included in the "products - completed operations hazard". CG 20 37 10 01 Copyright, ISO Properties, Inc., 2000 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176,006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. Clayton Moore for Cleveland Asphalt Products, INC. 2 ❑ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) -3J Name of local government officer about whom the information is being disclosed. Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yes 57 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? FlYes FT1 No 6 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. None 6 Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 10/28/2020 Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx. us Revised 11/30/2015 Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid orwill be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, Cleveland Asphalt Products, ]NG. certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signature of Contractor's Authorized Official Clayton Moore, Sales Rep. Printed Name and Title of Contractor's Authorized Official 10/28/2020 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing NA b. grant NA b. initial award NA b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter _ Prime _ Subawardee Name and Address of Prime: Tier_, if Known: NA NA Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: NA NA CFDA Number, ifapplicable: S. Federal Action Number, ii known: 9. Award Amount, ifknown: NA NA 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, MI): differentfrom No. IOa) (last name, first name, Ml): NA NA 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature:,^' - disclosure of of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Clayton Moore by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Sales Rep. U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: 800-334-0177 Date: 10/28/2020 Inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) Clayton Moore Representative the undersigned representative of Cleveland Asphalt Products, INC. (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signature of Representative Clayton Moore, Sales Rep. Print Name & Title 10/28/2020 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ 1 certify that is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) (* 1 certify that Cleveland Asphalt Products, INC. is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorize 7cgent Clayton Moore, Sales Rep. Printed Name and Title of Authorized Agent Date Please Type If handwritten, must be in ink and legible Vendor's Name: Cleveland Asphalt Products, INC. Address: PO Box 1449, Shepherd, Texas 77371 Remittance Address: Department#936 PO Box 4652, Houston, Texas 77342-1260 Telephone: 800-334-0177 Fax: 936-628-6602 Email: ccmcapco@msn.com Email(s) to send Bid Information: ccmcapco@msn.com Signature of Authorized Representative: L 5' Printed name of Authorized Rep: Clayton Moore, Sales Rep. ORDER - CONTACT INFORMATION Order Contact Name & Title: Freida Colburn Office Manager Order Contact Telephone: 800-334-0177 Order Contact Fax: Order Contact Email: capcoasphalt()msn com Wi 9 Request for Taxpayer Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to 1ywwdrs.g0v/F0b%W9 for instructions and the latest information. 1 Name (as shown on your income tax return). Name Is required on this line; do not leave this line blank. Cleveland Asphalt Products, INC. 2 Business name/disregarded entity name, if different from above m 3 Check appropriate box for federaf tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entitles, not individuals; see o. o ❑ Individuallsole proprietor or R1 C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/astate Instructions on page 31: m 0 single -member LLO Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) P. `o m Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC is LLC that is disregarded from code if any) 6 o mother not the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that Is disregarded from the owner should check the appropriate box for the tax classification of its owner. m ❑ Other (sea instructions)► t^•wres roewa,ms meMbnMomdm me us) y s Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) rn PO Box 1449 a City; state, and ZIP code Shepherd, Texas 77371 7 Ustaccount numberls) here (optional) Taxpayer Identification Number ('rIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid ) Social security number backup withholding. For individuals, this is generally your social security number (SSN). However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other HE _ [I]_ entities, it is your employer Identification number (EIN). If you do not have a number, see How to get e TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. rli — - T Under penalties of perjury, I certify that; 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2.1 am not subject. to backup withholding because; (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup wilhhotding; and 3. 1 am a U.S, citizen or other U.S. person (defined below); and 4. The FATCA cocle(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends an your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. 011l" signature of 10/27/2020 Here I U.S. person /'` ��.- -- Date General lnstructio Section references are to the 1 ernal. Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.1rs.gov1Form V9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns Include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tuhion) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only It you are a U.S. person (Including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X (Rev. 10-2018) ME Beginning January 1, 2021 and Ending December 31, 2021 U CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name & Address 9Nrtnl i �, �6 mwV-wt E>r'A-T-IrJ6 4 /nl & , 1 '- -I }-(A a of g xq • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. -The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch To Dust Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton 1 '7 •t�I 7 I �:^ .`I p� 1� Precinct 2 Ton �, I '�l; • N Precinct 3 Ton �• 1 „�� 4 Precinct 4-P Ton C� I . '/ $ 3 q r I Precinct4-S 1 Ton Remarks: Bid Item #2: Item 247, Type A Limestone, Grade 2, [13/4 Inch] Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton L/,417 4,,yy _>0,q 1 %a Precinct Ton C/ L/ e, Precinct Tony9 ; 3035" jI/O I Precinct 4-P ; Ton -70. Precinct4-SI Ton t'Lf ��✓.t12� 3D,`TS I //� Remarks: Page 1 of 8 Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct I I Ton I , f/ a I 30; 3 Precinct 2 Ton Y't/ Precinct ) Ton /� ) t'lY.1 ) <.t�, tl 7 J �.`) S I f N �✓� Precinct 4-P ; Ton t�,"7 / ..�� .d� I I'/ -$ d • �%.� I � Precinct4-S Ton � ) `� �'.tj'� � 30 Remarks: Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Bag (Cost per Pallet) List # of 47 lb Bags on a Pallet Price per unit / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton II _ of 47 lb � 1 Bags on Pallet 1 I I 1 1 Precinct 2 1 Ton 7 I 1 1 1 _ of 47 lb 1 Bags on Pallet 1 1ff 1 1 I I I I 1 Precinct 3 1 Ton 1 1 I I 1 of 47 lb Bags on Pallet i Precinct 4-13 1 Ton i of 47 lb 1 Bags on Pallet I Precinct 4-5 1 Ton 1 1 I 1 I i _ of 47 lb i i i Bags on Pallet Remarks: Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions —CONTINUED Item #5: item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL Precinct 1 Ton Precinct 2 I Ton 1 I I I I Precinct 3 Ton 1 1 I I Precinct4-P ; Ton 1 1 I Precinct 4-S ; Ton I I I (Remarks: Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL I Precinct 1 Ton I I Precinct 2 Ton I I I I Precinct 3 Ton I 1 Precinct 4-P I Ton I I I I Precinct4-S I Ton I I I Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I _ I Precinct 1 Ton 1 1 I I t I Precinct 2 I Ton I I I I 1 Precinct 3 1 Ton 1 I I I I Precinct 4-P I Ton I I I I I I 1 1 Precinct 4-S I Ton 1 ! I I TOTAL IdAI IJl1�TAII MINIMUM LOAD/ORDER MINIMUM LOAD/ORDER Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or lobsite LOCATION Unit MATERIAL DELIVERY Precinct 1 Ton 1 I I I I Precinct 2 Ton I I I I I Precinct I Ton I Precinct 4-P I Ton I I ; I 1 Precinct 4-S ; Ton I I TOTAL ILIIJIIiRllli6d Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton/ delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' I I Precinct 1 1 Ton I I I 1 I I I I I Precinct 2 1 Ton I I I I I I I I I Precinct 3 1 Ton I I I I I Precinct 4-P I Ton I I I I Precinct 4-S 1 Ton I I I I I I I I Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton i I Precinctz I Ton i /07) I 1 ��•t/3 I I Ac�9 Precinct 3 1 Ton i US ✓) I ��• 1'/3 AlIn Precinct4-P 1 Ton I ©.s-o � i� I �i9, 1 i per/ % Precinct4-S I. Ton .5�� t I T ��'.I N�. Page 4 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I i 1 Precinct 1 I Ton i I I i I Yard 3 I I I I I 50lb Bag I I l I I Precinct 2 1 Ton I I I I I I Yard' I i I SO lb Bag I I I I Precinct 3 1 Ton I I I ' Yard' I I I 1 50lb Bag ' i i I I Precinct 4-P I Ton I I I I ' Yard i I 50lb Bag I I I i i I Precinct 4-S I Ton I I 1 i Yard I I I l 50lb Bag Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table Its Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct l I Ton I I I I Precinct 2 Ton 1 ' I I I Precinct 3 Ton I Precinct 4-P I Ton I I I I , I Precinct4-S ; Ton 1 I Remarks: Page 5 of 8 Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts,. Oils and Emulsions -- CONTINUED Bid Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 I Ton 7 I •� i ��. (, j �.I'/ I�' /° �� i Precinct 2 ' i Ton i 99 i I Precinct 3 I Ton 11...3 Precinct 4-P ; Ton i Precinct 4-S ; i Ton ; I •3 I -1 I I s3_ /. V 6 Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil Price per gallon / delivery price to County S LOCATION I Unit I MATERIAL 1 1 Gallon 2 1 Gallon Precinct 3 I Gallon Precinct 4-P I Gallon 4-S i Gallon e and/or Jobsite DELIVERY TOTAL DEMURRAGE 1 1 I$ Per Hour After 1 Free Hours 1 1 1 l$ Per Hour After I— Free Hours I 1 I 1$ Per Hour After 1 ; Free Hours 1 1 1 l$ Per Hour After 1 1 1 Free Hours 1 , , 1$ Per Hour After Free Hours Page 6 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions — CONTINUED Item #15: RC-250 Temperature must be no lower than 1400 Price pergallon / delivery price to County Stockpile and/or Jobsite LOCATION I Unit I MATERIAL I DELIVERY Precinct 1 1 Gallon 1 I Precinct 2 1 Gallon i i Precinct 3 Gallon i i Precinct 4-P 1 Gallon i i Precinct 4-51 Gallon (Remarks: TOTAL Bid Item #16: CRS-2 Temperature must be no lower than 150' and no higher than 180° Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION I Unit I MATERIAL I DELIVERY I TOTAL Precinct 1 1 Gallon I 1 Precinct 2 1 Gallon 1 1 I 1 i i i Precinct 3 1 Gallon 1 1 1 1 1 Precinct 4-P 1 Gallon 1 I I I 1 i I i Precinct 4-S I Gallon I I 1 1 Remarks: Be sure to complete next page (page 8) DEMURRAGE Per Hour j Free Hours Per Hour After Free Hours _ Per Hour After Free Hours _ Per Hour After Free Hours —Per Hour After Free Hours DEMURRAGE _ Per Hour After Free Hours Per Hour After Free Hours _ Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Page 7 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid paciret and f &-understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: I I " 1 - n Authorized Signature & Title: Type Name &Title of Authorized Signature: �..,J O otji f_ — 4i�.I tlmf 6 wiyerrC Phone Number: 972"3?''2- /I'? -I Email: jGr-ai+krt a O✓rSkd+K4t`4Ck6P.C4,.A Exceptions and or Variations from Specifications and/or additional Notes: �%1 Page 8 of 8 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared i kP)VA known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at anytime hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affia Printed Name and Title of Affiant Name of Bidder (Company) 0(4Wi�J+( K (iRESI Ata nefea'nrl =, INi Address 0) 90X' tccosZ (X `i'l4SS— Phone Number 9 i � - (� L) Q, - � S �0 Fax Number C/ Email Address U � or -CIA, 'Z gre.site,N tY-,LC.(�ihe. -ccevt ,J SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this day of 1�c.✓ R AUREN MARIE ZBORIL NOTARY PUBLIC STATE OF TEXAS y Comm. Expires 01-281.2024 Notary Public in and for ' A ) k�G V-KN \ County, Texas c CERTIFICATE OF INTERESTED PARTIES FORM 1295 l of l 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: 2020-687560 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Johnnie R. Gresham Operating, Inc. Louise, TX United States Date Filed; 111 9/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County, Texas 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 services, goods, or other property to be provided under the contract. Bid Number 2021.03 Road Materials and Asphalts, Oils and Emulsions January 1, 2021 thru December 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. X 6 UNSWORN DECLARATION My name is .._)ZW ii I ¢' (i rie1,t /.k kv " , and my data of birth is i�ii' :a� 4. � 4r 3'a{gyp 3I'�K, 9F`Yy, �,iii �#'" Yl 1i5 rij Idi `�My address is s,. �tr. �4xt If We 1 declare under penalty of perjury that the foregoing is true and correct. �7A Executed in �l � q rL'Ti5 County, State of %i,:Y✓l.S , on the / / day of AII(iN6'{IJ, 20 z.o (month) (year) Sign re of authorized agent o cor(tracting business entity (Declarant) Forms Drovlded by Texas Ethirs Cnmmissinn mnenm othirc cinta w „� v.....:.._ .,, , .,_.,__.-,l CERTIFICATE F LIA ILL 4 Y I U NC l6/14 DAr 020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT., If the c rtificate holder is an ADDITIONAL INSURED, the Polleyfies) must be endorsed. if SUBRnraTJON IS WARIED, suH)>ct to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER TCL Insurance Agency Inc 1329 N University, Suite D7 Nacogdoches TX 75961 CONTACT NAME PHONE FAX c No Ext: 936-560-9393 Alc No:936-560-9394 ADDRESS rece fionisf fcllneurafice.cOrcl INSURERS AFFORDING COVERAGE NAIC# INSURER A : Clear Blue Insurance Companyp�p WE ; INSURED GRESTRU-02 INSURERB: Texas Mutual Gresham Trucking, LLC Johnnie R. Gresham Operating INSURER C: NSURERD: P. O. Box 211 Louise TX 77455 INSURER E: IN$VRERF: �___......._ COVERAGES CERTIFICATE NUMBER P9` 00 OMS0 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IR LTR LT ADDLSUBITWEOFINSURANCE INSR WYU POLICYNUMBER POLICYEFF IYYYY MMIDDTEXP LIMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS.MADE E OCCUR 'iy'ip,l. �I1lijAfFi 6I1512020 611512021 EACH OCCURRENCE $1.0C0.00O DAMAGES ( R PREMISES Ea occurrence) $100,000 MED EXP (Any one Peon) $ 5.000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2.000,000 _GEL AGGREGATE X POLICY LIMIT APPLIES PER: PRO, LOCJ"T PRODUCTS-COMP/OP AGO $1,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED Y. SCHEDULED X HREAUTOD AUTOS X ANUroSWNED k 0115/2020 5/15/2021 COMBINE. SINGLE LIirtlT a aaitlent 1 000.000 BODILY INJURY(Per po.o) S WDILYWJURY(Peracctdent) $ PROPERT nj DAMAGE $ UMBRELLA UAB EXCESS LIA6 OCCUR CIA AIMS-MADE EACHOCCURRENCE $ AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION ANDErk^LOY�mRVLIABILITY YIN ANY PROPRIETORIPAKINERIEXECUT VE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) I( describe antler DESCRIPTION OF OPERATIONS below NIA 'm "y , t �` n $ N� , I SI1TI2020 &1712021 WC5TATU- OTH- TORV LIMITS ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONSILOCATIONSI VESICLES jAIQeb ACORD 101, Admonel Rnmerke Schedule, U ..Pre e� _ei=r�Pirad) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ***SAMPLE*** AUTHORIZED REPRESENTATIVE reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the data the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1J Name of vendor who has a business relationship with local governmental entity. z ElCheck this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer -!j Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? F] Yes E-1 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes FIND 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signatur t vendor doing busines' 6 8-with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Name and Title of Authorized Agent 21 Signature of AutTrorized Agent I am unable to certify to the above statements. My explanation is attached. Date Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, 'Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). yrjl�- The Contractor,�rv,�if,Q tl S#A� V1e�4;'certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. 6 3801 at sea.. aoDly to this nPr ification and disclosure, if any. Date Approved by OMB - 0348-0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse fnr nnhlir hu.A,... A;—T — —i I. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing _ b. grant _ b. initial award _ b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Prime _ Subawardee Name and Address of Prime: Tier , if Known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agene3" 7. Federal Program Name/Description: CFDA Number, ifapplicable: 8. Federal Action Number, ifknown: 9. Award Amount, i(knowu: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address (ifindividua1, last name, first name, MI): di%ferentfrom No. 10a) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed PrintName: t{'. �•'1`tf/F%i'� by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 /} Title: /A'w (✓1. U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No: 279 -C 41-)5'20 Date: inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, OiirJNtf_ �(. /irl{S1-ua the undersigned representative of Re.pr-e�sentative _ Ku ti[ (C, /1f0Will` r/Ptw iTI �k i� (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes, and 2. "Company" means a for -profit sole proprietorship,organization,association, corporation, partnership,. Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signat, re of Representative '.. )f)lihMUC /C (a/lf:lllNlsvl iIL��JC�C- Print Name & Title Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ 1 certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) © 1 certify that o NWa t £. e LESHrt,^4 PegwrjeJW ' ista4"Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. (% 14 �'-' --, � 4,/- . Signaturdof Authorized Agent :...� � I'{ b,•h E �. �� t'Sf'�e�++'i . Ai GdNCr�= Printed Name and Title of Authorized Agent fir'- 9 ••� v Date VENDOR AND ORDER INFORMATION Please Type If handwritten, merit be in ink and legible Vendor's Name: Address: io • Kuf K „2 I.Z iWil . f .X I 745 Remittance Address: Telephone: T7I Fax: q 19 -- (, Yd �? — 2S ? y Email: 4-ruc14 Email(s) to send Bid Information: ,}or-jan z) <a re s'h,,,M"Fru �/� �.� J Signature of Authorized Representative:6 Printed name of Authorized Rep: bfwt L dc. (,7gr,fHkYw ORDER — CONTACT INFORMATION Order Contact Name&Title: .,D(09)) %e'fSFlr�f✓1 l�.s(�lZt{ Order Contact Telephone: 9 ? 1) - 3.3 "Z - o'32 Order Contact Fax: A] )A Order Contact Email: se9 Request for Taxpayer Give Form to �,e Farm (Rev. Octaber2018) Identification number and Certification requseter. ®o Rot Department of the Treasury _ send to the IRS. Internal Revenue service ► Go to wnvw.Irs govilcormW9 for instructions and the latest information. t Name (as shown on your income tax return). Name is required on this llne; do not leave this line blank. , iinlrv)' (', s< l+vmn 2y1 Ir1G' WC, 2 Business name/disregarded entity name, if different from above m 3 Check appropriate box for federal tax classification of the person whose name Is entered on line 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entities, not individuals; see a o j ❑ Individuayscle proprietor or b Corporation MSCorpomfian ❑ Partnership ❑TmsVestate Instructions on page 3); single -member LLC Exempt Exempt payee code (if any) �9 ❑ Unified liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► '0 2 Note: Check the appropriate box in the line above forthe tax classification of the single -member owner. Do not check Exemption from FATCA reporting c irn LLC 0 the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is ,d. ar e�•1 d$ another LLC that is not disregarded from the owner for U.B. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (am Instructions) P- d in 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optiona(i A V U ' c. � ) j CALHOUN COUNTY m 202 S ANN ST, PORT LAVACA TX 77979 5 City, state, and ZIP code -' "-'- 361-553.4610 FAX: 361-553.4614 ,i v\ . t°. `: 7 Usl account numbers) here (optional) Taxpayer Idenrificalican Number (TIN) Enter yourTiN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number l backup withholding. For Individuals, this Is generally your social security number . However, far a , late resident alien, sole proprietor, or disregarded entity, see the instructions for Pert I, later. For other _ m - entitles, It is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account Is in more than one name, see the Instructions for line 1. Also see What Name and I Employer Identification number Number To Give the Requesterfor guldelinsis on whose number to enter. ;- RIr�# ;W, '1 "*i1 Under penalties of perjury, I certify that: .,,..__........._.__.___ 1. The number shown on this form is my correct taxpayer identification number (or I am walling for a number to be Issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and S. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form Of any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (iRA), and generally, payments other than Interest and dividends,ygu.We not required to sign the certification, but you must provide your correct TIN. See the Instructions for Part II, later. civil atgnalure of Here uS. person► General Instrl Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Forthe latest Information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.lrs.gov/FbvmW9- Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns Include, but are not limited to, the following. • Form 1099-INT (interest earned or pald) Date► J/_9->) C"1 • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISO (various types of income, prizes, awards, or gross proceeds) • Form 1099-5 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuhlon) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What Is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) MARTIN MARIETTA MATERIALS, INC. w Fill • ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name & Address /VIV+-IVX A-4KK • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. •The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. Item#1: Limestone-3/4 Inch To Dust Price per ton / delivery price to County' rks: Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton I I I I Precinct 2 Ton I I I I ' Precinct I Ton I I Precinct 4-P ; Ton I i Precinct 4-S Ton i i i i i Bid Item #2: Item 247, Type A Limestone, Grade 2, [13/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite Remarks: Y i MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct ^� Ton dS® �°7 ® 3�,5® I I aq I Precinct2 ITon i 12,SQ j ��J �� dw, Precinct 3 1 Ton d3 , 5ci aLt . S Precinct 4-P ; ry Ton pt� , 50 4C I •p.W.S Precinct4-S ; Ton .rj� 13,Ao -DID a 4 4.� c Page 1 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -CONTINUED Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDER Precinct 1 I Ton I a3 e� 9 f nx ; 3 U , ' ; 0.00 I ) a I Precinct 2 -1 Ton I M Precinct Ton I Precinct 4-13 j Ton ; p(O.� I I, I C a .Q® ' I Precinct 4-S , Ton I I I Remarks: V t0. V 66V DW Q r Pry Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY Precinct 1 I Ton )2•� I �Orbl I `TOTAL boC.�j Precinct 2 Ton Precinct 1 I Ton ��• O Precinct 4-P Ton 4-S ; Ton ; gc� .0 I 3q aPrecinct G ,� .. [� r�' • !) I i i C i1\ Item 302, Type PE, Grade 3 Pre -Coated Rock d Item #7: (I ) *Material Source out of _jjva�l� Price per ton / delivery price to Cnunty Stnr4nfic �Ie41— I^k,;«., rks: MINIMUM LOAD/ORDE Of- LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER ' C� Precinctl Ton � ' a-7. I I I ^ , Precinct 2 I Ton I Precinct Ton aqo I , 1 I Precinct 4-P � Ton V"� , q � ,a 1 b rq l a , I Precinct4-S; Ton aT1;9 Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 Pr -Coated Rock g ) *Material Source out of � t�va Price per ton / delivery price to County Stockpile and/orlobsite LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER Precinct 1 Ton I•a� I j � I a4 r, I I Q Precinct 2 I Ton i I I ' Precinct 3 Ton ' � ,40 I Precinct4-P 1 Ton �i I o(jk I 3Q I e(3�, Precinct Si ' Ton II I . Ci`I ! . I p� ' W g Remarks Bid Item #9t Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM I I I Precinct 1 I Ton I I I I I I Precinct I Ton � I I I Precinct 3 Ton I L ecinct 4-P ' Ton I ecinct 4-S I 1 Ton I Remarks: % VIA Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL. DELIVERY MINIMUM LOAD/ORDER Precinct I Ton I 4� [TOTAL Precinct 2 , Ton I Precinct 1 Ton I I th ' Precinct4-P I Ton I J I Precinct4-S I Ton j(��(� �Ip ,VN I Remarks: `f k Qv 0'r Page 4 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I I Precinct 1 Ton 1I I I I I I Yard I I I I I I I 1 50 lb Bag I 1 1 Precinct I Ton i i I I I Yard' i I I I ' I 50 lb Bag I I Precinct 1 Ton 1 1 ' Yard' I I I I 1 50 lb Bag 1 1 I I Precinct4-P I Ton I 1 I i I ' I I 1 Yard' I I 1 I I I 1 50 lb Bag I I I I Precinct4-S 1 Ton I I I I 1 i 1 I Yard' I I I I I I I 1 50 lb Bag 1 Remarks: o Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I I Precinct I Ton 1 I I I I I Precinct Ton 1 I l I Precinct4-P ; Ton I I I Precinct4-S ; Ton I 1 I j ` Remarks: Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL I Precinct 1 I Ton I I I I I I I Precinct 2 1 Ton 1 I I I I I I I Precinct I Ton I I I I I I I Precinct4-P ; Ton I I i I I Precinct4-S ; Ton Al.emarks: 1 Q'A )HALTS. OILS AND EMULSIONS 300, Asphalts, Oils and Emulsions Item #14: Primer Oil Price per gallon / delivery price to County'. LOCATION I Unit I MATERIAL 1 1 Gallon 2 ; Gallon 3 1 Gallon 4-P 1 Gallon 4-S ; Gallon � 1 Remarks: e and/or Jobsite DELIVERY I TOTAL MINIMUM LOAD/ORDER DEMURRAGE $ Per Hour Free Hours $ Per Hour Free Hours $ Per Hour Free Hours $ Per Hour Free Hours $ Per Houn Free Hours Page 6 of 8 t Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #15: RC-250 Temperature must be no lower than 140' Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I � t t Per Hour After Precinct 1 ; Gallon ; ; ; ; Free Hours I I I I 1 I i I I$ Per Hour After Precinct 2 1 Gallon I 1 I I Free Hours I I 1 - I I I 1$ Per Hour After Precinct Gallon ;_Free Hours t I i I I I$ Per Hour After Precinct4-P I Gallon I I I 1_ Free Hours 1 I I I I i I !$ Per Hour After Precinct 4-S ; Gallon I I Free Hours fl] � Remarks: Bid Item #16: CRS-2 Temperature must be no lower than 150' and no higher than 180° Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE 1 1$ Per Hour After Precinct 1 1 Gallon Free Hours 1 I$ Per Hour After Precinct 2 1 Gallon 1 1 I I_ Free Hours I 1 1 1 I I$ Per Hour After Precinct 3 1 Gallon I I I I Free Hours 1$ Per Hour After Precinct 4-P 1 Gallon I I I I Free Hours 1 I 11 I 1$ Per Hour After t t t Precinct 4-S 1 Gallon I I i j Free Hours Remarks: Be sure to complete next page (page 8) Page 7 of 8 Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 11 r l/ )'(nn Authorized Signature & Title: Type Name & Title of Authori Phone Number: �Q"���" �o�� Email: m'Jk L1,1 WN1i l oN VMANi Q iR > il�d^ Exceptions and or Variations from Specifications and/or additional Notes: �p ( L d rer Page 8 of 8 STATE OF TEXAS U AFFIDAVIT COUNTY OF CALHOUN 0 The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. I/ BEFORE ME, the undersigned authority, on this day personally appeared Olcbmr Hedlez I known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. _ , , w . M Affiant Printed Name and Title of Affiant Name of Bidder (Company) Address 7 I Iv W Kku4/f.� nA Kd�l.Ll XA rkw+'0A a I CJ'I: f Phone Number Fax Number Email Address mawkZnmorI644a.fAkJ\ SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiaant, who, on oath, states that the facts contained in the above are true and correct, this U k day of /V ®JtWr 20 a® . KERRYCHAMPION My Notary ID 9 U64727 n e•0P 7' Eftplres Match 29, 2024 CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-687878 Martin Marietta San Antonio, TX United States Date Filed: 11/09/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021-03 ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS, JANUARY 1, 2021 THRU DECEMBER 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. X 6 UNSWORN DECLARATION My name is 1(` A lff� and my date of birth is„ ,°} ' My address is S ( top \,i Ins~ P1 ]'ti 13-1 A. (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. (� Executed in County, State of `� In' s , on the U day of'uoyOrtbfY , 20/10 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d AC®/z CERTIFICATE OF LIABILITY IN ' DATE 09f2912020 /YYYY) 2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: 100 North Tn Street, Suite 3600 PHONE FAX Charlotte, NaC 28202 Arc No: E-MAIL Attn: CA NON-RESIDENT NO.OB22889 DDRESS: INSURERS AFFORDING COVERAGE NAIC# 58548-1.MMM-GAWX-20-21 INSURER A: ACE American Insurance Company INSURED INSURED C4' Martin Marietta Materials, Inc. INSURER B: Indemnity Ins CD Of Noah America Dan Welsh 271 INSURER C: ACE Pro eit And Casualty Ins Co ;f y�;,•: 2710 Wycliff Road • y. PO BOX 30013 INSURER D: ((f p#' Ct`�:: Raleigh, NC 27622 l"+_ INSURER E : INSURER F: COVERAGES rcorinrntr.11 THIS INDICATED. CERTIFICATE EXCLUSIONS INSR LTR A IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY ISSUED OR MAY AND CONDITIONS OF SUCH TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMB-MADE X ❑ OCCUR OF PERTAIN, POLICIES. AODL INSURANCE SUER LISTED BELOW HAVE TERM AN CONDITION OF ANY THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN POLICYNUMBER I is ag 1 ��',.°Y$ _ ,. Y'�`t,' _ :l% , CONTRACT THE POLICIES REDUCED BY POLICY MM/DD/YYYYT Y 09/30I2020 . _.. E HE INSURED OR OTHER DESCRIBED PAID CLAIMS. POLICY EXP MM/DDIYYYY REVISION NUMBER: NAMED ABOVE FOR DOCUMENT WITH RESPECT HEREIN IS SUBJECT TO LIMITS THE POLICY PERIOD TO WHICH THIS ALL THE TERMS, /30/20 0921 EACH OCCURRENCE $ 3,00Q000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (An one person) $ PERSONAL It ADV INJURY $ 3,000,00D GEN'L X AGGREGATE LIMIT APPLIES PER R: POLICY 1-1JEST LOG OTHER: GENERALAGGREGATE $ 6,000,000 PRODUCTS - COMP/OPAGG $ 6,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ij� =' * .i^.. _ X 09130/2020 09I30/2D21 COMBINED SINGLE LIMIT Ea accitlent $ 5,000,000 OWNED SCHEDULED AUTOAUT HIRERS ONLY NON -OWNED AUTOS ONLY X AUTOS ONLY BODILY INJURY (Per person) $ X BODILY INJURY (Par accident) $ PROPERTY DAMAGE Per accitlent $ $ w"� - " _'�, X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 09/30/2020 09130/2021 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DIED RETENTION$ ' B A BCOMPENSATION AND KERSEMPLOYERS' ANYPROPRI TOR/PARN EMEXECUTIVE Y/N OFFICERIMEMBEREXDLODEDP ] (Mandatory in NH) Ues, tlescribe under SCRIPTIONOFOPERATIONSbelow N/A E `*ILITY54 4 13 `r"'��' °"T $„r.'I /30 20 09/30/2020 09/30/2021 09/30/2021 PER OTH- X STATUTE ER $ E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE -EA EMPLOYEE $ 2,000,000 E.L. DISEASE -POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be aHached if more space is required) Certificate holder is additional insured under General Liability and Automobile Liability as their interest may appear, h required by written contract with the named insured, subject to the terms and conditions of the policies. A waiver of subrogation applies in favor of the certificate holder, If required by written contract with the named insured, subject to the terms and conditions of the policies. General liability andauto liability insurance apply on a primary and non-contributory basis, if required by written contract, and subject to policy terms and conditions. CERTIFICATE HOI ri _.. a7 I"9���o�fmg+w ry, #LkF ar, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Annette Stefanl �i ©1988.2016 ACORD CORPORATION. All rluhts resenreH -- 1_,.... ' 1 ne AL umu name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICELISEONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Date Received vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 71h business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? F1 Yes FIND B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? F]Yes FIND 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts ❑ as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signature of vendor doing business with the governmental entity Dat orm provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. rLU QU, Qes 6Q^�. '100 Name and Title of Aut— hid Agent Signature of Authorized Agent V /'2o Date I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, MPJai� �4rjP3¢e certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signature f ContractorsAuthorizedOfficial /U`irLI'&J1 ck, fQS ��PSD Printed Name and Title of Contractor's Authorized Official LI/ q/a® Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nublic burden disclosure) 0348-0046 L Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c, cooperative agreement c. post -award d. loan A r /I For material change only: e.loan /1 J / Year quarter insguarantee f. loan insurance / vQ/ Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter _ Prime _ Subawardee Name and Address of Prime: Tier , if Known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicable: 8. Federal Action Number, ifknown: 9. Award Amount, if known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individua 1, last name, first name, MI): diiferentfrom No. IOa) (last name, first name, Ml): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed _ , Print Name: t J1Z Rp_JWk by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 r ry� Title: SIT IT IcL,wi&+''gge U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public pp QQC Telephone No.:�-�8-"55T� l Dater Inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, / taku the undersigned representative of Representative M&,-+lr N444A (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made far ordinary business purposes, and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. —gay Signature of Representative M," 1(4 llfc� �I&s Print Name & Title 11A/'�_® Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. ❑ 1 certify that is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) V I certify that Aoz�:A mu eAk is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authh1o��rized Agent Printed Name and Title foAuthorized Agent AZO Date Please Type If handwritten, must be in ink and legible Vendor's Name: Address: Remittance Address: K 75DC7- Telephone: Fax: WG - al - 40 9 Email: Email(s) to send Bid Information: 51P_ XLe Tier. AP1500Wft&iIAW"01i -G", Signature of Authorized Representative: :k/ Printed name of Authorized Rep: /V<iL�nAcI Ul ak ORDER — CONTACT INFORMATION Order Contact Name & Title: Order Contact Telephone: D-' � -DQ- io� Order Contact Fax: a 10-aQZ1' YG66 Order Contact Email: W®9 Request for Taxpayer Give Form to Form (Rev. October 2018) Identification Number and Certification 1 the requester. Do not Department oftheTreasury send to the IRS. Internal Revenue Service ► Go to wwvivJM.g0v1FormW9 for instructions and the latest information. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. MARTIN MARIETTA MATERIALS, INC. 2 Business name/disregarded entity name, If different from above m3 Check appropriate box forfederal tax classification of the person whose name is entered online 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not Individuals; see a o ❑ Individual/sole proprietor or ID C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estala Instructions on page 9): o. `o single -member LLC Exempt payee code(Ifany) Z�10 ❑ Umited liability company. Enterthe tax classification (C=C corporation, S=S corporation, P=Partnership)► `o 7e Note. Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting 7� LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is .1 another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code (If any) 0. a Is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ❑ Other wise Instructions)► fNPWR,..o.uM.. 1.rt .Idd.m. us) y 5 Address (number, street, and apt. or suite no.) Sae instructions. Requester's name and address (optional) m 2710 WYCLIFF ROAD e City, state, and ZIP code RALEIGH, NC 27607-3033 7 List account number(s) here (optional) Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSNI). However, for a r resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other entities, it is your employer Identification number (EIN). If you do not have a number, see How to get e L TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name andEr Number To Give the Requesterfor guidelines on whose number to enter. 13'N Under penalties of perjury, 1 certify that: 1. The number shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not requireq o-sjgn the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Here Sign\J/d ��tU.pue► / Here ISarDate ►r J 9 ( as 1% General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its Instructions, such as legislation enacted after they were published, go to www.irs.gowFormW9. Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (TIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of Information returns Include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third parry network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (Including a resident alien), to provide your correct TIN. If you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-V (Rev. 10-2018) a MARTIN ASPHALT COMPANY E ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY; TEXAS ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Name & Address • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. •The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE Page 1 of 8 Invitation To Bid Form-Annual5upply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to Countv Stockpile and/or Johsita MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 ' Ton 1 I ' � I I ' I Precinct Ton I I I I I I Precinct4-P; Ton I I I Precinct 4-5 Ton iI I marks: Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to Countv Stockpile and/nr Inh<itc MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 Precinct 1 I Ton 1 I I ' I Precinct 2 I Ton 1 1 I I Precinct 3 Ton I I I Precinct4-P I Ton 1 I 1 I I 1 �Preclnct 4-S ; Ton 1 j ' rks: Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of rks: Price per ton / delivery price to County Stockpile and/or Johsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I 1 , I N IA I Precinct 2 ' Ton I ' I Precinct 3 ; Ton 1 Precinct4-P I Ton 1 I I 1 I Precinct 4-5 1 Ton 1 1 I I Page 3 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions —CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite N Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER Ton6��-`�'®'�''""" I FPrecinct Ton I I I I To ' I Precinct 1 Ton I ; To i ; Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / del ivery nrlrp to rn,,nt%i c+,.emu..; i,.....A I_- LOCATION Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDER I 1 I I Ton iPrecinct , ' Precinct Ton 1I I I Precinct Ton I I ' I I Precinct4-P Ton I Precinct 4-S' Ton I I Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery nrira to rnnnt„ ....a 1__ LOCATION Unit I MATERIAL DELIVERY ; MINIMUM TOTAL LOAD/ORDER Precinct 1 I Ton I Precinct I Ton ; I I Precinct 3 Ton I I I I Precinct 4-P i Ton I , I I I { Precinct 4-5 I Ton I I I I Page 4 of 8 Invitation To Bid Form -Annual Supply Contractor Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt RRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER Precinct 1 I Ton Q /� Yard3 I 1 1 50 lb Bag 1 I I 1 Precinct 2 ' Ton I 1 1 1 Yard' 1 I 1 SO lb Bag 1 1 1 , I Precinct 3 I Ton I, I I Yard' 1 1 ' 1 1 50 lb Bag 1 I I Precinct 4-P Ton 1 I ' 1 1 I I ' I Yard3 1 1 ' I I 50 lb Bag I I 1 I Precinct4-S I Ton 1 I I 1 Yard3 1 ' ' I 1 ' I 50 lb Bag j Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.21MF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDER I Precinct 1 I Ton A I IV Precinct 2 1 Ton I 1 I ' I I I 1 Precinct 3 Ton 1 EE 1 Precinct 4-P 1 Ton 1 1 I I ' Precinct4-S 1 Ton 1 , Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to county Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL Precinct 1 Ton Precinct2 1 Ton I Precinct 3 I Ton Precinct 4-P ; Ton Precinct 4-S I Ton rks: Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil ® mlC_0 Price Der eallon +,. r,.....+.. c.__i._:j MINIMUM LOAD/ORDER LOCATION ' Unit MATERIAL DELIVERY TOTAL DEMURRAGE Precinct 1 I Gallon I • 1 ' C� + /® �' '$ 'I® Per Hour After ' I_ Free Hours Precinct 2 Gallon i I I I I $ 7® Per Hour After I ' I Free Hours Precinct I Gallon I "1' u°'J I v / I o?e Oa I j$,® Per Hour After I Free Hours Precinct 4-P I `i' °•�� I 1 ' C� I I$� Per Hour After Gallon I ' ' Free Hours I I (% I I I g � Per Hour After Precinct 4-S ; Gallon L e 'Z , I$—`— Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Be sure to complete next page (page 8) Page 7 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: �I Authorized Signature & Tit] Type Name & Title of Authc Phone Number:93: kg-(//. Email:I[(ilt/j��%�P/jjQ�y Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared V/pn )iZd9 known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. 1, f 'an Y Printed Name and Title 6f Affiant Name of Bidder (i Address Phone Number `//-j—,j60— CgKDcp Fax Number Email Address SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this 215f day of OCA)O P , 20ZO . . STEPHANIE AGUIRRE Notary Public, State of Texas Comm. Expires 02-OB•2024 °i°in Notary ID 130373086 Notary Public in and for�j uAlu/ S . County, Texas UER I IFICATE OF INTERESTED PARTIES FORM 1295 1of1 Complete Nos. 1- 4 and 6 if there are interested parties. Complete Nos. 1, 2, 3, 5, and 6 if there are no interested OFFICE USE ONLY parties. CERTIFICATION OF FILING 1 Name in business entity filing form, and the city, state and country of the business entity's place of business. Certificate Number: MARTIN ASPHALT 2020-681358 SOUTH HOUSTON, 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. Date Filed: 10/21/2020 CALHOUN COUNTY 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 services, goods, or other property to be provided under the contract. 2021.03 ROAD MATERIALS AND ASPHALT OILS AND EMULSIONSn,ylA't `J1 4 Name of Interested Party City, State, Country (place of business Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. X ❑ 6 UNSWORN DECLARATION 4q, k� '", YY and my date of berth Is i µ- u My address is I declare under pen ry of perjury that the foregoing is true and correct. Executed in "ems County, State of on the 2) day of (�6� (month) (Year) /) 0Sgn1t1re ent of contracting business entity (Declarant) 'orms provided by Texas Ethics Commission ou,;— ..._..... — Version V1.1.3a6aaf7d CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsementki PRODUCER LOCKTON COMPANIES 2100 ROSS AVENUE, SUITE 1400 DALLAS TX 75201 214-969-6700 INSURED Martin Resource Management Corporation 1302028 (See Listing Page 2) PO Box 191 Kilgore TX 75663 COVERAGES * CFQTIFIr ATE MIIMRCo- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED Bt�tyesr8.'$�6r} BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICYIEFF LTR TYPE OF INSURANCE INSD D POLICY NUMBER MM/DDIYYY MWDDIY%P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR ❑ POLLUTION LIABILITY Y N T2p'c-a ,,,�. ,y,,„3 M. tp"igakS'''. ".6C 3uy; IE{ ] e F�zisG 5/l/2020 5/1/2021 EACH OCCURRENCE $ 1,000,000 PREMISES Eaoccurenoe $ 100000 X MED EXP (Any one Person) $ Not Applicable X $IM-SIR PERSONAL BADVINJURY $ 1000000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY PE LOC GENERAL AGGREGATE $ 2 OOO OOO PRODUCTS - COMP/OPAGG $ 2000000 OTHER: A AUTOMOBILE LIABILITY ANY AUTO"'yu��, OWNED SCHESULED AUTOS ONLY AUTOS HIRED AUTOS ONLOV AUTOS ONLY X N N 5' 5/1/2020 5/1/2021 COMBINED SINGLE LIMIT Ea accident $ 5,000,000 X BODILY INJURY (Per person) $ XXXXXXX X BODILY INJURY (Per accident) $ XXXXXXX X PROPERTY DAMAGE Per accident $ XXXXXXX $XXXXXXX BRELLA LIAR �( OCCUR N N 1z 'w %F ' 5/1/2020 5/1/2021 EACH OCCURRENCE $ 10 0p0 p00 B ;DED X EXCESS LIAB CLAIMS -MADE "u'u' b�'".',.S AGGREGATE $ ](I 000000 X RETENTION $0 $ XXXXXXX WORKERS COMPENSATION�S C AND EMPLOYERS' LIABILITY N {[„},>AxJ � i+m^'i"fjjc 5/1/2020 5/1/2021 X STATUTE OERH ANY PROPRIETORIPARTNERIEXECUTIVE YIN 51�1�*�5Pn n E.L. EACH ACCIDENT $ ] 000000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE II es, describe under $ ] 000 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1.0006 D EXCESS AUTOMOBILE N NY LIABILITY5/1/2020. 5/1/2021 LIMIT $S,OOQ000 tK g Excess Liability r -' 5/l/2020 5/1/2021 Limit$10,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) r�onnrAry unr nr•n 211 S. ANN ST. ST 301 PORT LAVACA TX 77979 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r L Cee"'ril W 1988-2015 ACORD CORPORATION. All riahts reserved. ^_-•-•- -� ,�. •�•••••/ I ne �vmu name ana logo are registered marks of ACORD Producer: Lockton Companies, LLC 2100 Ross Ave„ Suite 1400 Dallas, TX 75201 WORKERS' COMPENSATION POLICIES OTHER STATES Policy Number TWE4,yµ Insurer: Indemnity Insurance Co. of North America California Policy Number REPRO,, Insurer: Ace American Insurance Co. Miscellan00� 'r er r NAMED INSUREDS MARTIN RESOURCE MANAGEMENT CORPORATION, MARTIN MIDSTREAM PARTNERS L.P. AND/OR ANY OF THEIR RESPECTIVE PARENTS, SUBSIDIARIES, AFFILIATES AND INTERRELATED COMPANIES AMERICAN SENTERFITT INSURANCE COMPANY, LTD. ASPIRE AMERICA, INC. BERRY PETROLEUM COMPANY CENTRAL OIL CO., INC. CROSS OIL REFINING & MARKETING, INC. CROSS OIL REFINING & MARKETING, INC. DBA CROSS OIL PACKAGING INTERNATIONAL GAS CONSULTING LLC L & L OIL AND GAS SERVICES, L.L.C. MARTIN GAS SALES LLC MARTIN INTEGRATED SULFUR SYSTEMS LLC MARTIN OPERATING PARTNERSHIP L.P. DBA MARTIN LUBRICANTS MARTIN MARINE MARTIN MIDSTREAM GP LLC MARTIN NATURAL GAS STORAGE CONSULTING LLC MARTIN NATURAL GAS STORAGE CONSULTING LLC DBA INTERNATIONAL GAS CONSULTING MARTIN OPERATING GP LLC MARTIN OPERATING PARTNERSHIP L.P. MARTIN OPERATING PARTNERSHIP L.P. DBA MEGA LUBRICANTS MARTIN PRODUCT SALES LLC MARTIN PRODUCT SALES LLC DBA ADVANTAGE FLUID PRODUCTS MARTIN PRODUCT SALES LLC. DBA GULF STATES ASPHALT CO. MARTIN PRODUCT SALES LLC DBA MARTIN ASPHALT COMPANY MARTIN PRODUCT SALES LLC DBA MONARCH OIL COMPANY MARTIN RESOURCE LLC MARTIN TRANSPORT, INC. MARTIN UNDERGROUND STORAGE, INC. MEH SOUTH TEXAS TERMINALS LLC MIDSTREAM FUEL SERVICE LLC MIDSTREAM FUEL SERVICE LLC DBA PETROLEUM ENERGY PRODUCTS COMPANY (PEPCO) PRISM GAS SYSTEMS GP, L.L.C. COAST SYSTEMS, L.L.C. INC. rvuwrt 1 IN IVIIU61 REAM FINANCE CORP. REDBIRD GAS STORAGE LLC MOP MIDSTREAM HOLDINGS LLC MARTIN ENERGY TRADING LLC MARTIN MIDSTREAM NGL HOLDINGS, LLC MARTIN MIDSTREAM NGL HOLDINGS II, LLC MEH TERMINALS ✓Y" { F C J�rlkd ty' g�{ tisv yif(iFi'JFr 7��.�'aY ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Numbar Martin Resource Management Corporation q Policy Symbol in F i''"r Y Y ;lv 5'%kcl ,aA{ Policy Period Effective Date of Endorsement XSLktaljw+. 05/01/2019 to 05/01/2020 Issued By (Name of Insurance Company) ACE American Insurance Company nsert the po my num er. a remain der of the in onna ion is o e comp e e on y w en t is en orsement is issue su Sequent o e prepara ion o e po cY. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization: Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III —Limits Of Insurance And Retained Limit: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Authorized Representative XS-6W25b (04/13) Includes copyrighted material of Insurance , CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code. by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Date Received vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. !J Name of vendor has a businessrelationship with local governmental entity. /who W LPzf l �vtw1 2 ❑ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information s being disclosed. r4— Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? E]Yes F] No B. Is the vendor receiving or likely to receive taxable income, other than investment income. from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? ElYes F--] No b Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts ❑ as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 �® tsignatuilb of vendor doirtgLtilusiness with the governmental entity Date/ Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT c& SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. 01plig F,?i/w, ®off a� Name aml Title of Authorized Agent Da e ignature of Ant l izedR Agent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor6�flcatic�wd certifies or affirms the truthfulness and accuracy of each statement of its disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signatu a of Contrac s Authorized llmhw9 ��0119" Printed Name and Tftle of Contractor's Authorized Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Ne'p rever.P Fnr..,.F,ti' i„".aun di..,.l,......a� 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant _ b. initial award _ b. material change C. cooperative agreement d. loan c. post -award c. loan guarantee loan insurance j / Or For material change only: Year quarter /f. Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter _ Prime _Subawardee Name and Address of Prime: Tier_, if �t{Known: /A - Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency:tp�/� 7. Federal Program Name/Descrip 'on: / CFDA Number, ifapplicable: =Federal=-Number,if brown: p /I 9. Award Amount, if knows 0`r $ 10. a. Name and Address of Lobbying Registrant (if individual, last name, fist name, MI): b. Individuals Performing Services (inclu ing address di/fcren{j•an No. 10a) f (last name, first name, MI): N 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: YJ disclosure lobbying activities is a material representation of fact upon which reliance was placed Print Name: by the tier above when this transaction was made or Y� entered into. This disclosure is required pursuant to 31 � n Title: ,t / U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any who fails file fr p�^-� Telephone No.2�3:�17(��Q �GDate: person to the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION A u A- a17LV,0WV, TJ c I -,the undersigned representative of e resentative (hereafter referred to as Company) being an company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in on Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. 0, � *Slgn�treeprese tive �A�) o, PrintName& Title �y � G� //o Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ 1 certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) f>d" 1 certify that/ /G�61�f✓/ Jis a "Resident Bidder" of Texas as �— (Conn any Name) defined in Government Code §2252.001. '0 i signature Authorized e/ Please Type If handwritten, must be in ink and legible Vendor's Address: Remittance Address: Telephone: Fax: ")/ 3 — AJ 0 - a, g 01 Email: no �l Emaii(s) to send Bid Information:V1 *f"ifi-° espin b ®/%� ]� /j�• C.®%%� Signature of Authorized Printed name of Authorized Rep: Order Contact Name & Order Contact Telephone: Ql 3 -A v — W ®% Order Contact Fax: Order Contact Email: Forth W-V Request for Taxpayer (Rev. Octobw2019) Identification Number and Certification rive Form to the DeRertmeavanunt of the Treasury Intamel Re Service ► w ®o to Ww,1Ps.99v1F0=W9 for Instructions and the latest Information. requester. Do not Send 40 the IRS. 1 Name (as shown on your Income laz return}. Name is required on Ihis line; do no! leave this line blank. MARTIN PRODUCT SALES LLC 2 Business nomerdlsregardetl entity name, If different from above MARTIN ASPHALT v m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven bozos. 4 Exemptions (codes apply only to certain entitles, not Individuals; sea a ElIndivi-mmole proprietor or ClCCarppralbn ❑SCorporelion El Partnership ❑TrusVeslata Instructions on page 3): nc single -member LLC Exempt payee code fif any) P.^ VS `o ❑O Umited liability compary.. Enter the tax classification (C=C corporation. S=S corporation, P=Padnership) ► S Note: C Check the appropriate box In the Ilne above for the tax classification of the single- member owner, Do not check LLC If the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC Is Exemption from FATCA reporting IL u another LLC that Is not disregarded from the owner for U.S. federal tax purposes. otherwise, a single -member LLC that code (if any) Is disregarded from the owner should check the appropriate box for the tax classification of Its owner, rq ❑ Dlher(see instructions)► 4bWa roeunuN mLLwF,q•ueuerM usJ 8 Address (number street, and apt. or suite no.) Sea Instructions. N Requester's name and I RI _ERWAY STE 1250 address (optionaii a City, slate, and ZIP code HOUSTON TX 77056 7 at account number(s) here (options, enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For Individuals, this is generally your social security number (SSN). However, for a s� resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it Is your employer identification number (EIN). It you do not have a number, see How to got e L TIN, later. or Note: If the account Is in more than one name, sea the instructions for line 1. Also see What Name and Es Number To Give the Requester for guidelines on whose number to enter, µW" Under penalties of perjury, I certify that: -`-�-�-- r,5.vs;s'.'ki'1•1. The The number shown on this form Is my correct taxpayer Identification number (or 1 am waiting for a number to be Issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a tenure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S, citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends an your tax return. For real estate transactions, item 2 does not apply, For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions for Part II, later. aryn I Signature of Z& _t—/ar/ g ('IePe U.S. parson► /I^�t _ Date / General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.frs.gowFormWg, Purpose of Form An individual or entity (Farm W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable an an Information return. Examples of Information returns Include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099.0IV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T Itulbon) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-g only if you are a U.S, person (including a resident alien), to provide your correct TIN, If you do not return Form W-9 to the requester with a 71N, you might be subject to backup withholding. See What is backup withholding, later. Cat. No, 10231X Farm )Ill-S (Rev. 10-2018) M ME Beginning January 1, 2021 and Ending December 31, 2021 - CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name Rc Address K-C Lease Service, Inc OBA Matagorda Construction & Materials • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. -The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. EE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS IATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE )AD MATERIALS i Item #1: Limestone-3/4 Inch To Dust Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I 5,5-O I �y 6® I 5% 'Is H Precinct 2 Ton Oa Precinct Ton S-SO I g21,00 Precinct4-P Ton Precinct 4-S Ton I S i I Remarks: Bid Item #2: Item 247, Type A Limestone, Grade 2, [13/4 Inch] Price per ton / delivery price to County Stockpile and/or Jobsite Remarks: MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton nv p n ! � o ! end ar Precinct Ton r5-•.o® ! o� cV i „, OU i [ Precinct I Ton r'o ;q.g, al" Precinct 4-P ; Ton 00 a.� 1-11 )S;-- !it &4%i / Precinct4-S Ton .Qs(® ®v ,�a �9, vely Page 1 of 8 - Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 1 Ton I I I I Precinct 2 Ton I) I 1 Precinct 3 1 Ton I I I I Precinct 4-P I I I I I Precincti Ton I I Remarks: Bid item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Bag (Cost per Pallet) List # of 47 lb Bags on a Pallet Price per unit / delivery price to County Stockpile and/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 i Ton I I I i of 47 lb I 1 Bags on Pallet I I I i I I Precinct 2 1 Ton I I I of 47 1 b /L I I Bags on Pallet f I !97 I I I I I Precinct 3 1 Ton I I I I I I of 47 lb I I I I Bags on Pallet I I Precinct 4-P I Ton I I i i I I _of Ib 1 Bags Pa11et Precinct 4-S Ton i i i i of 47 lb ; i Bags on Pallet Remarks: Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I i I Precinct 1 i Ton 1 1 Precinct 2 1 Ton 1 C 1 1 1 1 1 I 1 1 Precinct 3 1 Ton 1 1 1 1 1 1 Precinct 4-P ' on 1 ' 1 I 1 Preci -S ; Ton 1 Remarks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELI VE TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 1 Ton JA1 1 1 1 1 1 Precinct 3 1 To 1 Precinct 4-P Ton 1 1 1 1 1 1 1 Pr nct 4-S ; Ton 1 1 Remarks: Item 302, Type PE, Grade 3 (Pre -Coated Rock) Bid Item #7: *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIV TOTAL LOAD/ORDER Precinct 1 Ton 1 1 Precinct 2 Ton 1 1 1 1 Precinct 3 1 Ton 1 1 Precinct4-P 1 Ton 1 1 1 1 i 1 Prec' 4-S i Ton E1 1 Remarks: Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I i I i Precinct 1 I Ton Precinct 2 I Ton y(V I ' Precinct 3 Ton i i i i i Precinct 4-P I Ton I ' i i i i i Pre ' t 4-S Ton I I I Remarks: Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct l Ton 1rrd nl •'p ® n Precinct 2 Ton it ^ rV a? vo I 3[3V) o �itB/I atS'9il�.% Precinct 3 Ton ; j,j ; a , DaY-7u�- Precinct 4-P ; Ton i jfJ J� ;a2 ,. y ® I 0V L%t3P I % Precinct 4-S Ton 1 IWE/Iv .2 -jcS Remarks: Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DE LIV TOTAL LOAD/ORDER i Precinct 1 Ton i i i I i I { I I I Precinct 2 1 Ton , I Precinct 3 ; Ton I i i 1 I Precinct 4-P I Ton Preci 4-S i Ton Page 4 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 ; Ton ; Yard3 I I 50 lb Bag ; ; ; I Precinct 2 Ton ' I Yard' So lb Bag Precinct 3 ; Ton I Yard' I 1 50 lb Bag ; Precinct4-P ; Ton ' ; ; ; I Yar ; I I 5 Ib Bag ; I Precinct 4-S ' Ton ; ' Yard' 1 50 lb Bag Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laborato ixture Design Properties found in the Standard Specifications for Construction and Maintenance of Hi ays, Streets and Bridges. Price per ton / delivery price to County Stockpile andilbeloobsite MINIMUM LOCATION Unit MAT IAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 1 Ton I I I I I Precinct 2 Ton I I I Precinct 3 T � I I I Precinct 4-13 I Ton i iI ; Precin S ; Ton iI I Remarks: Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #15: RC-250 Temperature must be no lower than 140a Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION I Unit I MATERIAL I DELWERY Precinct 1 I Gallon i I Precinct 2 I Gallon I I Precinct 3 I I I Precinct 4-P Gallon I i inct4-S PZI Gallon arks: Item #16: CRS-2 TOTAL DEMURRAGE f ;$ Per Hour After I Free Hours i I$ Per Hour After Free Hours �$ Per Hour After Free Hours ;$ Per Hour After I Free Hours I I$ Per Hour After I Free Hours Temperature must be no lower than 150' and no higher than 180a Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVER TOTAL I I I I I I I I I$ Precinct 1 1 Gallon I I I I I I I I I$ Precinct 2 Gallon I I I I I I Precinct 3 I Gallon I I I I I I$ _ I I Precinct 4-P IZal I I I I I I I I I$ I I Precin 4-S i Gallon I � I I I I I$ I rks: Be sure to complete next page (page 8) DEMURRAGE Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Page 7 of 8 Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: /d—/P'Ro Authorized Signature & Title: rr'41 d/ Type Name &Title of Authorized Signature: l91P�/I �3�' e, Phone Number: ®/ Email: s Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEXAS {} COUNTY OF CALHOUN {} AFFIDAVIT The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant Printed Name and Title of Affiant Name of Bidder (Company) 1�—� L L'Ut S _ j0oA �% o Address Via) SEj Phone Number 9'99.- .3.0 ?, A9// Fax Number /V, Email Address SWORN TO AND SUBSCRIBED BEFORE ME by the abbo�v�eyA,fffiant, who, on oath, states that the facts contained in the above are true and correct, this day of� 20 JENIFER MF6IRELERE MY COMMISSIOPIRES NOVEMBER 21, 2021 v Notary Public in and for V County, Texas CERTIFICATE OF INTERESTED PARTIES 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. Name business entity filing form, and 4he city, state and country of the business entity's place of business. K-C Lease Service, Inc. DBA Matagorda Construction & Materials Bay City, TX United States being filed. Calhoun County FORM 1295 l of OFFICE USE E— ONLY CERTIFICATION OF FILING :ertificate Number: Date Filed: 10/19/2020 Date Acknowledged: Provide the rdenur r --e services, • goods, , or h r P governmental entity or state agency a track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. 2021.03 Road Materials Name of Interested Party Krauskopf, Bruce 5 Check only if there is NO Interested Party. UNSWORN DECLARATION City, state, country (place of business) Louise, TX United States My name is ij a ,yam,, 41 — Aleand my date of birth is of My address is / -5//' ems-- �� ��� "Az MeTMEE Qr(,- � �' 7X (street) � , , (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in ,6i �J�C.i!Ai ,.� p® County, State of , on the day of 4or°'110bP'✓', 20 ?10 (month) (year) Signature of authorized agent of contracting business entity by Te(Declarant) xas Ethics Commission ,...... _.'.__ . . OP ID. CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Policy(ies) must have ADDITIONAL INSURED Provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of su�h a..a...�.,....._„_. ice Group 77406 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ENAMED NABOVEB OR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMR R I ___ COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE X X X occuR ,4T y A X PrimaryPJonContrib11,1r � r'1 08/15/2020 08/15/2021 A X Pollution/Sud&Acc j� § �' 08/15/2020 08/15/2021 GEN'L AGGREGATE LIMIT APPLIES PER: F,ar,; i& L{'v 08/15/2020 08/15/2021 ' X POLICY ❑ JECT LOC C OMOBILE LIABILITY ANY AUTO a°Fxtr Xi,fir+ �y`y �� AUTOS ONLY AUTOSSCHEDULED X X �"L-Fly`k.?. rY� lQi5 t 08/15/2020 08/1572021 E AUTOS AUTOS AUT ONLY X OS ONLY A UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS-MADEX X" off ��r 7,N 08/1512020 08/15/2021 F DEO RETENTION$ P C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AFEREBEEXCLE?ECUTIYIN panC/MMR EXCLUDED' X MFlstory in NH) N/A ,, X !08/15/2020 08/15/2021 E If yes, tlescribe untler E DESCRIPTION OF OPERATIONS below D Inland Marine II bi7xt��u 08/15/2020 08/1512021 E A Auto Physical Dam N � 08/15/2020 08/15/2021 R, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 31anket Additional Insured & Waiver of Subrogation on the General Liability, 3usiness Auto & Umbrella Liability with a Blanket Waiver of Subrogation on :he Worker's Compensation where their interest may appear by a written :ontract. 10 Day NOC. Umbrella Policy Follows Form. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Calhoun County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 202 S Ann St. STE B ACCORDANCE WITH THE POLICY PROVISIONS. Port Lavaca, TX 77979 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Name of of vefn�do,�r who has a business relationship with local governmental entity. OFFICE USE ONLY Date Received Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) Name of local government officer about whom the information is being disclosed. Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? E] Yes D No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? ED Yes D No Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. ElCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/201s LirERTIFICATION REGARD 414"1- In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Name and I Itle of Authorized'Agen Signature of Authorized Agent I an, unable to certify to the above statements. My explanation is attached. Date Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). K-D Lease Service, tot 08A The Contractor, Matagorda Construction ii ft,gIiQlrtifles or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signature ofContractor's Authorized Official A",Y "Iw>, lev- 6,,,,' Printed Name and Title of Contractor'§ Authorized Official /a --<"- a Date Approved by OMB Disclosure of Lobbying Activities 0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See revers f 61' b e or u tc urden disclosure) e off Federal Action: 2. Status of Federal Action: 3. Report Type: . contract a. bid/offer/application a, initial filing grant F . b. initial award b. material change , cooperative agreement c. post -award . loanFor guarantee �� material chart a onlloan . loan insurance Yearquarttery; Date of last report 4. Name and Address of Reporting Entity: Prime 5. If Reporting Entity in No. 4 is Subawardee, Enter _ _ Subawardee Name and Address of Prime: y Tier_, if Known: Con ressional District, if known: 6. Federal Department/Agency. Con wessional District, if known: 7. Federal Program Name/Description: CFDA Number, ifapplicable: 8. Federal Action Number, ifknown: 9. Award Amount, ifknown: 10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, Ml): b. Individuals Performing Services (including address if ilf#erentfr»rn No. IOa) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed ,��!!� Print Name: Itt'/g"" i��Ie✓r+st3 '{� by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title:_ �cr�rrr�es^ U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No. �=�.�'i,.,S'+v'�o' Date:.40"i'%20 Inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION • 1 Representative "2y the undersigned representative of K-C Lease Service, Inc DBA Matagorda Construction & Materials (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities orbusiness associations that exist to make a profit. Signature of Representative (DOGS g9l !sc4"Fi/�'J}' ,n r4�6scT,� Print Name & Title A � Date —' State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ 1 certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. (Company Name) is a "Nonresident Bidder" of Texas as defined in Government Code §2252.001 and our principal place of business is (City and State) K-C Lease Service, Inc DBA Wl certify that Matagorda Construction & Materials is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Printed Name and Title of Authorized Agent %® -/- 20 Date e Please Type If handwritten, merit be in ink and legible K-C Lease Service, Inc BABA Vendor's Name: Matagorda Construction rt<Materials Address: 2a;/-S'/;/' f— ,S;V4,.4 d;A/ rA '77i°i Remittance Address: Telephone: 14**1%•-321- fqj/ Fax: Email: 00 Vopsrgffi➢. eU,.-9 Emall(s) to send Bid Information: pl�'ez�rmdr�,✓ _Cw r7 Signature of Authorized Representative: -- ��-- Printed name of Authorized Rep: l��iardr ryc�i/��r Order Contact Name & Title: 4.7 .dooms Yo 6e�ylA- &L., 4 Order Contact Telephone: 123 C%q/S &K fib/—5-7/—V..3 Order Contact Fax: Order Contact Email: ,-Icer,,I, _c", c ,117 �A Request for Taxpayer Give Form to the Form V Identification Number and Certification requester. Do not (Rev. October 2018) Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. K-C Lease Service, Inc. 2 Business name/disregarded entity name, if different from above DBA Matagorda Construction & Materials 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see a instructions on page 3): ii ElIndividual/sole proprietor or ElC Corporation ❑✓ S Corporation ElPartnership ElTrust/estate c single -member LLC Exempt payee code (f any) a o ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► `p Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code (if any) d o _ another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. .0 ❑ Other (see instructions)► (a•nrre: m•aro,.�rs memreireeoomme me us.7 y 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) in 2221 SH 35 south e City, state, and ZIP code Bay C ty TX 77414 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number backup withholding. For individuals, this is generally your social security number (SSN. However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to gets TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and number Employer identfication Number To Give the Requester for guidelines on whose number to enter. ' r>u.��• � g y,xt �,�'�"'^,,-n w� r � Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. .iryu Signature of Here I U.S. person► Date ► A# -Av' aV General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) Cat. No. 10231X • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Form W-9 (Rev. 10-2018) R AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors° Name & Address Please Type. If handwritten, must be in ink and legible. White out is not acceptable. •The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE Item #1: Limestone-3/4 Inch To Dust Price pen / delivery price to Count,, < LOCATION ,---� UNIT MATERIAL I DELIVERY I MINIMUM �Precmctl TOTAL LOAD/ORDER Ton - s U<. o=" I cei jCJ i Precinct 2. Ton Precinct 3 I , Ton 1 � � ' 2 y � l3' ,cry 'recinct 4-P I Ton 'p4n i 'recinct4-S Ton I �i,,, v o I D"? 4"" Bid Item #2: Item 247, Type A Limestone, Grade 2, 113/4 Inch] Price per ton / doI!van, —; «-.--- . _. . LOCATION I Unit MATERIAL DELIVERY MINIMUM 1 Precinct 1 1 Ton 1 ' 'p G3 1 ®c+ TOTAL I LOAD/ORDER �" c Precinct2 1 Ton I r%� I. �O I I I ed LV. i , y Precinct3 1 I Ton I <"C' �a0 1 i Precinct4-PI Ton I !v �.. Precinct4-S I Ton �� Page 1 of 8 invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM Precinct 1 I Ton 4 ( / D/ORDER L,OA�rr/ ' r1'• 1, , J �'f 1 Precinct 2 I Ton V I Precinct 3 Ton ' Precinct 4-P I Ton ' I I Precinct 4-S I Toni„ ' Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Ba Price per unit/ deliver g (Cost per Pallet) List # of 47 lb Bags on a Pallet y price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL MINIMUM DELIVERY TOTAL LOAD/ORDER Precinct I ' '' + Ton , I ; of 47 lb I Bags on Pallet i Precinct 2 I ' Ton I __ of 47 lb i i I Bags on Pallet Precinct 3 I Ton ' of 47 lb 1 ; i Bags on Pallet 1 Precinct 4-P I ' I ; Ton ' 1 _01`47lb I ; Bags on Pallet I I , i , ; Precinct 4-S I ' Ton I I 1 _of 47 lbj Bags on Pallet) I I Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #5. Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION I unit I I Precinct 1 1 Ton Precinct 2 ElTo Precinct 3 Precinct 4-P ; Ton Precinct 4-5 ; Ton MATERIAL I DELIVERY Item #6. Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I Precinct 1 ' I Ton I I I Precinct 2 ' Ton I i Precinct3 I Ton I I I Precinct 4-P ; Ton ' i I Precinct 4-5 i Ton I i I rks: Bid Item #7. Item 302, Type PE, Grade 3 (Pre -Coat ed Rock) *Material Source out of Price per ton /delivery price to County Stockpile and/or Jobsite LOCATION I ,ecinct I Ton I ecinct 2 Ton i ecinct 3_—ion I ecinct 4-P� Ton i !cinct4-S i Ton rks: TOTAL TOTAL MATE_ DELIVERY I TOTAL MINIMUM LOAD/ORDER MINIMUM MINIMUM Page 3 of 8 Invitation To Bid form - Annual supply Contract for Rood Materials and Asphalts, Oils and Emulsions -- CONTINUED Rid Item #8: Item 302, Type PEA Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL MINIMUM DELIVERY PrecincTOTAL LOAD/ORDER t 1 Ton ' Precinct 2 ; Ton ' I I ; ; 1 Precinct 3 1 Ton 1 1 1 i Precinct4-P Ton Precinct4-S I 1 ' Ton 1 f Item #9: Item 302, Type E, Grade S Price Per ton , lee Rock (Non -Coated Limesto /delivery price to County Stockpile and/orJobsite ne0nly) LOCATION Unit MATERIAL DELIVERY =OAID/ORDE TOTAL Precinct 1 Ton Precinct 2 ' 1 Ton i Precinct 3 ; Ton i1 ' 1 1 , Precinct 4-P ' 1 ' Ton ; 1 ; ; i Precinct4-Ton i Bid Item #10: Item 330,Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY MINIMUM I TOTAL LOADIMUM Precinct 1 1 Ton , I 1 ORDE ORDE 1 { 1 Precinct 2 Ton 1 ' I 1 I 1 Precinct 3 ' { , , Ton ; , Precinct 4-P ; Ton 1 I 1 ' 1 1 Precinct4-S I 1 Ton 1 1 marks: Page 4 of a Invitation To Bid Form -Annual Supply Contractfar Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item HIS, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 Precinct 1 I Ton Yarda I 1 1 1 50lb Bag I Precinct 2 Ton I I Yard3 1 I 1 1 I I I I I SO lb Bag I I I I I Precinct 3 1 Ton 1 1 1 1 1 � I I Yard 1 I I 1 I I 1 1 SO lb Bag 1 I I I Precinct 4-P I Ton 1 1 I I 1 1 I 1 1 Yard3 I I I I 1 I 1 SO lb Bag 1 I Precinct4-S I Ton I 1 1 1 i Yar3 d I I I 1 I 1 I 1 1 50 lb Bag I I Remarks: �Y j Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 I I I Precinct 1 1 Ton 1 1 I I I I I I 1 Precinct 2 Ton I I I I 1 i 1 1 Precinct 3 1 Ton I 1 I I Precinct4-P I Ton I I 1 I I Precinct 4-S I Ton I I 1 I �c:% ` Remarks: G Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions— CONTINUED Item #13: Item 432, Riprap, Section 2.3 Stone Riprap,12" Limestone Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL L Precinct 1 Ton i Precinct 2 1 i Ton L9C/ a 6, I sr ; ��✓,, � I —7/ cd I 1 6>• ; �- Precinct 3 I ' Ton / r,}—�'.: I ; Precinct 4-P ; Ton :�J} 1 Precinct4-S ; 1 Ton / (% " Remarks: 300, Asphalts, Oils and Emulsions Item #14: Primer Oil ILTA IIJIIPAIIIAjl Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I I ' ;$ Per Hour After Precinct 1 1 Gallon I I Free Hours 1 1 I � I 1 Per Hour After Precinct 1 Gallon ; 1—Free Hours 1 I I I I$ Per Hour After Precinct ; GallonFree Hours 1 I �$ Per Hour After Precinct 4-P 1 Gallon 1 1 I I Free Hours 1 1 $ Per Hour After Precinct 4-S ; Gallon ; ; ; l Free Hours arks: /��c/ /Jlli w Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I Per Hour After Precinct 1 ; Gallon ; Free Hours I , I I I I I I I I$ Per Hour After Precinct 2 I Gallon I I I I Free Hours I I I I , I Per Hour After Precinct 3 Gallon ; ; �$ Free Hours I I I I I I$ Per Hour After Precinct4-P Gallon Free Hours I I I �$ Per Hour After Precinct4-S 1 Gallon Free Hours (Remarks: Bid Item #16: CRS-2 Temperature must be no lower than 1500 and no higher than 1801 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE j I I$ Per Hour After Precinct I Gallon I I I (_Free Hours I I I �$ Per Hour After Precinct 2 Gallon I I I I Free Hours I I I I I I I I I$ Per Hour After Precinct 3 I Gallon I I ;_Free Hours I 1$ Per Hour After Precinct 4-P I Gallon I I I I Free Hours I !$ Per Hour After Precinct 4-S 1 Gallon I I I I Free Hours Remarks: Be sure to complete next page (page 8) Page 7 of 8 Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Authorized Signature & Title: Type Name & Title of Authorized Signature: Phone Number: l7l-/bfi "� C�0 Email: ,,VI c�7Pg t-"k ? Xe i2Is 42yn 4 Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared -, Zj1� sc f{ eli known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant v %feat i Yf�t V L,, s Printed Name and Title of Affiant Name of Bidder (Company) _f "�,�T.vu A-, 7,E,<«h Z-/--<�l Address Az5) &,,c /en N77`ai F ioF Z/ 7R, 'YO Phone Number �7 j '-�� �� 2✓� Fax Number �� 3 T Email Address jg i>/ r>s iytn (1-11ils /'f-j SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this 00�"'day of jJoVefVX 1QS'" 20 Rb . j •saMARISSAELLENgMtiLli ', Notary Public. State of Texas1 My Commission ExpiresFebruayas,202I !Jrs NINMVIDt32372®4i Notary in and for 4 u4J Q County, Texas CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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: 2020-687275 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Midtex Materials LLC Fayetteville, TX United States Date Filed: 11/06/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021.03 Road Materials and Asphalts, Oils and Emulsions, January 1, 2021 through December 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Schmitt, Mark Fayetteville, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION y My name is /�/ 'e J X % y 1` d c r w� i and m date of birth is Myaddressis P/q.C7r�k' (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in .^,:• /%F—' County, State of , on the day 041eMI1t'Q-, 20 dO (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d fit EVEL CERTIFICATE OF LIABILITY INSURANCE DATE(MINDD YVYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POUCYPes) must have ADDITIONAL INSURED Provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO TACT Anco Insurance NA�nE: Evelyn Stein, ACSR PO BOX 3889 PHONE AIC, Nq E><P): (979) %%`{-8212 Bryan, TX 77805 � ..,,,, _ iac, No1:(g79) 774$372 INSURED Mid -Tex Materials LLC K3 Transport LLC PO Box 187 Fayetteville, TX 78940 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID cl Amne IR COMMERCIAL GENERAL LIABILITY mmmD/Y YY (MM/DD/YYY CLAIMS -MADE ® OCCUR + "a�+' IM1.. 2/5/2020 215/2029 'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEOQT LOC ANYAUTO AUTOS SCHEDULED "�" ='� � i 21512020 215/2021 ALE� ASUTOSU Ep T OS ONLY AUTOS ONLY UMBRELLA LIAR LXJOCCUR y EXCESS DHB CLAIM&MADE 2/6/2020 T 2 S12021 YIN mlei',,'J a+I 21612020 1 2/6/2021 215/2020 1 215/2021 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remade. Schedule, may be ahaehed if more space fe required) LIMITS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mid -Tex Materials LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN K3 Transport LLC ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 187 Fayetteville, TX 78940 AUTHORIZED REPRESENTATIVE - ACORD 25 (2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Name of vendor who has a business relationship with local governmental entity. ,/. OFFICE USE ONLY Date Received Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) Name of local government officer about whom the information is being disclosed. /T-- Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the Officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages 4o this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? El Yes 0 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes D No Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). �l R,nature of vendor doing business with the governmental entity Form provided by Texas Ethics Commission www.ethics-state.tx.us � d.��t. CI Date Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a—d) of this certification. Name and Tit of Authorized Agent Signature bI`Wuthorized Agent I am unable to certify to the above statements. My explanation is attached. Date Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid orwill be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require thatthe language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subprants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor,, 111)l-,c/47`-e,-,-�, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. 1J Signat ur e of Contractor's Authorized/0 icial Pr nted Name and Title of Contractor's Authorized Official /% Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing _ b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f, loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If ReportingEntity in No. 4 is Subawardee, Enter Prime _ Subawardee Name and Address of Prime: Tierif Known: /tL Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicable: w;f 8. Federal Action Number, ifknown: 9. Award Amount, ifknown: ,q. /IF. 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (f individual, last name, first nanie, Ml): different f om No. 10a) (last name, first name, MI): iY/f- F 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material �+ representation of fact upon which reliance was placed / Print Name: {'$�lUk J< ilAi , v% by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title:U.S.C. 1352. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: ! Al" M�6 Date: I% lue, inspection. Any person who fails to file the required 6 6'v� O disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) • • • •, • •, • ► Li I, /J�2/l tf�zti7J the undersigned representative of Representative f19m%K P11AA "tiid4 S; /f (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include on action made for ordinary business purposes; and 2. "Company' means afor-profitsole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. zx Signature of Representative Print Name & Title /r , /.c Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. u I certify tha is a "Nonresident Bidder" of Texas v (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) I 'Certify that A/.O'7Tr-X %Te', ,* I , GdG' is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature /offf Authorized Age�nt�''' I l �y.L6^" �C9✓diA.i f/ r / d�f [YLLdi'r;•`�.._. Printed Name and Title of Authorfz`ed Agent Date Please Type If handwritten, must be in ink and legible Vendor's Name: Address: ey Remittance Address: A'4'0I e-1 AQ 7`ea , a 4 Telephone: ��%`� f" u��V Z `mil' 7- .5 7ff E fey: Fax: _ -/;`/'. 3,--? E " dyc� CJ Email: Email(s) to send Bid Information: sn �FFki r�-'fi�r,�e c:„�� c. e: �r✓c v 410,E C'C�xz Signature of Authorized Representative: Printed name of Authorized Rep: ORDER - CONTACT INFORMATION Order Contact Name & Title: Order Contact Telephone: Order Contact Fax: -7 ,� 6'v Order Contact Email: Al' fPy/Ml?%t'.-iLZ,S XL74cev- Cz'v`"� �o Request Request for Taxpayer Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Cepartmem of the Treasury send to the IRS. Imemal Revenue Service ► Go to w�vW.iR.goV/Form W9 for instructions and the latest irdormation. 1 Name (as shown on your Income tax return). Name is required on this line; do not leave this line blank "I_' _'- "Z A - e 2 Business nama/tlisregarded entity name, g di Brent from above m a Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see ¢ instructions on page 3): Cp ❑ Individuallsole proprietor or ❑ CCorporslon ❑ 8Corporation ❑ Partnership ❑ Trust/estate a g j single-member LLC n Exempt payee code (if any) UJIllanited liability company.Fster the tax classification (G-0corporation, S=6 corporation, P=Partnership)► `0 2 Note: Check the appropriate, box in the line above for the tax classification of the single -member owner. Do nm check Exemption from FATCA reporting ffi LLC it the LLC is classed as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code (if any) 'C another LLC that is not disregarded from the owner for U.S. federal tax purposes. Othemiso, a single -member LLC that C� is disregarded from the owner should check the appropriate box for the tax classification of its owner. 4 ❑ Other(sm instructions)► I fop •Wa=wno-� me U.S) H 5 Address number, street, and apt. or no.) See instructions. Requester's name and address (optional) B ! - �O 1 NZ CALHOUN COUNTY 202 S ANN ST, PORT LAVACA TX 77979 a city, state, end ZIP aerie • 'AS' fW,` 361-553-4610 FAX: 361-553.4614 z; d, �,F� ,,f 7 Lim account number(s) here (optional) -Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number I backup withholding. For Individuals, this Is your saint security number . However, for a dgenerallyity, , late resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other - m - entities, it is your employer identification number (Elm. If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1- Also see What Name and I Employer Identification numbers Number To Give the Requester for guidelines on whose number to enter, Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has refilled me that I am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S, person (defined below); and 4. The FATCA code(s) entered on this form Of any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, kern 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dlvidends, you are not required to sign the certification, but you must provide your correct TIN. Sea the Instwctlons for Part II, later. .ryrr Signature of Here I U.S. person► %/ . Date► // ,,. c: General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Forihe latest Information about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to wwwJm.gov1FormW9. Purpose of Form An individual or entity (Form W-9 requester) who Is required to file an information return with the IRS must obtain your correct taxpayer identification number (FIN) which may be your social security number (SSN), Individual taxpayer Identillcatlon number (Illm, adoption taxpayer Identification number (ATIN), or employer Identification number (Elm, to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (Interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brekem) • Forum 1099-5 (proceeds from real estate transactions) • Farm 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Farm 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be sub*t to backup withholding. See What Is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) QUALITY HOT MIX, INC. BED ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUN COUNTY, TEXAS ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors'Name & Address r a4l �y e's miy p qa 774 3 • Please Type, If handwritten, must be in ink and legible. White out is not acceptable. -The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICF Page 1 of S <. N'w'�l n u/ Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Page 2 of 8 �N�Mq Invitation To Bid Form -Annual Supply Contract for Rood Materials and Asphalts, Oils and Emulsions —CONTINUED Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I I TOTAL LOAD/II ORDE Precinct 1 I Ton I • GI7 �' �� I Precinct I Ton i7•CU ' �(,(,1 I 6j%.i�' �'rt I Precinct I Ton I ,) 3 (,1,' I �•(�(J I I �."t,(I�rll I Precinct 4-P I Ton I :� CU I I ' I _ Precinct4-S ; ' Ton I �S 3,GG ;lq Remarks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I TOTAL MINIMUM LOAD/ORDER Precinct 1 I Ton Precinct ' Ton ''� ; 6,-( tvnl Precinct 3 ; Ton Precinct4-P I Ton 1 1c"; ' ' t Precinct 4-S I Ton�.Gd �Lr i +V I j Remarks: Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I TOTAL MINIMUM LOA/ORDER Precinct 1 ; Ton I i I Precinct 2 ' Ton I I ' �•_�III Precinct 3 Ton ' Precinct 4-P Ton II'II ,I IIII Pecinct 4-S I Ton _ I Remarks: 0 Page 3 of 8 0 fw5 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions -CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price Der ton /delivery nrira rn MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 Ton ' I I I Precinct 2 ; Ton i I I Precinct 3 ' Ton I I Precinct 4-P I Ton I I I Precinct 4-S I _ Ton Remarks: Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery Price to Countv Stnrknile and/or 1 ,hdto MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton I .�(�.'� ; 'P 3 Precinct I Ton 1/Q I NI I i Precinct 3 ; Ton I I I Precinct 4-P Ton `� J(;�L 0-1_1571 -Zi.GU 1 ,9q n ..Precinct 4-S Ton 1 5'U I !� O S. �% I (,7i.G� I rI L r�"I I?n l rks: Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / del ivery Price to Cnuntv Stnrkni la and/nr Inkcut rks: MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 I Ton ; I I I \ ;rLi; I Precinct 2 I Ton I ; Precinct 3 ; Ton I Precinct 4-P ; Ton Precinct 4-5 ; Ton � I Page of a Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions —CONTINUED Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to Count, Stockpile anH/,r 1a1,6f, , MINIMUM LOCATION I Unit ' MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton ' Yard 1 1 I I 501b Bag Precinct 2 1 Ton I I Yard3 I I 50 lb Bag i Precinct 3 Ton I I 1 ' Yard' I 1 I 1 I 50lb Bag 1 I I Precinct 4-P 1 Ton I I 1 1 1 Yard 1 I ; I 50lb Bag I 1 1 Precinct 4-S I Ton I 1 1 Yard3 I 1 SO lb Bag I i Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.21MFTable #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Johsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ; Ton ' ' I �,�� ' 1 E ; _ - t ,(�; z.Nt 1 I ' Precinct 2 1 Ton I e '-1,(I �, u1 I $ •�,� 1 •� � Precinct I Ton i I Precinct 4P ; Tan • I e�S .. fi(} 1 I 9, r✓U 1 Precinct 4-SI Ton I 7',06 Ia Page 5 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL i I Precinct I ; Ton Precinct 2 I Ton Precinct 3 I Ton Precinct 4-P I j Ton Precinct 4-S I Ton Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer OII Price per Rallon / delivery nrira rn r� ­f., rks: MINIMUM LOAD/ORDER LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I Precinct 1 I Gallon I I I I I ; I I I I$ Per Hour After P � Free Hours i Precinct 2 ; Gallon � I I— ;$ Per Hour After Free Hours Precinct 3 ' ' Gallon ; I ' Per Hour After I I Free Hours I Precinct 4-P I Gallon I i i I ' $ Per Hour After Free Hours Precinct 4-S I ! Gallon j I Per Hour After Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED id Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION �Unj[MATER1,ALDELIVERY I TOTAL Precinct 1 i Gallon Precinct 2 j Gallon Precinct 3 , Gallon 4-P i Gallon 4-S ; Gallon Bid Item #16: CRS-2 Temperature must be no lower than 150' and no higher than 1800 Price per gallon / delivery price to county Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL I I I I Precinct 1 ' Gallon i Precinct Gallon j� I ;$ I I — � I i Precinct Gallon i i i Precinct 4-P I Gallon I I I I$- '$_ Precinct 4-S ; Gallon I ; Be sure to complete next page (page 8) DEMURRAGE Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours Per Hour After Free Hours DEMURRAGE _ Per Hour After Free Hours Per Hour After Free Hours Per Hour After' Free Hours Per Hour After Free Hours Per Hour After Free Hours Page 7 of 8 r� W Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements, FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 16 D AX, Authorized Signature&Title: SLAM AJ �'_ Vto Type Name & TitleofAuthorized Signature: F-pSjfM t Phone Number. Lei y,l L%�(G L Email: y � { � �'0; 4Ik( I1 A PA1X _ C v', Exceptions and or Variations from Specifications and/or additional Notes: /�yOnL *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Page 8 of 8 STATE OF TEXAS {} AFFIDAVIT COUNTY OF CALHOUN {} The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared a4� 51ty Ac known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. 1 further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. A A Affiant V "I 't'� 5n4Us �IYi%f� Wi Printed Name and Title of Affiant Name of Bidder (Company) l �uq iI i:� Address i' 0 A%JG 13UN Tx 7 %q Phone Number Fax Number ' ) I '�-c{ Email Address J lye La I'2t'4i i X GVY� t SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states ��tth�hat the facts contained in the ee above are true and correct, this C— day of 200a) . Y 61 V O 4 VICKIE ARNE 1 COMM. EXPIRES 12-19-2o2 Notary Public in and for t� NOTARY ID 1134552-5 Y �U Ai4 County, Texas Complete Nos. 1- 4 arid 6 if there are interested parties. Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. Name of business entity filing form, and the city, state and country of the business of business. Quality Hot Mix, Inc. El Campo, TX United States being filed. Calhoun County, Texas FORM 1255 1 of OFFICE USE ONLY CERTIFICATION OF FILING place Certificate Number: Date Piled: Acknowledged: 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. Bid # 2021.03 Road Materials and Asphalts, Oils, and Emulsions January 1, 2021 thru December 31, 2021 Name of Interested Party Snyder, Jeffrey 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION C City, State, Country (place of business) El Campo, TX United States My name is } t• �}@ r1y �CC li "t ; -� (� ,and my date of birth isti(a,.,V_,.,, My address is PO S�Ox (]I�L� "ol it (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in L� \` County, State of I h on the day ofClG}d ii, r pp (month) (year) Signature of author d Qdent of contracbng business entity (Declarant) ,I rinnr_nnl CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/2)2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If 4he certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions the of policy, certain policies may require an endorsement. A Statement on this certificate does not confer rights to the certificate holder in lieu of such entlorsement(s). PRODUCER Texas Associates Insurers1120 CONTgCT PHONE AIC, No, EXt : (512) 328-7676 F a/c, No:(512) 327-8337 Bldg 3-300al of TX Hwy South Austin, TX 78746 E-MAIL INSURERS AFFORDING COVERAGE NAIL p INSURED INSURERA: The Charter Oak Fire Insurance Com an INSURER B: The Phoenix Insurance I RAd Quality Hot Mix, Inc. Quality Hot Com / aD Travelers i 4t`x,j p Mix Trucking, Inc. INSURER c: Property Casualty Company of America P.O. Box 1244 El Campo, TX 77437 INSURER D: Texas Mutual Insurance Com an INSURER E: 2t1' ffr h ij,,q;.i COVERAGES CFRTIPICATR.'hit lanoPo. INBURER F : s NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BFFN RFni IrFn Pv Penn ni AIR — COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR I'L AGGREGATE LIMIT APPLIES PER POLICY ❑ JECT LOC OTHER: OMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY H ANOTNO ONLO UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE DED X RETENTION$ 10,000 (ERS COMPENSATION iMPLOYERS'LIABILITY I 'ROPRIETOR/PARTNERIEXECUTIVE YIN IatolrMV In NHR EXCLUDED?N/A 7/9/2020 1 7/9/2021 7/9/2020 1 7/9/2021 7/9/2020 1 7/9/2021 7/9/2020 1 7/9/2021 per DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Calhoun County Auditor's Office THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 211 S. Ann Street Suite 301 ACCORDANCE WITH THE POLICY PROVISIONS. Port Lavaca, TX 77979 AUTHORIZED �REPRESENTATIVE ACORD 25 (2016103) G%1i�l C Y/ cirr ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Name of vendor who has a business relationshi"ith local governmental entity. OFFICE USE ONLY Date Received ---------------- Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) Name of local government officer about whom the information is being disclosed. tit Q Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yes Ej No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? EJ Yes FIND Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. Ci Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts ❑ as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). �I l D a av Signature of vendliqrINMusiness with the governmental entity Date Farm provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2075 CERTIFICATION REGARDING (DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a— d) of this certification. Name and Title of Authorized Agent Date Signa 'e Authorized Wgent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995), The Contractor, Qy 1111v 041- Mil k �:-A r , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature,gf C01i actor's Authorized Official ^" c� �� n4Ir Printed Name and Title of Contractor's Authorized Official IuG��[ Date Approved by OMB rV/A Disclosure of Lobbying Activities 0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure I. Type of Federal Action: 2. Status of Federal Action: a. contract 3. Report Type: a. bid/offerla lication _ b. grant Pp a. initial filing _ b. initial award _ b. material change C. cooperative agreement d. loan c. post -award e. loan guarantee For material change only: f. loan insurance Year quarter Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Ent _ Prime _ Subawardee Name and Address of Prime: Tier , if Known: Action . a. Name and Address of Lobbying R, (findividual. last name, first name, Ml): IL Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such Federal Use Only Program CFDA Number, ifapplicoble: b. Individuals Performing; differentfront No. I0a) (last nante, first name, MI): Signature: PrintName: 'InG Title: @t R''SiU Telephone No.: S2 S'q Date: Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, S45 • r the undersigned representative of Representative ocnli 6+l n+ MIA ;�7n ( (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. 'Boycott Israel' means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means o for -profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. J��' tier Signature o-f�Rel6r�es�Ie"'nt�a`tive >rt�IP�Q�JijJul Print Name & Title Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ 1 certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) 0 I certify that Gg-1 J;t1j J:b j (j�; —1� t is a 'Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. I Signature of AulYoriz 'd Agent Printed Name and Title of Authorized Agent (0(a�(?-b Date Please Type If handwritten, must be in ink and legible Vendor's Name: L Address: Q U &,X la o q3 7 Remittance Address: Telephone: 7q3 i4zln Fax: 7 q S U 301 Y Email: 49I 176f474%x, 66VA Email(s) to send Bid Information: Signature of Authorized Representative: Printed name of Authorized Rep: �yy r1li G��i Order Contact Name & Title: ili55 1' 6 91< 0;,Sgsrj r Order Contact Telephone: i1$q3 qq(fb Order Contact Fax: `2795q3 sL�i Order Contact Email: I-o-5j Ld Z,dlii1' 110 M)1 CrYVw ■Y®� Request for Taxpayew Give Form to the Form (Rev.O1 ber2018) Identification (Number and Certification requester. Do not the DepartmeInternal Send to the IRS. Revenue a Serviceof ► Go to www.1mgov/FormM for instructions and the latest information. 1 Name (as shaven on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity name, if different from above m a Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (castles apply only to m following seven boxes. certain entities, not individuals; see a instructions on page 3); o ❑ Individual/sole proprietor or ❑ CCorporation ❑ SCorporation ❑ Partnership ❑ Trust/estate gsingle -member LLC Exempt payee code (if any) 0 $'1't ❑ Umred liability company. Enter the tax classtficafion(C=C corporation, 6=S corporation, P=Partnership)► `0 2 Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Donotcheck Exemption from FATCA reporting Yn LLC if the LLC is classed as a singla-member LLC that is disregarded from the owner unless the owner of the LLC is code Jan C another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that C IS Is disregarded from the owner should check the appropriate box for the tax classification of its owner. E ❑ Other (see instructions)► pou•.m.amere w a wmu•us y 5Addre (numbpper",,�street, and t. or suite no.) See instructions. Requester's name and address(optional) C !)(J PD 5 a x, I q CALF COUNTY O1 202 S ANN ST, PORT LAVACA TX 77979 6 City, state, no ZIP code C'� ") (.�)' 361-553.4610 FAX: 361-553-4614 v 7 List mccunl numbers) here (6ptional) Taxpayer Identification Number CHNI) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number backup wlien, sale For Individuals, this egajs generally your social security number (SSNr. However, fora _ m _� resident alien, sole proprietor, or disregarded entity, see the instructions for Pert I, later. For other entitles, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Nate: If the account is in more than one name, see the Instructions for line 1. Also see What Name and J Employer identification number Number To Give the Requester for guidelines on whose number to enter. ,9s}yg'M��"�ax".',j Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (a) the IRS has notified me that I am no longer subject to backup withholding; and S. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (f any) Indicating that I am exempt from FATCA reporting is correct. CertiRcation instructions. You must cross out Item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you ap not requlred to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. 01VTO SigneNre of Here US. person► General Instri Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to wimmirs.gov/Fa nW9. Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or pale) Date► tUW71,�'u • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutuei fund sales and certain other transactions by brokers) • Form 1C99-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party networktmnsactions) • Form 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuhion) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (Including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with aTIN, you might be subject to backup withholding. Sae What is backup withholding, later. Cat. No. 10231X Farm W-8 (Rev. 10-2018) VULCAN MATERIALS COMPANY dba VULCAN CONSTRUCTION MATERIALS, LLC ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 CALHOUNCOUNTY, TEXAS INVITATION TO RID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name St Address y.Q,�60u -791550 °�a�lA�fd✓ci� • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. 'The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch To Dust Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I I Precinct 2 Ton I i i Precinct 3 Ton I I Precinct4-P I Ton I I 1 i Precinct 4-S 1 Ton I 1 i Remarks: Bid Item #2: Item 247, Type A Limestone, Grade 2, [13/4 Inch) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER , Precinct I Ton I ,J�7 e Precinct 2 Ton Precinct 3 Precinct4-P I Ton �,�� ,�(� ' 00 1 I Precinct 4-S I Ton 5D q,1)0 1 � 1 ' -D 1_ 40,? c�2Q :S Remarks: Page 1 of 8 invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton 79.5 , I 4c i Precinct 2 Ton I 1 Precinct I Ton 1 26I a2l,f5b I ��•(� 10615 Precinct4-P 1 Ton Precinct 4-S Ton j 9,'� .50 A vo 1 y j,l In 1 � -Ind Mr,IT. 0n Bid Item #4: Item 275, Cement 275-2.1, Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Bag (Cost per Pallet) List # of 47 lb Bags on a Pallet Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I 1 1 Precinct 1 I Ton 1 I 1 1 1 1 1 1 of 47 16 1 1 I I I Bags on Pallet i i Precinct 2 I Ton i i i i of 47 lb 1 I Bags on Pallet I N I 1 1 Precinct 3 1 Ton l I I 1 of 47 lb 1 I I 1 i Bags on Pallet I 1 I I I Precinct 4-P I Ton 1 I I I _ of 47 lb Bags on Pallet ; N #r Precinct 4-S ; Ton N of47lb; Bags on Pallet ; N Remarks: Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to county Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY I ' i I Precinct 1 Ton I ; ' I i Ng i Precinct 2 1 ' Ton I ; I I Precinct 3 Ton ' I I Precinct 4-P .1 Ton I I i I Precinct4-S I Ton rks: Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to coMToni nty Stockpile and/orlobsite Unit MATERIAL DELIVERY ' I RJTon i ',I Ton ' I; Ton ��I i '1 la� ITon, I r,�----------------- ; Ton I N I I TOTAL TOTAL Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of ,1LU.v6ad1de)* Price per ton / delivery price to county Stockpile and/or Jobsite r�N Unit MATERIAL DELIVERY TOTAL I n ; Ton or� oi II Ton i �a,, Ton ! � i ,i Ton I ; Ton v50 ; N. ® , MINIMUM MINIMUM LOAD/ORDER MINIMUM LOAD/ORDER ' ?q ins Page 3 of 8 Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of * Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton Precinct 2 Ton Precinct Ton � ��•�p ��,� � �jj,� 1 Precinct 4-P I Ton „����aa �` 7U I I Precinct4-S 1 Ton ;'A-366 I I 2,Q(5 I '?z14r lS Remarks Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton I �� Precinct 2 Ton ; I Precinct 3 Ton 1 Precinct 4-P ; Ton I I i Precinct4-S I Ton Remarks: Bid Item #10: Item 330, Type D (Pre -Mix Limestone) L i rrl ed-cne icIa c ASphd lk Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 I Ton I I iV ✓V i I i Q 7�J, 24 Precinct l Ton ; , �(� ; �� , I 1.25 ; ciq Precinct Ton Q.!5 yQ, ; Dq Precinct 4-P ; Ton =f a % ^^77/} 74. orZ16=�,+ Precinct 4-S Ton j ®. yD �$,7 � y/ ( .;) ' )y_l 01 `I y Dn_ Remarks: Page 4 of 8 ' Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (L1RA) See Bid Item #15, Page 4, for more information on this material. dA 'p6 at) Aix Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER p Precinct 1 i Ton '1� &..6o I ', / I ' ,.2 Yard3 iivJPj I 1 50 lb Bag Precinct 2 Ton 1 �,b 1 1 1 aq lvns 1 Yard' 50 lb Bag ' Precinct . 1 Ton 1,P,' 1 0 D I cjjq 6,46 I 1 Yard' 1 I 1 I 1 I 50 lb Bag 1 Precinct4-PTon% ,�J 6 I Yard' 50 lb Bag lV 8 Precinct 4-5 Ton 1 ,5() 306, d6 ' Yard' NL.' ' 50 lb Bag Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 Ton 1 Precinct 2 Ton NJ F2 i i Precinct 3 Ton i i i Precinct4-P ; Ton Precinct 4-S ; Ton Remarks: Page 5 of 8 ' Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I p. I I 4600 ! ,Q 'C/b , M , ' c:92 400 Precinct 2Ton `p'�� = 1�5; 00 I , Precinct 3 I Ton I I p. I , w I q0, 00 I n r! Precinct 4-PI Ton i t1 gp.Qo or) l , ; Precinct4-S I Ton 'gO.Qo y6,vo ; 06.00 I as -1-on5 rks: m 300, Asphalts, Oils and Emulsions i Item #14: Primer Oil Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit I MATERIAL DELIVERY Precinct 1 I Gallon I I Precinct 2 Gallon I , NG i , I I Precinct 3 I Gallon I N 1 Precinct 4-P I Gallon Precinct 4-S ; Gallon rks: TOTAL DEMURRAGE I �$ Per Hour After , I Free Hours I i$ Per Hour After I— Free Hours i ;$ Per Hour After I_ Free Hours , i �$ Per Hour After I Free Hours I 1$ Per Hour After Free Hours Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #15: RC-250 Temperature must be no lower than 1401 Price per gallon / delivery price to County Stockpile and/or lobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE ;$ Per Hour After Precinct 1 ; Gallon ; X6 ; ; 1_ Free Hours 1 I I I I 1$ Per Hour After Precinct 2 1 Gallon I N I Free Hours I I I I 1 1$ Per Hour After Precinct 3 Gallon i I Free Hours 1 ;$ Per Hour After Precinct 4-P Gallon Free Hours 1 1 i Per Hour After Precinct 4-S 1 Gallon ♦ V f-/ I l_ Free Hours arks: Item #16: CRS-2 Temperature must be no lower than 150° and no higher than 1800 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I i i I i Per Hour After Precinct 1 i Gallon I_ Free Hours I I I I ;$ Per Hour After Precinct 2 1 Gallon I N I I 1 Free Hours 1 i I I I 1 I 1 1$ Per Hour After Precinct 3 1 Gallon I 1 I 1 Free Hours I 1 i 1 1 1 I I I$ Per Hour After Precinct 4-13 1 Gallon 1 i 1 I i Free Hours i I i I 1 1$ Per Hour After Precinct 4-S I Gallon I �� t✓ i I Free Hours Remarks: Be sure to complete next page (page 8) Page 7 of 8 'Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Authorized Signature & Title: Type Name & Title of Authorized Signature: Phone Number: 67 iq ` mbn Email: Vid eQYI4qt/lesi%� 1/IYItSVYIdd -eO111 Exceptions and or Variations from Specifications and/or additional Notes: Nn egexp t of?5 Page 8 of 8 STATE OF TEXAS 0 COUNTY OF CALHOUN {� The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared (,i/,L/4l�&L0 known to me to be the person whose name is subscribed to the following, who, u on oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant ;kV U tA)h akion Printed Name nd Title of Affiant Name of Bidder (Company) VU le n tcr)5+rac�lnn Ma heV &L) a rr-46 Address T O TDM -M ` 50 r Sari A 11knn i r) IX i 9Q-1 q Phone Number (a� 10) - 35©O Fax Number Email Address VI.LIP.rj.ytky$UdYS&V✓Y1C.Ma.11,COM _ SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this &_ day of lV r)WiMbPl' 20_20 . �� �4Pa='� ��i, LISA FiAY SCNP.A67Cf? �� :�,�-•d� MY 60MMIS3lON EXPIRE5 m� ?�sy`,. 4P� NOVEftAE3ER 22, 2023 i „'/OFjI��� NOTARY10:380&639 Notary Public in CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 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. 2020-687144 Vulcan Construction Materials LLC San Antonio, TX United States Date Filed: 11/06/2020 2 Name of governmental entity or state agency that is a party to the contract for w ich the form Wis being filed. Calhoun County, Texas 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 services, goods, or other property to be provided under the contract. Bid Number: 2021-03 Road Materials and Asphalts, Oils and Emulsions, January 1, 2021 thru December 31, 2021 Nature of interest 4 Name of Interested Party City, State, Country (place of business) (check applicable) Controlling Intermediary Vulcan Construction Materials LLC Birmingham, AL United States X 5 Check only if there is NO Interested Party. 6 UNSWORN DECLARATION Q My name is c.� , and my date of birth is -• b My addresses ,... ,:..:.. .4:. . (street) (city) w ,. (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in (�' County, State of TZ on the ,ji + day of MCl/ , 20,720. (month) (year) Signature 61 authorized agent of contracting business entity (Declarant) Cnrmc nrnvirlad by TPYAS Pthirc rnmmiccinn www.athirs.state.tx.us Version V1.1.3a(laaf7d 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 Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2020-687144 Vulcan Construction Materials LLC San Antonio, TX United States Date Filed: 11/06/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County, Texas Date Acknowledged: 12/17/2020 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. Bid Number: 2021-03 Road Materials and Asphalts, Oils and Emulsions, January 1, 2021 thru December 31, 2021 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Vulcan Construction Materials LLC Birmingham, AL United States X 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.tx.us Version V1.1.3a6aaf7d MEMORANDUM OF INSURANCE DATE 13-Dec- This Memorandum is issued as a matter of information only to authorized viewers for their internal usel only and confers no rights upon any viewer of this Memorandum. This Memorandum does not amend, extend or alter the coverage described below. This Memorandum may only be copied, printed and distributed within an authorized viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of Marsh Is prohibited. "Authorized viewer" shall mean an entity or person which is authorized by the insured named herein to access this Memorandum via hops eronline.marsh.com/marshconnectpublic/marsh2/public/moi?client=900114839. The information contained herein is as of the date referred to above. Marsh shall be under no obligation to update such information. USA Inc. ulcan Materials Company O Box 385014 35238-5014 COMPANIES AFFORDING COVERAGE A Old Republic Ins Co e THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. HAVE BEEN REDUCED BY PAID CLAIMS LIMITS SHOWN MAY CO LTR I IN UPE OF RANCE I POLICY NUMBER CY EFFEE CTIVE Auto A Liability EXPIRATION I LIMITS DATE LMITS IN USD UNLESS OTHERWISE WDICATED 1 A IExcess WC Memorandum of Insurance serves solely to rage. Any modifications here to are not aut MEMORANDUM OF INSURANCE nce policies, limits and DATE 13-Dec-2019 Memorandum is issued as a matter of information only to authorized viewers for their nal use only and confers no rights upon any viewer of this Memorandum. This orandum does not amend, extend or alter the coverage described below. This orandum may only be copied, printed and distributed within an authorized viewer and only be used and viewed by an authorized viewer for its internal use. Any other use, ration or distribution of this Memorandum without the consent of Marsh is prohibited. torized viewer" shall mean an entity or person which is authorized by the insured !d herein to access this Memorandum via ://online.marsh.com/marshconnectpublic/marsh2/public/moi?client=' The nation contained herein is as of the date referred to above. Marsh sha a un el no-- - USA Inc. ulcan Materials Company O Box 385014 as 35238-5014 States ess WC policies have $1,000,000 Self -Insured Retention for all covered states except TN and $500,000 SIR for Only. Liability is subject to $50,000 Self -Insured Retention and includes Contractual Liability I Insured includes: i Construction Materials, LLC i Rock Industries, Inc., its subsidiaries and affiliates Transportation, LLC Rock, LLC le Rock Products, LLC t Co. DBA Vulcan Materials Company, Western Division ide Transport, LLC ast Division Logistics, LLC in Gulf Coast Division Logistics, LLC d/b/a SGC Logistics ain West Logistics, LLC f Division Logistics, LLC d Division Logistics, LLC Co. DBA Shamrock Materials sates USA, LLC IERAL LIABILITY - ADDITIONAL INSURED party with which the named insured is contractually required to include as additional insured is automatically ted such. However, coverage under the policy only applies to the extent of the coverage required by such ractual requirement and for the limits of liability specified in such contractual requirement, but in no event for -ance not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the oy. Any insurance afforded to any such additional insured only applies to the extent permitted by law. 'OMOBILE LIABILITY - ADDITIONAL INSURED party with which the named insured is contractually required to include as additional insured is automatically ed such. However, coverage under the policy only applies to the extent of the coverage required by such d requirement and for the limits of liability specified in such contractual requirement, but in no event for not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the LIABILITY AND AUTOMOBILE LIABILITY - PRIMARY & NON-CONTRIBUTORY ce is urimary and u -mull, ul insurance serves solely to list i Lny modifications hereto are not authoriz Policies, limits and dates of CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Name of vendor who has a business relationship with local governmental entity. FORM CIQ OFFICE USE ONLY Date Received Vulcan Citidior7 Check this box If you are filing an update to a previously filed questionnaire. (The law 0requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which You became aware that the originally filed questionnaire was incomplete or inaccurate.) Name of local government officer about whom the information is being disclosed. & Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? 0 Yes E-J No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes F—I No Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts ❑ as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). Il ord/aoa.v Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 17/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. me and 7"Ic of Authorized Age ent Date 11 2;9=_ ­' `vaignature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). V t Con AAC DA The Contractor, v4. certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature f ontractor's Authorized Official ShrujlA11gar) Ana wsil- Printed Narryb and Title of Contractor's Authorized Official t l /0(a 90 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance NA /V A r Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Prime _ Subawardee Name and Address of Prime: _ Tier. if Known: x' ' /P( J0 Congressional District, if known: Congressional District if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: I V /Fir Aljft CFDA Number, ifopplicable: 8. Federal Action Number, ifk'nown: 9. Award Amount, ijAnown: N $ 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address it" ffindividual, last name, first name, MI): different from Na. IOa) (last name, first name, M1): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Cif W d i by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: i] @ U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone ate: inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, A4e_4 lc)i7 a! Ov7 the undersigned representative of Representative 1Aut1encn (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company" means a for-profitsole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signatu&df Representative ,�faw L)fh�r hya Print Name k Title II ZN21902.0 Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. ✓' RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001 (3) "Nonresident bidder" refers to a person who is not a resident. ❑ I certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) aL I certify that VjL rich &04&�Jt®✓7 is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Sign ure of Authorized Agent Printed NamA and Title of Authorized Agent t)/a�laA� Date Please Type If handwritten, must be in ink and legible Vendor's Name: !/ U tL' 0 LOY 6+(-UCb0t1 !"GIff1' .1g l L C Address: 12e) 13 p�/ 79 j 550 Remittance Address: V 0 ,13 pl., 94 J 131 7actbla 15,20 Telephone: cto) 594 - 351;. Fax: ( ;Z 10) 69 7 °,�JP-66 Email: Email(s) to send Bid Information: )1111rgn4x14uoi 6%/,2Vri7CYYai1-60M Signature of Authorized Representative: Printed name of Authorized Rep:y-%ao.l 10hea. w ORDER — CONTACT INFORMATION Order Contact Name & Title: Lpr^ryi, SC{1Pi5 1 Med i:Yla lV. ab U(atoi ide) Order Contact Telephone: Nol) 94 - `( 799. (,;a%5)56 -3g06 Order Contact Fax: Order Contact Email: g"ggp�np V(f1G' Jygag %.CDl� e Request for Taxpayer Give Form to the Form (Rev. October 2016) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www,irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown an your income tax return). Name is required on this line; do not leave this line blank. Vulcan Materials company 2 Business nameldisregarded entity name, if different from above Vulcan Construction Materials, LLC (EIN: 63-1211833 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see a instructions on page 3): C p ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation p ❑ Partnership ❑ Trust/estate w M single -member LLC Exempt payee code (if any) u❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► o Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting E w LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code (if any) o' another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that w is disregarded from the owner should check the appropriate box for the tax classification of its owner. .o m ❑ Other (see instructions)► f�emres,oaccoums mamianeaomsmeir,eusl W 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optional) d � Corp. Tax Dept., P.O. Box 385014 1200 Urban Center Drive 35242 6 City, state, and ZIP code Birmin gham, AL 35238-5014 7 List account numbers) here (optional) Identification Number Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid L backup withholding. For individuals, this is generally your social security number (SSN). However, for a F resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Iorr: Number To Give the Requester for guidelines on whose number to enter. ( o- Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 1 am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. zwgn Signature of t Here I U.S. person► --- k —_ Date► i'"a- General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.im.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-V (Rev. 10-2018) WALLER COUNTY ASPHALT, INC. AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2021.03 Beginning January 1, 2021 and Ending December 31, 2021 G4LHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Period: January 1, 2021 thru December 31, 2021 Bid Number: 2021.03 Vendors' Name & Address WALLER =i►`r; &pt+tle—T 27=D 1® OV MVOU40S RD. • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. •The Invitation to Bid Packet, in its entirety, will be the binding contract between Calhoun County and the successful vendor. Page 1 of 8 Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY =LOAIDN/110MRUDMER TOTAL i 1 Precinct 1 I Ton 1 i ' 1 PrecinctI Ton 1 1 I Precinct I Ton I I 1 ' I 1 I Precinct4-P 1 Ton iI I I 1 I 1 1 Precinct4-S Ton , arks:_14® BID Item #4: Item 275, Cement Remarks: 275-2.11 Hydraulic Cement Type 1, Bulk (Pneumatic Tankers, Spreader Bar Needed) 275-2.1, Hydraulic Cement Type 1, 47 lb Bag (Cost per Pallet) List # of 47 lb Bags on a Pallet Price per unit/ delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY MINIMUM , TOTAL LOAD/ORDER ' ; Precinct 1 Ton 1 1 1 I of 47 lb 1 ' Bags on Pallet ' 1 � Precinct 2 Ton I 1 I 1 1 � of 47 lb i i ' , 1 � Bags on Pallet � I Precinct 3 Ton I I 1 ' 1 of 47 lb I Bags on Pallet 1 Precinct 4- Ton I 1 1 1 _ of 47 lb I I Bags on Pallet 1 Precinct 4-S I Ton ' I 1 ' I 1 1 _of47lb1 1 ' 1 I 1 Bags on Pallet Page 2 of a Invitation To. Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY Precinct 1 I Ton 1 i 1 Precinct 2 1 Ton 1 I I 1 1 Precinct 3 { Ton 1 1 ; i Precinct4-P I I Ton i I i I I 1 1 1 Precinct 4-S I Ton I rks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY Precinct 1 I Ton I I 1 Precinct 2 1 1 Ton I I I 1 Precinct 3 1 1 Ton I I I 1 Precinct4-P 1 I Ton I I 1 1 1 1 Precinct4-S I I Ton I 1 I 1 (Remarks: TOTAL TOTAL Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL Precinct 1 1 Ton I I I Precinct 2 1 Ton 1 i 1 I Precinct 3 I Ton I I i Precinct4-P I Ton 1 Precinct4-S I Ton I I I I Remarks: MINIMUM MINIMUM LOAD/ORDER MINIMUM LOAD/ORDER Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions —CONTINUED Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY Precinct 1 Ton ; Precinct 2 Ton Precinct 3 Ton I I Precinct4-P I Ton I I I I ; i Precinct 4-S Ton I I I I MINIMUM TOTAL LOAD/ORDER Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) Price per ton / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton Precinct 2 1 Ton I 1 Precinct i Ton Precinct4-P I Ton I Precinct4-S I Ton Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton I I I I Precinct 2 1 Ton Precinct 3 Ton Precinct4-P; Ton Precinct 4-S 1 Ton i Remarks: Page 4 of 8 Invitation To Bid Form -Annual supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) See Bid Item #15, Page 4, for more information on this material. Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION:E1 =UnitMATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Yard I ' , I I I I 5016 Bag I I I i i i i Precinct 2 I Ton I I , I Yard' � I I I I I I SO lb Bag I I I ; Precinct Ton I I I I I I I , I Yard' I I I 50lb Bag I I I Precinct4-P I Ton I I I Yard' 50lb Bag I I I Precinct 4-S I Ton I I I I I I Yard' I I 50lb Bag Remarks: Ajo 61 Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.21MF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL Q LOAD/ORDER Precinct 1 Ton 0S I 3®. pI—$ , 51 ; 25 Tom' Precinct 2 Tona0 , j I p. �I j 2�S TOWS Precinct 3 Ton ; 4 9S 8D ; `$ Z 15 p aS Tom Precinct 4-P j Ton �, • ; }}�e ,q� �� 1 Hoag Precinct4-SI Ton I�S.a� IY3t�•9% I�olq.q� I S5'r Remarks: BID/6 Fain, MR EMAM&M ASPPWI Page 5 of 8 Invitation To Bid Form - Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE I I I I I Precinct 1 Ton I I I I 1 I 1 I I 1 Precinct 2 I Ton 1 I I I I Precinct 3 1 Ton I I I Precinct 4-P I Ton I Precinct 4-S ; Ton (Remarks: )HALTS, OILS AND EMULSIONS' 300, Asphalts, Oils and Emulsions Item #14: Primer Oil Price pergallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I I I I 1 1$ Per Hour After Precinct 1 1 Gallon I 1 i 1_ Free Hours I I I I I I$ Per Hour After Precinct 2 1 Gallon I I I I —Free Hours I i I I Is Per Hour After Precinct 3 1 Gallon I I I ;_ Free Hours I I I 1 I 1 I I I$ Per Hour After Precinct4-P I Gallon 1 1 I I Free Hours I I I I$ Per Hour After Precinct 4-S I Gallon I I I I —Free Hours Remarks: Page 6 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE $ Per Hour After Precinct 1 Gallon jFree Hours 1 I 1 I I Per Hour After Precinct 2 1 Gallon 1 I I ;_ Free Hours j i 1$ Per Hour After Precinct 3 Gallon Free Hours i 1 i Ii i i i 1$ Per Hour After Precinct4-P; Gallon I Free Hours i$ Per Hour After Precinct4-S 1 Gallon I Free Hours Remarks: 0 Bid Item #16: CRS-2 Temperature must be no lower than 1501 and no higher than 180° Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE 1$ Per Hour After Precinct 1 1 Gallon I I Free Hours 1$ Per Hour After Precinct i Gallon 1 1 1 1- Free Hours 1 1 1 1 1$ Per Hour After Precinct 3 1 Gallon 1 1 1 1_ Free Hours i `$ Per Hour After Precinct4-P 1 Gallon 1 1 1 1— Free Hours `$ Per Hour After Precinct4-S I Gallon I I I IFree Hours Be sure to complete next page (page 8) Page 7 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions --CONTINUED The undersigned affirms that they are duly authorized to execute this bid and that this company, corporation, firm, partnership or individual has not prepared this bid in collusion with any other bidder, that the contents of this bid as to prices, terms or conditions of said bid have not been communicated by the undersigned nor by their employees or agents to any official, employee or agent of Calhoun County or any other person engaged in this type of business prior to the official opening of this bid. The undersigned affirms that they have read the entire Invitation to Bid packet and fully understands and has followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: I I / a/ 2—o 20 Authorized Signature & Title: Type Name & Title of Authorized Signature: R63® D/ 804 VOW MUDWr Phone Number: 9779-SZ16-70%5- Email: /46MWCASPfMV-eo(q Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEXAS 0 AFFIDAVIT COUNTY OF CALHOUN 0 The undersigned certifies that the bid prices contained in this bid have been carefully checked and are submitted as correct and final and if bid is accepted, agrees to furnish any and/or all items upon which prices are offered, at the price(s) and upon the conditions contained in the Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Relb 1AY49crJ known to me to be the person whose name is subscribed to the following, who, upon oath says: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bids to which this affidavit is attached, and I have full knowledge of the relations of the Bidder with the other firms in this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of supplies bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this contract, that this company, corporation, firm, partnership or individual has not prepared this Bid in collusion with any other Bidder. I further affirm that the Bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or to any official, employee, or agent of Calhoun County in connection with the submitted bid. The contents of this Bid as to prices, terms or conditions of said Bid have not been communicated by the undersigned nor by any employee or agent to any other person engaged in this type of business or to any official, employee, or agent of Calhoun County prior to the official opening of this Bid. Affiant R EI ® D*Wsotj Viet PRgsl Printed Name and Title of Affiant Name of Bidder (Company) 'WALLz? wo`( Aspt OLT Address 22010 FAIP,019WuCS RD. HC- Lft—iAb .17704149- Phone Number "-8 116 °—%Cf A:' Fax Number g3Z-gLI7-® aoig- Email Address NFIDIR IIVCASNWL.-'i, 60AI SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the r above are true and correct, this day of aGLENDA DEGAGNE _ Notary Public, State of Texas r Comm. Expires 02•15-2023 Notary Public in d-for County, Texas Notary ID 11174365 omm• CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-684311 WALLER COUNTY ASPHALT, INC. Hempstead, TX United States Date Filed: 10/29/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County 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 services, goods, or other property to be provided under the contract. 2021.03 Road Materials 4 Nature of interest 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 UNSWORN DECLARATION My is I�® LL^ name and my date of birth is _��, f ���77ie�4lJ- �w ,r�J�,.w�, tr� IL,�r My address is 1® M94A WOW Fd3 n���l� V, WA (street) (city) (state) (zip code) (country) I declare un er penalty of perjury that the foregoing is tru and car r r IMP Executed in C State J '\ , on th ,44day of `"Will" GLENDA DEGAGNE (month) (year) Pberi pNy ;Notary Public, State of Texas 'S'•. rid 02-15-2023 Comm. rExpires � niNp� Notary ID 11174366 Signatur of authori ag nt of contmchn usiness entity Vecla nt) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 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. 2020-684311 WALLER COUNTY ASPHALT, INC. Hempstead, TX United States Date Piled: 10/29/2020 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County Date Acknowledged: 12/17/2020 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. 2021.03 Road Materials 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECLARATION My name is and my date of birth is My address is , (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of , on the _day of , 20_ (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d HI._.VKII DATE(MM/DDNYW) CERTIFICATE OF LIABILITY INSl4lSryptlipE 07/21/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiticateholder is an ADDITIONAL INSURED, the pDlicy(Ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEQCT Kyle Smilh Sterling Seacoast Partners, Inc PHONE P 0 Box 724137 _ is No Eat ' (678) 424.6500 FAx - (g7S142asen9 Atlanta INSURED A GA 31139 Stag Source Employment P.O. Box 1084 Cartersville GA 30120 HAVE -SEEN ISSUED TO THE INSURED NAMED INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WIDTH RFOR THE POLICYPER ESPECT To WHICH TI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Rf- 'MERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR rLAGGREGATE LIMITAPPLIES PER: POLICY ❑ JECT PRO- EJ LOC OTHER: OMOe1 .LIABILITY ANYAUTO OWNED AUTOSONLV HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY UMBgLIAR IAR OCCUR EXCECLAIMS MgDEDEDETENTION $WORKERS SATIONAND EMPLIABILITY6 ANY PROPRARTNER/EXECUTIVE YINOFFICER/MEXCLUDED9 F N/A(MandatoryItyas, descriDESCRIPTIPERATIONS below A Professional Liability Waller County Ashpalt Waller County Asphalt, Inc. 22010 Fairgrounds Rd. Hempstead 05/11/2020 1 05/11/2021 $ Ea ecdtle0 GINGLE LIMIT $ BODILY INJURY (Per Peroon) $ BODILY INJURY (Per eccldenq $ Pe�eccRdenl AMAGE $ 03/04/2020 103104/2021 05/11/2020 105/11/2021 (Aggregate Limit Deductible (ACORD 1a1, Atltlilional Remarks Schedule, may be allachetl ir more space is required) Insureds with regards to the General Liability Policy by written contract. A Waiver of Subrogation is in place TX 77445 $2,000,000 $5,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 26 (2016103) The ACORD name and logo are registered marks ofACORDIS ACORD CORPORATION. All rights reserved. WALLECOU ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/20/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such rndnreemnnuel PRODUCER USI Southwest Austin 7600-C N. Capital of TX Hwy #200 Austin, TX 78731 512 451-7555 County Asphalt, Inc.Waller County Construction,LLCmsuRE22010 Fairground Rd. TX 77445-2005 COVERAGES CERTIFICATE NUMBER: CONTACT Stefanie Wornell NAME: Est: 512 451-7555 FAX, NM No: 512 467-01 a_ ADDRESS: stefanie.wornell@usi.com INSURERS) AFFORDING COVERAGE INSURE2United re Lloyds Insurance CompanyINSUREDINSURELloyds Insurance CompanyWaller INSUREHempstead, INSURE REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY INDICATED, NOTWITHSTANDING ANY REQUIUI PERIOD REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY ISSUED OR MAY PERTAIN, THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE h6m, SUER ER INS WVD POLICY NUMBER MM%DON YV MMIDOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 10/21/2020 10/21/2021 EACH $1 000000 H` �OCCURRENCE PREMISES Ea occurrence $100000 X PD Ded•1,000 MED EXP(Any one person $$000 GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL A ADV INJURY $1 000,000 POLICY lid ECT LOC GENERAL AGGREGATE $2 000,000 PRODUCTS - COMP/OP AGG $2,000 000 OTHER: A AUTOMOBILE LIABILITY7:: 10/21/2026 10/21/2021 COMBINED SINGLE LIMIT Eaaccide t 1.000,000 X ANVAUTO OWNED SCHEDULED BODILYINJURY(Puperson) $ AUTOS GNLY AUTOSBODILY X X NON-OWNEDPROPERTY INJURY(Peraccidenl) $ AUTOS ONLY AUTOS ONLY DAMAGE $ Per accident A X UMBRELLALIAB X OCCUR10/21/2020 10/21/2021 EACH OCCURRENCE $1 OOO QOQ E%CESS UAB CLAIMS -MADE AGGREGATE S1,000,000 DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY PER OTH- OFFICER/MEMBER EXCLUDED?ECUTIVE� E.L. EACH ACCIDENT $ (Mandatory In NH) If yes, describe under E.L. DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below B Equipment Floater E.L. DISEASE -POLICY LIMIT $ "� 10/21/2020 10/21/2021 RENTED/LEASED EQUIPMENT „�.,„,w* $500,000 Per Item/Agg $1 000 Deductible DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE WAI OPR SAMPLE *For Bidding Purposes Only* SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988.2015 ACORTI r nnonRATtnht An .o.e.e AUUJKL Lb 2M � E x a1b1U3 1 of 1 The ACORD name and logo are registered marks of ACORD 4 *4 $ rr F111 a SZTHB CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governfnenta9 entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Sessio7An This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor has a business relationship as defined by Section 176.001(1-a) with a local governmental entity an vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not than the 7th business day after the date the vendor becomes aware of facts that require the statement tfiled. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Cadeoffense under this section is a misdemeanor. Name of vendor who has a business relationship with local governmental entity. 2 Check this box if you are filing an update to a previously filed questionnaire, (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7fh business day after the date on which You became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the offfcer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? ElYes E�No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? El Yes �F 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more, NONE 6 1 _ Check this box if vendor has given the local government officer or a family member of the officer one or more gifts ❑ as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 Sign Lure of veWW doing business with the governmental entity �6`—!F� 207-0 Dal •'^� `•"'�� ""^�a'�� www.ethics.stato.tx. us Revised 11/30/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a— d) of this certification. Re a)p-mew V e W PAE19 Name and Title of Authorized Agent Signe of Authorized Agent ®1 1 ZoZ® Date I am unable to certify to the above statements. My explanation is attached. Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, 'Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. 9 SIgnature,AfContractors Authorized Official Relb DAWswi V1WPWbsi De*n- Printed Name and Title of Contractor's Authorized Official I1O®1IZO20 Date Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract Ab. a. bid/offer/application a. initial filing grant A b. initial award A b. material change c, cooperative agreement c. post -award d. loan For material change only: c.loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter _jCPrime _ Subawardee Name and Address of Prime: Tier , if Known: WALa9 C®OX" ASPItAII�T =o90 FAA( Avaos R.® Hews'�t-tb I-N -n qr Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: C4V* JA3 COLWJ Y 209 Pogx (,mAc® 79 -rMq CFDA Number, ifapplicable: 8. Federal Action Number, if known: 9. Award Amount, if known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name,MI): diiferentfi»mMo. 10a) wAUGILFC � (last name, first name, MI): io �yN� ell -VA iC- It. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities Is a material representation of fact upon which reliance was placed Print Name: ]> T AWSCP! by the tier above when this transaction was made or - entered into. This disclosure is required pursuant to 31 Title: V 062 p9csicie U.S.C.1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: Ip� -92610WDate: l 0 inspection. Any person whofailsto file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) HOUSE BILL 69 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, Kill> EAWScA the undersigned representative of Representative WA L; Me, - (hereafter referred to as Company) being an Company or Business Name adult over the age of eighteen (18) years of age, verify that the Company named above, under the provisions of Subtitle F, Title 10, Texas Government Code Chapter 2270: 1. Does not currently boycott the country of Israel; and 2. Will not boycott the country of Israel during the term of the contract with Calhoun County, Texas. Pursuant to 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and 2. "Company' means afor-profit sole proprietorship, organization, association, corporation, partnership, Joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Si nature of1representative ROb 1 AVYWAu 9f1CG PRAESI:i&W-r Print Name & Title Al /O1 I zoz� Date State law requires certification from a Company for contracts (which includes contracts formed through purchase orders) involving goods or services regardless of the amount. RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contract; pertinent provisions of §2252.001 are stated below: Sec. 2252.001(3) "Nonresident bidder" refers to a person who is not a resident. ❑ 1 certify that (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and State) mo� I certify that WAElfN, Ca -We *WKAM�/AIC is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Si nature o uthorized Agent RIFID D9W8pw1 YAi^.0 PRQ2S1PWr Printed Name and Title of Authorized Agent IIIo-IIZOZD Date Please Type If handwritten, must be in ink and legible Vendor's Name: W ALLM dlnUN7Y 11"of WE' Address: 00. Ar4i" Remittance Address: -2Z01® f%1R6?At APC& P-®. Telephone: 7?- Slo - 7075- Fax: $'57-L7`7--30)4 Email(s) to send Bid Information: 8NFDA WCAWIJ11a. Signature of Authorized Representative: Z.— Printed name of Authorized Rep: ROD LAY4,604 ORDER - CONTACT INFORMATION Order Contact Name & Title: :1WD9A UHOWK� Order Contact Telephone: UY-8-7079- Order Contact Fax: 83Z- 7,-- ,30)q Order Contact Email: 4WFb(R ev °�,'yma-gem •T • Form WMV Request for Taxpayer (Rev. October 2018) Identification Number and Certification Give Form to the requester. Do not Department of the Treasury Internal Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. send to the IRS. 1 Name (as shown on your Income taxreturn). Name is required on this line; do not leave this line blank. LL -a6 Y Y !'41] M112. 2 Business name/disregartled entity name, If tlifferent from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the seven boxes. 4 Exemptions (codes apply only to afollowing certain entities, not Individuals; see a ❑ Indivlduallsole proprietor or �d Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate Instructions on page 3): 0 single -member LLC Exempt payee code (if any) o `o ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► (' S M Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do net check LLC 9 the LLC is classified as a single -member LLC that is disregarded from the owner unless the Exemption from FATCA reporting a 0 owner of the LLC is another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code (if any) ;t is disregarded from the owner should check the appropriate box for the tax classification of its owner. v ❑ Other (see Instructions)► (Pypnee m ncwuma mdmmnm •m.re• he U.S.) to 8 Address (number, street, and apt. or suite no. See Instructions. ) I Requester's name and address (optional) N 'z-oac FAM ^?—VVAJbS RD. 8+ City, state, and ZIP code 7 List account numbers) here (optional) �.� ,unlYwl1V11 IV UIIIVCI Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For Individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Instructions for Part I, later. For other entitles, it Is your employer Identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account Is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requesterfor guidelines on whose number to enter. penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer Identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that i am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that 1 am exempt from FATCA reporting is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions for Part 11, later. vlyn signature of Here u.s.peson► / ^— ' Dale" _TOLY 72. ?OZO General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its Instructions, such as legislation enacted after they were published, go to www.1rs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who Is required to file an information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may, be your social security number (SSN), Individual taxpayer identification number (ITIN), adoption taxpayer Identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include,but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-5 (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 109E-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9(Rev. 10-2018) #13 t T T Calhoun County Commissioner, Precinct #2 5812 FM 1090 ab�.ai or rf+ (361) 552-9656 Port Lavaca, TX 77979 Fax (361) 553-6664 24 boa November 19, 2020 Honorable Richard Meyer Calhoun County Judge 211 S. Ann, Port Lavaca, TX 77979: RE: AGENDA ITEM Dear Judge Meyer: Please place the following item on the Commissioners' Court Agenda f Discuss and take necessary action to open credit account with Bassco Services, Inc. and allow Commissioner Vern Lyssy to sign application. Bassco Services, Inc. 9219 Viscount Row, Dallas, TX 75247 (214)352-4432 APPLICATION FOR CREDIT ACCOUNT APPLICANT: COMPANY NAME CALHOUN COUNTY, PCT 2 ADDRESS: 5812 FM 1090 N CITY: 'PORT LAVACA STATE: TX ZIP: 77979 PHONE NO. 361-552-9666 EMAIL IeseJurek@calhouncotx.org .................................................................................. OWNERSHIP: CORPORATION( ) PARTNERSHIP( ) INDIVIDUAL.( ) GOVERNMENT YEARS IN BUSINESS SALES TAX NUMBER 74-6001923 PRINCIPALS ADDRESS CITY/STATE/ZIP PHONE EMAIL ................................................................................. BANK ADDRESS CITY/STATE/Z1P PHONE BANK OFFICER ACCOUNT NUMBER REFERENCES: NAME .ADDRESS CITY/STATE/ZIP PHONE FAX EMAIL I hereby apply for credit in accordance with the terms of NET 30 from date of invoice. I certify that all the information on this form is correct and will be held in the strictest confidence. I fully understand your credit terms and agree to prompt payment in consideration of extended credit. All accounts are due and payable in Dallas County,'1'exas. SIGNED DATE 11/25/2020 NAME: VERN LYSSY TITLE. COMMISSIONER Confidential Page 1 of 2 Bassco Services, Inc. 9219 Viscount Row, Dallas, TX 75247 (214)352-4432 ACCOUNTS PAYABLE CONTACT: NAME_ LESA JUREK Title: OFFICE MANAGER PHONE NO. 361-552-9656 EMAIL lesa.iurek@calhouncotx.org EMAIL FOR INVOICES: lesa.iurek(Mcalhouncotx.org BILLING ADDRESS: 5812 FM 1090 N CIl'Y PORT LAVACA NON -ACCOUNTING CORRESPONDENCES GO TO: Tx ZIP 77979 NAME LESA JUREK Title: OFFICE MANAGER PHONE NO. 361-552-9656 EMAIL lesa.lurek(Mcalhouncotx.org SCHEDULING SERVICES CONTACTS: NAME LOU SVETLIK Title: PROPERTY MANAGER PHONE NO. 361-552-1228 EMAIL Iou-0—gatewayflightcenter SHIPPING/SITE ADDRESS: 4876 FM 3084 CITY PORT LAVACA STATE: TX ZIP 77979 CREDIT CARD NO.: 5567 0980 0362 8292 EXPIRATION DATE - NAME ON CREDIT CARD: VERN LYSSY CALHOUN COUNTY CREDIT CARD BILLING ZIP CODE: 77979 CREDIT CARD SECURITY CODE: 089 DATE 1.1/25/2020. NAME: VERN LYSSY TITLE COMMISSIONER IF TAX EXEMPT PLEASE ATTACH YOUR TAX EXEMPTION CERTIFICATE FORM. Confidential Page 2 of 2 #14 Calhoun County Library Board Port Lavaca, Texas November 18, 2020 Judge Richard Meyer: The Calhoun County Library Board presents Lanyine Sajous and Lily Ko for approval by Commissioners' Court for appointment to this Board. Lanyine is replacing Linda Brush and Lily is replacing Jason Chu. We would greatly appreciate you including this on the agenda of your next meeting. Sincerely, Pam Lambden, President #15 #16 I i , N O O N r-i i O O S> n S � cu V ��J a OJ !° 2, Xs U 0 J� .Y vp cu v ao m O a 0 0 0 0 0 0 0 00 0 o O o 0 0 O 0 0 0 o O oLno LO » a \ } { { / , / \ z � . � � 0 Ely. CD NORM U- V) ro IN4 & o t = ƒ^ ■ . £ \ e ly % / \ ® \ ? CY w ¥ h LL / f -po $� �� 27 Qb-�2 � © 6 � � o 0 ± c o/ CD I m m e - m . % 0 Em CALHOUN COUNTY, TEXAS `- Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 1000 GENERALFUND 001 REVENUE A ESTIMATED BEGINNING CA... 20,000,000.00 (845,952.00) 19,154,048.00 0.00 0.00 (19,154,048.00) B TAXES 21,432,000.00 15,000.00 21,447,000.00 310,997.49 20,746,400.69 (700,599.31) C PERMITS 11,510.00 0.00 11,510.00 964.00 12,097.25 587.25 D INTERGOVERNMENTAL 173,421.00 43,593.00 217,014.00 105,005.76 451,027.39 234,013.39 E FEES 1,371,633.00 1,400.00 1,373,033.00 135,243.88 1,629,104.09 256,071.09 F FINES 173,100.00 0.00 173,100.00 17,014.15 174,449.69 1,349.69 G INTEREST INCOME 300.000.00 0.00 300,000.00 11,576.57 287,718.45 (12,281.55) H RENTS 14,100.00 0.00 14,100.00 850.00 29,183.60 15,083.60 1 MISCELLANEOUS REVENU... 209620.00 88805.00 298425.00 8174.26 358,390.15 59,965.15 Total... REVENUE 43,685,384.00 (697,154.00) 42,988,230.00 589,826.11 23,688,371.31 (19,299,858.69) 003 ADULT PROBATION Q SUPPLIES 2,600.00 0.00 2,600.00 333.03 494.78 2,105.22 R SERVICES 4,200.00 0.00 4,200.00 0.00 4,000.00 200.00 S CAPITAL OUTLAY 300.00 0.00 300.00 0.00 0.00 300.00 Total... ADULT PROBATION (7,100.00) 0.00 (7,100.00) (333.03) (4,494.78) 2,605.22 006 AID TO AGING R SERVICES 50,000.00 0.00 50000.00 0.00 35000.00 15000.00 Total... AID TO AGING (50,000.00) 0.00 (50,000.00) 0.00 (35,000.00) 15,000.00 009 AMBULANCE OPERATIONS -GENERAL Q SUPPLIES 13,213.00 0.00 13,213.00 89.61 5,379.43 7,833.57 R SERVICES 23,272.00 0.00 23,272.00 125.60 8,380.72 14,891.28 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total... AMBULANCE (36,486.00) 0.00 (36,486.00) (215.21) (13,760.15) 22,725.85 OPERATIONS -GENERAL 012 AMBULANCE OPERATIONS -MAGNOLIA Q SUPPLIES 1,700.00 0.00 1,700.00 0.00 0.00 1,700.00 R SERVICES 800.00 0.00 800.00 0.00 14.50 785.50 Total... AMBULANCE (2,500.00) 0.00 (2,500.00) 0.00 (14.50) 2,485.50 OPERATIONS -MAGNOLIA 021 AMBULANCE OPERATION -PORT O'CON Q SUPPLIES 411.00 0.00 411.00 0.00 0.00 411.00 R SERVICES 2,088.00 0.00 2,088.00 0.00 0.00 2,088.00 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total ... AMBULANCE OPERATION -PORT (2,500.00) 0.00 (2,500.00) 0.00 0.00 2,500.00 O'CON 024 AMBULANCE OPERATION-SEADRIFT Q SUPPLIES 1,200.00 0.00 1,200.00 0.00 0.00 1,200.00 R SERVICES 800.00 0.00 800.00 115.70 782.72 17.28 S CAPITAL OUTLAY 500.00 0.00 500.00 0.00 0.00 500.00 Total... AMBULANCE (2,500.00) 0.00 (2,500.00) (115.70) (782.72) 1,717.28 OPERATION-SEADRIFT Date: 11117/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 1 ' CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 027 BUILDING MAINTENANCE 0 SALARIES 362,174.00 0.00 362,174.00 36,542.25 270,088.05 92,085.95 P BENEFITS 165,450.00 0.00 165,450.00 14,144.85 120,349.21 45,100.79 Q SUPPLIES 42,200.00 (1,000.00) 41,200.00 5,734.97 35,814.13 5,385.87 R SERVICES 525,558.00 1,000.00 526,558.00 26,871.64 304,171.36 222,386.64 S CAPITAL OUTLAY 19006.00 74,170.00 93176.00 0.00 67,630.13 25545.87 Total... BUILDING MAINTENANCE (1,114,388.00) (74,170.00) (1,188,558.00) (83.293.71) (79B4O52.88) 390,505.12 030 COMMISSIONERS COURT 0 SALARIES 26,000.00 0.00 26,000.00 0.00 0.00 26,000.00 P BENEFITS 5,028.00 0.00 5.028.00 0.00 0.00 5,028.00 Q SUPPLIES 10,097.00 0.00 10,097.00 0.00 3,240.00 6,857.00 R SERVICES 500,320.00 3,162.00 503,482.00 20,039.53 353,836.17 149,645.83 S CAPITAL OUTLAY 17 277.00 (2,431.00) 14 846.00 0.00 1,719.11 13126.89 Total... COMMISSIONERS COURT (558,722.00) (731.00) (559,453.00) (20,039.53) (358,795.28) 200,657.72 033 CONSTABLE-PRECINCT#1 0 SALARIES 23,508.00 0.00 23,508.00 2,712.45 19,891.30 3,616.70 P BENEFITS 4,739.00 0.00 4,739.00 547.91 4,018.02 720.98 Q SUPPLIES 800.00 0.00 800.00 0.00 0.00 800.00 R SERVICES 503.00 0.00 503.00 0.00 0.00 503.00 Total... CONSTABLE-PRECINCT#1 (29,550.00) 0.00 (29,550.00) (3,260.36) (23,909.32) 5,640.68 036 CONSTABLE-PRECINCT#2 0 SALARIES 23,541.00 0.00 23,541.00 2,712.45 19,891.30 3,649.70 P BENEFITS 4,746.00 0.00 4,746.00 547.91 4,018.02 727.98 Q SUPPLIES 851.00 0.00 851.00 0.00 0.00 851.00 R SERVICES 2,403.00 0.00 2,403.00 0.00 693.84 1,709.16 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total... CONSTABLE-PRECINCT#2 (31.542.00) 0.00 (31,542.00) (3,260.36) (24,603.16) 6,938.84 039 CONSTABLE-PRECINCT#3 0 SALARIES 23,508.00 0.00 23,508.00 2,712.45 19,167.98 4,340.02 P BENEFITS 4,739.00 24.00 4,763.00 553.87 3,887.83 875.17 Q SUPPLIES 1,626.00 (790.00) 836.00 0.00 834.13 1.87 R SERVICES 4.00 0.00 4.00 0.00 0.00 4.00 S CAPITAL OUTLAY 401.00 1090.00 7,491.00 0.00 5487.95 2,003.05 Total... CONSTABLE-PRECINCT#3 (30,278.00) (6,324.00) (36,602.00) (3,266.32) (29,377.89) 7,224.11 042 CONSTABLE-PRECINCT#4 0 SALARIES 23,508.00 0.00 23,508.00 2,712.45 19,891.30 3,616.70 P BENEFITS 4,739.00 0.00 4,739.00 547.91 4,018.02 720.98 Q SUPPLIES 751.00 0.00 751.00 0.00 0.00 751.00 R SERVICES 2,500.00 0.00 2,500.00 0.00 0.00 2,500.00 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total... CONSTABLE-PRECINCT#4 (31,499.00) 0.00 (31,499.00) (3,260.36) (23,909.32) 7,589.68 045 CONSTABLE-PRECINCT#5 0 SALARIES 23,508.00 0.00 23,508.00 2,712.45 19,891.30 3,616.70 P BENEFITS 4,739.00 0.00 4,739.00 547.91 4,018.02 720.98 Q SUPPLIES 250.00 948.00 1,198.00 0.00 0.00 1,198.00 R SERVICES 2,250.00 (199.00) 2,051.00 0.00 0.00 2,051.00 S CAPITAL OUTLAY 750.00 (749.00) 1.00 0.00 0.00 1.00 Total... CONSTABLE-PRECINCT#6 (31,497.00) 0.00 (31,497.00) (3,260.36) (23.909.32) 7,587.68 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 2 J. Ac1o... Account Title 048 CONTINGENCIES 0 SALARIES P BENEFITS R SERVICES Total... CONTINGENCIES 051 COUNTYAUDITOR 0 SALARIES P BENEFITS 0 SUPPLIES R SERVICES S CAPITAL OUTLAY Total... COUNTYAUDITOR 054 COUNTY CLERK 0 P SALARIES O BENEFITS R SUPPLIES S SERVICES CAPITAL OUTLAY Total... COUNTY CLERK 057 COUNTY COURT R SERVICES Total... COUNTYCOURT 060 COUNTY COURT -AT -LAW AT -LAW P SALARIES 0 BENEFITS R SUPPLIES S SERVICES CAPITAL OUTLAY Total... COUNTY COURT -AT -LAW 063 COUNTYJUDGE 0 SALARIES P BENEFITS 0 SUPPLIES R SERVICES S CAPITAL OUTLAY Total... COUNTYJUDGE 066 COUNTYT O TAX SALARIES COLLECTOR P BENEFITS 0 SUPPLIES R SERVICES S CAPITAL OUTLAY 'otal... COUNTY TAX COLLECTOR 069 0 COUNTY TREASURER P SALARIES 0 BENEFITS SUPPLIES te: 11/17/20 04:28:06 PM SummaN Budget CALHOUN COUNTY, TEXAS Comparison - Unposted Transactions Incl uded In Report From 101,12020 Through 10/31/2020 Original Budget Amendments RevisedBudget CunAc= 5,000.00 219,000.00 1800200 ---- 0.00 5,000.00 (57,948.00) 165,000, 0 0.00 4P 625 00 � � 0,62700 .25 (1) (242,002.00) 15.323.00 (226,679.00) 1.25 306,904.00 118,965.00 4,496.00 0.00 472.00 306,904.00 119,437.00 35,411.64 15,974.00 (73.00) 4,423.00 11,761.06 - 0.00 �601.00 16,974.00 273.69 185.00 (446.841.00) �010300 1 _(4 (10,000.00) (456,841.00) 9 276,796.00 108,888.00 276,817.00 10,000.00 0.00 108,888.00 29 23.311.00 .00 0.00 (21.00) 10,000.00 9,662.80 9,662..80 295.86 -----6 95100 23,290.00 ----6 9510o 2.718.52 (425,946.00) 0.00 (425,946.00) (44,472.47) 1-1750.00 (15,750.00) 249.693.00 110,803.00 2,050.00 98,060.00 ---8 295.00 (466,901.00) 0.00 0.00 0.00 300.00 (4,309.00) �4,009.00 0.00 -- 15 750.Go (15,750.00) 249,693.00 110,803.00 2,350.00 93,751.00 �304.00 (468,901.00) 131,844.00 54,674.00 0.00 131,844.00 2,411.00 0.00 54,674,00 9,650.00 0.00 2,411,00 ----2 001.00 0.00 9,650.00 000 00 (200,579.00) 0.00 (200,579.00) 204,289.00 71,227.00 0.00 204,289.00 5,401.00 415.00 (167.00) 71,642.00 50,820.00 15, 00 5,234.00 �7 000 00 �/14 46 66, 133.00 (332,831.00) (15,415.00) (348,252.00) 191,806.00 73,329.00 0.00 5,544.00 191, 806.00 3,700.00 0.00 78,873.00 MONTHLY REPORT -CONDENSED ONDENSED 100.00 I/no„a�,_., YTDActual Variants 0.00 (6.41) 5,000.00 -6062700 161,058.41 6.41 226,686.41 259,338.20 99,066.63 2,416.76 20,370.37 2,408.86 2A ,007.24 861 00 65.14 4 242 00 42 00 (369,090.45) 87,750.55 233,207.46 80,094.84 5,587.98 11,312.17 --- _ 14 41 (333,916.86) 43,609,54 28.793.16 4,412.02 11,977.83 �238.59 92,029.14 �38900 �361.00 0.00 (1,389.00) 14,361.00 26,039.38 6,617,73 205,278.37 44,414,63 10.9g 59215 ,.55 51,587.45 7,129.55 726.60 48,696 3 1,623.40 142 �1, 4Z 63 45,054.27 ------ 1, 16137 (41,797.65) (325,059.88) 143.841.12 15,212.43 111,557.82 3,594.95 20,286.18 0.28,127.04 00 1,190.62 26,546.96 0..00 1,990.63 1,220.38 7,659.37 (18,807.38) BOO uu (142,866.11) 57,112.89 22,272.00 7,047.24 200.72 141.63 (29,661.59) 22,131.12 7,708.85 0.00 160,974.85 57,156.09 1,942.57 52,517.50 --0.00 (272,591.01) 159,408.42 64,323,51 9 ma 7a 43,314.15 14,485.91 3,291.43 13,615.50 �954.00 75.660.99 32,397.58 14,549.49 ' CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/112020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance R SERVICES 14,603.00 0.00 _ 14,603.00 1,287.21 5,741.59 8,861.41 S CAPITAL OUTLAY 2,000.00 0.00 2000.00 0.00 313.98 1,686.02 Total... COUNTY TREASURER (285,438.00) (5,544.00) (290,982.00) (31,127.18) (231,861.22) 59.120.78 075 DEBT SERVICE R SERVICES 112452.00 (70143.00) 42309.00 0.00 42,308.72 0.28 Total... DEBT SERVICE (112.452.00) 70,143.00 (42,309.00) 0.00 (42,308.72) 0.28 078 DISTRICT ATTORNEY 0 SALARIES 601,932.00 0.00 601,932.00 69,132.15 507,681.93 94,250.07 P BENEFITS 213,017.00 0.00 213,017.00 21,021.21 169,227.69 43,789.31 Q SUPPLIES 16,750.00 40.00 16,790.00 371.53 10,500.73 6,289.27 R SERVICES 61.621.00 (40.00) 61,581.00 1,563.45 15,390.63 46,190.37 S CAPITAL OUTLAY 33000.00 0.00 33000.00 2,517.51 21,488.15 11511.85 Total... DISTRICT ATTORNEY (926,320.00) 0.00 (926.320.00) (94,605.85) (724,289.13) 202.030.87 081 DISTRICT CLERK 0 SALARIES 266,815.00 0.00 266,815.00 29,993.46 218,979.95 47,835.05 P BENEFITS 113,652.00 2,975.00 116,627.00 11,181.51 95,025.40 21,601.60 Q SUPPLIES 9,681.00 (683.00) 8,998.00 1,279.97 4,917.16 4,080.84 R SERVICES 11,701.00 683.00 12,384.00 0.00 5,088.98 7,295.02 S CAPITAL OUTLAY 3,882.00 9,350.00 13 232.00 0.00 8,097.47 5134.53 Total... DISTRICT CLERK (405,731.00) (12,325.00) (418,056.00) (42,454.94) (332,108.96) 85,947.04 084 DISTRICT COURT 0 SALARIES 29,175.00 (2,109.00) 27,066.00 3,670.58 9,249.41 17,816.59 P BENEFITS 5,770.00 0.00 5,770.00 60.15 527.14 5,242.86 Q SUPPLIES 234.00 0.00 234.00 16.25 61.27 172.73 R SERVICES 211,869.00 0.00 211,869.00 10,928.95 164,418.45 47,450.55 S CAPITAL OUTLAY 2,549.00 2109.00 4,658.00 234.38 4,654.24 3.76 Total... DISTRICT COURT (249,597.00) 0.00 (249,597.00) (14,910.31) (178,910.51) 70,686.49 087 ELECTIONS 0 SALARIES 163.972.00 8,000.00 171,972.00 22,569.94 125,823.92 46,148.08 P BENEFITS 73,689.00 0.00 73,689.00 5,120.07 37,704.69 35,984.31 Q SUPPLIES 25,255.00 17,275.00 42,530.00 9,587.08 16,754.93 25,775.07 R SERVICES 37.163.00 (24.00) 37,139.00 19,421.05 27,144.69 9,994.31 S CAPITAL OUTLAY 3.735.00 768.00 4,503.00 0.00 4,078.17 424.83 Total... ELECTIONS (303.814.00) (26,019.00) (329,833.00) (56,698.14) (211,506.40) 118,326.60 090 EMERGENCY MANAGEMENT 0 SALARIES 93,017.00 2,396.00 95.413.00 10,732.71 79,687.90 15,725.10 P BENEFITS 38,748.00 0.00 38.748.00 3,484.64 29,376.83 9,371.17 Q SUPPLIES 7,250.00 (700.00) 6.550.00 866.02 3,737.80 2,812.20 R SERVICES 18,861.00 700.00 19,561.00 201.87 6,224.70 13,336.30 S CAPITAL OUTLAY 3,001.00 0.00 3,001.00 179.00 1,961.00 1.040.00 Total... EMERGENCY MANAGEMENT (160,877.00) (2,396.00) (163.273.00) (15,464.24) (120,988.23) 42.284.77 093 EMERGENCY MEDICAL SERVICES 0 SALARIES 2,498,668.00 (261,083.00) 2,237,585.00 256,751.78 1,818,788.73 418,796.27 P BENEFITS 772,720.00 (81,060.00) 691,660.00 66,065.58 517,244.31 174,415.69 Q SUPPLIES 87,541.00 46.903.00 134,444.00 7,680.25 115,103.14 19,340.86 R SERVICES 275,866.00 3.00 275,869.00 16,721.61 232,471.56 43,397.44 Date: 11/17120 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 4 CALHOUN COUNTY, TEXAS ' Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTDActual Variance S CAPITAL OUTLAY 15,840.00 295,237.00 311 077.00 641.96 123 717.95 187,359.05 Total... EMERGENCY MEDICAL (3,650,635.00) 0.00 (3,650,635.00) (347,861.18) (2,807,325.69) 843,309.31 SERVICES 096 EXTENSION SERVICE 0 SALARIES 138,366.00 368.00 138,734.00 15,943.86 117,290.14 21,443.86 P BENEFITS 34,452.00 815.00 35.267.00 2,562.06 20,640.70 14,626.30 Q SUPPLIES 12,900.00 (368.00) 12,532.00 369.57 4,288.90 8,243.10 R SERVICES 34,731.00 0.00 34,731.00 514.18 11,907.79 22,823.21 S CAPITAL OUTLAY 4,837.00 0.00 4.837,00 0.00 (57.24) 4.894.24 Total... EXTENSION SERVICE (225,286.00) (815.00) (226,101.00) (19,389.67) (154,070.29) 72,030.71 099 FIRE PROTECTION -MAGNOLIA BEACH Q SUPPLIES 4,999.00 (4,000.00) 999.00 0.00 0.00 999.00 R SERVICES 5,000.00 (4,000.00) 1,000.00 0.00 62.00 938.00 S CAPITAL OUTLAY 1.00 8,000.00 8,001.00 0.00 8,000.00 1.00 Total... FIRE PROTECTION -MAGNOLIA (10,000.00) 0.00 (10,000.00) 0.00 (8,062.00) 1,938.00 BEACH 102 FIRE PROTECTION-OLIVIAIPORT AL Q SUPPLIES 5,295.00 (975.00) 4,320.00 0.00 2,218.52 2,101.48 R SERVICES 2,963.00 690.00 3,653.00 82.57 1,230.93 2,422.07 S CAPITAL OUTLAY 1,742.00 285.00 2,027.00 0.00 2,026.47 0.53 Total ... FIRE PROTECTION-OLIVIAIPORT (10,000.00) 0.00 (10,000.00) (82.57) (5,475.92) 4,524.08 AL 105 FIRE PROTECTION -POINT COMFORT Q SUPPLIES 1,063.00 1,400.00 2,463.00 0.00 1,550.75 912.25 R SERVICES 6,976.00 (1,000.00) 5,976.00 14.50 2,602.48 3,373.52 S CAPITAL OUTLAY 1961.00 (400.00) 1561.00 0.00 0.00 1,561.00 Total ... FIRE PROTECTION -POINT (10,000.00) 0.00 (10,000.00) (14.50 ) (4,153.23) 5,846.77 COMFORT 108 FIRE PROTECTION -PORT LAVACA R SERVICES 206,714.00 0.00 206,714.00 0.00 200,671.51 6,042.49 Total... FIRE PROTECTION -PORT (206,714.00) 0.00 (206,714,00) 0.00 (200,671.51) 6,042.49 LAVACA ill FIRE PROTECTION -PORT O'CONNOR Q SUPPLIES 5,000.00 (4,690.00) 310.00 0.00 0.00 310.00 R SERVICES 4,999.00 4,690.00 9,689.00 73.59 9.542.90 146.10 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total ... FIRE PROTECTION -PORT (10,000.00) 0.00 (10,000.00) (73.59) (9,542.90) 457.10 O'CONNOR 113 FIRE PROTECTION -SIX MILE Q SUPPLIES 3,919.00 200.00 4,119.00 322.74 4,069.81 49.19 R SERVICES 3,200.00 (200.00) 3,000.00 92.96 1,961.07 1,038.93 S CAPITAL OUTLAY 2.881.00 0.00 2,881.00 0.00 1,097.57 1,783.43 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 5 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTDActual Variance Total... FIRE PROTECTION -SIX MILE (10,000.00) 0.00 (10,000.00) (415.70) (7,128.45) 2,871.55 114 FIRE PROTECTION-SEADRIFT Q SUPPLIES 5,000.00 (1,828.00) 3,172.00 0.00 2,401.17 770.83 R SERVICES 4,000.00 0.00 4.000.00 0.00 777.34 3,222.66 S CAPITAL OUTLAY 1,000.00 1,828.00 2,828.00 0.00 2827.77 0.23 Total... FIRE PROTECTION-SEADRIFT (10,000.00) 0.00 (10,000.00) 0.00 (6,006.28) 3,993.72 120 FLOOD PLAIN ADMINISTRATION Q SUPPLIES 1,195.00 0.00 1,195.00 19.49 493.63 701.37 R SERVICES 5,050.00 0.00 5,050.00 0.00 883.30 4,166.70 S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total... FLOOD PLAIN ADMINISTRATION (6,246.00) 0.00 (6,246.00) (19.49) (1,376.93) 4,869,07 123 HEALTH DEPARTMENT R SERVICES 80500.00 0.00 80,500.00 6,708.33 73,791.63 6708.37 Total ... HEALTH DEPARTMENT (80,500.00) 0.00 (80,500.00) (6,708.33) (73,791.63) 6,708.37 126 HIGHWAY PATROL 0 SALARIES 17,034.00 0.00 17,034.00 1,847.10 12,258.33 4,775.67 P BENEFITS 3,293.00 0.00 3,293.00 357.79 2,374.46 918.54 Q SUPPLIES 980.00 30.00 1,010.00 0.00 1,008.39 1.61 R SERVICES 3,163.00 (30.00) 3,133.00 124.95 979.61 2,153.39 S CAPITAL OUTLAY 970.00 0.00 970.00 0.00 0.00 970.00 Total... HIGHWAYPATROL (25,440.00) 0.00 (25,440.00) (2,329.84) (16,620.79) 8,819.21 129 HISTORICAL COMMISSION R SERVICES 4,002.00 (3,815.00) 187.00 0.00 185.00 2.00 S CAPITAL OUTLAY 1900.00 3,815.00 5,715.00 1,768.82 5715.00 0.00 Total... HISTORICAL COMMISSION (5,902.00) 0.00 (5,902.00) (1,768.82) (5,900.00) 2.00 132 INDIGENT HEALTH CARE R SERVICES 73032.00 0.00 73,032.00 1,961.00 48,965.04 24,066.96 Total ... INDIGENT HEALTH CARE (73,032.00) 0.00 (73,032.00) (1,961.00) (4B,965.04) 24,066.96 133 INFORMATION TECHNOLOGY 0 SALARIES 165,613.00 0.00 165,613.00 18,935.94 133,528.16 32,084.84 P BENEFITS 61,046.00 0.00 61,046.00 5,724.95 46,326.16 14,719.84 Q SUPPLIES 8.660.00 0.00 8,660.00 124.12 3,802.93 4,857.07 R SERVICES 43,200,00 0.00 43,200.00 4,296.64 11,680.09 31,519.91 S CAPITAL OUTLAY 25401.00 0.00 25401.00 1558.84 20792.28 4608.72 Total... INFORMATION TECHNOLOGY (303,920.00) 0.00 (303,920.00) (30,640.49) (216,129.62) 87,790.38 135 JAIL OPERATIONS 0 SALARIES 1,698,582.00 (8,152.00) 1,690,430.00 157,706.17 1,158,964.61 531,465.39 P BENEFITS 578,203.00 9.551.00 587,754.00 52,431.46 432,730.66 155,023.34 Q SUPPLIES 161,034.00 1,163.00 162,197.00 18,681.24 162,321.33 (124.33) R SERVICES 198,514.00 (36.830.00) 161,684.00 23,785.61 161,675.07 8.93 S CAPITAL OUTLAY 21251.00 43819.00 65070.00 37631.78 65069.09 0.91 Total... JAIL OPERATIONS (2,657,584.00) (9,551.00) (2,667,135.00) (290,236.26) (1,980,760.76) 686,374.24 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 6 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/3112020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTDActual Variance 138 JUSTICE OF THE PEACE -GENERAL 0 P SALARIES BENEFITS 1,000.00 0.00 11000.00 0.00 0.00 1,000.00 Q SUPPLIES 81.00 863.00 0.00 81.00 0.00 0.00 81.00 R SERVICES 100700 0.00 0.00 863.00 0.00 0.00 863.00 1,007.00 0.00 88.00 919.00 Total ... JUSTICE OF THE PEACE -GENERAL (2,951.00) 0.00 (2,951.00) 0.00 (88.00) 2,863.00 141 JUSTICE OF THE PEACE -PRECINCT 0 P SALARIES BENEFITS 96,238.00 280.00 96,518.00 9,888.12 83,288.88 13,229.12 Q SUPPLIES 38,358.00 0.00 38,358.00 3,210.04 27,845.69 10,512.31 R SERVICES 3,827.00 (280.00) 3,547.00 0.00 1,407.37 2,139.63 S CAPITAL OUTLAY 9,403.00 673.00 0.00 9,403.00 12.00 3,995.08 5,407.92 0.00 673.00 0.00 0.00 673.00 Total ... JUSTICE OF THE PEACE -PRECINCT (148,499.00) 0.00 (148,499.00) (13,110.16) (116,537.02) 31,961.98 144 JUSTICE OF THE PEACE -PRECINCT 0 P SALARIES BENEFITS 96,195.00 0.00 96.195.00 12,768.12 82,160.88 14,034.12 Q SUPPLIES 40,499.00 0.00 40,499.00 3,546.06 28.776.22 11,722.78 R SERVICES 5,000.00 0.00 5,000.00 155.47 2,315.73 2,684.27 S CAPITAL OUTLAY 9,725.00 3.001.00 0.00 9,725.00 201.00 4,081.28 5,643.72 0.00 3,001,00 0.00 0.00 3,001.00 Total... JUSTICE OF THE PEACE -PRECINCT (154,420.00) 0.00 (154.420.00) (16,670.65) (117,334.11) 37,085.89 147 JUSTICE OF THE PEACE -PRECINCT 0 P SALARIES BENEFITS 85,698.00 0.00 85.698.00 9,888.12 72,512.88 13,185.12 Q SUPPLIES 41,303.00 7,523.00 48,826.00 4,547.24 40,309.53 8,516.47 R SERVICES 3,429.00 1,084.00 4,513.00 255.08 2,867.26 1,645.74 S CAPITAL OUTLAY 17,018.00 1,571.00 0.00 17,018.00 531.42 9,266.98 7,751.02 (108400) 487.00 0.00 0.00 487.00 Total... JUSTICE OF THE PEACE -PRECINCT (149,019.00) (7,523.00) (156,542.00) (15,221.86 ) (124.956.65) 31.585.35 150 JUSTICE OF THE PEACE -PRECINCT 0 SALARIES P BENEFITS Q SUPPLIES R SERVICES S CAPITAL OUTLAY Total... JUSTICE OF THE PEACE -PRECINCT 153 JUSTICE OF THE PEACE -PRECINCT 0 SALARIES P BENEFITS Q SUPPLIES R SERVICES Date: 11/17/20 04:28:06 PM 69,770.00 0.00 69,770.00 7,900.69 57,036.24 12,733.76 19,822.00 0.00 19.822.00 1,511.68 10,837.80 8,984.20 2,651.00 0.00 2,651.00 69.42 1,077.62 1,573.38 12,958.00 0.00 12,958.00 142.76 7,428.51 5,529.49 700.00 0.00 700.00 0.00 0.00 700.00 (105,901.00) 0.00 (105,901.00) (9,624.55) (76,380.17) 29,520.83 63,903.00 0.00 63,903.00 7,212.53 28,488.00 1,253.00 29.741.00 2,811.19 1,800.00 0.00 1,800.00 147.44 12,350.00 0.00 12,350.00 371.04 MONTHLY REPORT -CONDENSED Unaudited 42,433.40 21,469.60 22,345.48 7,395.52 1,100.37 699.63 6,015.00 6,335.00 Page: 7 Summary Budget N COUNTY, Comparirison UUnpo ted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget S CAPITAL OUTLAY CurrActual YTD Actual Variance Total... JUSTICE OF THE 4,000 00 0 00 4000.00 000 PEACE -PRECINCT (110,541.00) (1,253.00 ) 0 00 4,000 00 (111,794.00) (10,542.20) (71.894.25) 159 JUVENILE COURT 39,899.75 0 SALARIES P BENEFITS R SE SERVICES 12,708.00 4,197.00 0.00 14,,197.00 1,466.28 195 65� 0.00 0 00 4,9700 356.75 10,752.72 3,034.88 1,955.28 Total... JUVENILE COURT 135,65400 764491 �� 88,357 97 1,162.12 162 (152,559.00) 0.00 (152,559.00) 47,296 03 JUVENILE PROBATION (9,467.94) (102,145.57) R SERVICES 50,413.43 Total... JUVENILE PROBATION 306 83� 0 00 3�6'831'00 000 (306,831.00) 0.00 3�6'831'00 000 165 LIBRARY (306,831.00) 0.00 (306,831.00) 0 SALARIES 0.00 P BENEFITS Q SUPPLIES 325,656.00 25,656.00 0.00 2,381.00 325,656.00 36,346.05 265,554.77 R SERVICES 22,557.00 2,500.00 96,684.00 25,057.00 9, 172.85 74,201.75 60,101.23 S CAPITAL OUTLAY 122,801.00 62583'00 (2,500.00) 120,301.00 772.85 17,484.36 22,482.25 7.572.64 Total... LIBRARY 000 62589'DO 7,,680.61 7691.65 61,043.98 59,257.02 (627,910.00) (2,381.00) �- _75 2508 168 MISCELLANEOUS (630,291.00) (58,659.31) (455,795.86) R SERVICES 17449514 Total... MISCELLANEOUS 784,51000 99,193.00 893703'00 1,26707 (784,510.00) (99,193.D0) 8 5 3 �8 379.97 171 MUSEUM (883,703.00) (1,267.07) (805,323.03 ) 0 SALARIES 18,379.97 P BENEFITS Q SUPPLIES 53,496.00 21,751.00 0.00 0.00 53,496.00 6,810.20 R SERVICES 6,100.00 0.00 21,751.00 6,100.00 2,003.36 ,46,89.60 1589.60 9 6,636.15 S CAPITAL OUTLAY 16.700.00 �700.00 0.00 16,700.00 9499 1.384.13 5,851. 4,715.87 Total... MUSEUM 000 3700.0 3,700.00 533.47 000 5,559,39 11,140.61 (101,747.00) 0.00 15399 3,546.01 174 NUISANCE ORDINANCE (101,747.00) 9,2.02 (9,442.02) (69,856.96) ENFORCEMENT 31.890.04 0 SALARIES P BENEFITS Q SUPPLIES 00 63,982. 22,577.00 4,979.00 68,961.00 7,370.88 R SERVICES 1,400.00 0.00 (670.00) 22,577.00 2,193.13 59,033.43 18'681.49 3,,927.51 S CAPITAL OUTLAY 1,701.00 0.00 730.00 7,772.00 0.00 646.02 3,895.51 Total... 2 00 67D 00 13.90 1,075.29 98 625.71 25.71 EMENTORDINANCE ENFORNUISACEMENT ENFORCEMENT (89,662.00) (497900) 66929 (94,641.00) 9,577.91 ( ) (80,105.52) 175 OTHER FINANCING 14,535.46 T OTHER FINANCING Total ... OTHER FINANCING (1001001 -('- 87234001 (- 88 29 _5 00) 0 00 1,001.00 87,234.00 (8723625) (99875) 177 PARKS AND RECREATION 88,235.00 0.00 87,236.25 Q SUPPLIES (998.75) R SERVICES S 5,001.00 0.00 51001.00 CAPITAL OUTLAY 2.00 100 0.00 2 00 0.00 0.00 5,001.00 Date: 11/17/20 04:28:06 PM 0 00 0.00 0.00 000 2.00 1 00 MONTHLY REPORT -CONDENSED Unaudited Page: 8 CALHOUN COUNTY, TEXAS " Summary Budget Comparison "Unposted Transactlons Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance Total ... PARKS AND RECREATION (5,004.00) 0.00 (5,004.00) 0.00 0.00 5,004.00 178 ROAD AND BRIDGE -PRECINCT #1 0 SALARIES 444,606.00 0.00 444,606.00 50,699.92 371,382.38 73,223.62 P BENEFITS 185,589.00 9,279.00 194,868.00 18,679.17 159,391.81 35,476.19 Q SUPPLIES 187,600.00 (16,544.00) 171,056.00 9,785.75 116,677.67 54,378.33 R SERVICES 118,913.00 (21,690.00) 97,223.00 2,574.30 53,749.68 43,473.32 S CAPITAL OUTLAY 125714.00 8557900 211,293.00 0.00 206,169.53 5123.47 Total... ROAD AND BRIDGE-PRECINCT#1 (1,062,422.00) (56,624.00) (1,119,046.00) (81,739.14) (907,371.07) 211,674.93 180 ROAD AND BRIDGE -PRECINCT #2 0 SALARIES 390,255.00 0.00 390,255.00 44,720.89 316,346.05 73,908.95 P BENEFITS 152,437.00 11,744.00 164,181.00 15,934.19 132,981.90 31,199.10 Q SUPPLIES 301,950.00 18,196.00 320,146.00 30,057.30 236,478.75 83,667.25 R SERVICES 61,529.00 (8,379.00) 53,150.00 7,841.81 47,261.92 5,888.08 S CAPITAL OUTLAY 48019.00 (7152.00) 40867.00 0.00 15,966.19 24900.81 Total... ROAD AND BRIDGE-PRECINCT#2 (954,190.00) (14,409.00) (968,599.00) (98,554.19) (749,034.81) 219,564.19 183 ROAD AND BRIDGE -PRECINCT #3 0 SALARIES 389,437.00 0.00 389,437.00 40,724.13 285,641.62 103,795.38 P BENEFITS 136,368.00 0.00 136,368.00 13,229.11 100,974.70 35,393.30 Q SUPPLIES 163,254,00 (8,125.00) 155,129.00 2,725.88 102,586.11 52,542.89 R SERVICES 58,015.00 8,125.00 66,140.00 10,181.45 33,494.07 32,645.93 S CAPITAL OUTLAY 110437.00 0.00 110,437.00 1,608.28 32,092.46 78,344.54 Total... ROAD AND BRIDGE-PRECINCT#3 (857,511.00) 0.00 (857,511.00) (68,468.85) (554,788.96) 302,722.04 186 ROAD AND BRIDGE -PRECINCT #4 0 SALARIES 632,814.00 0.00 632,814.00 76,180.93 512,116.98 120,697.02 P BENEFITS 272,828.00 0.00 272,828.00 21,365.93 163,602.85 109,225.15 Q SUPPLIES 677,551.00 (79,650.00) 597,901.00 43,291.39 476,964.92 120,936.08 R SERVICES 167,190.00 32,122.00 199,312.00 16,365.61 167,971.84 31,340.16 S CAPITAL OUTLAY 279,858.00 153,270.00 433,128.00 105 008.00 398274.54 34 853.46 Total... ROAD AND BRIDGE-PRECINCT#4 (2,030,241.00) (105,742.00) (2,135,983.00) (262,211.86) (1,718,931.13) 417,051.87 189 SHERIFF 0 SALARIES 2,025,255.00 13.00 2.025,268.00 212,405.99 1,611,502.57 413,765.43 P BENEFITS 752,891.00 5,854.00 758,745,00 72,261.48 615,059.12 143,685.88 Q SUPPLIES 125,860.00 (15,708.00) 110,152.00 10,500.91 67,874.68 42,277.32 R SERVICES 131,389.00 21,894.00 153,283.00 15,102.15 111,520.96 41,762.04 S CAPITAL OUTLAY 179 390.00 38 209.00 217,599.00 170,402.06 200,921.51 16 677.49 Total... SHERIFF (3,214,785.00) (50,262.00) (3,265,047.00) (480,672.59) (2,606,878.84) 658,168.16 192 SOIL AND WATER CONSERVATION R SERVICES 7750.00 0.00 7750.00 0.00 7,750.00 0.00 Total... SOIL AND WATER (7,750.00) 0.00 (7,750.00) 0.00 (7,750.00) 0.00 CONSERVATION 195 TAX APPRAISAL DISTRICT R SERVICES 319188.00 807.00 31999500 0.00 319993.76 1.24 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 9 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10131/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance Total... TAX APPRAISAL DISTRICT (319,188.00) (807.00) (319,995.00) 0.00 (319,993.76) 1.24 198 TRANSFERS U TRANSFERS IN (600,001.00) 0.00 (600,001.00) 0.00 (600,000.00) (1.00) V TRANSFERS OUT 690,002.00 3,039,850.00 3,729 852 00 3,027.389.35 3.220 866.43 508,985.57 Total... TRANSFERS (90,001.00) (3,039,850.00) (3,129,851.00) (3,027,389.35) (2,620,866.43) 508,984.57 201 VETERANS SERVICES 0 SALARIES 13,628.00 0.00 13,628.00 1,649.23 12,198.85 1,429.15 P BENEFITS 2,636.00 0.00 2,636.00 319.48 2.362.99 273.01 Q SUPPLIES 550.00 0.00 550.00 0.00 203.25 346.75 R SERVICES 4,051.00 0.00 4,051.00 0.00 604.24 3,446.76 S CAPITAL OUTLAY 500.00 0.00 500.00 0.00 0.00 500.00 Total... VETERANS SERVICES (21,365.00) 0.00 (21,365.00) (1,968.71) (15,369.33) 5,995.67 204 WASTE MANAGEMENT 0 SALARIES 14,535.00 0.00 14,535.00 1,207.25 8,758.75 5,776.25 P BENEFITS 3.097.00 0.00 3,097.00 245.44 1,767.42 1,329.58 Q SUPPLIES 2,340.00 20.00 2,360.00 62.98 769.99 1,590.01 R SERVICES 54,055.00 916.00 54,971.00 7,609.42 43,355.18 11,615.82 S CAPITAL OUTLAY 1,001.00 0.00 100100 0.00 468.00 533.00 Total... WASTE MANAGEMENT (75,028.00) (936.00) (75,964.00) (9,125.09) (55,119.34) 20,844.66 Total... GENERAL FUND 18.513,444.00 (4,071,703.00) 14.441,741.00 (4,853,323.61) 1,722,785.32 (12,718,955.68) 2610 AIRPORT FUND 001 REVENUE A ESTIMATED BEGINNING CA... 47,000.00 (1,947.00) 45,053.00 0.00 0.00 (45,053.00) D INTERGOVERNMENTAL 1.00 30,000.00 30,001.00 30,000.00 30,000.00 (1.00) G INTEREST INCOME 500.00 0.00 500.00 5.68 417.18 (82.82) H RENTS 1,200.00 0.00 1,200.00 100.00 1,000.00 (200.00 Total... REVENUE 48,701.00 28,053.00 76,754.00 30,105.68 31,417.18 (45,336.82) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 901.00 1,249.00 2,150.00 0.00 1,851.48 298.52 R SERVICES 33,002.00 31,453.00 64,455.00 2,272.88 62,985.22 1,469.78 S CAPITAL OUTLAY 10,123.00 32,998.00 43,121.00 0.00 41,215.40 1,905.60 U TRANSFERS IN (30 001.00) (10 000.00) (40 001.00) 0.00 (40,000.00) (1.00) Total ... DEPARTMENTS NOT (14,025.00) (55,700.00) (69,725.00) (2,272.88) (66,052.10) 3,672.90 APPLICABLE Total... AIRPORT FUND 34,676.00 (27,647.00) 7,029.00 27,832.80 (34,634.92) (41,663,92) 2620 APPELLATE JUDICIAL SYSTEM 001 REVENUE A ESTIMATED BEGINNING CA... 0.00 6.00 6.00 0.00 0.00 (6.00) E FEES 1,800.00 0.00 1,800.00 170.00 1,491.65 (308.35) F FINES 1.00 0.00 1.00 0.00 0.00 (1.00) G INTEREST INCOME 3.00 0.00 3.00 0.60 8.28 5.28 Total... REVENUE 1,804.00 6.00 1,810.00 170.60 1,499.93 (310.07) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 10 CALHOUN COUNTY, TEXAS ' Summary Budget Comparison - Unposted Transactions Included In Report From 10/112020 Through 10/3112020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 999 DEPARTMENTS NOT APPLICABLE R SERVICES 1804.00 0.00 1804.00 0.00 0.00 1,804.00 Total ... DEPARTMENTS NOT (1,804.00) 0.00 (1,804.00) 0.00 0.00 1,804.00 APPLICABLE Total... APPELLATE JUDICIAL SYSTEM ... 0.00 6.00 6.00 170.60 1,499.93 1,493.93 2660 COASTAL PROTECTION FUND (... 001 REVENUE A ESTIMATED BEGINNING CA... 1,000,000.00 55,982.00 1,055,982.00 0.00 0.00 (1,055,982.00) D INTERGOVERNMENTAL 100,000.00 0.00 100,000.00 0.00 1,034,675.74 934,675.74 G INTEREST INCOME 10,000.00 0.00 10000.00 924.64 16317.75 6317.75 Total... REVENUE 1,110,000.00 55,982.00 1,165,982.00 924.64 1,050,993.49 (114,988.51) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 105,366.00 481,375.00 586,741.00 750.00 27,080.00 559,661.00 S CAPITAL OUTLAY 70,000.00 0.00 70,000.00 0.00 0.00 70,000.00 V TRANSFERS OUT 0.00 7256.00 7256.00 0.00 7256.00 0.00 Total... DEPARTMENTS NOT (175,366.00) (488,631.00) (663,997.00) (750.00) (34,336.00) 629,661.00 APPLICABLE Total ... COASTAL PROTECTION FUND (... 934,634.00 (432,649.00) 501,985.00 174.64 1,016,657.49 514,672.49 2663 COUNTY AND DISTRICT COURT... 001 REVENUE A ESTIMATED BEGINNING CA... 6,000.00 122.00 6,122.00 0.00 0.00 (6,122.00) E FEES 600.00 0.00 600.00 41.30 723.70 123.70 G INTEREST INCOME 100.00 0.00 100.00 3.08 60.93 (39.07) Total... REVENUE 6,700.00 122.00 6,822.00 44.38 784.63 (6,037.37) 999 DEPARTMENTS NOT APPLICABLE E FEES 0.00 0.00 0.00 0.00 40.66 40.66 Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 40.66 40.66 APPLICABLE Total... COUNTY AND DISTRICT COURT... 6.700.00 122.00 6,822.00 44.38 825.29 (5,996.71) 2667 COUNTY CHILD ABUSE PREVE... 001 REVENUE A ESTIMATED BEGINNING CA... 630.00 31.00 661.00 0.00 0.00 (661.00) E FEES 10.00 0.00 10.00 0.34 5.05 (4.95) G INTEREST INCOME 10.00 0.00 10.00 0.30 6.31 (3.69) Total... REVENUE 650.00 31.00 681.00 0.64 11.36 (669.64) Total... COUNTY CHILD ABUSE PREVE... 650.00 31.00 681.00 0.64 11.36 (669.64) 2668 COUNTY CHILD WELFARE BOA... 001 REVENUE Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 11 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurnActual YTD Actual Variance A ESTIMATED BEGINNING CA... 5,300.00 379.00 5,679.00 0.00 0.00 (5,679.00) G INTEREST INCOME 10.00 0.00 10.00 2.70 54.77 44.77 1 MISCELLANEOUS REVENU... 500.00 0.00 500.00 32.00 296.00 (204.00) Total... REVENUE 5,810.00 379.00 6,189.00 34.70 350.77 (5,838.23) 999 DEPARTMENTS NOT APPLICABLE I MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.00 40.00 40.00 R SERVICES 5.000.00 379.00 5379.00 0.00 0.00 5379.00 Total ... DEPARTMENTS NOT (5,000.00) (379.00) (5,379.00) 0.00 40.00 5,419.00 APPLICABLE Total ... COUNTY CHILD WELFARE BOA... 810.00 0.00 810.00 34.70 390.77 (419.23) 2669 COUNTY JURY FUND 001 REVENUE E FEES 0.00 0.00 0.00 13.89 114.77 114.77 G INTEREST INCOME 0.00 0.00 0.00 0.05 0.21 0.21 Total... REVENUE 0.00 0.00 0.00 13.94 114.98 114.98 999 DEPARTMENTS NOT APPLICABLE E FEES 0.00 0.00 0.00 0.00 4.73 4.73 Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 4.73 4.73 APPLICABLE Total... COUNTY JURY FUND 0.00 0.00 0.00 13.94 119.71 119.71 2670 COURTHOUSE SECURITY FUND 001 REVENUE A ESTIMATED BEGINNING CA... 258,000.00 (417.00) 257,583.00 0.00 0.00 (257,583.00) E FEES 7,900.00 0.00 7,900.00 1,343.65 13,644.94 5,744.94 G INTEREST INCOME 3000.00 0.00 3,000.00 121.66 2495.85 (504.151 Total... REVENUE 268,900.00 (417.00) 268,483.00 1,465.31 16,140.79 (252,342.21) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 14,500.00 0.00 14,500.00 3,745.00 3,745.00 10,755.00 S CAPITAL OUTLAY 130500.00 0.00 130500.00 0.00 0.00 130500.00 Total... DEPARTMENTS NOT (145,000.00) 0.00 (145,000.00) (3,745.00) (3,745.00) 141,255.00 APPLICABLE Total... COURTHOUSE SECURITY FUND 123,900.00 (417.00) 123,483.00 (2,279.69) 12,395.79 (111,087.21) 2672 COURT -INITIATED GUARDIANS 001 REVENUE A ESTIMATED BEGINNING CA... 9,000.00 748.00 9.748.00 0.00 0.00 (9,748.00) E FEES 1,000.00 0.00 1,000.00 160.00 1,180.00 180.00 G INTEREST INCOME 1.00 0.00 1.00 4.85 96.50 95.50 Total... REVENUE 10,001,00 748.00 10,749.00 164.85 1,276.50 (9,472.50) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 12 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTDActual Variance Total... COURT -INITIATED GUARDIANS... 10,001.00 748,00 10,749.00 164.85 1,276.50 (9,472.50) 2673 COURT RECORD PRESERVATI... 001 REVENUE A ESTIMATED BEGINNING CA... 30,000.00 693.00 30,693.00 0.00 0.00 (30.693.00) E G FEES 3,000.00 0.00 3,000.00 391.68 3,816.72 816.72 INTEREST INCOME 500.00 0.00 500.00 15.37 305.36 _ (194.64) Total... REVENUE 33,500.00 693.00 34,193.00 407.05 4,122.08 (30,070.92) Total... COURT RECORD PRESERVATI... 33,500.00 693,00 34,193.00 407.05 4,122.08 (30,070.92) 2674 COURT REPORTER SERVICE F... 001 REVENUE E G FEES 0.00 0.00 0.00 6.02 104.17 104.17 INTEREST INCOME 0.00 0.00 0.00 0.04 0.14 0.14 Total... REVENUE 0.00 0.00 0.00 6.06 104.31 104.31 Total ... COURT REPORTER SERVICE F... 0.00 0.00 0.00 6.06 104.31 104,31 2675 COUNTY CLERK RECORDS AR... 001 REVENUE A ESTIMATED BEGINNING CA... 250,000.00 16,074.00 266,074.00 0.00 0.00 (266,074.00) E FEES 40,000.00 0.00 40,000.00 3,790.00 38,290.00 (1,710.00) G INTEREST INCOME 340000 0.00 340000 112.56 228984 (1110161 Total... REVENUE 293,400.00 16,074.00 309,474.00 3,902.56 40,579.84 (268,894,16) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 50.000.00 908.00 50.908.00 0.00 50.907.71 0.29 Total ... DEPARTMENTS NOT (50,000.00) (908.00) (50,908.00) 0.00 (50,907.71) 0.29 APPLICABLE Total... COUNTY CLERK RECORDS AR... 243,400.00 15,166.00 258.566.00 3.902.56 (10,327.87) (268,893.87) 2676 COUNTY SPECIALTY COURT FU... 001 REVENUE E G FEES 0.00 0.00 0.00 40.13 715.19 715.19 INTEREST INCOME 0.00 0.00 0.00 0.30 1.12 1.12 Total... REVENUE 0.00 0.00 0.00 40.43 716.31 716.31 Total... COUNTY SPECIALTY COURT FU... 0.00 0.00 0.00 40.43 716.31 716.31 2690 D A FORFEITED PROPERTY FU... 001 REVENUE A ESTIMATED BEGINNING CA... 15,000.00 23,429.00 38,429.00 0.00 0.00 (38,429.00) F G FINES 1.00 0.00 1.00 0.00 905.34 904.34 INTEREST INCOME 30.00 0.00 30.00 9.34 93.34 63.34 Total... REVENUE 15,031.00 23,429.00 38,460.00 9.34 998.68 (37,461.32) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 14,900.00 14,819.00 29,719.00 0.00 14,909.26 14,809.74 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 13 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance S CAPITAL OUTLAY 1.00 0.00 1.00 0.00 0.00 1.00 Total ... DEPARTMENTS NOT (14,901.00) (14,819.00) (29,720.00) 0.00 (14,909.26) 14,810.74 APPLICABLE Total ... D A FORFEITED PROPERTY FU... 130.00 8,610.00 8,740.00 9.34 (13,910.58) (22,650.58) 2697 DONATIONS FUND 001 REVENUE G INTEREST INCOME 0.00 0.00 0.00 44.12 832.44 832.44 1 MISCELLANEOUS REVENU... 0.00 0.00 0.00 19 906.46 121 472.94 121 472.94 Total... REVENUE 0.00 0.00 0.00 19.950.58 122,305.38 122,305.38 999 DEPARTMENTS NOT APPLICABLE G INTEREST INCOME 0.00 0.00 0.00 0.00 12.79 12.79 Q SUPPLIES 0.00 0.00 0.00 0.00 1,434.54 (1,434.54) R SERVICES 0.00 0.00 0.00 0.00 10,666.33 (10,666.33) S CAPITAL OUTLAY 0.00 0.00 0.00 302.36 69,390.50 (69 390.50) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 (302.36) (81,478.58) (81,478.58) APPLICABLE Total ... DONATIONS FUND 0.00 0.00 0.00 19,648.22 40,826.80 40,826.80 2698 DRUG/DWI COURT PROGRAM F... 001 REVENUE A ESTIMATED BEGINNING CA... 19,600.00 2,436.00 22,036.00 0.00 0.00 (22,036.00) E FEES 2,020.00 0.00 2,020.00 167.27 2,287.42 267.42 G INTEREST INCOME 250.00 0.00 250.00 10.89 218.44 (31.56) Total... REVENUE 21,870.00 2,436.00 24,306.00 178.16 2,505.86 (21,800.14) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 10.00 0.00 10.00 0.00 0.00 10.00 R SERVICES 20.00 0.00 20.00 0.00 0.00 20.00 S CAPITAL OUTLAY 10.00 0.00 10.00 0.00 0.00 10.00 Total ... DEPARTMENTS NOT (40.00) 0.00 (40.00) 0.00 0.00 40.00 APPLICABLE Total ... DRUG/DWI COURT PROGRAM F... 21,830.00 2,436.00 24.266.00 178.16 2,505.86 (21,760.14) 2699 JUVENILE CASE MANAGER FUND 001 REVENUE A ESTIMATED BEGINNING CA... 15,000.00 4,950.00 19,950.00 0.00 0.00 (19,950.00) E FEES 5,010.00 0.00 5.010.00 199.95 5,145.47 135.47 G INTEREST INCOME 150.00 0.00 150.00 9.44 205.09 55.09 Total... REVENUE 20,160.00 4,950.00 25,110.00 209.39 5,350.56 (19,759,44) 999 DEPARTMENTS NOT APPLICABLE E FEES 0.00 0.00 0.00 0.00 25.00 25.00 0 SALARIES 4,001.00 0.00 4,001.00 461.55 3,384.70 616.30 P BENEFITS 1575.00 0.00 1575.00 155.68 1315.80 259.20 Date: 11/17120 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 14 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Total ... DEPARTMENTS NOT APPLICABLE Original Budget Amendments Revised Budget CurrActual (5,576.00) 0.00 (5,576.00) (617.23) YTD Actual Variance (4,675.50) 900.50 Total ... JUVENILE CASE MANAGER FUND 14,584.00 4,950.00 19,534.00 (407.84) 675.06 (18,858.94) 2706 FAMILY PROTECTION FUND 001 REVENUE A ESTIMATED BEGINNING CA... 11,500.00 335.00 11,835.00 0.00 0.00 (11,835.00) E FEES 700.00 0.00 700.00 90.00 1,020.00 320.00 G INTEREST INCOME 100.00 0.00 100.00 5.75 115.66 15.66 Total... REVENUE 12,300.00 335.00 12,635.00 95.75 1,135.66 (11,499.34) Total... FAMILY PROTECTION FUND 12,300.00 335.00 12,635.00 95.75 1,135.66 (11,499.34) 2715 JUVENILE DELINQUENCY PREV... 001 REVENUE A ESTIMATED BEGINNING CA... 8,900.00 23.00 8,923.00 0.00 0.00 (8,923.00) G INTEREST INCOME 100.00 0.00 100.00 4.02 84.75 (15.25) Total... REVENUE 9,000.00 23.00 9,023.00 4.02 84.75 (8,938.25) Total... JUVENILE DELINQUENCY PREV... 9,000.00 23.00 9,023.00 4.02 84.75 (8,938.25) 2716 GRANTS FUND 001 REVENUE D INTERGOVERNMENTAL 0.00 0.00 0.00 28,736.68 140,193.52 140,193.52 G INTEREST INCOME 0.00 0.00 0.00 111.85 2,052.17 2,052.17 1 MISCELLANEOUS REVENU... 0.00 0.00 0.00 30,304.00 30,304.00 30304.00 Total... REVENUE 0.00 0.00 0.00 59,152.53 172,549.69 172,549.69 999 DEPARTMENTS NOT APPLICABLE D INTERGOVERNMENTAL 0.00 0.00 0.00 0.00 5,565.03 5,565.03 0 SALARIES 0.00 0.00 0.00 11,472.02 54,571.45 (54,571.45) P BENEFITS 0.00 0.00 0.00 1,641.12 10,123.64 110,123.64) Q SUPPLIES 0.00 0.00 0.00 2,439.79 5,410.47 (5,410.47) R SERVICES 0.00 0.00 0.00 199.35 17,191.24 (17,191.24) S CAPITAL OUTLAY 0.00 0.00 0.00 58,390.64 131 928.80 (131 928.80) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 (74,142.92) (213,660.57) (213,660.57) APPLICABLE Total... GRANTS FUND 0.00 0.00 0.00 114,990.39) (41,110.88) (41,110.88) 2719 JUSTICE COURT TECHNOLOGY... 001 REVENUE A ESTIMATED BEGINNING CA... 0.00 86,550.00 86,550.00 0.00 0.00 (86,550.00) E FEES 5.00 4,974.00 4,979.00 614.83 6,817.15 1,838.15 G INTEREST INCOME 1.00 693.00 694.00 40.85 840.27 146.27 Total... REVENUE 6.00 92,217.00 92,223.00 655.68 7,657.42 (84,566.58) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 1.00 0.00 1.00 0.00 0.00 1.00 Dale: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 15 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance S CAPITAL OUTLAY 5.00 92,217.00 92 222.00 227.73 1.462.05 90,759.95 Total... DEPARTMENTS NOT (6.00) (92,217.00) (92,223.00) (227.73) (1,462.05) 90,760.95 APPLICABLE Total... JUSTICE COURT TECHNOLOGY... 0.00 0.00 0.00 427.95 6,195.37 6,195.37 2720 JUSTICE COURT BUILDING SEC... 001 REVENUE A ESTIMATED BEGINNING CA... 4,000.00 1.736.00 5,736.00 0.00 0.00 (5,736.00) E FEES 1,600.00 0.00 1,600.00 35.01 863.31 (736.69) G INTEREST INCOME 50.00 0.00 50.00 2.83 57.94 7.94 Total... REVENUE 5,650.00 1,736.00 7,386.00 37.84 921.25 (6,464.75) 999 DEPARTMENTS NOT APPLICABLE E FEES 0.00 0.00 0.00 0.00 3.00 3.00 R SERVICES 0.00 275.00 275.00 0.00 275.00 0.00 S CAPITAL OUTLAY 5,000.00 (275.00) 4,725.00 0.00 0.00 4,725.00 Total... DEPARTMENTS NOT (5,000.00) 0.00 (5,000.00) 0.00 (272.00) 4,728.00 APPLICABLE Total... JUSTICE COURT BUILDING SEC... 650.00 1,736.00 2,386.00 37.84 649.25 (1,736.75) 2721 LATERAL ROAD FUND PRECINC... 001 REVENUE A ESTIMATED BEGINNING CA... 4,370.00 (21.00) 4,349.00 0.00 0.00 (4,349.00) B TAXES 4,230.00 0.00 4,230.00 4,303.84 4,303.84 73.84 G INTEREST INCOME 50.00 0.00 50.00 0.00 39.35 (10.65) Total... REVENUE 8,650.00 (21.00) 8,629.00 4,303.84 4,343.19 (4,285.81) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 4460.00 0.00 4,460.00 0.00 4,398.08 61.92 Total ... DEPARTMENTS NOT (4,460.00) 0.00 (4,460.00) 0.00 (4,398.08) 61.92 APPLICABLE Total... LATERAL ROAD FUND PRECINC... 4,190.00 (21.00) 4,169.00 4,303.84 (54.89) (4,223.89) 2722 LATERAL ROAD FUND PRECING... 001 REVENUE A ESTIMATED BEGINNING CA... 4,370.00 (21.00) 4,349.00 0.00 0.00 (4,349.00) B TAXES 4,230.00 0.00 4,230.00 4,303.84 4,303.84 73.84 G INTEREST INCOME 50.00 0.00 50.00 0.00 39.35 (10.65) Total... REVENUE 8,650.00 (21.00) 8,629.00 4,303.84 4,343.19 (4,285.81) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 4460.00 0.00 4460.00 0.00 4398.08 61.92 Total ... DEPARTMENTS NOT (4,460.00) 0.00 (4,460.00) 0.00 (4,398.08) 61.92 APPLICABLE Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 16 Acco... Account Title Total ... LATERAL ROAD FUND PRECINC... 2723 LATERAL ROAD FUND PRECINC... 001 REVENUE A ESTIMATED BEGINNING CA... B TAXES G INTEREST INCOME Total... REVENUE 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES Total ... DEPARTMENTS NOT APPLICABLE Total ... LATERAL ROAD FUND PRECINC... 2724 LATERAL ROAD FUND PRECINC... 001 REVENUE A ESTIMATED BEGINNING CA... B TAXES G INTEREST INCOME Total... REVENUE 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES Total ... DEPARTMENTS NOT APPLICABLE Total ... LATERAL ROAD FUND PRECINC 2726 JUROR DONATIONS COUNTY H. 001 REVENUE A ESTIMATED BEGINNING CA... I MISCELLANEOUS REVENU... Total... REVENUE 999 DEPARTMENTS NOT APPLICABLE R SERVICES Total ... DEPARTMENTS NOT APPLICABLE Total ... JUROR DONATIONS COUNTY H... 2729 PRETRIAL SERVICES FUND 001 REVENUE A ESTIMATED BEGINNINGCA... E FEES G INTEREST INCOME CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Original Budget Amendments Revised Budget CurrActual 4,190.00 (21.00) 4,169.00 4,303.84 (54.89) (4,223.89) 4,370.00 (21.00) 4,349.00 0.00 0.00 (4,349.00) 4,230.00 0.00 4,230.00 4,303.82 4,303.82 73.82 50.00 0.00 50.00 0.00 39.35 (10.65) 8,650.00 (21.00) 8,629.00 4,303.82 4,343.17 (4,285.83) 4,460.00 0.00 4,460.00 0.00 4,398.06 61.94 (4,460.00) 0.00 (4,460.00) 0.00 (4,398.06) 61.94 4,190.00 (21.00) 4,169.00 4,303.82 (54.89) (4,223.89) 4,370.00 (21.00) 4,349.00 0.00 0.00 (4,349.00) 4,230.00 0.00 4,230.00 4,303.84 4,303.84 73.84 50.00 0.00 50.00 0.00 39.35 (10.65) 8,650.00 (21.00) 8,629.00 4,303.84 4,343.19 (4,285.81) 4,460.00 0.00 4460.00 0.00 4,398.08 61.92 (4,460.00) 0.00 (4,460.00) 0.00 (4,398.08) 61.92 4,190.00 (21.00) 4,169.00 4,303.84 (54.89) (4,223.89) 2,450.00 380.00 2.830.00 0.00 0.00 (2,830.00) 500.00 0.00 500.00 8.00 320.00 - 180.00 2,950.00 380.00 3,330.00 8.00 320.00 (3,010.00) 2,500.00 380.00 2,880.00 0.00 0.00 2,880.00 (2,500.00) (380.00) (2,880.00) 0.00 0.00 2,880.00 450.00 0.00 450.00 8.00 320.00 (130.00) 78,000.00 2,071.00 80,071.00 0.00 0.00 (80,071.00) 1,000.00 0.00 1,000.00 500.00 906.20 (93.80) 1,000.00 0.00 1,000.00 36.29 763.34 (236.66) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 17 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance Total... REVENUE 80,000.00 2,071.00 82,071.00 536.29 1,669.54 (80,401.46) Total ... PRETRIAL SERVICES FUND 80,000.00 2,071.00 82,071.00 536.29 1,669.54 (80,401.46) 2730 LOCAL TRUANCY PREVENTION/... 001 REVENUE E FEES 0.00 0.00 0.00 593.54 4,197.19 4,197.19 G INTEREST INCOME 0.00 0.00 0.00 1.61 6.00 6.00 Total... REVENUE 0.00 0.00 0.00 595.15 4,203.19 4,203.19 Total ... LOCAL TRUANCY PREVENTION/... 0.00 0.00 0.00 595.15 4,203.19 4,203.19 2731 LAW LIBRARY FUND 001 REVENUE A ESTIMATED BEGINNING CA... 211,000.00 (2,425.00) 208,575.00 0.00 0.00 (208,575.00) E FEES 10,000.00 0.00 10.000.00 1,190.00 10,266.64 266.64 G INTEREST INCOME 3000.00 0.00 3,000.00 94.78 1,993.11 1,006.89) Total... REVENUE 224,000.00 (2,425.00) 221,575.00 1,284.78 12,259.75 (209,315.25) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 800.00 0.00 800.00 0.00 0.00 800.00 S CAPITAL OUTLAY 25,600.00 0.00 25600.00 0.00 7504.65 18095.35 Total ... DEPARTMENTS NOT (26,400.00) 0.00 (26,400.00) 0.00 (7,504.65) 18,895.35 APPLICABLE Total... LAW LIBRARY FUND 197,600.00 (2,425.00) 195,175.00 1,284.78 4,755.10 (190,419.90) 2733 LEOSE EDUCATION FUND 001 REVENUE D INTERGOVERNMENTAL 0.00 0.00 0.00 0.00 1,370.53 1,370.53 G INTEREST INCOME 0.00 0.00 0.00 17.00 359.93 359.93 Total... REVENUE 0.00 0.00 0.00 17.00 1,730.46 1,730.46 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 0.00 0.00 0.00 1556.25 (1556.25) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (1,556.25) (1,556.25) APPLICABLE Total ... LEOSE EDUCATION FUND 0.00 0.00 0.00 17.00 174.21 174.21 2736 POC COMMUNITY CENTER 001 REVENUE A ESTIMATED BEGINNING CA... 50,000.00 (12,823.00) 37,177.00 0.00 0.00 (37,177.00) G INTEREST INCOME 600.00 0.00 600.00 12.34 384.59 (215.41) H RENTS 17,000.00 0.00 17,000.00 500.00 18,450.00 1,450.00 1 MISCELLANEOUS REVENU... 1.00 0.00 1.00 0.00 0.00 (1.00) Total... REVENUE 67,601.00 (12,823.00) 54,778.00 512.34 18,834.59 (35,943.41) 999 DEPARTMENTS NOT APPLICABLE Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 18 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTDActual Variance 0 SALARIES 1,652.00 0.00 1,652.00 142.05 1,041.70 610.30 P BENEFITS 500.00 0.00 500.00 45.92 385.12 114.88 R SERVICES 34,040.00 41,287.00 75,327.00 2,140.68 68,584.64 6,742.36 S CAPITAL OUTLAY 14,969.00 (11,437.00) 3,532.00 0.00 0.00 3,532.00 U TRANSFERS IN (10 000.00) (29 850.00) (39 850.00) 0.00 (39 850.00) 0.00 Total... DEPARTMENTS NOT (41,161.00) 0.00 (41,161.00) (2,328.65 ) (30,161.46) 10,999.54 APPLICABLE Total... POC COMMUNITY CENTER 26,440.00 (12,823.00) 13,617.00 (1,816.31) (11,326.87) (24,943.87) 2737 RECORDS MGMT/PRESERVATI... 001 REVENUE A ESTIMATED BEGINNING CA... 8,300.00 1,571.00 9,871.00 0.00 0.00 (9,871.00) E FEES 1,500.00 0.00 1.500.00 236.02 2,304.00 804.00 G INTEREST INCOME 100.00 0.00 100.00 4.14 82.60 (17.40) Total... REVENUE 9,900.00 1,571,00 11,471.00 240.16 2,386.60 (9,084.40) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 5000.00 6,790.00 11790.00 0.00 2750.00 9.040.00 Total... DEPARTMENTS NOT (5,000.00) (6,790.00) (11,790.00) 0.00 (2,750.00) 9,040.00 APPLICABLE Total ... RECORDS MGMT/PRESERVATI... 4,900.00 (5,219.00) (319.00) 240.16 (363.40) (44.40) 2738 RECORDS MANAGEMENT FUN... 001 REVENUE A ESTIMATED BEGINNING CA... 149,000.00 3,008.00 152,008.00 0.00 0.00 (152,008.00) E FEES 35,000.00 0.00 35,000.00 3,840.61 38,906.90 3.906.90 G INTEREST INCOME 2,000.00 0.00 2000.00 75.53 1,533.57 (466.43) Total... REVENUE 186,000.00 3,008.00 189,008.00 3,916.14 40,440.47 (148,567.53) 999 DEPARTMENTS NOT APPLICABLE 0 SALARIES 4,061.00 0.00 4,061.00 0.00 0.00 4,061.00 P BENEFITS 786.00 0.00 786.00 0.00 0.00 786.00 Q SUPPLIES 2,500.00 0.00 2,500.00 0.00 0.00 2,500.00 R SERVICES 20,000.00 0.00 20,000.00 0.00 19,470.17 529.83 S CAPITAL OUTLAY 14000.00 0.00 14,000.00 0.00 0.00 14000.00 Total ... DEPARTMENTS NOT (41,347.00) 0.00 (41,347.00) 0.00 (19,470.17) 21,876.83 APPLICABLE Total ... RECORDS MANAGEMENT FUN... 144,653.00 3,008.00 147,661.00 3,916.14 20,970.30 (126,690.70) 2739 RECORDS MANAGEMENT AND... 001 REVENUE A ESTIMATED BEGINNING CA... 21,000.00 3,926.00 24,926.00 0.00 0.00 (24,926.00) E FEES 4,000.00 0.00 4,000.00 353.23 5,749.95 1,749.95 G INTEREST INCOME 200.00 0.00 200.00 13.65 257.40 57.40 Total... REVENUE 25,200.00 3,926.00 29,126.00 366.88 6,007.35 (23,118.65) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 19 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrAcfual YTDActual Variance 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 1,000.00 0.00 1,000.00 0.00 0.00 1,000.00 R SERVICES 1,000.00 0.00 1,000.00 0.00 0.00 1000.00 Total ... DEPARTMENTS NOT (2,000.00) 0.00 (2,000.00) 0.00 0.00 2,000.00 APPLICABLE Total... RECORDS MANAGEMENT AND... 23,200.00 3,926.00 27,126.00 366.88 6,007.35 (21,118.65) 2740 ROAD AND BRIDGE FUND GEN... 001 REVENUE A ESTIMATED BEGINNING CA.., 1,500,000.00 188,806.00 1,688,806.00 0.00 0.00 (1,688,806.00) C PERMITS 260,000.00 0.00 260,000.00 0.00 266,930.00 6,930.00 D INTERGOVERNMENTAL 15,000.00 0.00 15,000.00 14,188.07 29,145.22 14,145.22 F FINES 37,100.00 0.00 37,100.00 4,714.74 66,741.59 29,641.59 G INTEREST INCOME 14,000.00 0.00 14,000.00 725.36 14,040.02 40.02 1 MISCELLANEOUS REVENU... 200000.00 0.00 200,000.00 20,530.00 200,360.00 360.00 Total... REVENUE 2,026,100.00 188,806.00 2,214,906.00 40,158.17 577,216.83 (1,637,689.17) 999 DEPARTMENTS NOT APPLICABLE V TRANSFERS OUT 600 000.00 0.00 600 000.00 0.00 600 000.00 0.00 Total ... DEPARTMENTS NOT (600,000.00) 0.00 (600,000.00) 0.00 (600,000.00) 0.00 APPLICABLE Total... ROAD AND BRIDGE FUND GEN... 1,426,100.00 188,806.00 1,614,906.00 40,158.17 (22,783.17) (1,637,689.17) 2860 SHERIFF FORFEITED PROPERT... 001 REVENUE A ESTIMATED BEGINNING CA... 9.764.00 37,884.00 47,648.00 0.00 0.00 (47,648.00) D INTERGOVERNMENTAL 0.00 0.00 0.00 2,768.00 2,768.00 2,768.00 F FINES 500.00 0.00 500.00 0.00 0.00 (500.00) G INTEREST INCOME 50.00 0.00 50.00 16.53 172.76 122.76 1 MISCELLANEOUS REVENU... 2.00 2767.00 2769.00 0.00 2768.00 (1.00) Total... REVENUE 10,316.00 40,651.00 50,967.00 2,784.53 5,708.76 (45,268.24) 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 2,500.00 0.00 2,500.00 64.53 705.28 1,794.72 R SERVICES 6.002.00 0.00 6.002.00 6.962.43 12,232.04 (6,230.04) S CAPITAL OUTLAY 2.00 1.709.00 1.711.00 0.00 1,710.00 1.00 Total... DEPARTMENTS NOT (8,504.00) (1,709.00) (10,213.00) (7,026.96) (14,647.32) (4,434.32) ) Total ... SHERIFF FORFEITED PROPERT... 1.812.00 38.942.00 40,754.00 (4,242.43) (8,938.56) (49,692.56) 2870 6MILE PIER/BOAT RAMP INSUR/... 001 REVENUE A ESTIMATED BEGINNING CA... 45,000.00 (2,326.00) 42,674.00 0.00 0.00 (42,674.00) G INTEREST INCOME 650.00 0.00 650.00 17.44 391.25 (258.75) 1 MISCELLANEOUS REVENU... 1.00 0.00 1.00 0.00 0.00 (1.00) Total... REVENUE 45,651.00 (2,326.00) 43,325.00 17.44 391.25 (42,933.75) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 20 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/31/2020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 999 DEPARTMENTS NOT APPLICABLE R SERVICES 44294.00 (2326.00) 41968.00 747.09 4795.97 37172.03 Total ... DEPARTMENTS NOT (44,294.00) 2,326.00 (41,968.00) (747.09) (4,795.97) 37,172.03 APPLICABLE Total ... SMILE PIER/BOAT RAMP INSUR/... 1,357.00 0.00 1,357.00 (729.65) (4,404.72) (5,761.72) 4165 DEBT SERVICE FUND REFUNDI... 001 REVENUE A ESTIMATED BEGINNING CA... 28,000.00 14,207.00 42,207.00 0.00 0.00 (42,207.00) B TAXES 489,850.00 0.00 489,850.00 554.48 495,669.63 5,819.63 D INTERGOVERNMENTAL 10.00 0.00 10.00 0.00 23.18 13.18 G INTEREST INCOME 2,000.00 0.00 2,000.00 15.62 1,697.59 (302.41) Total... REVENUE 519,860.00 14,207.00 534,067.00 570.10 497,390.40 (36,676.60) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 517,800.00 0.00 517,800.00 0.00 517,000.00 800.00 Total ... DEPARTMENTS NOT (517,800.00) 0.00 (517,800.00) 0.00 (517,000.00) 800.00 APPLICABLE Total... DEBT SERVICE FUND REFUNDI... 2,060.00 14,207.00 16,267.00 570.10 (19,609.60) (35,876.60) 4170 DEBT SERVICE FUND REFUNDI... 001 REVENUE A ESTIMATED BEGINNING CA... 31,000.00 18,237.00 49,237.00 0.00 0.00 (49,237.00) B TAXES 639,900.00 0.00 639,900.00 725.97 649,466.15 9,566.15 D INTERGOVERNMENTAL 10.00 0.00 10.00 0.00 30.41 20.41 G INTEREST INCOME 2500.00 0.00 2500.00 21.01 2277.22 (222.78) Total... REVENUE 673,410.00 18,237.00 691,647.00 746.98 651,773.78 (39,873.22) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 670850.00 0.00 670850.00 0.00 670184.94 665.06 Total ... DEPARTMENTS NOT (670,850.00) 0.00 (670,850.00) 0.00 (670,184.94) 665.06 APPLICABLE Total ... DEBT SERVICE FUND REFUNDI... 2,560.00 18,237.00 20,797.00 746.98 (18,411.16) (39.208.16) 5101 CPRJ-BOGGY BAYOU NATURE ... 001 REVENUE D INTERGOVERNMENTAL 0.00 10,883.00 10,883.00 0.00 0.00 (10883.00) Total... REVENUE 0.00 10,883.00 10,883.00 0.00 0.00 (10,883.00) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 18,138.00 18,138.00 0.00 0.00 18,138.00 U TRANSFERSIN 0.00 (7256.00) (7256.00) 0.00 (7256.00) 0.00 Total ... DEPARTMENTS NOT 0.00 (10,882.00) (10,882.00) 0.00 7,256.00 18,138.00 APPLICABLE Dale: 11/17120 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 21 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 1011/2020 Through 10/31/2020 Acco... Account Title Original Budgef Amendments Revised Budget CurrActual YTD Actual Variance Total ... CPRJ-BOGGY BAYOU NATURE ... 0.00 1.00 1.00 0.00 7,256.00 7,255.00 5111 CAP.PROJ: CDBG-DR INFRAST... 001 REVENUE D INTERGOVERNMENTAL 0.00 5,936,548.00 5,936,548.00 0.00 253,395.90 (5683152.10) Total... REVENUE 0.00 5,936,548.00 5.936,548.00 0.00 253,395.90 (5,683,152.10) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 914,653.00 914,653.00 0.00 253,395.90 661,257.10 S CAPITAL OUTLAY 0.00 5,021895.00 5021895.00 207119.10 207119.10 4814775.90 Total ... DEPARTMENTS NOT 0.00 (5,936,548.00) (5,936,548.00) (207,119.10) (460,515.00) 5,476,033.00 APPLICABLE Total... CAP.PROJ: CDBG-DR INFRAST... 0.00 0.00 0.00 (207,119.10) (207,119.10) (207,119.10) 5117 CAP.PROJ-CHOCOLATE BAYOU... 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 0.00 0.00 0.00 5,799.99 (5799.99) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (5,799.99) (5,799.99) APPLICABLE Total ... CARPROJ-CHOCOLATE BAYOU... 0.00 0.00 0.00 0.00 (5,799.99) (5,799.99) 5172 CAP.PROJ: AIRPORT RUNWAY I... 999 DEPARTMENTS NOT APPLICABLE S CAPITAL OUTLAY 0.00 0.00 0.00 0.00 63,500.00 (63500.00) Total... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (63,500.00) (63,500.00) APPLICABLE Total ... CAP.PROJ: AIRPORT RUNWAY I... 0.00 0.00 0.00 0.00 (63,500.00) (63,500.00) 5225 CAPITAL PROJECT -GREEN LAK... 001 REVENUE I MISCELLANEOUS REVENU... 0.00 2,000,000.00 2,000,000.00 0.00 0.00 (2,000,000.00) Total... REVENUE 0.00 2,000,000.00 2,000,000.00 0.00 0.00 (2,000,000.00) 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 200,000.00 200,000.00 0.00 0.00 200,000.00 S CAPITAL OUTLAY 0.00 1,800000.00 1,800,000.00 0.00 0.00 1800000.00 Total ... DEPARTMENTS NOT 0.00 (2,000,000.00) (2,000,000.00) 0.00 0.00 2,000,000.00 APPLICABLE Total ... CAPITAL PROJECT -GREEN LAK... 0.00 0.00 0.00 0.00 0.00 0.00 5255 CPROJ-HURRICANE HARVEY D... 001 REVENUE D INTERGOVERNMENTAL 0.00 0.00 0.00 0.00 1517.49 1517.49 Dale: 11117/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 22 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/1/2020 Through 10/3112020 Acco... Account Title Total... REVENUE Original Budget Amendments Revised Budget CurrActual 0.00 0.00 0.00 0.00 YTD Actual Variance 1,517.49 1,517.49 Total... CPROJ-HURRICANE HARVEY D... 0.00 0.00 0.00 0.00 1,517.49 1,517.49 5260 CAPITAL IMPROVEMENT PROD... 999 DEPARTMENTS NOT APPLICABLE S CAPITAL OUTLAY 0.00 0.00 0.00 0.00 9,516.80 (9516.80) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (9,516.80) (9,516.80) APPLICABLE Total ... CAPITAL IMPROVEMENT PROJ... 0.00 0.00 0.00 0.00 (9,516.80) (9,516.80) 5280 CAPITAL PROJECT -HOSPITAL I... 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 0.00 0.00 0.00 7,576.25 (7,576.25) S CAPITAL OUTLAY 0.00 0.00 0.00 0.00 1,440.75 1 440.75 Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (9,017.00) (9,017.00) APPLICABLE Total ... CAPITAL PROJECT -HOSPITAL I... 0.00 0.00 0.00 0.00 (9,017.00) (9,017.00) 5285 CPROJ-MMC LOANS 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 3,000.000.00 3,000,000.00 0.00 500,000.00 2,500,000.00 U TRANSFERS IN 0.00 (3,000,000.00) (3,000,000.00) (3,000,000.00) (3,000,000.00) 0.00 Total ... DEPARTMENTS NOT 0.00 0.00 0.00 3.000,000.00 2,500,000.00 2,500,000.00 APPLICABLE Total ... CPROJ-MMC LOANS 0.00 0.00 0.00 3,000,000.00 2,500,000.00 2,500,000.00 6010 MEMORIAL MEDICAL CENTER ... 001 REVENUE A ESTIMATED BEGINNING CA... 1,500.001.00 3,999,999.00 5,500,000.00 0.00 0.00 (5,500,000.00) 1 MISCELLANEOUS REVENU... 33,870.483.00 58.866.189.00 92,736672.00 0.00 67747371.00 (24989301.00) Total... REVENUE 35,370,484.00 62,866,188.00 98,236,672.00 0.00 67,747,371.00 (30,489,301.00) 999 DEPARTMENTS NOT APPLICABLE 0 SALARIES 12,079,781.00 0.00 12,079,781.00 0.00 8,619,500.00 3,460,281.00 P BENEFITS 4,180,676.00 0.00 4,180,676.00 0.00 2,917,320.00 1,263,356.00 0 SUPPLIES 4,064,944.00 0.00 4,064,944.00 0.00 2,370,213.00 1,694,731.00 R SERVICES 13,445,083.00 62,844,487.00 76,289,570.00 0.00 53,591,109.00 22,698,461.00 S CAPITAL OUTLAY 272 922.00 576,290.00 849,212.00 0.00 0.00 849,212.00 Total ... DEPARTMENTS NOT (34,043,406.00) (63,420.777.00) (97,464,183.00) 0.00 (67,498,142.00) 29,966,041.00 APPLICABLE Total ... MEMORIAL MEDICAL CENTER ... 6012 CAL CO INDIGENT HEALTHCARE Date: 11/17/20 04:28:06 PM 1,327,078.00 (554,589.00) 772,489.00 MONTHLY REPORT -CONDENSED Unaudited 0.00 249,229.00 (523,260.00) Page: 23 CALHOUN COUNTY, TEXAS Summary Budget Comparison - Unposted Transactions Included In Report From 10/112020 Through 10/3112020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 999 DEPARTMENTS NOT APPLICABLE I MISCELLANEOUS REVENU... 0.00 0.00 0.00 27,513.77 132,163.92 132,163.92 R SERVICES 0.00 0.00 0.00 23345.95 127909.60 (127909.60) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 4,167.82 4,254.32 4,254.32 APPLICABLE Total... CAL CO INDIGENT HEALTHCARE 0.00 0.00 0.00 4,167.82 4,254.32 4,254.32 6019 MEM MED CTR PRIVATE WAIVE... 999 DEPARTMENTS NOT APPLICABLE I MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.16 1.59 _ 1.59 Total... DEPARTMENTS NOT 0.00 0.00 0.00 0.16 1.59 1.59 APPLICABLE Total ... MEM MED CTR PRIVATE WAIVE... 0.00 0.00 0.00 0.16 1.59 1.59 6020 MMC CLINIC CONSTRUCTION C... 999 DEPARTMENTS NOT APPLICABLE I MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.20 1.99 1.99 Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.20 1.99 1.99 APPLICABLE Total ... MMC CLINIC CONSTRUCTION C... 0.00 0.00 0.00 0.20 1.99 1.99 7400 ELECTION SERVICES CONTRA... 001 REVENUE E FEES 0.00 0.00 0.00 0.00 2,833.38 2,833.38 G INTEREST INCOME 0.00 0.00 0.00 36.17 752.70 752.70 H RENTS 0.00 0.00 0.00 0.00 1,506.00 1,506.00 1 MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.00 6353.56 6353.56 Total... REVENUE 0.00 0.00 0.00 36.17 11,445.64 11,445.64 999 DEPARTMENTS NOT APPLICABLE Q SUPPLIES 0.00 0.00 0.00 0.00 1,420.62 (1,420.62) R SERVICES 0.00 0.00 0.00 0.00 4932.94 (4932.94) Total ... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (6,353.56) (6,353.56) APPLICABLE Total ... ELECTION SERVICES CONTRA... 0.00 0.00 0.00 36.17 5,092.08 5,092.08 7520 JUROR DONATIONS TEXAS CRI... 001 REVENUE I MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.00 40.00 40.00 Total... REVENUE 0.00 0.00 0.00 0.00 40.00 40.00 Total ... JUROR DONATIONS TEXAS CRI... 0.00 0.00 0.00 0.00 40.00 40.00 Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 24 ' CALHOUN COUNTY, TEXAS ' Summary Budget Comparison - Unposted Transactions Included In Report From 1011/2020 Through 10/3112020 Acco... Account Title Original Budget Amendments Revised Budget CurrActual YTD Actual Variance 7730 LIBRARY GIFTIMEMORIAL FUND 001 REVENUE G INTEREST INCOME 0.00 0.00 0.00 22.51 428.69 428.69 1 MISCELLANEOUS REVENU... 0.00 0.00 0.00 0.00 65.00 65.00 Total... REVENUE 0.00 0.00 0.00 22.51 493.69 493.69 999 DEPARTMENTS NOT APPLICABLE R SERVICES 0.00 0.00 0.00 0.00 99.99 (99.99) S CAPITAL OUTLAY 0.00 0.00 0.00 0.00 1 176,15 (1,176.15 Total... DEPARTMENTS NOT 0.00 0.00 0.00 0.00 (1,276.14) (1,276.14) APPLICABLE Total ... LIBRARY GIFT/MEMORIAL FUND 0.00 0.00 0.00 22.51 (782.45) (782.45) 9200 JUVENILE PROBATION FUND 001 REVENUE A ESTIMATED BEGINNING CA... 60,000.00 (13,435.00) 46,565.00 0.00 0.00 (46,565.00) D INTERGOVERNMENTAL 289.539.00 339,622.00 629,161.00 18,708.00 342,897.60 (286,263.40) E FEES 1.000.00 0.00 1,000.00 45.00 1,022.71 22.71 G INTEREST INCOME 150.00 0.00 150.00 106.51 2,761.73 2,611.73 1 MISCELLANEOUS REVENU... 306831.00 0.00 306831.00 44105.50 559983.25 253,152.25 Total... REVENUE 657,520.00 326,187.00 983,707.00 62,965.01 906,665.29 (77,041.71) 999 DEPARTMENTS NOT APPLICABLE 0 SALARIES 206,450.00 105,727.00 312,177.00 24,769.83 180,415.17 131,761.83 P BENEFITS 74,843.00 0.00 74,843.00 6,323.55 47,028.77 27,814.23 0 SUPPLIES 7,600.00 8,500.00 16,100.00 215.79 8,433.68 7,666.32 R SERVICES 301,028.00 224,021.00 525,049.00 75,423.83 526,495.97 (1,446.97) S CAPITAL OUTLAY 1.00 1,374.00 1,375.00 2,569.84 3,944.84 (2,569.8 Total ... DEPARTMENTS NOT (589,922.00) (339,622.00) (929,544.00) (109,302.84) (766,318.43). 163,225.57 APPLICABLE Total... JUVENILE PROBATION FUND Report Difference 67,598.00 (13,435.00) 23,282,777.00 (4,816,937.00) 54,163.00 (46,337.83) 140,346.86 86,183.86 18,465,840.00 (2,008,171.07) 5,277,040.00 (13.188.800.00) Date: 11/17/20 04:28:06 PM MONTHLY REPORT -CONDENSED Unaudited Page: 25 P.0011003 CALHOUN COUNTY, TEXAS COUNTY TREASURER'S REPORT MONTROFI OCIOBER 2020 JIE67NNING ENDJND FUND FVNDBALANCE RECRIPTS DIRRURREMENTS FUND RAUNCE OPERATING FUND81 GENERAL S 2S,739,8%,26 S 597,906.03 S 5,263,067.0 $ 21,074,634.41 AIRPORT MAINTENANCE S 12,748,26 30,105.63 2,272.88 40,SB1.06 APPELLATE JUDICIAL SYSTEM S 1,340.89 170.60 1,111.49 FU COASTAL PROTECTION ND S 2.076.611.73 924.64 750.00 2.076,736,39 COUNTY AND DIST COURT TECH FUND 3 4,925.52 44.38 56969.90 COUNTY CHUM ABUSE PREVENTION FUND S 674.52 0.64 675.16 COUNTY CHILD WELFARE BOARD FUND S COMM 34.70 6,0%.92 COUNTYJURYFUND S 105.17 13.94 - 119.71 COURTHOUSESECURITY $ 273,229.71 1,455.31 3,745.00 270,950.02 COURT INITIATED GUARDIANSHIP FUND S 10.894.62. 164.95 11,059.67 DIST CLK RECORD PRESERVATION FUND S 34,519.08 407.05 34,926,13 COURT REPORTERS SERVICE FUND S 98.25 4.06 - 106.31 COCLK RECORDS ARCHIVE FUND S 252,003,82 3,902.56 255,M..38 COUNTY SPECIALTY COURT FUND S 475.89 40.43 716.31 DONATIONS S 99.491.97 19.%7.45 302,36 111,777,06 DRUGJDWI COURT PROGRAM FUND -LOCAL S 24.442.64 17E.16 - 24,620,00 FJVENILE CASE MANAGER FUND S 21,195.84 209.39 350.81 20,834.42 FAMILY PROTEC71ONFUND S 12,919.53 93.75 13,015.28 JUVENILE DELINQUENCY PREVENTION FUND S 9,03B.DS 4.02 9,N2.07 GRANTS 5 B36,IB2.D3 0,152.53 72,943.53 822,491.03 JUSTICE COURT TECHNOLOGY S 91,748.12 653.68 227.73 92,176.07 JUSTICE COURT BUILDING SECURITY FUND S 6,164.87 37,94 5.402,71 LATERAL ROAD PRECINCT 61 S 5.09 4,303.94 - 4,308.93 LATERAL ROAD PRECINCT E2 S 5.09 4,303.84 - 4.308.93 LATERAL ROAD PRECINCT 03 S 5,D9 4,90312 4,303.91 LATERAL ROAD PRECINCT B4 S 5.09 4,303.54 4,305.93 JUROR DONATIONS -HUMANE SOCIETY 5 3,142.00 8.00 - 3,1l0.00 PRETRIAL SERVICES FUND S 81,809A6 536.29 82,045.95 LOCAL TRUANCY PREVLNnONRJNERSION FUNT S 3,601,04 59515 - 4,203.19 LAWLIBRARY $ 212.854.21 1,284.73 - 21441,99 LAW ENF OFFICERS STO. EOUC (LEOSE) S 33.173.26 17.00 - 39.190.26 POCCOMMUNJTYCENTER S 27,MSI 1,162.34 2.793.71 26,001.54 RECORDS MANAGEMENT•DISTRICTCLERK B 9,301.79 240,16 9,641.95 RECORDS MANAGEMENT-000NTY CLERK S 169,625.86 3.916.14 173,$42.90 RECORDS MOMT&PRESERVATION S 30,652.11 366.88 - 31,OL9,69 ROAD&BRIDORGENERAL 8 1.629.05618 40,159.17 • 1.669,214.43 SMILE PIERMOAT RAMP INBUNMANT 5 39,166.08 17.44 747.09 38.43643 CAPITAL PROI• BOUOY BAYOU NATURE PARK $ 67,939.W - - 67,939.00 CAPITAL PROI• CDBG OR INFRASTRUCTURE $ 34937.00 207,119.10 115,817.90 CAPITAL PROJ CHOCOLATE BAYOU BOAT RAMP S 176AS0,01 17Q250,01 CAPITAL PROI AS INFRASTRUCTURE S 9.714.41 - 9,714.41 CAPITAL PROJ AIRPORT RUNWAY IMPROVEMRN S 14.972.13 - - 14.972.13 CAPITAL PRO) MAGNOLIA BEACH EROSION CON7 $ 175,000.00 - - 175,000.00 CAPITAL PRO/EVENT CBNTER S 125,927.09 - 125,927.09 CAPITAL PROD FIRE TRUCKS & SAFETY EQUIP S 6,441.61 6,u9,6B CAPITAL PROJ -ORRI N LAKE PARK S 7.160.74 7,160.74 CAPITAL PR13J HATERIUS PARKIBOAT RAMP S 20,7A2.76 - - 20,242.36 CAPITAL PROD PORT ALTO PUBLIC BEACH $ 223,132.58 - - 223,132.38 CAPITAL PRO) HURRICANE HARVEY PIMA S 41,01528 41,01SAS CAPITAL PRO) IMPROVEMENTS PROJECTS 5 346.717.55 - 346,717.5S CAPITAL PROJ HOSPITAL IMPROVEMENTS 1 2,959.059.25 - 21959,05913 CAPITAL PROI -MMC LOANS S 300,000.00 3.000.000.00 - 3,500,000,0D ARREST PEES S 712.79 199.89 318.83 393.94 BAIL BOND FEES (NO 1940) S 1,110.00 OSAo 1,B15.00 30.00 CONSOLIDATED COURT COSTS (NEW) S 5.935.05 1.132.41 7,701,94 65.52 CONSOLIDATED COURT COSTS 2020 S 17.976.84 8,007.7E 26.020.13 (35.51) DNA TESTNO FUND S 34022 0.81 91.10 230.00 DRUG COURT PROGRAM FUND• STATE 5 47754 167.25 6a4Ae 051 8 3 793 463.37 $ 3 70I 849.64 1 ! 391 11.62 $ N 98610259 87OTALR Page 1 oT3 11/1512020 08:47 CALHOUN CO AUDITREAS ffA1p3615534614 P.0021003 COUNTY TREASURER'S REPORT MONTB Of: OCTOEER xvx0 9EGINNING ENDING FUND FUND BALANCE RECEIP73 D/RBU1441TMBNT9 FUNDBALANCE OPERATING FUNDS -BALANCE FORWARD 1 36.795,465.57 S 3.791,84964 S 5,591,2u.62 S 34,986,1D2.59 ELECTION SERVICES CONTRACT 84,174.99 3,079.55 3,636.94 µ,319.60 ELECTROMC FILING FEE FUND 3.057.66 1,487.93 4,543.49 0.00 EMS TRAUMA FUND 1,662.23 635.43 1.191.00 126.17 FINES AND COURT COSTS HOLDINO FUND 7.847.31 - INDIGENT CIVIL LBOAL SERVICE 574.30 274.00 7,947.31 JUDICIAL FUND(ST. COURT COSTS) 268.1D 123.64 824.00 "1.74 24.30 JUDICIAL A COURT PERSONNELTRAININO FUND 451.43 246,72 0100 JUDICIAL SALARIES FUND 31920.58 1.919,96 690.66 5,84031 14.49 JUROR DONATION -TX CRIME VICTIMS FUND 352.00 0.02 JUVENILE PROBATION RES71TUTION 62.57 - - 352.00 LIBRARY GIFT AND MEMORIAL 30,$47.87 22.51 6237 MISCELLANEOUS CLEARING 10,059.22 1,443,81 1,548.82 50,570.3g 9.934,28 REFUNDABLE DEPOSITS 2,000.00 STATE CIVIL PRE FUND 5,195.43 2,399.11 . 7,617.62 1,(27.00 (20.00) CML JUSTICE DATA REPOSITORY POND l.43 2.19 7.62 JURY REIMBURSEMENT FEE 393.99 154.51 548.50 6.00 0.OD SUBTITLE C FUND 7,596.81 3,717.34 11.300.38 13.77 SUPP OF CRIM INDIGENT DEFENSE 204.39 21,97 286.34 0.00 TIME PAYMENTS 898.03 299.69 1,177.67 0.05 TRAFFIC LAW FAILURE TO APPEAR 717.11 580,2S 1,297.36 0.00 UNCLAIMED PROPERTY 11,515.62 0.43 TRUANCY PREVENTION AND DIVERSION FUND 241.99 47.89 - 11,516.07 BOOT CAMPDJABP 147.43 lit" 105.10 JUVENILE PROBATION 239,197.79 - 1159.31 62061.69 147.43 195995.61 SUBTOTALS S 37,217,254.49 S 3.827.233.06 S 5 9393.394.41 S 33,349,105.14 TAXES IN ESCROW 0.00 78 668.39 782660,39 TOTAL OPERATING FUNDS S 37217254A9 S 4 099a345 769 JNAI S 36131773,63 OTHER FUNDS D A FORFEITED PROPERTY FUND 24,5D9.15 934 SHERIFF NARCOTIC FORFEITURES 4052.40 2,7US3 7,026,96 24.518.0 38,709.97 CERT OF OB•CRTHSE REF SERIES 2010 21,866.60 21,216.49 CERT OF BB-CRTHOUSE I&S SERIES 2012 3g678.70 27,756,95 - 43.043.08 CAL. CO. FEES &PINES TOT" OTHER CO. F 89336,29 79160.51 90743.78 57,835.65 77751,09 IQL70,i4 MEMORIAL MEDICAL CENTER OPERATING 6.705,059.06 3,457,415.99 3.151,736.04 S 7,003,719.01 INDIGENT HEALTHCARE 5.033.09 27.313.77 23,345.93 9.220,91 PRIVATE WAIVER CLEARING FUND 429.71 0.16 CLINIC CONSTRUCTION SERIES 2014 525.73 0.20 - 429,87 NH ASHFORD 213,262.22 771.501.37 735.71083 $33.93 229,052.96 NH BROADMOOR NH CRESCENT 74,395.53 421,448.02 400,348.13 95,494.0 NH FORT BEND 40,140.04 77,739.26 537,068.31 476,014.23 101,203.19 NH SOLERA 204,805,43 149,689.53 133.656.16 NH GOLDEN CREEK 57,SSR59 670,721,37 587.619.10 1409554.86 NH SOLERA DACA 101.419.35 481,296.13 424,308.19 105,007.31 NH ASHFORD DACA O00 0.00 _ OW NH BROADMOOR DACA 0.00 - - 0.00 NH GULF PODRE-PRIVATE PAY 14.173.91 72,521.20 49.959.12 000 NH GULP POINT PLAZA MEDICARE I MEDICAID 997.99 28;844.34 227,79639 33,737.99 NH BETHANY SENIOR LIVING 20,793.75 1,158,603.86 816.185.93 55,935.83 363.211,70 NHTUSCANYLIVMO 111,181.701 58942432 376946.01 329659.07 TOTAL MEMORIAL MEDICAL CENTER FUNDS S 7431 32.12 S 3575165.71 S 7305,981-14 S 8601 17.39 DRAINAGE DISTRICTS NO.6 NO. B 39.737.84 395.17 - S 40,123.01 NO. 10•MAINTENMCE 115,ON.10 17I6%..% 1.202.43 116,247.55 NO. II-MAINTENANCEMPERATING 204.474.48 2,246.89 19,678.17 25.38 40,279,52 1",912.47 183.874.13 NO. 11-RESERVE 162,718.59 62,05 MIN 0.63 TOTAL DRAINAGE DISTAILTFUNDS i 699743.96 S 235M,73 S 40,30M S 683 Ox3.79 CALHOUN COUNTY WCID al OPERATINGACCOUNT S 373,039,55 269.97 44.549.96 S 329.760.96 PAYROLL TAX S 1492.81 0.00 155.72 S 1397.59 TOTAL WCHJ FUNDS S 37493.36 x69.97 7R9.78 S 37 3.5 CALHOUN COUNTY PORT AUTHORITY 5 30 6I59 S 398.13 S S 30761.72 MAINTENANCE AND OPERATING CALHOUN COUNTY FROST BANK 6 2010.87 S 5 SAO f 1075.97 S 8 53R 652.90 S 1699 41LE4 $ 7 9,M3,81 S 9 47177.32 TOTAL MMC, DR. DIST.. NAB DIST, WCID & FRO TOTALALLFUNDS S 48,964,660.23S 13,440,241.17 1 S 13,384.050.97 5 46,020,BIg,13 Page 2 of COUNTY TREASURER'S REPORT MONTH OF: OCTOBER2MO BANKRECONCILLATION I=.- CEBT.OFDEDI FUND OU25370DCDEPI PLUS, CHECKS BANE FUND BALANCE OTHER ITEMS OUTSTANDING EAUNCE OPERATING- S 36,131,77343 21,999,999.06 754,399.59 S 14,886,174.06 OTHER D A FORFEITED PROPERTY FUND 24,519.0 24,510.49 SHER" NARCOTIC FORFEITURES 38,709.97 51336A0 44.243,97 CERT OF 09•CRTHSE UP SERIES 2010 43,003.08 - - 0,063.03 CERT OF OB-CRTHOUSE HtS SERIES 2012 57,333.63 - 57,835.65 CAL CO FEES B PINES 77,751.09 7,93000 6,1M,79 75.925.88 MEMORIAL MEDICAL CENTER OPERATING 7.003.719.01 - 254,907.% 7,25B,526.95 INDIGENT HEALTHCARE 9,220.91 23,915,% 33,036,17 PRIVATE WAIVER CLEARING FUND 429.67 - 429.87 CLINIC CONSTRUCTION SERIES 2014 53393 - - 333.93 NH ASHFORD 229.052.96 - 229,052.96 NH BROADMOOR 95,49C67 - MA94.67 NH CRESCENT 101.203.12 - 101,203.12 NH FORT BEND 133.656.16 - 133.656.16 NH SOLERA 140.934.96 - - 140.954.66 NH COWEN CREEK 105,407.31 - 105,40.31 NH SOLERA DACA 0.00 - 0.00 NH ASHFORD DACA 0.00 0.00 NH BROADMOOR BACA 0.00 - 0.00 NH GULP POINT PRIVATE PAY 38,737.99 - - 39,737.99 NH GULP POINTE PLAZA MEDICARE MEDICAID 35.931&3 55,935,83 NH BETHANY SENIOR LIVING 363,211.70 363.211.70 NH TUSCANY VILLAGE 323,459.07 - - 323.639.07 DRAINAGE DISTRICT: NO.6 40.132.01 40033,01 NO. & 116,247.55 - 116,247.55 NO. IU MAINTENANCE 179.915.47 - 25.38 179.943.93 NO. 11 MAINTENANCWOPERA77NO 183,174AS - - 183,874.13 NO. 11 RESERVE 162,850.63 - 162,850,63 CALHOUN COUNTY WCm 01 "•"• OPERATING ACCOUNT 328,760.96 - 329,76o.96 PAYROLLTAX L337.59 - - 1,337.59 CALHOUN COUNTY PORT AUTHORITY •"•^ MAINTENANCB/OPERATINO 30,751.72 30,161.72 CALHOUN COUNTY """" FROST BANK 2.073.37 2,075.87 TWAL9 s 46 MO H9 3 3.66 3 23 M7 M.73 'set PROSPERITY BANK CDs -OPERATING FUND $22.299,327.85 ••++ THE DEPOSITORY FOR CALHOUN COUNTY WCm IS INTERNATIONAL BANK OF CONMRCR - PORT LAVACA •••• THE DEPOSITORY FOR CALHOUN CO. NAVIGATION DISTRICT IS FIRST NATIONAL BANK -PORT LAVACA •••+THE DEPOSITORY FOR CALHOUN COUNTY FROST IS FROST BANK • AUSTIN. TEXAS THE DEPOSITORY FOR ALL OTHER COUNTY FUNDS 19 PROSPERITY BANK. PORT LAVACA Court costs and fees collected and reported may not Trent and up -to- to due to no m lia oe by other county offices. 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Im w N a � :z :z :§ :« § :§ k B � ( : § . 0 :k B § o iz § § :LU :L w g .a § �§a2= §kj( k B Q 2 E:� November 25, 2020 2020 APPROVAL LIST - 2020 BUDGET COMMISSIONERS COURT MEETING OF BALANCE BROUGHT FORWARD FROM APPROVAL LIST REPORT PAGE FICA MEDICARE FWH NATIONWIDE RETIREMENT SOLUTIONS OFFICE OF THE ATTORNEY GENERAL - CHILD SUPPORT RELIANCE STANDARD LIFE TEXAS ASSOCIATION OF COUNTIES HEBP TMPA TRUSTMARK UNITED WAY OF CALHOUN COUNTY AT&T MOBILITY CALHOUN COUNTY DISTRICT CLERK - PETTY CASH FUND CDW-G COMM CRT CITY OF PORT LAVACA FRONTIER COMMUNICATIONS JOANE MCDONOUGH CCJPD PEAGASUS SCHOOLS INC CCJPD TCSI LLC CCJPD WHITE TRASH SERVICES 23 11/25/20 P/R P/R P/R P/R P/R P/R P/R P/R P/R P/R A/P A/P A/P A/P A/P A/P A/P A/P A/P $185,739.81 $ 50,453.68 $ 11,998.88 $ 34,512.90 $ 4,427.00 $ 1,523.07 $ 7,444.49 $ _205,947.55 $ 392.00 $ 3,102.48 $ ; 10.00 $ 946.32 $ 54.67 $ 18,069.27 $ 2,381.31 $ 2,883.59 $ 1,200,00 $ 5,031.30 $ 6,168.39 $ 1,219.80 PAYROLL FOR 11/25/20 P/R $ 307,146.20 TOTAL PAYROLL AMOUNT: $ 307,146.20 TOTAL AMOUNT FOR APPROVAL: $ 850,652.71 4 p MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 25 2020 TOTALS TO BE APPROVED - TRANSFERRED FROM ATTACHED PAGES TOTAL PAYABLES, PAYROLL AND ELECTRONIC BANK PAYMENTS $ 7830122:00 TOTAL TRANSFERS BETWEEN FUNDS $ _ 189,746,74, / 'TOTAL NURSING HOME UPL EXPENSES $ 660A89.70 TOTAL>INTER-GOVERNMENT TRANSFERS $ MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 25 2020 PAYABLES AND PAYROLL 11/19/2020 Weekly Payables 11/23/2020 McKesson-340B Prescription Expense 11/23/2020 Amerisouroe Bergen-3408 Prescription Expense 11/23/2020 Payroll Liabilities -Payroll Taxes 11/23/2020 Payroll Prosperity Electronic Bank Payments 1/19/2020 Cleargage-Patient Financing Service I-11120/20 Pay Plus -Patient Claims Processing Fee TRANSFER BETWEEN FUNDS -NURSING HOMES 11/1912020 MMC Operating to Golden Creek Healthcare -correction of NH insurance payment deposited into MMC Operating 11/19/2020 MMC Operating to Gulf Pointe Plaza -correction of NH insurance payment deposited into MMC Operating 11/1912020 MMC Operating to Tuscany Village -correction of NH insurance payment deposited into MMC Operating 11119/2020 MMC Operating to Bethany Senior Living- correction of NH insurance payment deposited into MMC Operating MOTALTRAN&JERS BETWEEN^FUNDS NURSING HOME UPL EXPENSES 11/23/2020 Nursing Home UPL-Cantex Transfer 11/23/2020 Nursing Home UPL-Nexion Transfer 11/2312020 Nursing Home UPL-HMG Transfer 11/23/2020 Nursing Home UPL-Tuscany Transfer 11/23/2020 Nursing Home UPL-HSL Transfer QIPPIINTEREST/RECOUP CHECKS TO MMC 11123/2020 Broadmoor 11/23/2020 Gulf Pointe 11/23/2020 Bethany TOTAL NURSING BIOME UPL EXPENSES TOTAL.INTERGb1/ERNMENT'TRANSFERS 384,332.64 1,528.92 382.77 96,759.62 299,922.80 67.40 127.85 39,975.92 42,070.59 36,268.61 64,431.62 .',184*.74 483,924.64 38.734.40 32,175.24 50,221.69 52,796.34 54.08 1.656.31 528.00 $ 660,088.70 GRAND TOTAL DISBUttSEIiAENTS.APPROVEQNovember 25, 2020 1mp_cw0rep0rtl b/8839964518495019.html 11/19/2020 MEMORIAL MEDICAL CENTER 11:17 �'4'(,(ti ?f,,i AP Open Invoice List 0 Due Dates Through: 12/09/2020 ap_open_invoice.template Vand9fk,;..,�,_ �-..,,;.,J.y, .,.;.. Vendor Name Clash Pay Code 10995 ABILITY NETWORK (SHIFTHOUNq / Invoice# Ccant Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net POM0169633 44/19/2020 11/06/2020 12/06/2020 586.52 0.00 0,00 586.52 r/ SCHEDULING SERVICES Vendor Totals: Number Name Gross Discount No -Pay Net 10995 ABILITY NETWORK 586.52 0.00 0.00 586,52 Vendor# Vendor Name Class Pay Code 13180 ADVANCED STERILIZATION PROD v% Invoice# Comm�nent Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 8020075649v11/1.7/2020 11/09/2020 12/09/2020 7,500.00 0.00 0.00 7,500.00 STERRAD NX ALL CLEAR SERV C( Vendor Totals: Number Name Gross Discount No -Pay Net 13180 ADVANCED STERIL 7,500.00 0.00 0.00 7,500.00 Vendor# Vendor Name Class Pay Code A1680 AIRGAS USA, LLC - CENTRAL DIV M v `+ Invoice# Com%dant Tran Dt Inv Dt Due Dt Check Dt. Pay Gross Discount No -Pay Net 9975007B29 v1'1/17/2020 10/31/2020 11/25/2020 495.91 0.00 0.00 _ 495.91 ✓F OXYGEN 9975007949 /17/2020 10/31/2020 11/26/2020 703.94 0,00 0.00 703,94✓`. OXYGEN 997500795od /11W2020 10/31/2020 11/25/2020 65.35 0.00 0,00 65,35 / OXYGEN 9106685627r'Il/17/2020 10/31/2020 11/25/$020 2,248.76 0.00 0.00 2,248.76 OXYGEN Vendor Totals: Number Name Gross Discount No -Pay Net Al 680 AIRGAS USA, LLC - 3,613.96 0.00 0.00 3,513.96 Ventlor# Vendor Name Class Pay Code At 690 ALCON LABORATORIES, INC. y/ M Invoice# Corn ant Tran Dt Inv Dt Due Dt Check Dt Pay Grass Discount No -Pay Net 9658930795 a9/17/2020 10/28/2020 11/27/2020 1,338.49 0.00 0.00 1,338.49 SERVICE CONTRACT Vendor Totals: Number Name Gross Discount No -Pay Net Al 690 ALCON LABORATO 1,338.49 0.00 0.00 1,338.49 Vendor# Vendor Name Class Pay Code A2218 AQUA BEVERAGE COMPANY r/- M Invoice# Comment Tran Dt Inv Dt Due DI Check Dt Pay Gross. Discount No -Pay Net 999880 11/17/2020 10/31/2020 11/25/2020 38.95 0.00 0.00 38.95 f' / WATER 999877 11/17/2020 10/31/2020 11/25/2020 ✓ 19.00 0.00 0.00 19.00 r.f WATER Vendor Totals: Number Name Gross Discount No -Pay Net A2216 AQUA BEVERAGE C 57.95 0.00 0.00 57,95 Vendor# Vendor Name Class Pay Code 12060 AQUA PURIFICATION. INC. Invoice# omment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 431668' 11/18/2020 11/02/2020 11/02/2020 179.00 0.00 0.00 179.00 LOW WATER PRESSURE f= Vendor Totals: Number Name Gross Discount No -Pay Net 12060 AQUA PURIFICATIC 179.00 0.00 0.00 179.00 Vendor# Vendor Name Class Pay Code A0400 AUREUS RADIOLOGY LLC Invoice# {C°mment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 2071910 V 11/17/2020 10/26/2020 11/25/2020 2,705.13 0.00 0.00 2,705.13 s,(' STAFFING 2080597 1,.A/17/2020 11/09/2020 12/09/2020 2,755.38 0.00 0.00 2,755,38 STAFFING file://IC:/Users/Mmckissacklcpsitmemmed.cpsinetcom/u88l5Oa/data_5/tmp_pwBrepon1576839964519496019.html 1f10 "r rmp_cwbreport15788s9964518496019.html Vendor Totals: Number Name Gross Discoid A0400 AUREUS RADIOLO( 5.460,51 0.00 Vendor# Vendor Name `j Class 11756 AYA HEALTHCARE INC ✓ Invoice# omment Tran Dt Inv Dt Due Dt Check Dt Pay Gros 801131 11f17/2020 09/17/2020 10/17/2020 1,576.25 STAFFING SURGERY / 810355 ✓ 11/17/2020 10/01/2020 11/01/2020 1,477.50 STAFFING SURGERY 815507 �j J11/17/2020 10/08/2020 11/08/2020 2,290.00 STAFFING SURGERY 819970 /11/17/2020 10/15/2020 11/15/2020 5,345.00 SATFFING SURGERY 825332 „/11/17/2020 10/22/2020 11/22/2020 2,656.25 STAFFING SURGERY 830000 .,/� 11/17/2020 10/29/2020 11/29/2020 2,802.50 STAFFING SURGERY 835600 ✓11/17/2020 11/05/2020 12/05/202o 2,422.50 STAFFING SURGERY Vendor Totals: Number Name Gross Discoun 11756 AYA HEALTHCARE 18.570.00 0.00 Vendor# Vendor Name Class B1150 BAXTER HEALTHCARE f W Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross 68645526J 11/17/2020 10/30/2020 11/24/2020 13"5 SUPPLIES 68693878,/11/17/2020 11/02/2020 11/27/2020 718.88 / SUPPLIES 68693841 v'11/17/2020 11/02/2020 11/27/2020 526.44 SUPPLIES Vendor Totals: Number Name Gross Discount B1150 BAXTER HEALTHC/ 1,376,57 0,00 Ventlor# Vendor Name Class 13264 CERVEY, LLC �, Invoice# /Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross 1808 ✓ 11H0/2020 11/09/2020 12/04/2020 1,699.00 MONTHLY LICENSING FEE Vendor Totals: Number Name Gross Discount 13264 CERVEY, LLC 1,699.00 0.00 Vendor# Vendor Name Class 13572 COMMUNITY INFUSION SOLUTION Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross IC20200829 14/19/2020 08/26/2020 08/26/2020 21,000.00 OUTPATIENT INFUSION CENTER 1% 000-p0 IC20201119 V/19/2020 11/04/2020 11/04/2020 140,F100;00 OUTPATIENT INFUSION CENTER[ (W k rt W c av,t ClikcVa.4,, Vendor Totals: Number Name Gross Discount 13572 COMMUNITY INFUE 161,�0.00 3' ar(U17,� 0,00 Vendor# Vendor Name Class 10789 DISCOVERY MEDICAL NETWORK Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross MMC111520 p,(17/2020 11/15/2020 11/15/2020 146,604.57 PRO FEES PhJSc+an('v%4US t4OV. i-(S ,-M-747 Vendor Totals: Number Name Gross Discount 10789 DISCOVERY MEDIC 146,604.57 0.00 Vendor# Vendor Name Class 11291 DOWELL PEST CONTROL y/ Invoice# , Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross 19476/ 11/17/2020 10/31/2020 11/25/2020 505.00 PEST CONTROL 19475 J 11/17/2020 10/31/2020 11/25/2020 160.00 file:/I/C;/Users/mmekissacktcpaltmemmed.apainet.comfu88150a/data_5/tmp_cw5reportl576839964518496019.html No -Pay 0.00 Pay Code Discount No -Pay 0.00 0.00 0.00 0.00 0= 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 No -Pay 0.00 Pay Code Discount No -Pay 0.00 0.00 0.00 0.00 0.00 0.00 Net 5,460.51 Net 1,576.25 1,477.50 f 2,290.00 v< 6,345.00 2,656,25 2,802,50 2,422.50 Net 18,570.00 Net f 132.25 y 718.88 525.44 No -Pay Net 0.00 1,376.57 Pay Code Discount No -Pay Net 0.00 0.00 1,699.00 No -Pay Net 0.00 1,699.00 Pay Code Discount No -Pay Net 0.00 0.00 21,000.00 ✓ 1*1)00.A7 0.00 0.00 140A00:00 �/ No-Pay'35.uw w Net 0.00 161,000.00 Pay Code 1 Discount No -Pay Net 0.00 0.00 146,604.57 No -Pay Net 0.00 146,604,57 Pay Code Discount No -Pay Net 0.00 0.00 505.00 0.00 0.00 160.00 v' 2/10 r unp_cwbmPortl576839964518496019,html PEST CONTROL 19327 11/17/2020 10/31/2020 11/25/2020 105.00 0.00 0.00 105,00 PEST CONTROL 19477 11/17/2020 10/31/2020 11/25/2020 260:00 0.00 0.00 260.00 PESTCONTROL Vendor Totals: Number Name Gross Discount No -Pay Net 11291 DOWELL PEST COP 1,030.00 0.00 0.00 11030.00 Vendor# Vendor Name Class Pay Code D1710 DOWNTOWN CLEANERS wf W Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 110120 11/17/2020 11/01/2020 11/11/2020 361.90 0.00 0.00 361.90 ✓� LAUNDRY VendarTotals: Number Name Gross Discount No -Pay Net D1710 DOWNTOWN CLEAT 361,90 0.00 0,00 361.90 Vendor# Vendor Name Class Pay Code 12488 / C DURFOLDORPORATION. ✓ Invoice# omment Tran Dt Inv Dt Due Dt Check Or Pay Gross Discount No -Pay Net IN7784 '1�11/17/2020 11/09/2020 12/09/2020 1,412.16 0.00 0.00 1,412.18 SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net 12488 DURFOLD CORPOF 1,412.16 0.00 0.00 1,412.16 Vendor# Vendor Name Class Pay Code E3400 EMERGENCY MEDICAL PRODUCTM ✓! Invoice# Comment Tran Dt Inv Dt Due Dt Check Ot Pay Gross Discount No -Pay Net 2211252 ✓J 11/17/2020 10/30/2020 11/17/2020 90.87 0.00 0.00 90.87 SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net E3400 EMERGENCY MEDI 90.87 O,OD 0.00 90.87 Vendor# - Vendor Name Class. Pay Code 11284 EMERGENCY STAFFING SOLUTIO Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 39722 ✓ 11/18/2020 11/15/2020 111I5/2020 40,062.50 0.00 0.00 40,062.50 v' PRO FEES If I'I'o ti.1 Vendor Totals: Number Name Gross Discount No -Pay Not 11284 EMERGENCYSTAF 40,062.50 0.00 0.00 40,082.50 Vendor# Vendor Name Class. Pay Code 10042 ERBE USA INC SURGICAL SYSTB .-' Invoice# Comment Tran Dt Inv Dt Due Dt 640385 11/17/2020 Cheek Ot Pay Gross Discount No -Pay Net �/ 11/02/2020 11117/2020 157.24 0.00 0.00 157.24 SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Not 10042 ERBE USA INC SUF 157,24 0.00 0.00 157.24 Vendor# Vendor Name Pay Code 10689 FASTHEALTH CORPORATION /Class Invoice# 07%'�ment Tran Dt Inv Dt Due Dt Check. Dt Pay Gross Discount No -Pay Net 11A20MMC ✓11/18/2020 11/01/2020 11/16/2020 1.ogg.t09900 0.00 0.00 99voo 414' WEBSITE( VN M t) Ar,•,i' tA(tyI JL) 11820MMC,/i �1/18/2020 11/03/P020 11/18/2020 100.00 0100 0.00 100.00, / STANDARD SSL Vendor Totals: Number Name Gross Discount No -Pay Net 10689 FASTHEALTH CORE 6q'� 1d1 1,09p100 0.00 0.00 1,0g0.cn 9'151 Vendor# Vendor Name Class Pay Code F1403 FISHER & PAYKEL HEALTHCARE M Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net / 90930621 ✓ 10/28/2020 10/20/2020 12/04/2020 61.38 0.00 0.00 61.38v✓'' SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net F1403 FISHER & PAYKEL 1 61.38 0.00 0.00 61.38 Vendor# Vendor Name Class Pay Code F1400 FISHER HEALTHCARE >/ M Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net file:///C:/Users/rnmckissack/cpsi/memmed.cpsinet:com/u$8150a/data_5/tmp_cw5roport1576839964518496019.html 3/10 • ------- ' / tmp_oWSreport1576839964518496019.html 2120750 J 11/18/2020 10/28/2020 11/22/2020 193.50 0100 0,00 193.50 t,! SUPPLIES 2236156 ✓11/18/2020 10/29/2020 11/23/2020 484.64 0.00 0.00 484.64 SUPPLIES 2236168 ✓- 11/18/2020 10/29/2020 11/23/2020 10.64 0100 0.00 10.64 11/ SUPPLIES 2236183.,E11118/2020 10/29/2020 11/23/2020 52.75 0.00 0100 52.75 / SUPPLIES ✓ �/ 2236177 11/18/2020 10/29/2020 11/23/2020 1,746.98 0.00 0100 1,746.98 SUPPLIES 2383290 r/'11/18/2020 10/30/2020 11/24/2020 165.86 0,00 0.00 165.86 V " / SUPPLIES 2383291 ✓ 11/18/2020 10/30/2020 11/24/2020 165,86 0.00 0A0 165.86 y/ / SUPPLIES 2383292 ✓11/18/2020 10/30/2020 11/24/2020 23.42 0.00 0.00 23.42 f SUPPLIES 2590222./ 11/18/20PO 11/04/2020 11/29/2020 379.15 0.00 0.00 379.15,,.E SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net F1400 FISHER HEALTHCA 3,222.80 0,00 0,00 3.222.80 Vendor# Vendor Name . Class Pay Code 11184 FLDR DESIGNS LLC / Invoice# Comment Tran Dt Inv Dt Due Ot Check Ot Pay Gross Discount No -Pay Net 15355 11/16/2020 09/24/2020 11/16/2020 1,279.70 0.00 0.00 1.279.70 SUPPLIES PPf({jpv{ fcKjj ju, 7., .;1 • 15357 11/16/2020 09/30/2020 11/16/2020 1,952.24 0.00 0.00 1,95224 SUPPLIES/FOLDERS QAtn:ilYMtlt3f✓"°ydh''_i"''I='k: r) j„i,jaLtri Vendor Totals: Number Name Gross Discount No�Pay Net 11184 FLDR DESIGNS LLC 3,231.94 0,00 0.00 3.231.94 Vendor# Vendor Name Cla Pay Code 12944 FRASIER HEALTHCARE CONSULT Invoice# (.Comment Tran Dt Inv Dt Due Dt Check Dt pay Gross Discount No -Pay Net 19040 ✓ 11/16/2020 11/09/2020 11/16/2020 9,140.16 0.00 0.00 9,140,15 6,,/ COLLECTIONS Vendor Totals: Number Name Gross Discount No -Pay Net 12944 FRASIER HEALTHC 9,140.16 0.00 0.00 9,140.16 Vendor# W1300 Vendor Name Class GRAINGER yi M Pay Code Invoice# Com t T Ten ran Ot Inv Dt Due Ot Check Dt Pay Gross Discount No -Pay 9698223626 A/17/2o20 10l26/2o20 11/22/2o20 54.04 0.00 0.00 � SUPPLIES 9702340325 Wl/17/2020 10/30/2020 11/24/2020 62,38 0.00 � SUPPLIES 9702373151 d'1/17/2020 10/30/2020 11/24/2020 312.00 0.00 q1 017j:l5U a-7 SUPPLIES 40842 11/17/2020 11/02/2020 11/27/2020 1,028.50 0.00 SUPPLIES Vendor totals: Number Name Gross Discount NO -Pay W1300 GRAINGER 1,456.92 0.00 0.00 Vendor# Vendor Name Class Pay Code G1210 GULF COAST PAPER COMPANY 4 Invoice# C 0.00 0.00 Net 54.04 V" 62,38L, " 0.00 1,028.50 y,/ Net 1,456.92 omment Tran Dt Inv Dt Due Dt Check Dt 1955047Z11/11/2020 11/0W2020 Pay Gross Discount No -Pay Net 12/03/2020 64.11 0.00 0.00 64,11v SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net G1210 GULF COAST PAPE 64.11 0.00 0.00 64.11 Vendor# Vendor Name Class Pay Coda 11552 HEALTHCARE FINANCIAL SERVICI Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 100379224 .11`1/17/2020 10/27/2020 12/01/2020 PHONE/STE 4,610.52 0100 0.00 4,610.52 ' RLIZER/GEM PREM 4k filet/IC:/Users/mmckissack/cpsi/memmed.cpsinet.com/u$8150a/data 5/tmp_cw5report1576839964518496019.html 4110 If mr<veo t tmp_cwarepon1ornoeaao4otu4at II J.ntmi t 100385688 v11/17/2020 11/06/2020 12/01/2020 1,797.44 0.00 0.00 1,797.44 t// LEASE 100385865 y11/17/2020 11/08/2020 12JO112020. 4,919.41 0.00 0.00 4,919.41 v✓ LEASE ��, 100385686 ✓I1/17/2020 11/06/2020 12/01/2020 7,154.17 0.00 0.00 7,154.17 LEASE 100385687y41117/2020 11/06/2020 12/01/2020 7,447.86 0.00 0.00 7,447.86 LEASE Vendor Totals: Number Name Gross Discount No -Pay Not 11552 HEALTHCARE FINA 25,929.40 0.00 0.00 25,929.40 Vendor# Vendor Name Class Pay Code H0031 HEB CREDIT RECEIVABLES DEP-R , Invoice# lornment Tran Dt. Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 255264 11/19/202D 09/28/2020 11/25/2020. 24.20 0.00 0.00 24,20,, �' SUPPLIES 584743 ✓/ 11/19/2020 10/01/2020 11/25/2020 112,94 0.00 0.00 112.94,„ , SUPPLIES 586413 ✓ 11/19/2020 10/05/2020 11/25/2020 45.50 0.00 0.00 45.50t,,/ SUPPLIES 586712 ✓ 11/19/2020 10/06/2020 11/25/2020 53.87 0.00 0.00 53.87,„/ SUPPLIES 587181 ✓ 11/19/2020 10/06/2020 11/25/2020 34.68 0.00 0.00 34.6B y, ' SUPPLIES 588570,/ 11/19/2020 10/08/2020 11/26/2020 13.87 0.00 0.00 13,87 y! SUPPLIES 588103 ✓ 11/19/2020 10/08/2020 11/25/2020 19.90 0.00 0.00 19.90 SUPPLIES 589766✓ 11/19/2020 10/11/2020 11/25/2020 65.17 0.00 0.00 55.171/' SUPPLIES 731356 11/19/2020 10/15/2020 11/25/2020 39.97 0.00 0.00 39.97 / SUPPLIES 319788�/ 11119/2020 10/17/2020 11/25/2020 34.40 0.00 0.00 34.40 ✓� SUPPLIES 213127 „/ 11/19/2020 10/24/2020 11/25/2020 37.16 0.00 0.00 37a6,,/ SUPPLIES 260968 ✓1 11/19/2020 10/25/2020 11/25/2020 49.97 0.00 0.00 49.97 ✓f / SUPPLIES 259310 a/ 11/1912020 10/25/2020 11/25/2020 61.99 0.00 0.00 61.991111� SUPPLIES 329777 V/11/19/2020 10/26/2020 11/25/2020 139.74 0.00 0.00 139.741,,+'� SUPPLIES Vendor Totals:. Number Name Grass Discount No -Pay Net H0031 HEB CREDIT RECEI 723.36 0.00 0.00 723,36 Vendor# Vendor Name Class Pay Code 11692 INJOY HEALTH EDUCATION / Invoice# CoTment Tran Ot Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Not INV333438%AI/16/2020 11/21/2020 ll/21/2020 225.00 0.00 0.00 225.00 WEB APP ANNUAL PORTAL FEE Vendor Totals: Number Name Gross Discount No -Pay 11692 INJOY HEALTH EDL 225.00 0.00 0.00 Vendor# Vendor Name Class Pay Code L1288 LANGUAGE LINE SERVICES j✓ W Invoice# Comment Tran DI Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay / 4887792 ✓ 11/17/2020 09/30/2020 10/25/2020 41.28 0.00 0.00 interpertation 4901722,%11/17/2020 10/31/2020 11/25/2020 41.28 0.00 INTERPERTATION SERVICES Vendor Totals: Number Name Gross Discount No -Pay L1288 LANGUAGE LINES[ 82,56 0.00 0.00 Vendor# Vendor Name Class Pay Code L1640 LOWE'S HOME CENTERS INC /W file:///C:/users/mmckissack/cpsilmemmed.cpsinet.com/u88150aldata_5/tmp_cw5report1576639964518496019.html Net 225.00 Net 41.28� 0.00 41.28 Net 82.56 5/io • ���� Imp cWOreponl 01M $J%fUt54a16495UI 9.ntml ' r Invoice# Comment Tram Dt Inv Dt Due Ot Check Dt Pay Gross Discount No -Pay Nat 11591 f 11/19/2020 10/28/2020 11/28/2020 132.66 0.00 0,00 132.66 SUPPLIES 36231,/ 11/19/2020 10/29/2020 11/28/2020 -10.11 0.00 0.00 -10.11 41-1 REFUND TAXES 85665 Z 11/19/2020 10/30/2020 11/28l8020 539.11 0.00 0.00 539.11 SUPPLIES t% Vendor Totals: Number Name Gross Discount No -Pay Net L1640 LOWE'S HOME CEN 661.66 D.DO 0.00 661.66 Vendor# Vendor Name Cass Pay Code J1350 M.C. JOHNSON COMPANY INC Invoice# Comment Tran Dt Inv Dt Due Dt ",M Check Dt Pay Gross Discount No -Pay Net 00385580 r,,f1/17/2020 11/02/2020 11/17/2020 104.25 0.00 0.00 104,25 tr' SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net J1350 M.C. JOHNSON COI 104.25 0.00 0.00 104.25 Vendor# Vendor Name Class, Pay Code M2178 MCKESSON MEDICAL SURGICAL 1 v,/ Invoice# Co moot Tran Dt Inv Dt Due Ot Check Dt Pay Gross Discount No -Pay Net 13469824 11/1781/20 09/18/2020 10/03/2020 163.59 0.00 0.00 163.59 ✓ SUPPLIES 11/17/2020 15145592,e 11/02/2020 11/17/2020 14.86 0.00 0.00 14.86 Wr SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net M2178 MCKESSON MEDIC 178,45 0.00 0.00 178,45 Vendor# Vendor Name Class Pay Code 10613 MEDIMPACTHEALTHCARE SYS, It A/P Invoice# Comment Tran Dt Inv Dt Due Dt t/ Check Dt Pay Gross Discount No -Pay Net 111620 11/18/2020 11/16/2020 11/16/2020 71.26 0.00 0.00 , J 71.26 INDIGENT Vendor Totals: Number Name Gross Discount No -Pay Net 10613 MEDIMPACT HEAL1 71.26 0.00 0.00 71.26 Vendor# Vendor Name Class Pay Code M2470 / MEDLINE INDUSTRIES INC �1 M Invoice# Com ent Tran Dt Inv Dt Due On Check Dt Pay Gross Discount No -Pay Net 1928677357 /18/2020 10/24/2020 11/18/2020 616.38 0.00 0.00 616.38 t% // SUPPLIES 1929869960 %t /18/2020 11/04/2020 11/29/2020 6,302.17 0.00 0.00 6.302.77 t,/r �// SUPPLIES 19208899six /18/2020 11/04/2020 11/29/2020 132.93 0.00 0.00 132.93 � SUPPLIES 1929869961,1'1/18/2020 11/04/2020 11/29/2020 188.42 0.00 0.00 188.42 SUPPLIES 1929869951 al' 1/18/2020 11/04/2020 11/29/2020 203.00 0.00 0.00 203.00 t/! � SUPPLIES 1929889954,,,i1/18/2020 11/04/2020 11/29/2020 42.48 0,110 0.00 42.4811. SUPPLIES 1929869950J4 18/2020 11/04/2020 11/29/2020 78.32 0.00 0.00 / SUPPLIES 1929869962 j4/18/2020 11/04/2020 11/29/2020 24.94 0.00 0.00 24.94 y+� SUPPLIES 1929869955 V/18/2020 11/0412021) 11/29/2020 18.57 0.00 0.00 18.57 SUPPLIES 1929869957 LI/ 8/2020 11/04/2020 11/29/2020 1,371.01 0.00 0.00 1,371.01 6 / SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net M2470 MEDLINE INDUSTR 8,976.82 0.00 0.00 8,976.62 Vendor# Vendor Name Class Pay Code 10536 MORRIS & DICKSON CO,. LLC Invoice# Comment Tran Dt Inv Dt Due Dt 6273175 /11/17/2020 Check Dt Pay Gross Discount No -Pay Net 11/11/2020 11/21/2090 338.35 0.00 0.00 338.35 .% nie:///C:/Users/mmckissacktcpsi/memmed.cpsinet.com/U88i50a/data_5/Imp_OwSreportl576839964618496019.html 6110 [mp_cworepottmrtltl4a9ti4b184ytiu79.html SUPPLIES 6273858 /11/1712020 11/11/2020 11/21/2020 24.46 0,00 0.00 24.46 L,+ INVENTORY 6271982�/ 11/17/2020 11/11/2020 11/21/2020 434.26 0.00 0.00 434.25 L, • INVENTORY 6276838✓ 11/17/2020 11/12/2020 11/22/2020 938,18 0,00 0.00 938.18t✓ INVENTORY 6279643 "11/17/2020. 11/12/2020 11/22/2020 95.22 0.00 0.00 95.22 v INVENTORY 8279644 1/17/2020 11/12/2020 11/22/2020 541.17 0.00 0.00 541.17 �..� / INVENTORY 6276837 r./ 11/17/9020 11/12/2020 11/22/2020 28.36 0.00 0.00 28:361,-, - INVENTORY 6278118// 11/17/2020 11/12/2020 11/22/2020 78.07 0.00 0.00 78.07 INVENTORY 6278117 11/17/2020 11/12/2020 11/22/2020 21.88 0.00 0.00 21.88 /' INVENTORY 6279645 6/11/17/2020 11/12/2020 11/22/2020 172.79 0.00 0.00 179.79 j'� INVENTORY 6276835,%11/17/2020 11/12/2020 11/22/2020 4,637.70 0.00 0.00 4,537.70 6276834 vf11/17/2020 11/12/2020 11/22/2020 3,390.58 0.00 0.00 3,390.584,/' INVENTORY 6276836 ✓11/17/2020 11/12/2020 11/22/2020 5.770.73 0.00 0.00 6,770.73 INVENTORY 6286139 11/17/2020 11/15/2020 11/25/2020 505.72 0.00 0.00 505.72 INVENTORY 6286138 ,/ 11/17/2020 11/15/2020 11/25/2020 102.29 0100 0.00 102.29 t,/ INVENTORY 6286140 /111117/2020 11/15/2020 11/25/2020 39.32 0.00 0.00 39.32 ,,�� INVENTORY 6284239 „/ 11/17/2020 11/15/2020 11/25/2020 52.05 0.00 0.00 52.05 INVENTORY /11/19/2020 6964240 11/15/2020 11/25/2020 102.42 0.00 0.00 102.42:.� INVENTORY Vendor Totals: Number Name Gross Discount No -Pay Net 10536 MORRIS & DICKSOI 17,173.54 0.00 0.00 17,173.54 Vendor# Vendor Name / Class Pay Code M2659 MXR IMAGING, INCH"' M Invoice# Comrfent Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 8800686768%11/17/2020 11/03/2020 12/03/2020 181.80 0.00 0.00 181.80✓' SUPPLIES Vendor Totals: Number Name Grass Discount No -Pay Net M2659 MXR IMAGING, INC 181.80 0.00 0.00 181.80 Vendor# Vendor Name Class, Pay Code 13548 NACOGDOCHES TRANSCRIPTION ./ Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 7205 11/17/2020 11/13/2020 536.20 0.00 0.00 536.20", Vendor Totals: Number Name Gross Discount No -Pay Net 13548 NACOGDOCHES TF 536.20 0.00 0.00 536.20 Vendor# Vendor Name Class Pay Code 01500 / OLYMPUS AMERICA INC ✓ M Invoice# Cc�ment Tran Dt Inv Dt Due DI Check Ot Pay Gross Discount No -Pay Net 30002129 .f11/17/2020 11/02/2020 11/27/2020 289.51 0.00 0.00 289.51 SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net 01500 OLYMPUS AMERIQ 289.51 0.00 0.00 289.51 Vendor# Vendor Name Class Pay Code P0706 / PALACIDS BEACON ✓ w Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net file:NC:/Users/mmckissack/cpsi/memmed.opsinet.com/u88150a/data S/tmp_cw5repod1576839964518496019.html 7/10 onp_cworeponl b/6839964518496019.html �,// 33067628 .t' 11/18/20200 10/26/2020 11/26/2020 187.50 0.00 0.00 187.50�' AD Vendor Totals: Number Name Gross Discount No -Pay Net P0706 PALACIOS BEACON 187.50 0.00 0.00 187.50 Vendor# Vendor Name Class Pay Code 12544 PATRICK OCHOA / Involce# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Not 110120 11/16/2020 11/01/2020 11/01/2020 380.00 0.00 0.00 / 380.00 Y CLINIC LAWN 110120E 11/18/2020 11/01/2020 11/01/2020 200.00 0.00 0.00 200.00,,i r REHAB LAWN 110120A 11/18/2020 11/01/2020 11/01/2020 520.00 0.00 0.00 520.00 HOSPITAL LAWN t/ Vendor Totals: Number Name Gross Discount No -Pay Not 12544 PATRICK OCHOA 1,100.00 0.00 0.00 1,100.00 Vendor# Vendor Name Class Pay Code 12480 PRO ENERGY PARTNERS LP Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 20100600 r41/1812020 10/31/2020 11/16/2020 2.940.36 0.00 0.00 2,940.36 ✓Z GAS Vendor Totals: Number Name Gross Discount No -Pay Net 12480 PRO ENERGY PAR- 2,940.36 Oleo 0.00 2.940.36 Vendor# Vendor Name Class Pay Code 10896 OIAGEN INC /� Invoice# Co ment Tran Dt In14' t Due Dt Check Dt Pay Gross Discount No -Pay Net 997571245, 1/17/2020 10/28/2020 11/27/2020 1,627,69 Oleo 0.00 1,627.69 SUPPLIES Vendor Totals: Number Name Gross Discount No -Pay Net 10896 OIAGEN INC 1,627.69 0.00 0.00 1,627.69 Vendor# Vendor Name Class Pay Code 10987 REVCYCLE+,INC. I/ Involce# /'Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 40514 ✓ 11/17/2020 11/04/2020 11/29/2020 1,926.35 0.00 0.00 1,926,35 COOING SERVICE Vendor Totals: Number Name Gross Discount No -Pay Not 10907 REVCYCLE+, INC. 1,926.35 0.00 0.00 1,926.35 Vendor# Vendor Name Class Pay Code 10936 SIEMENS FINANCIAL SERVICES Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 5638210000:111i 7/2020 10/30/2020 11/24/2020 lq b 1,333.33 0.00 0.00 1,333.33 , LEASE AND RENTAL AGREEMENT 5638210000t11/17/2020 11/02/2020 11/20/2020 4,038.24 0.00 0.00 4,038.24✓"- 'J;1 j LEASE Vendor Totals: Number Name Grass Discount No -Pay Not 10936 SIEMENS FINANCIA 6,371.57 0.00 0.00 5,371.57 Vendor# Vendor Name Class Pay Code 10195 SINGLETON ASSOCIATES PA / ICP Involce# Comment Tran Dt Inv Dt Due Dt/ Check Dt Pay Gross .Discount No -Pay Net 9019 V/11/16/2020 07/10/2018 11/16/2020 1,182.94 0.00 0.00 1,182.94,/ CONTRACT BILLING 9017 ,r' 11/16/2020 07/10/2018 11/16/2020 1,143.74 0= 0.00 1,143.74y.✓ CONTRACT BILLING 9024 11/16/2020 07/01/2010 11/16/2020 1,075.02 0.00 0.00 1,075.02 1/ CONTRACT BILLING 9023 �� 11/16/2020 07/01/2019 11/16/2020 11009.80 0.00 0.00 1,009.80 " CONTRACT BILLING 9025 11/16/2020 07/22/2019 11/16/2020 856.37 0.00 0.00 858.37 ✓,- j CONTRACT BILLING 9026 �f 11/16/2020 08/09/2019 11/10/2020 2,084.53 0.00 0.00 2,084.53 CONTRACT BILLING 9027 / 11/16/2020 10/08/2019 11/16/2020 2,179.21 0.00 0.00 2,179.21 if file:///C:/Users/mmekissecktopsi/memmed.cps(not.com/u88150afdata 5/tmp_cw5reportIS76839964518496019.html silo �•���� Imp_cwbrepon1576839964518496019.html • r CONTRACT BILLING 9018A 11/16/2020 07/10/2020 11/16/2020 976.69 0.00 0.00 976.69 CONTRACT BILLING V� 761 / 11/16/2020 08/27/2020 11/16/2020 d 10.91 0.00 0.00 10.91 CONTRACT BILLING 542 ✓ 11/16/2020 09/03/2020 11/16/2020 2,101.25 0.00 0.00 2,101.25 f CONTRACT BILLING 613 11/16/2020 09/09/2020 11/16/2020 150.56 0.00 0.00 150.564,.'� / CONTRACT BILLING 1051 ✓ 11/16/2020 09/10/2020 11/16/2020 22.37 0.00 0.00 22.37✓ • CONTRACT BILLING 521A✓r11/16/2020 09/16/2020 11/16/2020 51.57 0.00 0.00 51.57 ✓- CONTRACT BILLING 523 / 11/16/p020 09/16/2020 11/16/2020 39.16 0.00 0.00 39.16 CONTRACT BILLING 522 ,% 11/16/2020 09/16/2020 11/16/2020 85.19 0.00 0.00 85.19 CONTRACT BILLING 105211/16/2020 09/29/2020 11/16/2020 104.61 0.00 0.00 104.61 CONTRACT BILLING 514 11/16/2020 09/29/2020 ,,� 11/16/2020 120.01 0.00 0.00 120.01 i / CONTRACTBILLING 524 �.�` 11/16/2020 09/29/2020 11/16/2020 19.64 0.00 0.00 19.64 CONTRACT BILLING / 541 ✓ 11/16/2020 10/09/2020 11/16/2020 1,326.02 0.00 0.00 1,326.02✓j CONTRACT BILLING 525 11116/2020 10/22/2020 11/16/2020 57.90 0.00 0.00 57.90 p% CONTRACT BILLING 762 ,,i 11/16/9020 10/22/2020 11/16/2020 10.91 0.00 0.00 10.91 j CONTRACT BILLING ✓ 515 ✓ 11/16/2020 10/22/2020 11/16/2020 109.10 0.00 0.00 109.10 �. CONTRACT BILLING Vendor Totals: Number Name Gross Discount No -Pay Net 10195 SINGLETON ASSOC 14,719.60 0.00 0.00 14.719,50 Vendor# Vendor Name Class Pay Code 12440 SUN LIFE ASSURANCE COMPANY ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 101620 11/17/2020 10/16/2020 11/01/2020 2,441.69 0.00 0.00 2,441.69 INSURANCE ✓ Vendor Totals: Number Name Gross Discount No -Pay Net 12440 SUN LIFE ASSURAI, 2,441.69 0.00 0.00 2,441.69 Vendor# Vendor Name Class Pay Code T2539 T-SYSTEM, INC ✓ W Invoice# /Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 39947 ,/ 10/31/2020 10/27/2020 11/30/2020 431.42 0.00 0.00 431.42,/ ERX LICENSE 40045 ✓ 10/31/2020 10/31/2020 11/30/2020 5.699.00 0.00 0.00 5,699.00 �. TRACKING/STAT/CLOUD HOSTINC Vendor Totals: Number Name Gross Discount No -Pay Net T2539 T-SYSTEM, INC 6,130.42 0.00 0.00 6,130,42 Vendor# Vendor Name Class Pay Code 11944 TALX CORPORATION ✓� Invoice# Cc��ment Tran Ot Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 1002130880✓11/1012020 11/08/2020 12/08/2020 10,99 0.00 0.00 10.99 EMPLOYEE VERIFICATION Vendor Totals: Number Name Gross Discount No -Pay Not 11944 TALX CORPORATIC 10.99 0.00 0.00 10.09 Vendor# Vendor Name Class Pay Code 11100 THE US CONSULTING GROUP ✓ Invoice# Coniment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net 340380481/11117/2020 11/01/2020 11/26/2020 245.47 0.00 0.00 248.47 ./ TRASH SERVICE file:///CaUserslmmckissack/cpsi/memmed.cpsinetoom/u88150a/data_5/tmp_cw5reportt 576839964518496019.html 9110 I II I `J/cucu tuly_uwJrkfiJCll a ur uoJn.Yu4a wY00 V , C.uum ` 340380480 J4/17/2020 11/01/202D 11/26/2020 2,037.62 0.00 0.00 2,037.62 tf•. TRASH SERVICE Vendor Totals; Number Name Gross Discount No -Pay Net 11100 THE US CONSULTII 2,286.09 0.00 0.00 2,286.09 Vendor# Vendor Name Class Pay Code 10732 THERACOM, LLC Invoice# Comment Tran Ot Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 2197386883f^09/29/2020 09/08/202D 12/07/2020 1,564.08 0.00 0.00 1,564.08� 30 INVENTORY Vendor Totals Number Name Gross Discount No -Pay Net 10732 THERACOM, LLC 1,564.08 0.00 0.00 1,564.08 Vendor# Vendor Name Class Pay Code T2250 THYSSENKRUPP ELEVATOR CORI M. ✓ Invoice# Com�ant Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 5001376739 a.1717/2020 10/15/2020 10/15/2020 834.00 0.00 0.00 834.00 OIL GREASE Vendor Totals: Number Name Gross Discount No -Pay Net T2260 THYSSENKRUPP El 834,00 0,00 0.00 834.00 Vendor# Vendor Name Class Pay Cade 11067 TRIZETTO PROVIDER SOLUTIONS Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 36FK112000VI1612020 1V01/2020 11/26/2020 1,964.96 0.00 0.00 1,964.96 PT STATEMENT Vendor Totals: Number Name Gross Discount No -Pay Net 11067 TRIZET70 PROVIDI 1,964.96 0.00 0.00 1,964.96 Vendor# Vendor Name Class Pay Code U1054 UNIFIRST HOLDINGS dr. W Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 840034718BJ4/18/2020 11/09/2020 12/04/2020 45,15 0.00 0.00 45.16,/ LAUNDRY 8400347189 a4/18/2020 11/09/2020 12/04/2020 42,07 0.00 0.00 42.07 LAUNDRY 8400347213111%18/2020 11/09/2020 12/04/2020 854.81 0.00 0.00 854,81 ✓ LAUNDRY 8400347583,,,11/18/2020 11/12/2020 12/07/2020 139.04 0.00 0.00 139.04 ✓ - LAUNDRY 8400347564A,(11812020 11/12/2020 12/07/2020 240.73 0.00 0.00 240.73 LAUNDRY 8400347562 14% 812020 11/12/2020 12/07/2020 217.32 0.00 0.00 217.32 LAUNDRY 840034756111/1812020 11/12/2020 12/07/2020 121.55 0.00 0.00 121.55 LAUNDRY 84003475751�Y41812020 11/19/2020 12/07/2020 76.49 0.00 0.00 76.49,,,,�- LAUNDRY 8400347594.1]/18/2020 11/12/2020 12/07/2020 1,248.36 0.00 0.00 1.248.36 V LAUNDRY 8400347659 A/18/2020 11/12/2020 12107/2020 22.57 0.00 0.00 22.87 LAUNDRY Vendor Totals: Number Name Gross Discount No -Pay Net U1054 UNIFIRST HOLDINC 3,008.09 0.00 0.00 3,008.09 Vendor# Vendor Name Cla§s Pay Code 10943 WALLER,LANSDEN, DORTCH & Dd Invoice# Comment Tran Dt Inv Dt Due Ot Check Dt Pay Gross Discount No -Pay Net 4r2�9�064460M.,A%18/2020 11/11/2020 11/11/2020 312.00 0.00 0.00 312.00 D�D'F l7 I LEGAL jr Totals: Number Name Gross Discount No -Pay Net 6 4 - 343 WALLER,LANSDEN, 312,00 0.00 0.00 312,00 ,i• �� , Gross Discount No -Pay Net I i51�82'�.614ja�?I Ili - 0.00 0.00 510,827.64 �iV01000.005 j'�?<Wrvu.hW1 Ttu! oo0, 1GNH0,00:10/10 ao 4 J 5 U U ;psJmemme8tcpsinet conGt188A60a/data_5/tmp_cw5mport15766398fi451849601 111Ytld�t,(rypr}layx � ��� . . ,• M .. 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G r C 0 =E 0`a V m J r fJ N Q F O QF m nU # W Z U H Z '�- P 9 �rc 3 y�o 13 a t O '01E �i m O :° o a d L.G E mrmm m mmm a mo�i a m T C �' mm m a of0mr 0 r `axmySSmrS$$m E N� Mpg pN N o y' t� u,�d„�bd N2 NNNmNN d.6dn�bN O N N ad+ F- � TOLL FEE PHONE NUMBER: 1-800-555-3453 (EFTPS TUTORIAL SYSTEM: 1-800-572-8683) "ENTER 9-DIGIT TAXPAYER IDENTIFICATION NUMBER" Q"ENTER YOUR 4-DIGIT PIN" "MAKE A PAYMENT, PRESS 1" "ENTER THE TAX TYPE NUMBER FOLLOWED BY THE # SIGN" ETIF FEDERAL TAX DEPOSIT ENTER 1" "ENTER 2-DIGIT TAX FILING YEAR" "ENTER 2-DIGIT TAX FILING ENDING MONTH" 1ST QTR - 03 (MARCH) -Jan, Feb, Mar 2ND QTR - 06 (JUNE) - Apr, May, June 3RD QTR - 09 (SEPTEMBER) - July, Aug, Sept 4TH QTR -12 (DECEMBER) - Oct, Nov, Dec "ENTER AMOUNT OF TAX DEPOSIT - FOLLOWED BY # SIGN" "1 TO CONFIRM" "ENTER W/CENTS AMOUNT OF SOCIAL SECURITY" "ENTER W/CENTS AMOUNT OF MEDICARE" "ENTER W/CENTS AMOUNT OF FEDERAL WITHHOLDING" "6-DIGIT SETTLEMENT DATE" "1 TO CONFIRM" ACKNOWLEDGEMENT NUMBER #w ENTER: ### C` 941 # �" 20 �' 12 0 $ 96 759.62 , 1 $ 49,279.96 $ 11,936.92 $ 35,542.74 CHECK $ CALLED IN BY: CALLED IN DATE: CALLED IN TIME: F:%P•Paymil FileslPayrall Taxes%2020W24 MMC TAX DEPOSIT WORKSHEET 11.19.20.x15 1112312020 Run Date: 11/23/20 NIIORIAL I!EDICAL ul; cR Trine: 12:25 Payroll Recisc.r Bi-Weekly I Pay Per?od 11/06/2G - 17/10/26 pun, I Final Sutl_mary '-- P a y C 0 d e S u m m a r y .......................... � PayCd ------------ Descr eticn •.......................................... Ers Oi SH�HE�HO C9; 1 REGIHA9. PAY-Sl 10041,25 N 11 11 1 REGULAR PAY-SI 1710.25 V 11 IT II 1 REGULAR PAY-S! 315.25 Y ?I I; 2 REGULAR PAY-S2 2613.75 N N IT 2 RE-GLUaR PAY-S2 4.00 11 R IN 11 2 REGULA.R PAY-52 146.25 Y 9 11 1 REGULAR PAY-S2 .25 Y N N !; i REGULAR PAY-S 1575.25 IT 11 E 3 REGULAR PAY-S3 118.25 Y N 1; CALL EACR PAY v.DO N I !1 17 C CALL PAT 2348.50 1; 1 N 11 E EYTR.A WAGE5 11 11 IT N E EXTRA WAGES N I N 11 E EXTRA WAGES Ii 1 N !I I1 F PUMERAL LEAVE 30.00 11 i 11 1; INSERVICE 33.G0 N 1 11 It E FRTEINENILLNE59-3W 1?<.ee N 1 I! 11 • PAIC-TINE•OFF iE.70 N N N 11 P PAID -TIME -OFF 938.00 1! 1 IT 11 Y CALL PAY 2 234.00 17 1 11 N YMCA/CURVES N IT N, IT Z CALL PAY 3 96.00 N i N IT p PAID TIME OFF - PRCEAriON 12.N v COVID-FFCRA HAD E 1 I1 N pace 112 P2REG -----•--- - -Deductions 5emma r• Gross I Code Am,= ---•------------------•---•-- --... I97982.92 A/F. Tr0.00 A/P.2 123.OD AIRS 75566.41 ADVAIC WARDS SCOTS 8652.55 CAFE E CAFE-1 CAFE-2 59934.69 CAFE-3 CAFE-4 CAFE-E 278.00 CAFE-C CAFE-D 1,04.74 CAFE-F 457I.39 CAPE-R 16969.55 CAFE-1 CAFE-L 6.69 CAFE•P CUM CHILD 299.51 "252.34 CLINIC L6.OD CCM31?? 436.37 CF_T i 4795.22 DD AD), DENTAL, DEP-6F 1H.02 DIS-Li EAi EATCEti 4697.00 FEDTA% 35542.74 FICA-M 5966,46 FICA-0 24639.98 36.39 IIRS TC FUX S 4206.37 F-2 ,^•o 30.00 FORT D FLTA GIFT S 345,75 3a73 c0 GRAFT GRP-IN GIL 1081.55 ROSP•I ID IF- LRAF 989.52 LEGAL 385.08 I:kS, 619.D0 nus 196.62 5048,91 RISC MIBC/ IDICSRR 4774, 09 NA.M,IL 1997,12 OTEER PHI 23160.i7 PHI- PR FIN RELAY 466.00 REPAY SAIS SCRUBS 15.EI SIGNON ST-TX SICNDF 790.66 286.00 SMZ STONE2 STUDEN 145.90 MIAI: 886.43 SUIIILL 1267.26 SET :IF 1237.64 937, OG SDNSTD 103.55 SLIMS 1163.50 SDRCRG 670.00 ISA: 1 TSA-2 T3A-C TSA-P ISA-R 30572.90 TUTION 0,"FGR 2D13.62 L'dr'HOS • Checks Count:- FT 203 IT 4 Ocher 46 .eTale 224 Yale 29 Credit OverAmt^7�. 136e:7,9, t: Total: 253 1 �rard totals: 205"1.iG--..... (Gress: 4v754.79 DedLia o ---- - E--011et Tell ....... Q co m '0 N 10 u '14NII- rn C; cc cc r E vwn 0 J2 0 0 a 0 E cc > 0 z E w z 19 > 0 . z z in 3 0. in 0 0 0: CL L9 ry a c to z z ui N m y O N 0 M T N 'A CL w 0 0: PO m oO n G N yxi 0 0 a C tA z Ct -tr U u D < z < X u mo .'g! OI 0 0 it tmp_cwbreport8804908435087238117,html MEMORIAL MEDICAL CENTER 11:20 AP Open Invoice List Dates Through: Vendor#Vendor Name Class Pay Code G1r�.�'YCTadi:+=� 11'+uliF>p' GOLDENCREEK HEALTHCARE 0 ap_open_invoice.template Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay 111120A 11/18/2020 11/11/2020 12/18/2020 TRANSFER NN 'IftU'tkt U_ 9, Lt 111120 11/18/2020 11/11/2020 12/18/2020 V TRANNFER Ukt jl'lbtlyX(<.1..- 111320 11/18/2020 11/13/2020 12/t8/2020 pU t&t TRANSFER '�}j jf%ij(PtLtL n j 111620 11/18/2020 11 / 1612020 12/18/2020 TRANSFER tJjfSnb�."L(_ k..t Vendor Totals: Number Name 2,387.19 0.00 0.00 Cjlirritwt- ih}, (A'Atl_ Orun I- 176.00 00.00(J'�1�0.00 LI i.'70Si¢r-J- 33,414.61 0.00 0 0.00 kfoa,Uk- iwb Vkwk.c opu-� 3,998.12 0.000.00 �,r,� ��. Ag0tai'jzC� , n b hkK_ Optab Gross Discount No -Ay 11636 GOLDENCREEK HE 39.975.92 0.00 0.00 part un unary Grand Totals: Gross Discount No -Pay 39,975.92 0.00 0.00 ,..',7'p!1'.'/'!7!! ►t il.:_;1�R:�itl "71L',ia�• '.11-.iR">.; Net 2,387.19 yi 176.00 33,414.61 3,998.12 c,/ Net 39,976.92 Not 39,975.92 file:!/IC:IUsers/mmckissacklcpsi/memmed.cpsinet.com/u88150aldata 51tmp_cw5report8804908435087238117.html tlt tmp_cw5repod5088892941367223771.html 11/19/4p�029 f MEMORIAL MEDICAL CENTER 11:21i'��, `�•��! J� d AP Open Invoice List 0 Dates Through: ap_open_Invoice.tempiate Vendor Name Class Pay Code 12696 GULF POINTE PLAZA Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 111120 11/18/2020 11/11/2020 12/18/2020 2.789.67 0.00 0.00 2,789.67,/ TRANSFERN11 In``UVIINIL-No joilc(red. ail Wo "L, O'QCV�i"1`�' 111120A 11/18/2020 11/11/2020 12/18/2020 352.00 0.00E 0.00 352.00 TRANSFER N1{ 1j%lj yLU_ NVkj dLp0S3 }z�l 1r1.}I 1kWkC_ DVCV? Ily 111320 11/18/2020 11/13/2020 12/18/2020 20,660.37 0.00 0.00 % 20.660.37 TRANSFER N1i 1ylWR(1.L1. qmA JLf041 4- Mb MW-1~ D'pCm4i� 111620 11/18/2020 11/16/2020 12/18/2020 2,252.55 01.0�0 0.00 2,252.55 TRANSFER V" i"SOXIILL_P�0 Jo(;;i JZA- 111820A 11/18/2020 11/18/2020 111.11 MPAL- OpCA, 12/18/2020 10,912.00 0.00 0.00 10,912.00 1F TRANSFER NH IY1jlM44lL NVA{- 111820 11/18/2020 11/18/2020 12/18/2020 5,104.00 0.00,,, 5,104.00 TRANSFERN1 InSOypV.UL (7�IK1} QChOSi'ts� IM1-E1 VYv&L I0.00 ootkV_ i"! Vendor Totals: Number Name Gross Discount No -Pay Net 12696 GULF POINTE PLA2 42.070.59 0.00 0.00 42,070.59 I+corl-�rnmeia Grand Totals: Gross Discount NaPay Net 42,070.59 0.00 0.00 42,070.59 .T1M`7w list file:NC:/Usersfmmckissack/cpsi/memmed.cpsinet.com/u8815Ga/data_5/tmp_cw5report5088892941367223771.html 1/1 I --- tmp_ow5mport8313320356573589332.html v 11/19/✓ '� q �I�f� MEMORIAL MEDICAL CENTER 1122 AP Open Invoice List 0 ,^ _til!'Li 1Dates Through; !.. b4gyYi' ap_open_(nvoice.template+,t�r Vendor# Vendor Name Class Pay Code 13004 TUSCANY VILLAGE Invoice# Comment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net 111120 11/18/2020 11/11/2020 IPJ18/2020 3,313.81 0.00 0.00 3,313,81 TRANSFERVO illsv RkL pl�w 4014( W_ 14, WN.Wu, pPCX>` it - v 111320 11/18/2020 11/13/2020 12/18/2020 10,969.39 0.00) 0.00 10,969.39 ✓" TRANSFERNii IfiSOrkftU. `�gt- (CpDi/ toj- IR-61 "N-(.- Oft-ras-p, 111620A 11/18/2020 11/16/2020 12/18/2020 660.56 0.00 0.00 660.56 ,,1 TRASNSFER h/W JVjLWVMLL ?�Ri e{C�70h1 kL l vkb, 'wKw L.� fJ UpLyt{•�',.��- 111620 11/18/2020 11/16/2020�Iy112/18/2020 4,75L2`.00 0.00 ` 0.00 4,752.00 1l TRANSFER tJ" 1V1&VnYLLt_ roiIA:' J(PG1"�' & IA�o Kitt.L, 0PC"\ 1116208 11/18/2020 11/16/2020 12/18/2020 11,853.00 0.00 0.0 11,853.00 b% TRANSFER M1 I MMALL F91ltki aCnO raj 'I-P.�.I N-I-1 TvIC`'>•/— Uvi-Ylt 111820 11/18/2020 11/18/2020 12/18/2020 542.88 0.00 0.00 542.88/✓ TRANSFER Vo jVj&0Vi KjL Vytj Ij(poyl fed ,Rk MWNL 0peVI, 111820A 11/18/2020 11/18/2020 12/18/2020 4,176.97 TRANS�{ 'Inh, 0.00 0 / 4,176.97 V a�tfYMW-LQ- t Vendor Totals: NumberFER Gross Discount No-4y Net 13004 TUSCANY VILLAGE 36,268.61 0.00 0.00 36,268.61 nepn;t SLMp 11,1u1'11 Grand Totals: Gross Discount No -Pay Net 36,268.61 0.00 0.00 36,268.61 ,s1 NO, 51 19 29 ja n!� 9•h'p'� dd11(ltiiipg fils:///C:/Users/mmckissack/cpsi/memmed.cpsinet.com/u88150a/data_5/tmp_cw5report8313320356573589332.html 1/1 [mp_bwbrepon62UU61929/Z66448445.html 11/19/2o201\1Qty ! 11:23 MEMORIAL MEDICAL CENTER AP Open Invoice List ft,,;ts1t •'Lc.11±P i' �',il.ztub• Dates Through: VenborN = tWj Vendor Name Class Pay Code 12792 BETHANY SENIOR LIVING Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount 111120 11/18/2020 11/11/2020 12/18/2020 8,355.47 0.00 TRANSFER Njjiyyy,}-dtpas�+zc1 jv h INI1ti(_ OpUv-i1 Yt'^� 111320A 11/18/2020 11/13/2020 12/18/2020 10.520.06 0.00 g TRANSFER NN p�INA.E dt.p's4 TCxI. 'a b lr\'hkL. 111320 11/18/2020 11/13/2020 12/ 8/2020 36,696.82 0.00 TRANSFER W" ��Ut��iiAt..f d?e0' aA lh'(N hkWAt- UeC.Ytijlri-\ 111620A 11/18/2020 11/16/2020 704.00 0 0.00 i�12/1$/2020 TRANSFER NI' VgKtt kpolrj,,k- 1l^F` YtANiI., 0PCw� 111620 11/18/2020 11/16/2020 210.42 U 0.00 `12/18/2020 TRANSFER N1� pUJ16A{ �(,�10Gri f'ca- i A IV N\NA l- O'(1t,/ljl''�/ 111820A 11/18/2020 11/18/202012/18/2020 7,723.48 0 0.00 �/ `_ TRANSFER Ivi+ P MX :t Jq,k TUk In MVLy L oroi_I- 111820 11/18/2020 11/18/2020 12/18/2020 220.44 0.00 TRANSFER �% tj(pD� W V H MV1 L. 0 ap_open_involce.template No -Pay Net 0.00 8,355.47 0.00 10,520.99 ✓ 0.00 36,696.82 0% 0.00 704.00 a/ 0.00 210.42 0.00 7,723.48 0.00 220.44vj Vendor Totals. Number ame Gross Discount No -Pay Net 12792 BETHANY SENIOR 1 64,431.62 0.00 0.00 64,431.62 litaporl Suunrr.�ry Grand Totals: Gross Discount No -Pay Net 64,431.62 0.00 0.00 64,431.62 IrAIN101 ;*.irk ,iv i4tia/ 19 2020 IOU00t,lwntaucq PTA` x_kM1 vC.v_vt'" ''.w file:/IIC;lUserslmmckissacklcpsilmemmed.cpsinet.com/u88l50aldata_5/tmp_pw5ropod6200619297266448445.html 1/1 Memorial Medical Center Nursing Home UPL Weekly Canted Transfer Prosperity Accounts 11/23/2020 prevbm ARaunt Ben nln9 AOI / Nwtln Xeme Numhe[. pNania gntMPOut /nnaltlin PWN Oe etlN T4daYr ae9lnnpt Amountle6e Tantlemetp MYry101 5),196.04 P� 112.44).)9, blame Nama 112,629.22 121,44].]9 Bank8alance 112,619.22 wdame Lave In ealanca 100.p4 QIPP 1&2 QIP3,4 &Upse October lnu,.,t 81.43 ✓ NavemberinlereN - 0asmbul.wndn Adjust aalanca(rnnsferAmt /� 112.44).]9 vur t7,98).46 ✓17,849.13 ✓ ,`T10,563.82 210,702.15 210.509.74 Bans Balance 2101ID2.15 Vabn<a Les... Bala. Uow QIPP1&2 QIPP 3p&bpae MMCchfmpavmenat "M ONobellntareat 38,33 Novamherinevat 0ecemberl.,.a Adjust blsncOmnderAmt /f // / 45,654.82 ✓ 45$09A5 U0.509.74 ✓ / SB.Sa6A8 ,/' 59,031.15 // 58,986.09 bn48abnce 49,03435 ✓ Ntlance Leavelneabna Mass QIPP 1 &1 QIPP3,4&Lapse OOoberintenst 45,07 f November Interest - Oecemberinwreat Adjust 8a1-nce]Tmmfer Ama s8.886.08 f 11A0].13 11.266.31 ✓29,600.31 - 29.721.12 / 24,60051 Bans Balan[e 29,731.12 s/ Variance leavean Balm¢ 100.00 QIPP 1 &2 QIPP3,4&lapse omberinterate 20.01 NPvemberlmerett - Oecembalntmut % Pdlui<aahnce/TnruferAmt La,600.31 � // �� 8),9)3.58 a/ 80,345.10✓/ )2,480]2 ✓ BQ109.16 72NO.72 flank 0alanae ✓� 80,109.16 Varied Aila:"I'YIN Lesain Balance lOD.00 ,� ' -'—^-.n✓sol oae wn Takeback-::.dWMMC ),4]6.62 ✓ L i i) j QIPP 3,4&LgPae r ,,11 00.1svintanat S 52,81 N4vambarlmemN 2 9 n 6 0 C; •� Qecembsrlaered 44i low, e-lt{i[B3i15� i T '! C a t; i; (� .r Atllun BaNncependarAmt )2,/WA3 r�Y/ L7 TOTALTMNSrE85 483,924.64 Nale:OnlyWlon[ero/avel$$.4bJWlllbr b4NrrllM lPlllenwb'nphPme. ApprOVed: y a:\xN WeaHy TramlergNN uplTranrl<r Summary\3010\Havemher\HN UVl iranaler SummW 111340aHa 1 IAryll WN61y TMm)elf\&n40awnbeJ Wu4Ng3rUD30LNOYem0e1\MX{rn30nwnbatl 1116U0 Wr llilU6Xa I!]e 3 MM[PORTON apP/ dnw )lN3{SC9W jflalglp aPP/[ampl ql)T/6mp2 OIPP/Canty 1ppK OUMT NN PoR¶ON IU16/1NO AmaHfouDTN[NCC]AIMPM]333Ng1D IlIWO1RN'L')I06TI]R]9A1001111\ - ],N6.0 31/1UE010 YN[COMMYNM1YIL MCCUIMPFR]KWIg1191M1OThN'1'}p1p11131]300110.19LLWS161'WAl[ROl\ - L,Ij9]p 161643 LVIFaDIO UK COMMYMI]Y Pl HCC1AIMPW7461014119lM RN•1`30N1113HaW1P1911W0361'MWHN01\ K,p1p.5) 11j9 p0 Il/IB/3020 UK COMMUMNY PL XCCWMPMT)INWIll 91c,mo H'2.1W0111]I1j0A)1]'191]pa361•Wblfp0l\ - 23,10135 16,NB.0 tl/16/tutOVNCCOMMUXNYPLNCCWMPMT]16W31)1910pOpTgN'V1aN1113t60GSP1y911SN61'WlORYN\ 981,15 1),tt]JS 12/16/2020 HFµTN "UNION SIC REMNANT 1141WI41130Z 31gN'1.OS416W13tN]61K•I]460WI56- y0210 Il/P/103D UNC[OMMUHRY Pt11CiWMPMTNfi0N01191WW NN•1•}a0111g1g5D]I05.1911�)fil•OOMIf)o1\ 3166W ),I6flE0 if/fi/SaO HU)MNACIN 01[B HCCUIMPMgIp14p1]W001>9]iPX•1'01MW{aK95K'14110{3IN\ gmas 9da&65 NKWMPMPW746 RBi1IUHIU, '1tlg49%Kp•Il}l6Wil3\ NUNCIO - i32.95 VA.05 1113WI MU 10,K IOIOf IV19ROl0UNCCOUTMHFO NFAL%agEC)60W411910000NH•1'101O113S3510K1i'1911Ng161•ttW]FXa\ IV30/30}0 YAq[OUTNNEORONGLMURE[]ryl[IIRp - S).116.K 4,31061 AJULM, UHC L910.VOlgN•1•lp]p11N153WV1•]91EWN61.OMgtISfYlq 0.10 WJE1HUO UmM Mtv AMCCOLAIMPM4m4li jl/19/olo UHCCOmrmM]Y PINC[UIMPMry16A311191W%I TqN'1']010111N01013fi6.1913WN61'IXpJId01\ - 6,560.W 0,10 31/2a1010 01pa11 61560.W L/20/EO]0 UNC[AMMUNIry PINCCWMpMT]KOOH11910.YUlRN•l•]O]O33I930100E%•%I]KU61'000OTFX01\ - 1,111.K 653.24 I,I3l.N Ilt2WEV0 UMCCpmmw11Y I1NCMIMPMT]CWDN11910[W1RN'1`lUEa119153W19V191EWNb1•W]JI3%01\ )p2]) 65024 11/1WWO WHIKSOUHOH NCIWMIMTNS)]IIlOOOIV]TBN•1•[R6999N5•HMENIN'OLSVM9I1\ j09 iy 1112COWD NM6TMHUMAN SYC HCCIMMIMT L116CN41U0,151 ThH'1'OSWOSaI3NN61i9.1T4Nalifi ;35.14 )p56}4 L9b.15 - 1.90015 PLtK.N 11LMi.T MMC ONR IN aFFffamp4 Tnn�fe. a"f j1ypP apP/CemDl O]PP/Coop! app/C4mPl ihpse agT, N4P000WM 11/l6/laO UNRIDNUUXUp[NCCWFIPMT]I600KIIIN)M1RN'1.0}R1M9N)0.11113N146•gYpR]l6\ - ]O.NOW llJ]]/]OEO UN[COMMUNIIY P{NCCUWPMT]I60Ni1]91WMTpN•1.3aa1H1650p]K•19llW]l01.OWOtfYAl\ - [IIAS 30.NO.W 1U19p030 WMF WIGNIF%NWTHCMfCENRP9111 R.K9.H - - 63fA1 1V39/]p}oUH<COMMUMRPIHCMIMPMp14W111191NLOTRN•1.1N0111p119D:0N•19IN]]I6VOK0}fg01\ - 496)3] )B UNCCPmmPMW 91 N[CWMPMTIKWNI1910.'NTIH'1•]03011Ip115W3N'1913aUfil6•1NWGOWI 656)il WAVIER) AG66.O ;6I,,31I6Sg6b1..WC1O6 MAOINY. pepp W 3,243.UNwala 9010 2F13 ll120/jptOUHC[OMMYNIIYPIIK[WMPMT)KM141191OG%]RN'1•N10111914IC0150'19HPoK61'WaIFp01\ N,9N.20 11/Ea3010 NOV145 SOLUIX]HNCMIMPMTN6l5)41dYn1)61RN•1'[]15]63651•Il0]NIJi•OfIXgpll\ 13B$U.61 11,9a.]0 i - 1]4513.61 U.619.13 11%563A3 ✓ ---�- ) MMCpO0M1X aPP/Cmp4 Irene ale aPP(CPmpt aP1/famp3 aPI/UTH WWe aPpT1 I NMggTON W341Ib YNChmm PMI]16tR34119{OM]}pN•1.3NDIS111KOH40'19UWN61'00)mF]01\ ),p]KS.W IVEAE12D20 NDNM719MNSPMNWW5]61 W ]W345..WW HUMANAINSW IKLUMMT39WK 0JAIREANS. IVSR/NVE MAMAGIANOM[TI]16 MNS PMNI WNCWMW1266410157MI NUUMOID 7312S - ]IHA9 II/19/N30 WIRF0VI4NRINFµMURF(fNRRf IN IP,N915 ]0t250 11110/la0 N,O 15})R06 15,5)ON ll/10f2NO XUMANAIN3GG N[fWMPMiJARE4Nd'Oa%9)B1RN•1.OJI}9f453]13104•INI1N4]3\ - E47aft 1 - l6•I01.W 4s301.1s 5tN6.N I gip MAH MAN ON avv/amw TI30Ua-0nt jIN[hC30 a/I/COmPI aM/Cony] apvfeanw Wpa OIPPT AN PORTON 'IlIVAOlp YNC[anmuNry PINCCWMPMTT46W11119tOW]1NN'I•Ih]OW3301WLK•3911aUft'NCOI]g0\ 1,3]O.fO Na1N- NLLLTHNUMR"PtiN WMPMi11KPoH103a6]10N•L'aV36ll4l5 1,00.0 1111V1a0 YKKCOMMUNRY pIIKCWMPMTil60N1l191WMTRN•1•10}01114159W151.19II07N61'400]RR01\ 4-191Z 4M.05 14WHIEO 31/IR/lOjO UHCCOMMYMRY PIHCCUIMPMTi16aLtl 910]NIAX•1•EOja119313p]a]•1911a6161'4WI1[MOII 1i,99p,a 1V19/10I0 WIREOU1dNRR NFµTIGAF[FH}NSIII - 11,E06A1 5,9)O.II - 1112002p10 INH." 1.691.01 - 1491.{9 ItAK.)I -ANJI - L961Y MM<PORJION avpff mp4 aPPlfwnpl aN/fanpi aIP/Coop] lUpw app P1 NNIOR110H WIVlNp UNCCOMMYNI]Y PL KK[IAW1M}]16MNbll%0.WTRM'3• lNOLL131510N)!'1911GNI01rpL0]jlXpll - 6,a0.a 1416/30t0UN[COMMVXIIY PLM[CWMPM1i16C0311191WW1RX•19010111113N0]]b•I912WN61•IXWt[g01{ - 6,a0f6 MNN[CWMPMt Na69MX•1•[PR]SNK•Aal%I1Y6347ak ) U91.16 4,69d16 W171a0 HUYANA INS E&EIM ll/b/laO NYMRHAINS[O NCUAIMPFR390Nl N0.Wi9Ill91RN'3•a¢90E3N1K9.119136H]31 ;5)I,W LRLW EI/Nhap MAH.W WIOHETI]IB MMS IMMOMOCO>aW]HIIIO15IN9 - 4.0].10 4O7.24 11/N/2N0 gmefymuPTgSC H[CWMPMTSA6B%N9 L10.tlfiN•t'11JN96N9.1]5360jN1\ 1381S0 Sl/39/!a0 WIRE VttINRX HIRLIN ME aM]R5111 N,NIJI 3.10 - 3.10 11/10/IaD UNCCII-1WHWCWM?W7AAWM%II10Ytl IGN'1'tWa31NNOh12.3912N%6L0pNIN011 IV39/]aDMRP$uplhmenu NfGU1MPMTAEW3111]24lNTXN•l'1N25N019.1)62]3%11.00a19])3l - p,]]p,pp 11.)ffipp WARMER, IN." - ;614M 9,624,W 1V10/EaO MVIAfAAIMCHCCWMPMT3U71M610111T01RN'1•11311RK16.1]S16a2)1\ Il/10/EOtD UNCCOMlRVNR INCCUNIPM}]4NII411 IXW1gNrl'1a0111930]a1N•1912WN61r[apl[yp}\ 12..2] IVEa1030 NUMAMAIN3COIKMIMIMi39a6I63[�OS9pR6TRN•1•N1!%OSy>2]45I'UPI363gi1\ IB.OWdl 18.Oa.N Al l)NWIaO HUMANACHA 000 Ha WMPMT3901114SODXHUM 1M1N•L014K01ag1)N•1611a3163\ - IOCRAI Lm IVIW3010 HEALTH HUMAN WC 14CCWMPM'17160 HSIIa)E IRN'1•aGN6U119143N9'I]KOa156 AAI4 IV2012030 AARF UPARmnnuHRWMPMI]KaK111343N 1RN•195p1H960.136ET9]]1'O]V163N\ }$5)Jg }}0).19 3.936.a ;91pW TWAAS 21?,II437 N;9R)2 1112312020 Quick View Select Quick View Accounts Account Number / Name Accounl Type Treasury Center Select Group Groups Add Group tuur, Data reported as of Nov 23 2021 Account Number Current Balance Available Balance Collected Balance Prier nav 6elanr MEMORIAL MEDICAL S112.629.22 ✓ $149.961.24 $112,62922 S103,12CE CENTER I NH ASHFORD - '4403 MEMORIAL MEDICAL CENTER/NH $210,702.15 ✓ S223.431.95 $210.702.15 S41,499.' BROADMOOR '4411 MEMORIAL MEDICAL S59,031.15 $268.345.14 S59,031.15 $16,751.0 CENTER / NH CRESCENT '4446 MEMORIAL MEDICAL S29.721.12 / $34,460.38 529,721.12 S28,029.E CENTER/NH FORT BEND ✓ •4436 / MEMORIAL MEDICAL CENTER/SOLERAAT S80.109.18 ✓ SO4,648,41 $80,109.16 $53,306.E WEST HOUSTON mtliull. Page generuec cn 1 Vq3;?O�iO; hllps:Bprosperity.olbanking.comlonlineMessenger 1!1 Memorial Medical Center Nursing Home UPL Weekly Nexion Transfer PrOSPOrity Accounts 11/23/2020 prowaua A¢aunt Bll... xurYn Home Abash.,a u her ahnce rtnahreul h9,B1149 W..5T).09 Net'. Onfy babncerW over 55, 000 will be tmnaJrneQ ro the num0p dome. Nate S: Each account her abase balance af$100 that h Copen.,roan. I:\n i Wormy Tnmlex\NH Upt Usntler5ummary\30M\HaMmher\XH UPl4amh, summary 11-23.20a1u Today's Belinnly pmauntlaWTanYlrreOW Nunin6 - 41,46810 / Bank Balanee 41.468.80 C� W rlenn Leave In Balm. 100.00 Takebe04wedtulwM[ 2,583.41 ✓ October lntereat 50.99 Naelmbe, Interest December Interest - Mlurt BalannyrranderAmt 3.B.I1(Ta94`.00 V ABE..& M Lien Anglin, CEO 11/23/2020 ,NkvbI- " .01 MMCIORMN alllfxnp4µ NX RIfiJ)1Y0LJ II}ndeWn aoy([anpl g111/4mq all/Compl JN' alp" POAVON 11/S9A0)O NOVISAS SgIUtXIM IpCWMIMi N6m]NttV3151 TRN'1'F9Sf156N9.1ia19611>'OCN%011\ - i,Qi.31 11119/2NO WIN O%NaION HMTH ATWWeNCNM- M4131 V/l9/}NOX[AVXXYMMIIVCNIXU�MPM1 V4600A1I101lilRN•I'%N91NI33J%SYN•1]JSW]ISfi• ].09}.36 I V30gN0 g1p34 ].%].}6 11/lNID20 ISY3/IMNSSIMtBX[OIRMTSN6NSSSN69O9fUbp6535)89U OgINHCRFERHGITXCAR {LINO HAS. ll/1a1020 HEALTH HVNW VCH WIMTV46%39t110llliflN•1'aW%%1561%3961'lM6WOt56 ),)]6% 1,316.01 },9}Od3 - 1.91Y.33 CgN)A9 t 11/2312020 Treasury Center Quick View Select Quick View Accounts Select Group Account Number / Name Grou s Account Type Add Group Baarrh All Account Number Data reported as of Nov 23 2021 Current Balance Available Balance Collected Balance Prior Day Belanc ^904 MEMGRIALMEDICALI NH GOLDEN CREEK S41468.80 S141,395.19 $41,468.80 S12,257,C HEALTHCARE page gonvatec on 11123?202C v hllps://prosperity.0lbanking.COm/OnllneMessenger s tit Memorial Medical Center Nursing Home UPL Weekly HMG Transfer Prosperity Accounts 12/29/2020 Pn"N" Be A[enuM N1. n. v.nelry —..P Tnn.In.e In xW xmm. u..mh.r ulrt. u.wnnom Tnmin.ln 9. Ek... e Davem. Tna..Be In n qw[. xam xane 10635 33d36,31 33.381.39 /.-f3rIT9.t6 &nk pxnn 3;iB..59 VvI.n. u.vem .W. . law P. &.1 WPI10.S IXlobvintmtt 6.36k/ NarNph.rinl...X On rcrAm.ntt Ndlmtpm.rt,.mX.NbmL ,9xma. Pmlw, nm.umte a. a. b,: e- .1 8N Iendlnl mmP.n.a.0 Xumber xn TrLnxerom hmdmin elu O..nd p i atlN .r`NYNnt Name Nanrp:lPhobn[ c/ SS.YO MXl OIm[s0$1001h. MMMC.d.—lN/IPlmon opma[[ouN. 1:\NMwnYryinnllen\M1NYx IILmPerlumm.ry\3a3a\Mwe.r.6MNN YPLTr.m/ellumm.n Il�tlIW W Lnnmkxnn soaoo� OPP P.ym.ntPeluxm.nx IA9i31 t on.lm 1.,., 19.33 Nwembrin..nn O.nmbrintneat ptllun l.Ynw/inwNr Nnt 1.e7159 TOINTXY3!![RB U?LS9 ) Lwn Pgliry So ll/la/IOIb arliglir"M IWT /.ial rx d:/erg„f:�d MMCPORTION QIIP/Cemp4B PIN TnnAerAut Tons2enln WPI/Camel Omp/CemP2 01,10 4p43 QIPPO PORTION 11/1)/102p HI1MAN.gCNgpISB HCCIAIMPMt 62L9R31jpp9pp91 TRry•Ig196401036fi)161.1611013183\ vuE.24 1217524 3L315.24 311T$ M MMCPORNON NPI/Cump4& NN Tun3ler-Out Too -I. I QIPP/CumP1 QIpP/omp3 QNP/QMP3 del Op"I PORTION 11/19/2020 WIRE 00 HMG SEBVICB5, 11C 39,566.49 13/20/2020 DIpPLI 3,SI6.90 . 3526.90 39.556.49r/ 3.S2fi.90 352690 39.956.49 35,102.14 M 14 11123/2020 Quick view Select Quick View Accounts Account Number, Name Account Type Treasury Center Select Group Groups Add Group as of Nov -ennn MMC -NH GULF POINTE 53,646.22 557,550:88 PLAZA - $3,646.22 5119.; MEDICARE/MEDICAID '5433 MMC -NH GULF POINTE $32,281.59 $32,281.59 $32.281.59 $32281f PLAZA - PRIVATE PAY md, :;& Pa.ie generated on 1112302020; https:/i prosperity.olbanking.comronlineMessenger 1/1 Memorial Medical Canter Nuning Home OPL Weekly Tmmny Transfer Prosperity Accounts 12/23/2020 h.Nom HeNn Nero ArcrM Par, pym:[ve)arlr $Sa'q iwHq IgnfrymlM Menonlnp Asme. Morr YfYA a[[oonlAu vOOY lYugr vJ $I411MI MAX MpYXIle 00M awunl Ams r.wea n.nn.H.a r. Brrd a.Xne Sq$M.11 Am aIn anlnr. !roan lrvpsp OIYp l.af 4vn mew «Lnn w XaWpNI FI.mt aemb.r Mrnrl NWr1 AMwe.RnnWr4n Y r lawnenphefa "niftaln �.14 Y�211�1f� Mi ail MMC PORTION QIPP/ComP4 Tmmfer43ot Tmosifer-11IPPIC.-ol QIPP/C9mp2 QIPP/ComP3 &UPle QIPPT 17,,262.48 - 120,057.43 11/16/2020 NOVITASSOLVTION HCCIAIMPMT6T62O1420000ISITRN'I'E 11/19/2020 WIRE 00T LIN9AR ENTERPRISES, LLC 11/20/2020 OFPPSIt - 32.959.21 - 33.959.21 120,053.43 /50,221.69 / 5022169 NH PORTION 17,262.48 r 11/23/2020 Treasury Center Quick View Select Quick View Accounts Select Group - Account Number 1 Name Grou s Aad Group Account Type Sean:h All OOA Data reported as of Nov 23 2021 :. Account Number Current Balance Available Balance r..11..mn 01.1.... o.r_. r%... a_._... IAMC -NH TUSCANY $60,326 27 $50,326.27 VILLAGE S50,326.27 $17.367,( llitns://prosperity.albanking.comlonlineMessenger 3,2024 n. Papa pene.alra onI1:23',>.020. 1r1 Memorial Medial Center Nursing Nome UPL Weekly NSLTranster Prosperity Accounts 11/23/2020 prwlpu. Psmunt Bp1nnIN pmNry nmo.mmae x Npms .....Hr h.{md 3E .koM[ ,n CY.CkneA ptl mml n.aa {]S,]63.95 ✓ 1)S.SBS] 53.3idL.39 $3.324 31.50i.fa Si.)98.39 &nh&hntt SI,SW.ie Wru— un lxvein&hna ICODO MMCLUIm p9ymeM SU.M p✓ Onpherinterea tip9 f xwomWelnt<ml M[.mh.nm.mn delu¢pkepepnnmrnmY st.>Sp.31 Gon./<mtllp M1pme. xvn:evlu&"u—n ft%uj eW-ID9 Cdoxnnp fKil Y. Em/rv[[wn(Mlvdm[Idon[ev/$1Wnu1MMCtlrtrolrt<Elveptn0[[Ount. gporwea: Iron Rnh4ry(EO Ei 11,13/101D I:\xn..", uen\xxmunmrnsumm,ntlWgxn,mdv\NN on Rmun I.., ,,Q.n. 13/38/2020 Oepotil 11/18/2020 Deposit 12/18/2020 NOVITASSOWTIONHCQAIMPMT6764814200MO188TF 11/19/2020 WIRE OUT BETHANY SENIOR LIVING, LTD 12/20/2020 Deposit 11/20/2020 Deposit MIMIC PORTION sep4 Transfer -Out Transfer-InLMPI QIPP/ComP2 OIPP/Comp3 OI&La p gIPPTI NH PORTION 3,636.23 - 3,636.23 1,400.13 13 10,665.46 . 10,665.46.65 vssel.sl - - 34,627.38 - 34,627.38 2,995.14 - 2,995.14 175.981.51 33,324.34 53 334 34 I , 1 11/2312020 Quick View Select Quick Mew Accounts Account Number / Name Account Type Treasury Center Select Group Groups Ann Group Account Number Current Balance Available Balance CnllaeleA R.I.- as Of NOV 23. 2021 MMC -NH 13ETHANY $53,508.28 5327,558.43 553.508.28 `. SENIOR LIVING 515.885.7 mtps9/prosperity.clbanking.comlonlineMessenger pane genera3. generated un 11, 2r2020. ' IK P MMIC OPERATING MEMORIAL MEDICAL CENTER CHECK' REQUEST Date Requested: 11/23/2020 A Y INCN 1� 3 211,12d AMOUNT $54.08 EXPLANATION- MMC CLAIM PAYMENTS — E064KOW EF) BY: MAYRA MARTINEZ -------- ------- - ---- -- FOR ACCT. USE ONLY FlImprestCash nA/P Check ElMall Check to Vendor Return Check to Dept GA NUMBER: 10255040 AUTHOR17H) 8 v: MEMORIAL MEDICAL CENTER TER CHECK REQUEST P MMCOPERATING Data Requested: 11/23/2020 .. A - 11L�! E gip'?ti tic amif+ur FOR ACCT. USE ONLY FlImprest Cash FA/P Check D Mail Check to Vendor Return Check to Dept AMOUNT $1,655.31 GA NUMBER: 10255040 EXPLANATION: QIPP PAYMENT ADJUSTMENTS_ — REQUESTED BY: MAYRA MARTINEZ AUTHORIZED BY: Caitlin Clevenger From: Caitlin Clevenger Sent: Tuesday, November 10, 2020 9:42 AM To: 'Yvonne Kirsch' Subject: RE: HMG Deposit Yes, sorry, I will withhold the difference and I will be paying our operating account back with a check, Golden Creek received their correct portion. Thanksl Re.�ectfuU�jr, Ccutt,;,tvClevP.rt�er Memorial Medical Center Accountant 815 N Virginia. St Port Lavaca, TX 77979 Ph: 361,552.0272 Fax: 361.551.4504 From: Yvonne Kirsch [mailto:Yvonne.Kirsch@healthmarkgroup.com] Sent: Tuesday, November 10, 2020 8:26 AM To: Caitlin Clevenger <cclevenger@mmcportlavaca.com>; lames Oswalt <James.Oswalt@healthmarkgroup.com> Cc: Sara Wright <Sara.Wright@healthmarkgroup.com>; Bill Dohn <Bill.Dohn@healthmarkgroup.com>; Shannin DeLong <Sha nni n.De Long@ hea Ithmarkgroup.com> Subject: RE: HMG Deposit ICAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Do you mean withhold the difference? $1655.31? yvonAe kirsch cash may veer HE LT H CARE. L L C 1780 Hughes Landing Boulevard, Suite 500 The Woodlands Texas 77380 281-419-5520 x 185 wi*N\d 40M Hanel 1Ycuigtr r Lvnv cYuc, *L. From: Caitlin Clevenger <cclevenger@mmcoortlavaca.com> Sent: Tuesday, November 10, 2020 8:10 AM To: James Oswalt <James.Oswalt@healthmarkgrouo.com> Cc: Sara Wright <Sara.Wright@healthmarkgrouo.com>; Bill Dohn<Bill.Dohn@healthmarkgroup.com>; Yvonne Kirsch <Yvonne.Kirsch@healthmarkgroup.com>; Shannin DeLong <Shannin.DeLong@healthmarkgroup.com> Subject: RE; HMG Deposit This message comes from outside the HMG organization. Do not open attachments or click on links unless you are sure of the sender. James, I can withhold the $4,458.25 from the next transfer and I will write a check to Golden Creek from the Gulf Pointe account. Sorry for the mistake! Cade U+11CleveVLge' Memorial Medical Center Accountant 815 N Virginia. St Pori Lavaca, TX 77979 Ph: 361,552.0272 Fax: 361.551.4504 From: James Oswalt [Mailto:James.OswaIt@healthmarkgroup.comj Sent: Monday, November 09, 2020 4:53 PM To: Caitlin Clevenger <cclevengerPmmcportlavaca.ccm> Cc: Sara Wright <Sara.Wright@healthmarkgroup.Com>; Bill Dohn <Bill, DohnCephealthmarkgroug.com>; Yvonne Kirsch <Yvonne. Kirsch@healthmarkgroup.com>; Shannin DeLong SShannin.DeLong@healthmarkgfoup.com> Subject: RE: HMG Deposit CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Hello Caitlin, It appears that you sent us the wrong amount for the second UHC payment. For the NH Portion, instead of sending us $2802.94 for Gulf Pointe Plaza you sent us the $4458.25 for Golden Creek. How would you like us to proceed? Best, James Oswalt Banking Associate H E AL,i HC A A f LLC 1780 Hughes Landing Boulevard, Suite 500 The Woodlands Texas 77380 From: Caitlin Clevenger<cclevenger(cDmmcportlavaca.com> Sent: Monday, November 9, 2020 4:03 PM To: Sara Wright <Sara.WrightCdhealthmarkgroup.com>; Bill Dohn <Bill. Dohn 6Dhealthmarkgroup.com>; James Oswalt <lames.OswaitCalhealthmarkgrouo.com>; Yvonne Kirsch <Yvonne.Kirsch@healthmarkgroup.com>; Shannin DeLong <Sha nn in. De Lonetmhea Ithma rkgroup.com> Subject: HMG Deposit This message comes from outside the HMG organization. Do not open attachments or click on links unless you are sure of the sender. Good afternoon, Please see attached deposit support for deposit made on 11.5.20. Please let me know if you have any questions. Thanksl IWpe tftkUy, Cae tt livCtmenger Memorial Medical Center Accountant 615 N Virginia. St Port Lavaca, TX 77979 Ph: 361.552.0272 Fax: 361.551.4504 N/IEMORIAL MEDICAL CENTER.__ -- CHECK REQUEST P MMC OPERATING Date Requested: 11/23/2020 A Y F. — E_ AMOUNT $528 EXPLANATION: MMC CLAIM PAYMENTS REQU[5'FEI> BY: MAYRA MARTINEZ FOR ACCT. USE ONLY s�ew'asr ❑ImprestCash hsf ❑A/P Check s�! 1 "121 ❑Mail Check to Vendor ❑Return Check to Dept !Rii'JA'RCA:? :}9rg.,y'7, :.".;�1L.1:3 -..- •_�.-_ G/L NUMBER: 10255040 AU-FHtJRIZFF) BY: Caitlin Clevenger From: Tatum Gordon <tgordon@bethany-living,com> Sent: Wednesday, November 18, 20201:47 PM To: Caitlin Clevenger; Aphton Taylor Subject: RE: deposit support 11.13.20 Attachments: DP 282 MMC WIRE $2,992.00.pdf CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Caitlin, J'Whuld korn y % wok ue- J b11b11e The $528 wire transfer for Curnutt was already transferred on the last wire. The 2 insurance check #'s match. From: Caitlin Clevenger <cclevenger@mmcportlavaca.com> Sent: Tuesday, November 17, 202010:18 AM To: Aphton Taylor <ataylor@hslfamily.net>; Tatum Gordon <tgordon@bethany-living.com> Subject: deposit support 11.13.20 Good morning, Please see attached deposit support for 11.13.20. Please let me know If you have any questions. Thanks! P."Pectf A&" CMUUtVC1""LcffW Memorial Medical Center Accountant 815 N Virginia. 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