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2021-11-24 Meeting Packet.pdfOL All Agenda Items Properly Numbered ✓ontracts Completed and Signed _ All number Flagged for Acceptance numbe r of 1295's �) �Ui9mFJ Gdw All Documents for Clerk Signature Flagged /Gf2�iy� `cc,wa.t On thisWAday of 2021 a complete and accurate packet for «Ieof 2021 Commissioners Court Regular Session Day Month was delivered from the Calhoun County Judge's office to the Calhoun County Clerk's Office. 6LZ"--- Calhoun County Judge/Assistant COMMISSIONERSCOURTCHECKLIST/FORMS AGENDA NOTICE OF MEETING— 11/24/2021 Richard H. Meyer County judge David Flall, Commissioner, Precinct I Vern Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 Cary Reese, Commissioner, Precinct 4 ][caddie Smith, Deputy Cleric NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, Novernlher 24, 2021 at 10:00 a.m. in the Commissioners'Courtroom in the County Courthouse at 211 S. Amin Street, Suite 104, Port Lavaca, Calhoun County, Texas. AGENDA The subject matter of such meeting is as follows: 1. Call meeting to order. 10:01 a.m. 2. Invocation. Commissioner David Hall 3. Pledges of Allegiance. US Flag- Commissioner Gary Reese Texas Flag- Commissioner Vern Lyssy 4. General Discussion of Public Matters and Public Participation. Happy Thanksgiving! 5. Hear report from Memorial Medical Center. Pass 6. Approve the minutes of the November 10, 2021 meeting. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judqe Mever, Commissioner Hall, Lvssv, Behrens, Reese Page 1 of 7 NOTICE OF MEETING — 11/24/2021 7. Public Hearing to amend the 2021 and 2022 county budgets. Regular meeting closed at 10:02 a.m. Peggy Hall read the report. Opened back up at 10:07 a.m. 8. Consider and take necessary action to amend the 2021 and 2022 Calhoun County budgets. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 9. Consider and take necessary action to enter the District Court Order Appointing Cynthia L. Mueller as Calhoun County Auditor for a two (2) year term beginning November 1, 2021 and ending October 31, 2023 into the Official Court Records. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 10. Consider and take necessary action to approve County Deputy bonds in the amount of $75,000 each per Local Government Code 82.002 (Surety Bond on Deputy Clerks and Employees). (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 11. Consider and take necessary action to accept an anonymous donation of $4,000.00 to the Sheriff's Office to be deposited into account 2697-001-49082-669 to help purchase a K9 vehicle. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 12. Consider and take necessary action to approve a resolution establishing a multidisciplinary Sexual Assault Response Team in accordance with the applicable definitions and legislative requirements set out in SB476, Subchapter J and authorize the County Judge to sign. (RHM) Sara Rodriguez read the resolution. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese NOTICE OF MEETING — 11/24/2021 13. Consider and take necessary action to award the bid for the Annual Supply Contract for Inmate Food Services for the Calhoun County Adult Detention Center, Bid Number 2022.04 for the period beginning January 1, 2022 and ending December 31, 2022 with the option to renew annually if agreeable with both the successful bidder and Calhoun County. (RHM) Bobby Vickery explained Bid. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 14. Consider and take necessary action to award the bid for the Annual Supply Contract for Delivered Fuel, Bid Number 2022.01 for the period beginning January 1, 2022 and ending December 31, 2022 with an option for renewal for an additional three — one (1) year periods, if agreeable with both the successful bidder and Calhoun County. (RHM) Peggy Hall explained Bid. Richard Meyer abstained from voting. Bid from New Distributing awarded. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Commissioner Hall, Lvssv, Behrens, Reese 15. Consider and take necessary action to award the bids for the Annual Supply Contract for Insecticides for Mosquito Control, Bid Number 2022.02 for the period beginning January 1, 2022 and ending December 31, 2022. (RHM) Peggy Hall explained Bid. Low Bid awarded RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 16. Consider and take necessary action to award the bids for the Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions, Bid Number 2022.03 for the period beginning January 1, 2022 and ending December 31, 2022. (RHM) Peggy Hall explained Bid. Bid from Quality Hot Mix Inc. awarded. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 3 of 7 NOTICE OF MEETING — 11/24/2021 17. Consider and take necessary action on a charge made by Judge Alex Hernandez on his County credit card in the amount of $230.40 to Magnum Steno Inc. for a Magnum Steno Beginning Theory, 4th Edition Steno book. (RHM) Cindy Mueller, Rhonda Kokena and Sara Rodriguez explained their concerns. Commissioners agreed this charge would be approved, but a formal policy needed to be in place for similar situations in the future. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioners Pct 1 SECONDER: Vern Lyssy, Commissioners Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 18. Consider and take necessary action to authorize the installation of an emergency key holder for fire and law enforcement agencies at the Calhoun County Library. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 19. Consider and take necessary action to award the bid for drainage and sewage improvements in Alamo Beach for Calhoun County, under Texas General Land Office Contract No. 20-065-064-C182 and Calhoun County CDBG-DR Contract Work Order No. D-1. (DH) Awarded to Lester Contracting, Inc. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER. Vern Lyssy, Commissioner Pct AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 20. Consider and take necessary action on a request from Brigid Berger, Texas Master Naturalist, Mid -Coast Chapter, to utilize the Port O'Connor Community Center as an overflow facility to house turtles in the event of severe winter storms and the turtles need to be rescued. (GR) Brigid Berger gave a report on the importance of additional emergency housing for turtles in the event of a major winter storm. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 4 of 7 NOTICE OF MEETING — 11/24/2021 21. Consider and take necessary action to accept payment of $3,832.55 from The Hartford for damages caused by Victoria Electric Cooperative at Port O'Connor Community Center and place funds in the Port O'Connor Community Center budget to cover costs of damages that have already been paid. (GR) Commissioner Gary Reese explained the reasoning for this payment. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 22. Consider and take necessary action to approve the final plat of the Jameson Subdivision, Port O'Connor, Texas. (GR) Pass 23. Consider and take necessary action to approve the final plat of the Saltwater Haven No. 2 Subdivision, Port O'Connor, Texas. (GR) Scott Mason with G&W Engineers explained the final plat. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 24. Consider and take necessary action to approve the following changes to the Calhoun County Library Board: (RHM) a. Charlene Terrell to replace Reese Vaughn b. Mary Rubio to replace Joe Castaneda c. Mike Stroup to replace Susan Bryant RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 25. Consider and take necessary action to authorize the Calhoun County Librarian to apply for fifty (50) Hotspots and ten (10) Laptops from the Federal Communications Commission's Emergency Connectivity Fund Program. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 5 of 7 NOTICE OF MEETING— 11/24/2021 26. Consider and take necessary action to accept the Texas J & J/Janssen Settlement Agreement for $33,681 and authorize the County Judge to sign all relevant documents. (RHM) Sara Rodriguez explained details of the Settlement Agreement. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 27. Consider and take necessary action to declare Inventory No. 24-0407, a 1990 Fiat -Allis Motorgrader, Model 75-B, as Surplus/Salvage to be used as trade-in and remove from Precinct 4 R & B inventory. (GR) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 28. Consider and take necessary action to transfer certain items of County property from the County Auditor's Department to other County Departments. (See Attached List) (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 29. Consider and take necessary action to declare the attached list of equipment from MMC as Waste. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 30. Accept a report from the following County Office: I. Justice of the Peace, Precinct 4 — October 2021 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 6 of 7 NOTICE OF MEETING — 11/24/2021 31. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 32. Approval of bills and payroll. (RHM) MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese ADJ: 11:18 a.m. Page 7 of 7 I NOI It 1 Uf M I IIN1G 1 U211/2U'_1 Richard H. Meyer County judge David Hall, Commissioner, Precinct I Vern ]Lyssy, Commissioner, Precinct 2 Joel ]Behrens, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, November 24, 2021 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. AGENDA The subject matter of such meeting is as follows: lu;�'7 FiLEo ATlbCLOCK M 4'. Call meeting to order. NOV 19 2021 G. 1nVOCatIOn. ANNAM&OODMAN COu E'K(TOUNNTFXAS{� B - I) 6 L3: Pledges of Allegiance. E General Discussion of Public Matters and Public Participation. Hear report from Memorial Medical Center. 6/Approve the minutes 'of the November 10, 2021 meeting. 'i. Public Hearing to amend the 2021 and 2022 county budgets. Consider and take necessary action to amend the 2021 and 2022 Calhoun County budgets. (RHM) `ef/Consider and take necessary action to enter the District Court Order Appointing Cynthia L. Mueller as Calhoun County Auditor for a two (2) year term beginning November 1, 2021 and ending October 31, 2023 into the Official Court Records. (RHM) 1Consider and take necessary action to approve County Deputy bonds in the amount of $75,000 each per Local Government Code 82.002 (Surety Bond on Deputy Clerks and Employees). (RHM) Page 1 of 3 N011( I ()I IVI1 111N(:, i I/1,4/?O) 1 S.Consider and take necessary action to accept an anonymous donation of $4,000.00 to the Sheriff's Office to be deposited into account 2697-001-49082-669 to help purchase a K9 vehicle. (RHM) consider and take necessary action to approve a resolution establishing a multidisciplinary Sexual Assault Response Team in accordance with the applicable definitions and legislative requirements set out in SB476, Subchapter J and authorize the County Judge to sign. (RHM) k3. Consider and take necessary action to award the bid for the Annual Supply Contract for Inmate Food Services for the Calhoun County Adult Detention Center, Bid Number 2022.04 for the period beginning January 1, 2022 and ending December 31, 2022 with the option to renew annually if agreeable with both the successful bidder and Calhoun County. (RHM) t4__`Eonsider and take necessary action to award the bid for the Annual Supply Contract for Delivered Fuel, Bid Number 2022.01 for the period beginning January 1, 2022 and ending December 31, 2022 with an option for renewal for an additional three — one (1) /year periods, if agreeable with both the successful bidder and Calhoun County. (RHM) 4i Consider and take necessary action to award the bids for the Annual Supply Contract for Insecticides for Mosquito Control, Bid Number 2022.02 for the period beginning January 11,, 2022 and ending December 31, 2022. (RHM) K Consider and take necessary action to award the bids for the Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions, Bid Number 2022.03 for the period �beginning January 1, 2022 and ending December 31, 2022. (RHM) 17_'. Consider and take necessary action on a charge made by Judge Alex Hernandez on his County credit card in the amount of $230.40 to Magnum Steno Inc. for a Magnum Steno Beginning Theory, 41h Edition Steno book. (RHM) 'r8. Consider and take necessary action to authorize the installation of an emergency key holder for fire and law enforcement agencies at the Calhoun County Library. (RHM) b9. Consider and take necessary action to award the bid for drainage and sewage improvements in Alamo Beach for Calhoun County, under Texas General Land Office Contract No. 20-065-064-C182 and Calhoun County CDBG-DR Contract Work Order No. D-1. (DH) 20. Consider and take necessary action on a request from Brigid Berger, Texas Master Naturalist, Mid -Coast Chapter, to utilize the Port O'Connor Community Center as an overflow facility to house turtles in the event of severe winter storms and the turtles need to be rescued. (GR) 21. Consider and take necessary action to accept payment of $3,832.55 from The Hartford for damages caused by Victoria Electric Cooperative at Port O'Connor Community Center and place funds in the Port O'Connor Community Center budget to cover costs of damages that have already been paid. (GR) Page 2 of 3 >`,IOil( i )1 kdl t Ili"Ki -1 1/art/7021 MrConsider and take necessary action to approve the final plat of the Jameson Subdivision, Port O'Connor, Texas. (GR) 73. Consider and take necessary action to approve the final plat of the Saltwater Haven No. � 2 Subdivision, Port O'Connor, Texas. (GR) 24. Consider and take necessary action to approve the following changes to the Calhoun County Library Board: (RHM) tr.' Charlene Terrell to replace Reese Vaughn %Mary Rubio to replace Joe Castaneda c. Mike Stroup to replace Susan Bryant 7 Consider and take necessary action to authorize the Calhoun County Librarian to apply for fifty (50) Hotspots and ten (10) Laptops from the Federal Communications Commission's Emergency Connectivity Fund Program. (RHM) '26. Consider and take necessary action to accept the Texas J & J/Janssen Settlement Agreement for $33,681 and authorize the County Judge to sign all relevant documents. ��(RHM) 27. Consider and take necessary action to declare Inventory No. 24-0407, a 1990 Fiat -Allis Motorgrader, Model 75-B, as Surplus/Salvage to be used as trade-in and remove from ,Precinct 4 R & B inventory. (GR) 28. Consider and take necessary action to transfer certain items of County property from the County Auditor's Department to other County Departments. (See Attached List) (RHM) Consider and take necessary action to declare the attached list of equipment from MMC was Waste. (RHM) � Accept a report from the following County Office: ,/ I Justice of the Peace, Precinct 4 — October 2021 31Consider and take necessary action on any necessary budget adjustments. (RHM) 3'. 2. Approval of bills and payroll. (RHM) Richard H. Meyer, County JQAe 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. cal houncotx.org under "Commissioners' Court Agenda" for any official court postings. Page 3 of 3 #5 NOTICE OF MEETING — 11/24/2021 Richard H. Meyer County fudge David Hall, Commissioner, Precinct 1 Vern ]Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 (nary Reese, Commissioner, Precinct 4 Kaddie Smith, Deputy Clerk NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, November 24, 2021 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. AGENDA The subject matter of such meeting is as follows: 1. Call meeting to order. 10:01 a.m. 2. Invocation. Commissioner David Hall 3. Pledges of Allegiance. US Flag- Commissioner Gary Reese Texas Flag- Commissioner Vern Lyssy 4. General Discussion of Public Matters and Public Participation. Happy Thanksgiving! 5. Hear report from Memorial Medical Center. Pass Page 1 of 28 #6 NOTICE OF MEETING— 11/24/2021 6. Approve the minutes of the November 10, 2021 meeting. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judoe Mever, Commissioner Hall, Lvssv, Behrens, Reese Page 2 of 28 Richard H. Meyer County judge David Hall, Commissioner, Precinct I Vern ]Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 (sally Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 10, 2021, 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. r Richard H. Meyer, Co Judge Calhoun County, Texas Anna Goodman, County Clerk Page 1 of 1 NOTICE OF MEETING — 11/10/2021 Richard H. Meyer County Judge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 Kaddie Smith, Deputy Clerk NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, November 10, 2021 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. AGENDA The subject matter of such meeting is as follows: 1. Call meeting to order. Judge Richard Meyer called the meeting to order at 10:00 a.m. 2. Invocation. Commissioner David Hall 3. Pledges of Allegiance. US Flag- Commissioner Gary Reese Texas Flag -Commissioner Vern Lyssy 4. General Discussion of Public Matters and Public Participation. Commissioner Gary Reese asked the court to sing happy birthday to Commissioner Vern Lyssy, whose birthday was on November 91h. Page 1 of 4 NOTICE OF MEETING — 11/10/2021 5. Consider and take necessary action to authorize the County Treasurer to issue a credit card to Roshanda Thomas, interim CEO of Memorial Medical Center, with a credit limit of $10,000. (RM) Rhonda stated it was simple to edit the limit, in the event that there is a disaster. RESULT: APPROVED[UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 3 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 6. Consider and take necessary action to authorize Ron Reger, IT Coordinator, to sign an agreement with NetMotion to upgrade the current NetMotion installation to the most current version and migrate from permanent licenses to a subscription. (RM) Ron Reger explained the benefits of upgrading. RESULT: APPROVED[UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 7. Consider and take necessary action to authorize the Emergency Management Coordinator to submit applications through TDEM and other agencies to request funding for renewing/updating the existing Hazard Mitigation Plan. (RM) LaDonna Thigpen explained the reason for renewing/updating the plan. RESULT: APPROVED[UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 8. Consider and take necessary action to approve the Canvass Report with Official Results of the Calhoun County, Texas 2021 Constitutional Amendment Election. (RM) Mary Orta explained the voter turnout. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 9. Consider and take necessary action to acknowledge an increase in the Sheriffs Forfeited Property Fund for 2021 as follows: 2860-001-49086 Contribution Intergovernmental $2,678.00 and 2860-999-63920 Miscellaneous $10,000.00. (RM) RESULT: APPROVED[UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 3 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 2 of 4 NOTICE OF MEETING — 11/10/2021 10. Consider and take necessary action to accept an anonymous donation to the Sheriffs Office to be deposited into 2697-001-49082-669 account to help purchase a K-9 vehicle. (RM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 11. Consider and take necessary action to accept a $100 restitution payment from the City of Seadrift Municipal Judge and placed in Precinct 4 Road & Bridge line item, Road & Bridge Supplies, 570-53510. (GR) Commissioner Reese explained the situation and reason for the payment. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 12. Consider and take necessary action to accept the summary report and a check for $447.84 from Janik Alligators LLC for the 2021 Alligator Harvest. (RM) Judge Richard Meyer read a letter from the Janik Alligators LLC. Judge and Commissioners explained the situation amongst themselves. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 13. Consider and take necessary action to establish a multidisciplinary Sexual Assault Response Team in accordance with the applicable definitions and legislative requirements set out in SB476, Subchapter ]. (RM) PASS Page 3 of 4 NOTICE OF MEETING — 11/10/2021 14. Accept reports from the following County Offices: i. County Auditor — September 2021 ii. District Clerk — October 2021 iii. Floodplain Administration — October 2021 iv. Justice of the Peace, Precinct 1 — October 2021 v. Justice of the Peace, Precinct 2 — October 2021 vi. Justice of the Peace, Precinct 3 — October 2021 vii. Justice of the Peace, Precinct 5 — October 2021 viii. Sheriff's Office — October 2021 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 15. Consider and take necessary action on any necessary budget adjustments. (RM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 16. Approval of bills and payroll. (RM) ulu RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County RESULT: APPROVED [UNANIMOUS] MOVER: David Hail, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Adjourned 10:23 a.m. Page 4 of 4 NOTICE OF MEETING — 11/24/2021 7. Public Hearing to amend the 2021 and 2022 county budgets. Regular meeting closed at 10.02 a.m. Peggy Hall read the report. Opened back up at 10:07 a.m. Page 3 of 28 NOTICE OF PUBLIC HEARING — 11/24/2021 \a I IC I I (a1 19,! low,)) I I(lull ..�\I"ION, E \ \ I I .lu1 W, 1111111111111111M1011 The Calhoun County Commissioners' Court will hold a Public Hearing to amend the 2021 and 2022 Budgets in the Calhoun County Commissioners' Courtroom, Suite 104 of the Calhoun County Courthouse, on November 24, 2021 at 10:00 a.m. This notice is in accordance with Section 11.007 and Section 111.0075 of the Texas Local Government co G Richard Meyer, County Ju e Calhoun County, Texas Anna Goodman, County Clerk By: el DeputyClerk 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 tot he 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 ww w.calhouncotx.ora under "Commissioners' Court Agenda" for any official court postings. FLED AT �� O,cLOCK M NOV 0 8 2021 pNKAM. HOUCMAUNN� S COON T 8a Page 1 of 1 Mae Belle Cassel From: cindy.mueller@calhouncotx.org (cindy mueller) <cindy.mueller@calhouncotx.org> Sent: Monday, November 15, 2021 9:24 AM To: Mae Belle Cassel Cc: Richard Meyer, Candice Villarreal; peggy hall; Erica Perez Subject: Budget Amendment Hearing Agenda Items Please include the following items on the agenda for 11/24/21: • Public Hearing regarding amending the 2021 and 2022 Calhoun County budgets. • Consider and take necessary action to amend the 2021 and 2022 Calhoun County budgets. Cindy Mueller County Auditor Calhoun County 202 S. Ann, Suite B Port Lavaca, TX 77979 V: 361.553.4610 F: 361.553.4614 Cindv.mueller@calhouncotx.ore Calhoun County Texas 0 NOTICE OF MEETING—11/24/2021 8. Consider and take necessary action to amend the 2021 and 2022 Calhoun County budgets. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 4 of 28 Mae Belle Cassel From: cindy.mueller@calhouncotx.org (cindy mueller) <cindy.mueller@calhouncotx.org> Sent: Monday, November 15, 2021 9:24 AM To: Mae Belle Cassel Cc: Richard Meyer; Candice Villarreal; peggy hall; Erica Perez Subject: Budget Amendment Hearing Agenda Items Please include the following items on the agenda for 11/24/21 • Public Hearing regarding amending the 2021 and 2022 Calhoun County budgets. • Consider and take necessary action to amend the 2021 and 2022 Calhoun County budgets. Cindy Mueller County Auditor Calhoun County 202 S. Ann, Suite B Port Lavaca, TX 77979 V: 361.553.4610 F: 361.553.4614 Cindy. muellerPcalhouncotx.org Calhoun County Texas i m m p_ d i m m G- C e m m 00 (�_ a m m z z '� = ° z z o A m e Z_ m C Zrn O 0 o �0 o m = m = � DA a O' z n O' Cc -o m 3= H >o z a= Z R7 GOD m �y= Z:A e z Q= O-. m !C= �? m Z_ j e a �GOD - 00 A a_ 3 o,_ oP, g a p N _ _ m = R7 p 9 - 5 Z in O O T� m_ O OTT a �Cp M_ c a f9 EA T T= N dl. 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Mueller as Calhoun County Auditor for a two (2) year term beginning November 1, 2021 and ending October 31, 2023 into the Official Court Records. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 5 of 28 COUNTY OF CALHOUN STATE OF TEXAS ORDER APPOINTING CYNTHIA L. MUELLER COUNTY AUDITOR We, Jack Marr, Kemper Stephen Williams and Robert E. Bell, Judges of the 241h, 1351h, and 26711 Judicial District Courts respectively of Calhoun County, Texas, and having jurisdiction in the County of Calhoun, State of Texas, which said County has a population of more than 10,000 inhabitants according to the last preceding Federal Census, this day having considered the appointment of an Auditor of Accounts and Finances for said County for a term of Two Years, beginning November 1, 2021 and ending October 31, 2023, do after consideration appoint Cynthia L. Mueller County Auditor in and for Calhoun County, Texas for the said term and until her successor shall have been appointed and qualified. IT IS ORDERED that said Cynthia L. Mueller shall before entering upon her duties, execute a good and sufficient bond as provided by law. IT IS FURTHER ORDERED that this appointment shall be recorded in the Minutes of the District Courts of Calhoun County, Texas; and the clerk is directed to certify the same to the Commissioners' Court of Calhoun County for observance. SIGNED AND APPROVED on this the Jyr day of October, A.D., 2021, Marr, Judge, 24" District A raper Stephen Williams, Judge, 135'h District Robert E. Be , Ju ge, 267" District FILED AT_19. O'CLOCKA, M -NOV �8 ANNA KABELA DISTRICT CLERK, CALHOUN COUNTY, TEXAS BY __DEPUTY #10 NOTICE OF MEETING— 11/24/2021 10. Consider and take necessary action to approve County Deputy bonds in the amount of $75,000 each per Local Government Code 82.002 (Surety Bond on Deputy Clerks and Employees). (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 6 of 28 Mae Belle Cassel From: Anna.Goodman@calhouncotx.org (Anna Goodman) <Anna.Goodman@calhouncotx.org> Sent: Wednesday, November 10, 2021 9:04 AM To: MaeBelle.Cassel@calhouncotx.org Cc: Richard Meyer; David Hall; Vern Lyssy; Gary Reese;joel.behrens@calhouncotx.org Subject: COUNTY CLERK DEPUTY BONDS Attachments: LGC 82.002 DEPUTY CLERK BONDS.pdf Good morning, Will you please add the "Approval of County Clerk Deputy bonds in the amount of $75,000 each per Local Government Code 82.002 (Surety Bond on Deputy Clerks and Employees) " to the next available agenda? Thanks Alto R �aoalwalr Calhoun County Clerk 361-553-4416 Only I can change my life. No one can do it for me. Carol Burnett CONFIDENTIALITY NOTICE: The information contained in this transmission may be strictly confidential. If you are not the intended recipient of this message, you are notified that you may not disclose, print, copy or disseminate this information. If you have received this transmission in error, please reply and notify the sender (only) and delete the message. Unauthorized interception of this e-mail may be a violation of criminal law. Calhoun County Texas LOCAL GOVERNMENT CODE CHAPTER 82. COUNTY CLERK https://statutes.capitol.texas.gov/Docs/LG/htm/LG.82.htm LOCAL GOVERNMENT CODE TITLE 3. ORGANIZATION OF COUNTY GOVERNMENT SUBTITLE B. COMMISSIONERS COURT AND COUNTY OFFICERS CHAPTER 82. COUNTY CLERK SUBCHAPTER A. GENERAL PROVISIONS Sec. 82.001. SURETY BOND AND OATH OF COUNTY CLERK; SELF-INSURANCE. (a) The county clerk must, before beginning to perform the duties of office, execute a bond either with four or more good and sufficient sureties or with a surety company authorized to do business in the state as a surety. (b) In lieu of the clerk obtaining the bond, the county may self - insure against losses that would have been covered by the bond. (c) The bond must be: (1) approved by the commissioners court; (2) made payable to the county; (3) conditioned that the clerk will faithfully perform the duties of office; and (4) in an amount equal to at least 20 percent of the maximum amount of fees collected in any year during the term of office preceding the term for which the bond is to be given, but not less than $5,000 or more than $500,000. (d) The clerk must take and subscribe the official oath, which must be endorsed on the bond if the bond is required. The bond and oath shall be recorded in the county clerk's office and deposited in the office of the clerk of the district court. (e) An injured party in a suit to which the county is a party may use and enter in the record in the suit a certified copy of the bond. Acts 1987, 70th Leg., ch. 149, Sec. 1, eff. Sept. 1, 1987. Amended by Acts 1989, 71st Leg., ch. 1, Sec. 9(a), eff. Aug. 28, 1989. Sec. 82.002. SURETY BOND ON DEPUTY CLERKS AND EMPLOYEES; SELF- INSURANCE. (a) Except as provided by Subsection (b), the county clerk shall execute one or more surety bonds in accordance with this section to cover each deputy clerk or other employee. The county clerk shall 1 of4 I1/10/2021, 835 AM LOCAL GOVERNMENT CODE CHAPTER 82. COUNTY CLERK https:Hstatutes.capitol.texas.gov/Docs/LG/htm/LG.82.httn execute: (1) an individual bond for each deputy clerk and other employee_ in an amount for each bond that is equal to the county clerk's bond; or (2) a schedule surety bond or a blanket surety bond to cover all deputy clerks and all other employees in a total amount that is equal to the county clerk's bond. (b) In lieu of a clerk obtaining a bond as required by Subsection (a), the county may self -insure against losses that would have been covered by the bond. (c) A bond covering a deputy clerk or other employee must be conditioned in the same manner as the county clerk's bond. A bond covering a deputy clerk or other employee must be made payable to the county for the use and benefit of the county clerk. Acts 1987, 70th Leg., ch. 149, Sec. 1, eff. Sept. 1, 1987. Amended by Acts 1989, 71st Leg., ch. 1, Sec. 9(a), eff. Aug. 28, 1989. Amended by: Acts 2019, 86th Leg., R.S., Ch. 179 (H.B. 1494), Sec. 3, eff. September 1, 2019. Sec. 82.003. ERRORS AND OMISSIONS INSURANCE; CONTINGENCY FUND. (a) The county clerk shall obtain an insurance policy or similar coverage from a governmental pool operating under Chapter 119 covering the clerk and each deputy clerk against liability incurred through errors and omissions in the performance of their official duties. (b) The policy or other coverage document must be in an amount equal to the maximum amount of fees collected in any year during the term of office preceding the term for which the policy is to be obtained. However, the policy or other coverage document must be in an amount of at least $10,000 but is not required to exceed $500,000. If the policy or other coverage document provides coverage for other county officials, the policy or other coverage document must be in an amount of at least $1 million. Text of subsection effective until January 01, 2022 (c) The commissioners court may establish a contingency fund to provide the coverage required by this section if it is determined by the county clerk that insurance coverage is unavailable at a reasonable cost. The commissioners court may set an additional filing fee in an amount not 2 of 4 11/10/2021, 8:35 AM LOCAL GOVERNMENT CODE CHAPTER 82. COUNTY CLERK https://statutes.capitol.texas.gov/Does/LG/litm/LG.82.h[m to exceed $5 for each suit filed to be collected by the county clerk. The fee shall be paid into the fund. When the contingency fund reaches an amount equal to that required by this section, the clerk shall stop collecting the additional fee. Text of subsection effective on January 01, 2022 (c) The commissioners court may establish a contingency fund to provide the coverage required by this section if it is determined by the county clerk that insurance coverage is unavailable at a reasonable cost. Acts 1987, 70th Leg., ch. 149, Sec. 1, eff. Sept. 1, 1987. Amended by Acts 1989, 71st Leg., ch. 1, Sec. 9(a), eff. Aug. 28, 1989; Acts 1993, 73rd Leg., ch. 561, Sec. 3, eff. Aug. 30, 1993. Amended by: Acts 2021, 87th Leg., R.S., ch. 472 (S.B. 41), Sec. 3.01, eff. January 1, 2022. Sec. 82.004. PREMIUMS. The commissioners court of a county shall pay out of the general fund of the county the premiums for a bond or insurance policy required by this chapter. Acts 1987, 70th Leg., ch. 149, Sec. 1, eff. Sept. 1, 1987. Sec. 82.005. APPOINTMENT, OATH, AND POWERS OF DEPUTY CLERK. (a) An appointment by the county clerk of a deputy clerk must be in writing, be signed by the county clerk, and bear the seal of the county court. The county clerk shall record the appointment in the county clerk's office and shall deposit it in the office of the district clerk. (b) A deputy clerk must take the official oath. (c) A deputy clerk acts in the name of the county clerk and may perform all official acts that the county clerk may perform. Acts 1987, 70th Leg., ch. 149, Sec. 1, eff. Sept. 1, 1987. SUBCHAPTER B. MISCELLANEOUS POWERS AND DUTIES Sec. 82.051. ELECTRONIC DISPLAY OF OFFICIAL AND LEGAL NOTICES BY COUNTY CLERK. (a) In this section, "electronic display" includes a display: (1) by the use of an electronic kiosk, electronic bulletin 3 of 4 11/10/2021, 8:35 AM LOCAL GOVERNMENT CODE CHAPTER 82. COUNTY CLERK https://statutes.capitol.texas.gov/Docs/LG/hbn/LG.82.htm board, or other similar device designed to provide readily accessible information; or (2) on a county's public Internet website. (b) A county clerk may post an official and legal notice by electronic display instead of posting a physical document. An electronic display of information posted under this section using a device described by Subsection (a)(1) must meet the location, time, and accessibility requirements provided by law for the posting of the notice. An electronic display of information posted under this section on a county's public Internet website must meet the time requirements provided by law for the posting of the notice. Added by Acts 2009, 81st Leg., R.S., Ch. 968 (H.B. 3601), Sec. 2, eff. June 19, 2009. 4 of 4 11 / 10/2021, 8:35 AM #11 NOTICE OF MEETING— 11/24/2021 11. Consider and take necessary action to accept an anonymous donation of $4,000.00 to the Sheriff's Office to be deposited into account 2697-001-49082-669 to help purchase a K9 vehicle. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 7 of 28 11-17-'21 12:59 FROM- 361-553-4668 T-540 P0001/0002 F-498 CALHOUN COUNTY, TEXAS COUNTY SHERIFF'S OFFICE 211 SOUTH ANN STREET PORT LAVACA, TEXAS 77979 PHONE NUMBER (361) 553-4646 FAX NUMBER (361) 553-4668 MEMO TO: RICHARD MEYER, COUNTY JUDGE SUBJECT: ACCEPT DONATION TO SHERIFF'S OFFICE DATE: NOVEMBER22,2021 Please place the following item(s) on the Commissioner's Court agenda for the date(s) indicated: AGENDA FOR NOVEMBER 22, 2021 * Consider and take necessary action to accept anonymous donation to the Sheriff's Office to be deposited into 2697.001-49082-669 account to help purchase a K9 vehicle. Sincerely, %/0,bbie Vickery Calhoun County Sheriff #12 NOTICE OF MEETING— 11/24/2021 12. Consider and take necessary action to approve a resolution establishing a multidisciplinary Sexual Assault Response Team in accordance with the applicable definitions and legislative requirements set out in SB476, Subchapter J and authorize the County Judge to sign. (RHM) Sara Rodriguez read the resolution. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 8 of 28 RESOLUTION CREATING THE CALHOUN COUNTY ADULT ASSAULT RESPONSE TEAM WHEREAS, the State of Texas has enacted ChapterJ51 of Local Government Code for the creation of "County Adult Sexual Assault Response Teams;" WHEREAS, The State of Texas believes the creation of these county adult sexual assault response teams will strengthen the collaborative response and enhance health and judicial outcomes for sexual survivors who are adults; WHEREAS, Chapter 351 of the Local Government Code requires the commissioners court of each county in the State of Texas to create and appoint members of the adult sexual response team by December 1, 2021; and WHEREAS, Chapter 351 of the Local Government Code permits two or more counties each with a population of 250,000 or less, within a contiguous area to partner to form a multicounty response team. NOW, THEREFORE, the Commissioners Court of Calhoun County hereby creates and appoints the statutorily mandated members of the Calhoun County Adult Sexual Assault Response Team (hereinafter "Response Team") as follows: 1. Membership a. Maria Walton is Executive Director of the Harbor Children's Alliance and Victim Center, which provides a sexual assault program for Calhoun County b. Dan Heard or his designee as the Criminal District Attorney for Calhoun County c. Bobbie Vickery or his designee as the Sheriff of Calhoun County d. Colin Rangnow or his designee as the Chief of Police for the City of Port Lavaca e. Erin Clevenger or her designee as the representative from the Memorial Medical Hospital, the largest health care provider in the county f. Jacklyn Hartl, LPC, M. Ed, a behavioral health service provider in Calhoun County. g. Any other person the Presiding Officer of the Response Team considers necessary for the operation of the Response Team as recommended by the Response Team 2. Officers: The Response Team shall elect a Presiding Officer from the members of the Response Team 3. Duties: The Response Team shall act in accordance with the statutory requirements of Chapter 351 of the Local Government Code. 4. Multi -county Team Election: Since Chapter 351 of the Local Government Code permits two or more counties each with a population of 250,000 or less, within a contiguous area to partner to form a multicounty response team, and, at any point, should the Response Team be in favor of merging with a contiguous area to form a multi -county response team, the Presiding Officer of the response team is authorized to make this recommendation to Commissioners Court. After presentment to Commissioner's Court and if approved, the County Judge shall enter into an interlocal agreement for the creation of a multi -county adult sexual assault response team. The above -named positions and individuals shall also be members of and attend the meetings of the multi -county adult sexual assault response team. 5. Severability: If any section, clause, sentence, or phrase of this Resolution is held to be invalid or unconstitutional by any court of competent jurisdiction, then said holding shall in no way affect the validity of the remaining portions of this resolution. APPROVED THIS 24T" DAY OF NOVEMBER 2021, BY THE CALHOUN COUNTY COMMISSIONERS COURT. r Richard H. Meyer Calhoun County Judge ATTEST: 1�4/Ior_ 1,kn. -, Anna Goodman, County Clerk Senate Bill 23 sets guidelines intended to prevent lowering the police -to -citizen ratio, and limit reallocation of law enforcement funding to other departments without specific voter approval. Several specific portions of the new Chapter 120 detail what must be made public in the event an election is called, limits the expenditure of public funds that may be used in a campaign related to such an election, and details the process by which complaints are reported and investigated. In the event the State Comptroller determines a county has violated this statute, the comptroller may freeze the ad valorem tax rate of the county, preventing the adoption of an ad valorem rate that exceeds the county's no -new -revenue tax rate until the issue is addressed. Chapter 351, Subchapter J. [SB 76 N_EW STATUT . Senate Bill 476 adds Subchapter J, which establishes the newly created Sexual Assault Response_. This legislation requires the creation of multidisciplinary sexual assault response teams by the commissioner's court of each county. The bill contains the applicable definitions and legislative requirements. Each commissioner's court shall establish such te_ ams: Multi -county teams can be established so long as the member counties are contiguous and each county has a population of fewer than 250,000 persons. Each response team shall consist of the following persons: • the chief administrator, or the chief administrator's designee, of a sexual assault program that provides services for the county; • a prosecutor with jurisdiction over sexual assault cases involving adult victims; the Chief of Police, or designee, of the largest municipality within the county; • the County Sheriff, or designee; • either a sexual assault nurse examiner or forensic examiner from a facility that conducts sexual assault forensic exams for the county, or a representative from the largest health care provider in the county if the county does not have a SANE or forensic examiner from a facility that conducts sexual assault forensic exams for the county; a behavioral health services provider or a representative from the county health department if no behavioral health services provider exists; and • other persons deemed necessary or requested by the response team. The sexua[assault response team shall meet no less than once quarterly. The team must also meet not later than the 90th day after the last day of a regular legislative session. The teams must beindependentof child advocacy center multidisciplinary team meetings: Senate Bill 476 additionally specifies the required response protocols which include, but are not limited to, Investigative and prosecutorial procedures for sexual assault cases with adult victims; • interagency information sharing; • notifications to survivors of the case status and court proceedings; • biennial evaluations of the effectiveness of individual agency and interagency protocols and systems; and • a minimum of four hours of annual, cross -agency training for the team members. Page 39 of 44 pages The purpose of the protocols developed is to ensure coordination between all agencies involved in sexual assault cases to increase the efficacy of response and to minimize survivor traumatization. The response team shall provide the protocol to each agency in the county that responds to disclosures of sexual assault. This legislation further requires the team to conduct a minimum of biennial reports to the commissioner's court containing information, including: The number of sexual assault cases -reported to each agency; , • thenumberof investigations resulting from those reports; the number of indictments presented and the disposition of those cases; and. the number of reports of sexual assault for which no indictment was presented; or an explanation of why no such report was submitted to the commissioner's court. The team may review only cases in which the victim has signed a written consent form specifying • the information and records covered by the release, • the reason and purpose for the release, and • the person or agency to whom the information is to be released. The sexual assault teams members must be appointed and conduct the first meeting -by Dgcember 1. 2021.?The enumerated written protocols must be established by December 1. 2022. Lastly, it is important to note that SB476 applies only to sexual assault cases involving adult victims. Chapter 179, Authority of Certain First Responders to Carry Handgun [HB1069]. House Bill 1069 establishes the ability for certain first responders to carry a handgun during the discharge of their duties. This legislation is complex and should be read in detail by anyone who employs such first responders and who is attempting to comply with the requirements. To give the reader an idea of the complexity of this legislation, the House Research Organization's enrolled bill summary for House Bill 1069 reads as follows: House Bill 1069 amends the Civil Practice and Remedies Code, Government Code, Local Government Code, and Penal Code to set out provisions relating to the carrying of a handgun by certain first responders employed or supervised by or providing services for certain municipalities and counties that have not adopted The Fire and Police Employee Relations Act. The bill requires the Department of Public Safety (DPS) to establish minimum standards for training and continuing education courses for applicable first responders who are handgun license holders and to issue a corresponding certificate upon their completion of the course. The bill provides for the authority of the first responders to carry a concealed or holstered handgun while on duty and to store a handgun on the premises of or in a vehicle owned or leased by the municipality or county. The bill requires the first responders to maintain liability insurance coverage for carrying a handgun that is not an essential part of their duties while on duty and sets out provisions relating to when the handgun may be discharged, the limited liability of municipalities and counties arising from that discharge, and handgun storage in locations where handgun carry is prohibited. Page 40 of 44 pages #13 NOTICE OF MEETING— 11/24/2021 13. Consider and take necessary action to award the bid for the Annual Supply Contract for Inmate Food Services for the Calhoun County Adult Detention Center, Bid Number 2022.04 for the period beginning January 1, 2022 and ending December 31, 2022 with the option to renew annually if agreeable with both the successful bidder and Calhoun County. (RHM) Bobby Vickery explained. Bid from Ben K. Keith awarded. MOVER: David Hall, Commissioner Pct 1 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 9 of 28 November 16, 2021 To: Judge Meyer From: The office of the County Auditor Forthe Calhoun County Adult Detention Center Please place the following item on the Commissioners Court Agenda for November 24, 2021: Consider and take necessary action to award the bid for the Annual Supply Contract for Inmate Food Services for the Calhoun County Adult Detention Center, Bid Number 2022.04 for the period beginning January 1, 2022 and ending December 31, 2022 with the option to renew yearly if agreeable with both the successful bidder and Calhoun County. Commissioners Court — November 24, 2021 BID INFORMATION FOR Annual Supply Contract for Inmate Food Services Bid Number 2022.04 January 1, 2022 thru December 31, 2022 With the option to renew yearly if agreeable with both the successful bidder and Calhoun County Bids were received until 2:00 pm, Tuesday, November 9, 2021 Two (2) Bids were received: 1. Ben E Keith 2. Sysco Central Texas After reviewing both bids, only one bid met specifications: Ben E Keith Sysco Central Texas did not meet specifications: 1. Affidavit was not signed by the Affiant 2. Affidavit was not notarized and was not signed by a notary 3. The County's Invitation to Bid Form was not used. Sysco supplied their own list of food and non-food items plus additional items on the same list. Calhoun County, Texas Calhoun County Adult Detention Center INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INMATE FOOD SERVICES Bid Number 2022.04 January 1, 2022 thru December 31, 2022 With the option to renew yearly (one year terms) if agreeable with both the successful bidder and Calhoun County. Bidder's Name and Address Ben E Keith 17635 Ben E Keith Way Selma, TX 78154 • PLEASE TYPE. IF HANDWRITTEN, MUST BE IN INK AND LEGIBLE. • WHITE OUT IS NOT ACCEPTABLE • ITEM OR ITEMS NOT BIDDING: MARK "NA" UNDER COST OR LEAVE BLANK • ADDING ITEMS: LIST ON A SEPARATE PAGE AND NOTE AS AN ATTACHMENTTO THE INVITATION TO BID FORM • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • BE SURE TO COMPLETE, SIGN AND DATE THE LAST PAGE OF THE INVITATION TO BID FORM PLEASE NOTE: The bidder may request the Invitation to Bid Form be emailed to them in the Excel Format. If the bidder requests the Invitation to Bid Form be sent to them in the Excel Format, the bidder understands that the form and/or format shall not be changed in any way. The bidder shall not delete and/or add items to the Invitation to Bid Form. THE BIDDER UNDERSTANDS THAT BY CHANGING THE FORM AND/OR FORMAT OF THE INVITATION TO BID FORM IN ANY WAY SHALL DISQUALIFY THEIR BID. The Excel Format may be requested only as a means to enter the required information. Requests for the Excel Format of the Invitation to Bid Form must be sent to Peggy Hall, Assistant Auditor, at peggy.hall@calhouncotx.org or by calling 361-553-4610. Page 1 of 17 Invitation to Bid Form -Annual Supply Contract forInmate Food Services— CONTINUED Item # Pack / Size Pack/Size if different from Listed Brand Description cost M11M TE on Often rowUsed: 136575 1 140 lb 4/31b Sunrich Apples Sliced Solid Pack Fresh $35.39 Weekly 009848 2412 oz Sunrich Apple Slice Red $15.27 Weekly 125049 61#10 Ellington Apple Sauce unsweet $31.69 Weekly 125048 6 /#10 Ellington Apple Sauce Sweet $33.18 weekly 530824 11300 ct FBstnesy Bacon Precooked Thin $53.29 Weekly 01756 1 130 lb Coverwgn Bacon Slab Sliced Raw $76.89 weekly 398821 1216 ct Lenders Bagel Plain Sliced 2.3 oz $18.19 Weekly 696005 615 lb Clabgirl Baking Powder $57.59 Quarterly 696130 2411 lb Hosptlty Baking Soda $19.67 Quarterly 018004 1 140 lb Packer Bananas green tip $24.48 weekly 811196 217 lb th/Home Base - Beef Granular $37.38 Quarterly 124194 2 / 9 Ib Kth/Home Base - Chicken Flavor Paste $42.78 Quarterly 774007 115 oz Mcormick Basil Ground $11.67 Quarterly 774010 1 / 5 oz Mcormick Basil Leaf $5.91 Quarterly 774911 111 lb Mcormick Bay Leaves $11.88 Quarterly 650061 6 / #10 Aliens Bean Baked Oven Prepared $38.68 Weekly 123884 6 /#10 Ellington Bean Chili Homestyle $70.48 weekly 650070 6 / #10 Aliens Bean Chili Chuck wagon Max $30.88 Weekly 334355 1 / 20 lb Mrkn/Fc Bean Cut Green Bean - Frozen $22.18 weekly 650010 61 #10 Aliens Bean Cut Green Bean - Canned $30.88 weekly 334355 1 120 lb Mrkn/Fc Bean Green Regular Cut $22.18 weekly 158788 61 #10 Bushbest Bean Kidney Dark Red $28.78 Quarterly 122432 1 / 20 lb Ellington Bean Baby Lima Bean - Dry $25.47 Quarterly 122437 1 120 lb Ellington Bean Navy Pea Dry $18.28 Quarterly 650082 61#10 Bushbest Been Pinto Fancy $26.39 Weekly 652031 1 150 lb Gransabr Bean Pinto Triple Clean Dried $35.78 Weekly 111698 1 61#10 1 Lakeside Bean Pork and Beans Fancy $27.37 weekly 650085 1 6/#10 1 Ranchsty Bean Ranch Style Fancy $39.69 Weekly Page 2 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services - CON7INUED Item# Pack/Size Pack/Size Ifdifferent from Listed Brand Description Cost STIMATEO" How Often Used: 782002 6/#10 Allens Bean Refried $37.07 Weekly 117441 6/ #10 Bushbest Bean Vegetarian Baked Beans $38.28 weekly 546001 4 15 lb tub Tx Chili Beef BBQ Beef Chopped with Sauce $55.59 Weekly 504853 5 / catch Swift Beef - Brisket Boneless 120 No Rol $3.69/lb Quarterly 501004 217 lb avg Wilson Beef - Roast Top Round Cooked $4.99/lb Quarterly 506080 8110 lb avg Packer Beef Ground Fine 73/27 $2.25/lb Weekly 506104 40 14 oz Holten Beef - Patty 4/1 with Tvp $25.79 weekly 168480 4014 oz Holten Beef - Patty Breaded $51.54 Weekly 509345 90 13 oz Tndrbrl Beef - Patty Flame Broiled $92.32 Quarterly 509306 10212.5 oz Tndrbd Beef Patty Charbroiled pre-cooked $88.24 Quarterly 504750 3 / 24 lb avg Cargill Beef Shoulder Clod $3.47/lb Quarterly 508013 4014 oz Beko Beef Steak Fritter Natural 4/1 Raw $35.77 Weekly 154223 215 lb 4/51b Texas Fd Beef Stew Meat $93.38 weekly 510413 16011 oz Advance Beef Steak Finger Breaded Cooked 1 oz $41.98 Weekly 2418 oz Biscuits Buttermilk 10 ct NA Monthly 398435 9611.55 oz Roteilas Biscuits Dinner Rolls Thaw & Serve $28.79 weekly 140607 21612.2 oz Ellingtn Biscuits Dough Southern Style $36.49 Weekly 290073 8124 oz Frsh/Kth Bread Sandwich Wheat Loaf $16.67 weekly 290020 8124 oz Frsh/Kth Bread Sandwich White Loaf $14.49 Weekly 106047 6112 doz Gransabr Bread Tortillas Com $25.27 Weekly 408617 18124ct Mex Orig Bread Tortillas Flour $23.97 Weekly 547106 1211 lb Farmind Bologna Turkey Club $42.27 Weekly 335209 1 /20lb Mrkn/Fc Broccoli Cuts $19.27 weekly 808022 12 / 49 oz Vanee Broth Chicken $35.89 Quarterly 2 120 ct Bun Hamburger Wheat NA Weekly 161826 618 ct Orowheat Bun Hamburger Wheat $13.87 Weekly 155868 2120 ct Mrsbaird Bun Hamburger White $9.37 Weekly 106518 6 / 6 ct 5/12ct Frsh/Kth Bun Hamburger White $11.22 Weekly 290220 6 / 12 ct Frsh/Kth Bun Hot Dog $13.98 Weekly 168497 7214 oz 64/4oz Tines Burrito Beef & Bean $23.68 Weekly 385147 64 / 4 oz Eimontry Burrito Beef & Bean Red Chili $36.89 Weekly Page 3 of 17 Invitation to Bid Form - Annual5upply Contract for Inmate Food Services — CONTINUED Item If Pack / Size Pack/Size if different from listed Brand Description Cost ESTMOTATE on How Often Used: 092005 1150 lb Packer Cabbage Green $26.67 Monthly 691402 615lb Contmill Cake Mix Chocolate $29.29 Monthly 691402 6 / 5 lb Contmill Cake Mix Devils Food $29.29 Monthly 691401 6 / 5 lb Contmill Cake Mix White $29.38 Monthly 691400 6 / 5 lb Contmill Cake Mix Yellow $29.38 Monthly 117566 1 112 a Mrkn/Fc Cantaloupe Fresh $33.38 weekly 098010 1 / 50 lb sack Packer Carrots Jumbo $20.88 Weekly 336335 12 / 2 lb Mrkn/Fc Carrots Diced $24.37 weekly 113583 6 / #10 Lakeside Carrots Sliced Canned $28.88 Weekly 336151 1 ! 20 lb Mrkn/Fc Carrots Smooth Sliced $22.47 Weekly 113583 6 r #1 a Lakeside Carrots Sliced Medium $28.88 Weekly 337112 1120lb Mrkn/Fc Cauliflower LCF $23.98 Monthly 102012 1 / 40 lb Mrkn/Fc Celery Fresh $26.67 Weekly 799100 4126 oz Kelloggs Cereal Bulk Com Flakes $25.68 Weekly 799224 12126 oz Quaker Cereal Cream of Wheat $26.88 Weekly 799226 12 / zB oz HOsptity Cereal Farina Enriched $23.28 Weekly 799116 4146 oz MOM Cereal Bulk Frosted Flakes $34.78 Weekly 799120 4146 oz MOM Cereal Bulk Fruit Dyno Bites $35.49 Weekly 799276 4 / 39 oz Cheerios Cereal Bulk Honey Nut Cheedos $53.19 weekly 799204 1 150 lb Quaker Cereal Oats Rolled #5 $26.52 Weekly 799114 6136 oz MOM Cereal Bulk Raisin Bran $37.07 Weekly 799103 4135 oz MOM Cereal Rice Toctie Fruitie $32.09 Weekly 761010 6 / 5 lb Gldhrvst Cheese American Melt Loaf $74.67 Monthly 133070 6 / 5lb Hilldale Cheese Product American 120 Slices $69.99 Weekly 121802 4 / 5 lb Schreibr Cheese American 184 Slices $46.47 Weekly 121801 416lb Schreibr Cheese Cheddar Shredded Imitation $34.88 Quarterly 740078 2 / 5lb Gldhrvst Cheese ChedderJack Shredded $26.08 weekly 016181 2 / 5 lb Schreibr Cheese Cheddar & Mont. Jack Shreeded $58.37 Weekly 158931 2 / 5 lb 4/51b Daisy Cheese Cottage Cheese Sm Curd 4% $29.98 weekly Page 4 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services — CONTINUED Item# Pack/Size Pack/Size If different from Usted Brand Description cost ESnMATE on How Often used: 742022 10 / 3 Ib Gldhrvst Cheese Cream Cheese Loaf Grade A $60.29 Monthly 761010 6 15 lb Gldhrvst Cheese Melting Loaf Yellow $74.67 Monthly 107524 415 lb 6/51b 1950-127 Cheese Mozzarella Reg Shredded $75.67 Monthly 759001 215 lb Gldhrvst Cheese Pimento Cheese Spread $40.58 Monthly 121922 6129 oz Gldhrvst Cheese Powdered Cheese Mix $44.27 weekly 158882 5 / 5 lb Welcomed Cheese Queso Melt $59.07 Weekly 487156 4110 lb Packer Chicken Boneless Skinless Chicken Thighs - Plain 27 $85 Weekly 167546 1110lb 1/401b Martin Chicken Boneless Skinless Chicken Thighs- Flavored $81 78 Weekly 487831 6013.1 oz 67/2.4oz Brkbush Chicken Breast Patty Breaded $32.88 weekly 115457 16013 oz Minutemn Chicken Patty Breaded Cooked $62.87 Weekly 114922 215 lb Tyson Chicken Breaded Chicken Fritter $26.78 Weekly 122494 107 11.5 oz Jones Chicken Breakfast Patty $35.38 Quarterly $84.22 215lb Plathvst Chicken Diced All White Cooked $43.67 Weekly 487431 5213 oz Smrtsrve Chicken Breast Fillet Fajita $46.83 Monthly 122391 1110 lb 4/101b Texas Fd Chicken Fajitas Sliced Chicken Raw $111.17 Weekly 487365 215 lb Perdue Chicken Fajita Strip Cooked $41.67 Monthly 102198 216 lb Gransabr Chicken Fajita Meat Lacocina $3.59/lb Monthly 487080 1 110 lb Supreme Chicken Fajita Thigh Meat Frozen $44.38 Monthly 487856 4110 lb Packer Chicken Leg Meat Sonless $77.38 Weekly 126814 1 120lb Dixie Chicken Nuggets Raw $20.89 Monthly 487156 4110 lb Packer Chicken Thigh Meat Raw Frozen $85.27 Monthly 123884 414 lb 6/#10 Ellingtn Chili Frozen -With Beans $70.48 Weekly 106559 6 / 5 lb Cocinagr Chili Frozen - Without Beans $60.28 Weekly 123884 61 #10 Ellingtn Chili Canned - With Beans $70.48 weekly 123883 61 #10 Ellingtn Chili Canned - Without Beans $91.78 weekly 123885 6 / #10 Ellingtn Chili Hot Dog Sauce w/meat $57.57 Monthly 699399 B 11 lb Fritos Chip Fnto Cont Bulk $16.24 weekly 149126 10 / 16 oz Deeprivr lChip Potato Kettle $32.48 Weekly Page 5 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services - CONTINUED Item # Pack / Size Pack/She if different from listed Brand Description cost E is rn on How Often Usetl: 699514 6 / 16 oz Lays Chip Potato Regular Bulk $15.41 Weekly 699253 8 / 16 oz Ruffles Chip Potato Ridged Ruffled $21.06 Weekly 106058 6 / 2 Ib Gransabr Chip Tortilla Yellow Round $19.09 Weekly 168684 3 / 50 ct 2/50ct Fritolay Chip variety $33.14 Weekly 774022 1 / 5 lb Spicecls Cinnamon Ground $27.67 Monthly 692113 1 110 lb Snowflak Coconut Sweetened Coconut $27.88 Monthly 640345 12 / 2 lb 6/21b Elgtncof Coffee Traditional $87.79 Weekly 12 / 2 lb Coffee Can NA Weekly 640555 4211.25 oz S&D Coffee Todays Gourmet w/Filter $19.89 Weekly 92071 415 lb ct Mrkn/Fc Coleslaw Mix Shredded $19.48 Weekly 772015 1 / 10 lb Homestyl Cookie Chocolate Chip $23.28 Weekly 772021 1 / 10 lb Homestyl Cookie Oatmeal Homestyle $21.22 Weekly 772023 1 / 10 lb Homestyl Cookie Sugar Homestyle $20.57 weekly 772010 1 / 5 lb 6/13.3oz Keebler Cookie vanilla wafers $14.47 Weekly 432441 320/1 oz Valuzone Cookie Dough Chocolate Chip $46.19 Weekly 432442 320 / 1 oz Valuzone Cookie Dough Oatmeal Raisin $49.98 Weekly 432443 320 / 1 oz Valuzone Cookie Dough Sugar $43.28 Weekly 650172 6 / #10 Aliens Com Cream Style $37.29 Monthly 338602 1 / 20 lb Mrkn/Fc Com Cut $21.29 weekly 338837 612 It, Freds Com Com Nuggets Sweet Battered $31.38 Weekly 125734 6/*10 Ellingtn Com Whole Kernel Fancy Canned $29.98 Weekly 124525 240 / .67 oz Ellingtn Com Dogs No Sticks $38.67 Weekly 240 / .67 oz Com Dogs Turkey Mini - No Sticks NA Weekly 691056 6 / 5 It, Pioneer Combread Mix Homestyle $32.68 Weekly 117439 613.5 to Ellingtn Combread Stuffing Mix $58.69 Monthly 119165 1 /25lb Ellingtn Cornmeal $10.09 quarterly 772080 200 / 2 pk Honymaid Crackers r P Graham Honey Mid - Individually $21 48 Monthly 771314 12116 oz Nabisco Crackers Saltine - Bulk $36.18 weekly 771332 500/2 pk Lanec Crackers Saltine - Individually Wrapped $12.57 Monthly 771510 300 / 2 pk 500/2ct Lance Crackers Cafe Club $17.38 Monthly 639071 24112 oz N ,joy Creamer Non Dairy Canister $40.29 Weekly 104930 114.5 lb Gransabr Cumin Ground $24.07 quarterly Page 6 of 17 Invitation to Bid Form -Annual Supply Contractfor Inmate Food Services -- CONTINUED Item# Pack If Size Pack/Size If different from Listed Brand Description Cost Estimalte on Now often Used: 119441 411 gal Ellingtn Dressing Coleslaw $41.75 Quarterly 674077 200 / 12 gm PPI Dressing PC Italian Packets $14.78 Monthly 119440 1 4/1 gal Ellingtn Dressing Lt Italian Dressing Gallon $24.98 Monthly 119442 4/1 gal Ellingtn Dressing Ranch Buttermilk Gallon $47.74 Quarterly 674146 200112 gm PPI Dressing PC Ranch Buttermilk $16.49 Weekly 122557 18 / 3.2 oz Ellingtn Dressing Ranch Mix $26.18 Weekly 164879 60 / 1.5 oz Ellingtn Dressing PC Thousand Island $13.87 Monthly 662323 411 gal Select Dressing Honey Mustard $55.38 Monthly 122648 12 / 24 oz Ellingtn Drink Mix Fruit Grape Powdered $33.68 Weekly 122645 12124 oz Ellingtn Drink Mix Strawberry Powdered $33.68 Weekly 122642 12 / 24 oz Ellingtn Drink Mix Fruit Punch Powdered $33.68 Weekly 122647 12 / 24 oz Ellingtn Drink Mix Pink Lemondade Powdered $33.68 Weekly 122644 12124 oz Ellingtn Drink Mix Peach Powdered $33.68 Weekly 630281 1211.8 oz Crystigt Drink Mix Sugar Free Fruit Punch Powdered $46.97 Weekly 630280 12 ! 2.2 oz CryStlgt Drink Mix Sugar Free Pink Lemonade Powdered $46.97 Weekly 118454 15 / 2 lb Ellingtn Egg Mix Scrambled w/2% Milk $40.67 Weekly 118455 1 / 20 lb Ellingtn Eggs Whole Liquid w/citric $49.08 Weekly 118455 2 /20 lb, Egg Whole Liquid wlcitric $49.08 Weekly 016522 200 / 1 oz 153/1.25oz Echolake Egg Scrambled Patty Round $33.98 weekly 138229 1 / 10 lb Papettis Egg Hard Cooked Peeled $24.07 Weekly 122785 11200 ct Packer Egg Fresh Shell Jumbo USDA $31.07 Weekly 385417 90 / 1.75 oz Femando Enchilada Cheese IQF $26.17 Weekly 777035 1/Pt MCOrmick Extract Vanilla Imitation $4.10 Quarterly 117880 1 115 lb Admiral Fillet Swell Fillet 5-7 oz $58.38 weekly 455779 1 110 lb Fpi Fish Strip 1.5 oz Breaded $39.29 Weekly 451711 4 / 10 lb Packer Fish Pollock Fillet 4-6 oz $103.17 Weekly 151727 1110 lb Highline Fish Pollock Rect Breaded Wg $37.71 Weekly 119163 1 /50lb Ellingtn Flour All Purpose $16.07 Monthly 536111 8012 oz Farmland Franks All Meat 811 $26.59 Monthly 492029 215 lb Butterbi Franks Turkey $20.27 Monthly 137957 6 / 5lb Farmers French Fries RC 318 IN $21.58 Weekly 125647 6 / #10 KthNaly Fruit Cocktail X Lt Syrup $49.99 Weekly 125646 6 / #t 0 KthNaly Fruit Mix Lt Syrup $49.47 Weekly Page 7 of 17 Invitation to Bid Form - Annual Supply Contract for Inmate Food Services - CON77NUED Item# Pack/Size Pock/Ske if different from Listed Brand Description Cost ESSTIMAM on Often Now used: 104929 1/71b 1/6.51b Gransabr Gadic Granulated $29.77 Monthly 767052 24 / 3.14 oz Jello Gelatin Cup $10.08 Monthly 122655 12 / 24 oz Ellingtn Gelatin Mix Mixed Assorted Citrus $34.67 Monthly 767043 12124 oz Royal Fd Gelatin Mix Lime $28.17 Monthly 122654 12124 oz Ellingtn Gelatin Red variation $34.67 Monthly 027120 1 / 35 to Packer Grapefruit Ruby Choice 40 $39.78 Weekly 797058 6 / 13 oz Morrison Gravy Mix Brown Country Style $21.58 Monthly 797060 6114 oz I Pioneer Gravy Mix Chicken $23.19 Monthly 797246 6 / 24 oz Morrison Gravy Mix Peppered $17.38 Monthly 797237 6111.3 oz Pioneer Gravy Mix Pork Roast $26.29 Monthly 797240 6 / 11.3 oz Pioneer Gravy Mix Turkey Roasted $21.58 Monthly 012362 613 to Packer Greens Mustard Greens $20.78 Weekly 538680 2110-12 lb Menumstr Ham Buffet Style $2.51/lb Weekly 127801 615 lb 4/101b Hormel Ham Chopped $146.78 Quarterly 538043 413lb 6/21b Breadrdy Ham Pre -Sliced $43.07 Quarterly 2113 lb Ham Shaving Cooked 4 x 6 Deli NA weekly 2 / 10-12 lb Ham Shaving Smoked Boneless NA Quarterly 128886 4 / 3 lb Hiishire Ham Sliced Smoked $59.67 Quarterly 155869 2120 ct Mrsbaird Hamburger Huns $9.97 Weekly 361069 12012.2 oz Ore Ida Hashbrowns Golden Patty $29.69 Weekly 650337 6 / 3 to GDidngrl Hashbrowns Redi Shred $46.09 Weekly 361030 6 / 3 lb Traditni Hashbrowns Lqf Shredded $25.27 Weekly 1 130 lb Honey Dew Melon US #1 8 ct NA Weekly 290220 6112 ct Frsh/Kth Hot Dog Buns $13.98 Weekly 123003 2 15 to Ellingtn Hushpuppies Regular Round $17.97 Weekly 405128 415 lb Hagys Hushpuppies Homestyle $34.69 weekly 766108 1 112 lb Richs Icing Chocolate $25.80 Quarterly 766107 1112 lb Richs Icing Vanilla $23.27 Quarterly 77092 200 / .5 oz Heinz Jelly PC Assorted Cup $13.78 Monthly 677036 200 / .5 oz Smuckers Jelly PC Grape Cup $12.48 Weekly 318011 70 / 4 oz Ard Frn Juice Apple 100% Carton Carton $12.38 1 Weekly 318034 1 7014 oz I Ard Frm 1juice Orange 100% Carton $14.50 weekly Page 8 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate food Services — CONTINUED Item# Pack/Size Pack/Size ifdffferent from Usted Brand Description Cost man How Often Used: 146968 100019 gr 1906 Ketchup Individual Packets $18.78 Weekly 122416 6 / #10 Kth/Home Ketchup Standard $26.57 weekly 138201 1/case Mrkn/Fc Lettuce Iceberg $39.67 weekly 123065 4 15 lb Mrkn/Rss Lettuce Shred 1/41nch $29.18 weekly 148179 900 / 5 gr 912/5gr Landolak Margarine PC Cup Spread $ 22.97 Monthly 129724 432114 gr Gldhrvst Margarine pcks $29.49 119460 3011 lb Ellingtn Margarine Solids Pure Vag $34.39 Monthly 800711 12116 oz Jetpufed Marshmallows Jet Puffed $24.68 1 quarterly 111293 411 gal Kens Mayonnaise Heavy Duty Gallon $40.97 Monthly 170220 200112 gm Flavrfrs Mayonnaise PC $18.47 weekly 1 130 It, Melons Honey Dew US #1 8 at NA weekly 104374 2 15 lb Bonici Meatballs Beef & Chicken $42.28 weekly 522410 320 / .5 oz Advancep Meatballs Flame Broiled $53.68 weekly 509618 76 / 3.15 oz Smartpic Meadoof Patty Deluxe $88.28 Weekly 798022 24 / 14 oz Magnolia Milk Condensed Sweetened $48.87 Monthly 798001 24112 oz Velvet Milk Evaporated $24.59 Monthly 798059 1 / 25 It, Ramsen Milk Powdered Skimmed NF $57.78 Monthly Milk Powdered Homo Vitamin D NA Monthly 171984 4/1 gal Oakfarms Milk 2% Reduced Fat 1 Gallon $19.69 Weekly 71983 411 gal Oakfarms Milk Homo Vitamin D 1 gallon $20.57 weekly 284410 25 / 1/2 pt Oakfarms Milk 1% Reduced Fat 1/2 pint cartons $9.47 Weekly 119825 251112 pt Dairypur Milk 2% Reduced Fat 1/2 pint cartons $9.37 Weekly 119826 251 112 pt Dairypur Milk Homo Vitamin D 1/2 pint cartons $9.67 Weekly 124165 4/1 gal KthNaly Mustard Prepared Gallon $12.99 Quarterly 160130 500 15.6 gr Frenchs Mustard PC Pouch $12.69 weekly Page 9 of 17 Invitation to Bid Form - Annual Supply Contract for Inmate Food Services — CON77NUED Item # Pack / Size Pack/Size if different from Listed Brand Description Cost E MA—Teon NOW Often Used: 119462 6/1 gal Ellingtn Oil Butter Flavored $83.30 Monthly 119462 8/1 gal Ellingtn Oil Pan & Grill Trans Fat Free $83.30 1 Monthly 698007 6 / 17 oz Pate Oil Pan Spray $21.47 Monthly 779032 1 / 35 lb Bunge Oil Shortening Clear Fry $43.08 Monthly 342131 1 120 lb Pictswt Okra Cut 1/2 inch Grade A $17.99 Weekly 325205 1 120 lb Beko Okra Cut Heavily Breaded $20.47 Weekly 124370 6 12 lb Ellingtn Okra Cut Breaded Southern Style $13.88 Weekly 775002 1 / 3 lb MCOrmick Onion Dried Flakes Chopped $13.48 Monthly 155091 415lb Taylorfm onion Sliced $49.59 Monthly 155030 1 150 lb Packer Onion Yellow Jumbo Sack $24.77 Monthly 031111 1 135 lb Mrkn/Esn Oranges Fresh $34.17 Weekly 031112 1 135 lb Mrkn/Esn Orange Choice $43.09 Weekly 134842 6/ #10 EWlmport Oranges Mandarin Oranges Broken Lt $51.07 weekly 774929 1112 oz Txcustom Oregano Ground $9.69 quarterly 168088 14411.2 oz Krusteaz Pancake Original - Frozen $21.30 Weekly 774727 1 / 10 Oz Mcormick Parsley Flakes $14.47 quarterly 151773 2 15 lb Bellacib Pasta Egg Noodle Wide 112 Inch $15.48 Monthly 151772 2110lb Bellacib Pasta Elbow Macaroni $19.98 Monthly 151784 12116 oz Bellacib Pasta Lasagna Ribbed $15.97 Monthly 151778 2 / 10lb Bellacib Pasta Spaghetti Thin 10 Inch $19.98 1 Monthly 125643 6/ #10 KthNaly Peaches Sliced Extr Lt Syrup $47.77 Weekly 125648 6/ #10 KthNaly Peaches Diced Extra Lt Syrup $47.77 Weekly 165099 615 lb Ellingtn Peanut Butter creamy $49.39 Weekly 170314 20010.75 oz Jif Peanut Butter Pc $40.99 Weekly 125641 6/ #10 KthNaly Pears Sliced Light Syrup $48.39 weekly 113580 61 #10 Lakeside Peas Blackeyed $28.59 Weekly 104049 1 / 20lb 12/21b Sunfield Peas Peas & Diced Carrots Frozen $22.19 weekly 343503 1120lb I I Simplegd jPeas Green $23.57 Weekly Page 10 of 17 Invitation to Bid Form - Annual Supply Contract for Inmate Food Services - CONTINUED Item # Pack/ Size Pack/Size if different from Listed Brand Description cost EsrIMATEon Often HaUsed: used: 71- 12574 6 / #to KthNaly Peas Sweet Mixed $34.28 Weekly 774165 1118 oz $ icecls Pepper Black Gourd Fine Pure $9.47 Monthly .685214 12 127 oz Rosarita Peppers Chili Diced Green $51.27 Monthly 165010 1/1 1/9 Bulk Mrkn/Esn Pepper Bell Green Chopper $23.38 Monthly 110417 6 / #10 Gransabr Pepper Jalapeno Nacho Sliced $28,07 quarterly 774829 1 / 7 lb TXcustom Pepper Lemon Seasoning $23.58 Quarterly 100059 4/1 gal Bstmdpro Pickles Dill Relish $24.09 Monthly 680023 1 / 5 gal Chefsupr Pickles Dill Sliced Hamburger $20.59 Monthly 430075 6 / 43 oz Chef P Pie Pumpkin 10 Inch PreBaked $39.88 quarterly 600379 6 / 81 oz Dole Pineapple Chunks in Extra Lt Syrup $39.55 Weekly 134844 6 / #10 Ewimport Pineapple Sliced in Juice 52.98 Weekly 600373 6/#10 Dole Pineapple Tidbits in Juice $47.38 Weekly 384029 12813.31 oz Tonys Pizza Breakfast Turkey Sausage $52.97 Monthly 384420 96 14.48 oz Tonys Pizza Pepperoni Whole Grain $54.19 1 Monthly 653001 3618 oz Fan fart Popcorn Kit All In One $26.77 Monthly 153400 6 / 6-81b Smithfid Pork Loins Boneless $2.13/lb Monthly 544251 40 13.75 oz Advance Pork Patty Breaded Cooked $35.87 Monthly 532351 5213.1 Oz Qtf Pork Patty Rib Shape Cooked $44.57 Monthly 532010 46 13.5 oz Advance Pork Rib Patty $51.38 Monthly 532421 80 / 3 oz Kingcmnd Pork Rib Patty w/BBQ Sauce $58.27 1 Monthly 650337 612.5 lb Goldngrl Potato Hashbrown Redi Shred $46.09 Weekly 650332 6 /#10 6/5.311b Basic Potato Instant with milk $56.17 Weekly 170105 1150 lb Mrkn/Esn Potato Idaho #2 $24.17 Weekly 169149 1150lb Mrkn/Fc Potato Red#2 $22.27 Weekly 170050 1 / 50 lb Mrkn/Fc Potato Russet 10 oz US #2 $22.27 Weekly 170048 Mrkn/Fc Potato Russet 80 ct IDA $25.28 Weekly 650380 6/#10 Princela Potato Sweet Cut Fancy $37.58 Weekly 123013 8 15 lb Madeira Potato Tater Bites Seasoned $41.19 Weekly 360811 6 15 Ib Ore Ida Potato Tatar Tots $47.28 Weekly 650314 6/#10 Allens Potato White Diced $32.57 Weekly 765086 6/#10 Myhmtwn Pudding Banana $29.07 Weekly 765085 6 / #10 Myhmtwn Pudding Chocolate $29.57 Weekly 765037 2413.625 oz Jelio Pudding Chocolate Sugar Free $13.08 Weekly 148023 6/#10 Thankyou Pudding Lemon 1 $39.29 Weekly 123296 6/#10 Ellin to Pudding Tapioca $37.19 Weekly 765084 6/#10 MyhmtWn Pudding Vanilla $28.69 Weekly 168464 6 / #10 3/#10 Lucklf Pudding Vanilla Sugar Free $24.18 Weekly Page 11 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services - CONTINUED Item# Pack/Size Pock/She Ifd/Miarent from Listed Brand Description Cost EMMATE on Used: used: 800042 24 16 / 1 oz Vlypride Raisins Individual Packs 38.89 Weekly 800058 24115 oz Sunmaid Raisins Golden Seedless $53.98 Weekly 786203 6/ #10 Chefboy Ravioli Beef RTU $59.97 weekly 654044 1150 lb Producer Rice Long Grain $19.17 Weekly 654060 1 / 50 lb Comet Ri Rice Long Grain Parboiled 4% Broken $21.77 Weekly 100059 4/1 gal Bstmdpro Relish Dili Premium $24.09 Monthly 127018 4 15 lb Mrkn/RSS Salad Mix Lettuce in Beg $30.18 Weekly 768119 1130 lb 1/321b Rons Salad Potato Homestyle $49.73 Monthly 547118 384 1.5 oz Smithfid Salami All Meat Sliced $45.97 Weekly 676026 1125 lb Morton Salt Iodized Table $7.07 quarterly 660017 4 / 1 gal Lil Pig Sauce BBO $19.39 Monthly 660556 6/#10 Gehls Sauce cheese $40.27 Weekly 660583 6I#10 Mipueblo Sauce Cheese Nacho $40.17 weekly 600060 24 / 14 oz 6/#10 Oceanspr Sauce Cranberry Jellied $39.89 quarterly 168550 4/1 Gal 2/.5gal Gransabr Sauce Enchilada Mild RTU $14.98 Weekly 60220 6/ #10 Lavictor Sauce Enchilada Mild RTU $39.28 Weekly 785065 4/ #10 Manwich Sauce Manwich Sloppy Joe $29.09 Weekly 168549 411 Gal 2/.5gal Gransabr Sauce Picante Mild Gallon $14.67 Monthly 125659 6/#10 Ellingtn Sauce Pizza $29.58 weekly 124163 4 / 1 gal Ellingtn Sauce Soy Sauce Gallon $20.77 Monthly 125660 6 / #10 Ellingtn Sauce Spaghetti RTU $31.07 Weekly 169281 20019 gr Flavfrs Sauce PC Taco $8.78 Weekly 674096 50019 gr Heinz Sauce PC Taco $28.07 weekly 674812 200/7/16 oz Kraft Sauce Tarter Creamy Packets $16.17 Weekly 125658 6/ #10 Ellingtn sauce Tomato Fancy $25.17 Weekly 660298 4/1 gal Caj Chef Sauce Worcestershire $19.09 quarterly 541205 2/5 Ib Alamo Sausage Beef Breakfast Chorizo $25.49 weekly 122494 107 / 1.5 oz Jones Sausage Chicken Patty Cooked $35.38 weekly Page 12 of 17 Invitation to Bid Form - Annual Supply Contract for Inmate Food Services - CONTINUED Item # Pack / Size Pack/Size if different from Listed Brand Description Cost ESTIMATE on "ONf 0fteO Used: 492773 128 11.25 oz J Dean Sausage Turkey Cooked $39.88 Weekly 41029 2 15 lb Alamo Sausage Chorizo Pork Raw $26.68 Weekly 539067 215 lb Tenn Prd Sausage Ground Bulk Raw Mild $24.47 Weekly 541578 200 / .a oz 256/.75oz Tenn Prd Sausage Link Natural .8 oz Cooked $37.29 Weekly 541587 9211 oz 192/1 oz Beko Sausage Link Mild 1 oz Cooked $35.17 Weekly 549125 2 / 5 lb Pizzano Sausage Pork Topping Cooked $25.61 Weekly 158485 1 / 10 lb J Bar B Sausage Smoked Rope Cooked $23.78 Weekly 540018 154 / 1.26 oz Tenn Prd Sausage Patty Cooked $36.07 Weekly 774458 12 117 oz Chachere Seasoning Creole $32.37 Quarterly 115570 1 / 8 lb Chachere Seasoning Creole original $13.69 Quarterly 774434 1 124 oz 1/30oz Mcormick Seasoning Mexican Rub Mix $11.78 Quarterly 774450 1 / 23 oz Mcormick Seasoning Montreal $9.63 Quarterly 774396 114.5 lb Mcormick Seasoning Salt Traditional $13.30 Monthly 60606 6 115 oz Mcormick Seasoning Sloppy Joe Mix $26.77 Weekly 660714 1124 oz Mcormick Seasoning Taco $10.67 Quarterly 779032 1135 lb Bunge Shortening Clear Fry Liquid $43.08 Monthly 808040 12 / 50 oz Campbells Soup chicken Noodle $45.09 Monthly 808030 12 / 50 oz Campbells Soup Cream of Chicken $48.81 Monthly 808061 12150 oz Heinz Soup Cream of Mushroom $47.07 Monthly 12 150 oz Soup Cream of Potato NA Monthly 808090 12 / 50 oz Campbells Soup - Tomato $36.59 Monthly 808100 12150 oz Campbells Soup -Vegetable $51.77 Monthly 669027 4 15 lb Daisy Sour Cream Cultured $23.27 Monthly 6/ #10 Spinach Chopped Fancy NA weekly 200098 Vol Fill Packer Squash Zucchini Med 18-25 $25.09 Weekly 697100 24 / 1 lb, Argo Starch Corn $19.97 Quarterly 117439 6 13.5 lb Ellin to Stuffing Mix Combread $58.69 weekly 780009 12 12 lb Imperial Sugar Brown light in Beg $27.88 Monthly 140073 1 150 lb Unitedsu Sugar Pure Cane Extra Fine $30.97 Weekly 140073 1 150 lb Unitedsu Sugar Pure Cane Granulated $30.97 Weekly 781005 12 / 2 lb Imperial Sugar Powdered White $27.88 Quarterly 677255 too i 1 oz Smuckers Isyrup PC Pouch -Cup $13.59 Weekly 793036 10011 oz I Smuckers jSyrup PC Pouch -Cup Sugar Free 1 oz $16.17 Monthly Page 13 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services — CONTINUED Item It Pack / Size Pack/Sire if different from Listed Brand Description Cost ESTIMATEon How Useadten d: 168936 96 / 1 oz Elgtntea Tea Bags 1 oz $18.27 Weekly 167861 96 / 1 oz Ceylonat Tea Iced Filter Pouch 1 Gal $23.87 Weekly 211111 1 125 lb Packer Tomatoe Bulk Cafe $26.67 Weekly 125654 6 /#10 Ellingtn Tomatoe Diced in Juice $25.87 Weekly 171913 12128 oz Del Sol Tomatoe Diced with Green Chills $24.57 Monthly 210114 1125 lb Packer Tomato Roma#2 $23•38 Weekly 791075 6 / #10 Jubilee Topping Chocolate Fudge $71.59 Monthly 122650 1211 lb Ellingtn Topping Whip Mix Add Water $36.07 quarterly 134852 6 / 66.5 oz Ewimport Tuna Chunk Light in Water $70.29 Monthly 492954 12 / 1 lb Butterbl Turkey Breast Lunchmeat Combo $32.18 Weekly 492131 218-9 lb Jennie 0 Turkey Breast oven Roasted $2.19/lb Monthly 492291 219.9.5 lb o Carolina Turkey Breast Smoked Skinless $2.00/Ib Monthly 100167 4110 lb Carolina Turkey Ground Tubes 80120 $40.17 Weekly 492682 217-81b Carolina Turkey Ham Buffet Deluxe $1.78/Ib Weekly 515 lb Turkey Medallion Roasted NA Monthly 492681 215 Ito Butterbl Turkey Ham - Diced Cured $23.27 Weekly 492773 12811.25 oz J Dean Turkey Sausage Patty Cooked $39.88 weekly 139312 61#10 Lakeside Vegetables - Mixed Fancy $32.39 Weekly 104049 1 120 Ito Sunfieid Vegetables - Blend Peas & Carrots $22.19 Weekly 125737 6 / #10 Ellingtn Vegetables For Stew Fancy Chunky $31.77 Monthly 349198 1212 lb Mrkn/Fc Vegetables - Blend Stir Fry $45.69 Monthly 344137 1 / 20 lb Mrkn/Fc Vegetables - Mixed 5 Way $21.78 Weekly 127425 1 12112 ct E o Waffles $23.19 weekly 650380 61#10 Princela Yams -Cut $37.58 Monthly 697001 2011 lb I Saf Yeast Saf Instant Red Label $63.57 quarterly Page 14 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services —CONTINUED Item # Pack / Size Pock/Slze if different from Listed Brand Description Cost ESTIMATE on HDU OftenUsed: NON FOOD ITEMS: 883595 10 / 100 at Disco Apron, Plastic Full Length Mad Wt 24x42 $105.27 Quarterly 883597 1 / 100 ct DISCO Apron, Plastic White Disposable $11.99 Quarterly 875379 1 / 500 ct Wet Pak Bag Ice 10 lb Draw String $65.87 875027 1 / 2000 ct Essntial Bag Sandwich w/Flip Top $33.27 Quarterly 875403 1 / 500 ct Reynolds Bag Sandwich Reclosable 6.5x6 $17.66 Quarterly 875405 1 / 500 ct Reynolds Bag Zip Seal Quart $33.59 Quarterly 875321 11200 ct Reynolds Bag Freezer Reclosable 1 Gallon $23.78 Quarterly 129707 11250 ct Essntial Bag Reclosable Zip 1 Gallon $37.58 Quarterly 875322 11100 ct Reynolds Bag Freezer Reclosable Zip 2 Gallon $24.07 Quarterly 114852 11500 ct Duro Bag - White Paper Bag $28.09 885225 12812 oz SSDC Cleaner Floor Degreaser $44.08 Quarterly 64 / 2 oz Coffee Filter Packs NA Monthly 138524 2 1100 ct Pactiv Container Foam Hngd 3-¢ White $27.77 Quarterly 860041 40 / 25 at Dart Cup, Foam 12 oz $45.48 Monthly 860060 40125 ct Essntial Cup, Foam 16 oz $65.67 Monthly 860042 101100 a Dart Cup Lids for 12 oz $29.39 Monthly 860045 to / too a Dart Cup Lids 12L Trans Slotted $28.77 Monthly 860117 10 / 100 at Dart Cup Lids for 16 oz $34.98 Monthly 860055 101100 ct Dart Cup Udis for 16L Trans Slotted $29.39 Monthly 887097 211 gal SSDC Detergent Paramount Heavy Duty $81.98 weekly 887056 115 gal Essntial Detergent Speed Clean $104.79 weekly 887056 115gal ��tGl� Detergent Dishwasher $104.79 weekly Page 15 of 17 Invitation to Bid Form -Annual Supply ContractforInmate Food Services --CONTINUED Item # Pack / Size Pack/She If different from Listed Brand Description cost ESnMATE on Howoften Used: 877019 11 rail Reynolds Film 18 x 1000 Clear Wrap $27.18 Monthly 876063 1 1 roll Medallon Foil 18 By 1000 $81.07 876111 1 1 roll Durable Fail 24 x 500 #633 EX H $151.18 Monthly 888048 4 11 D ct SCOtChbr Grill Cleaning Pad $64.69 weekly 883860 10 / 100 ct Cellucap Gloves Clear Plastic Large $18.08 weekly 883757 101100 a Valugard Gloves Vinyl Powder Free Large $46.99 weekly 883769 101100 at Valu and Gloves Vinyl Powder Frae Merge $46.99 weekly 883708 11144 ct DISCO Haimet Dark Brown Light Weight $17.89 weekly 117334 11 roll Cambro Label 100% Dissolvable $17.09 weekly 878231 11250 ct Daymark Label 2 x 3 Dissolvable Use By $16.09 weekly 875476 111000 ct Dixie Liner Pan Lift Off Grease $46.28 Monthly 162196 11250 ct Wallace Meal Kit (K F S Napkin) MW W $19.77 Quarterly 115577 1 as Johnritz Mitt - Oven Mitt Black 17 $10.07 877036 11roll Reynolds Plastic wrap $22.47 Monthly 887078 115 gal Essntial Rinse Aid Fast Dry $137.47 weekly 885915 6/1 qt SSDC Sandizer Red! San Rtu $26.19 Weekly 1540991 41500 ct 10/500ct Cellocor Straws 7.75 Jumbo Clear Wrap $51.89 Monthly BE SURE TO COMPLETE, SIGN AND DATE THE NEXT PAGE Page 16 of 17 Invitation to Bid Form -Annual Supply Contract for Inmate Food Services —CONTINUED Food and Non -Food Items not listed on this Invitation to Bid Form shall be provided at: Cost Plus 2 % Basis Other equipment, services or products used in the DETENTION FACILITY'S Kitchen will be offered at: Free of Charge, a Discounted Price, or Cost Plus % Basis Example: Dispensers for coffee, chemicals and other products Bidder understands that Calhoun County or their representative may audit the Cost Plus Percentage Basis at any time and the documentation necessary for this audit will be provided at no additional charge to Calhoun County. Attachment(s) to Invitation to Bid Form: X YES NO ---------------------------------------------------------------------------- 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 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 any official, employee or agent of Calhoun County in connection with 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: October 11th, 2021 Authorized Signature & Title: Type Name & Title of Authorized Signature: Emily Lynch DSM Phone Number: 361-205-4070 Email: eslynch@benekeith.com Exceptions and/or Variations from Specifications and/or Additional Notes: Page 17 of 17 Attachment to Invitation to Bid Form -Additional Bid Items Item # Pack/Size Pack/Size if different from Listed Brand Description Cost ESTIMATE on How Often Used: Menu Analysis, Dietician, etc No Charge 398824 72/3oz Lenders Bagel Cinnamon Raisin Sliced $21.89 115464 160/3oz Minutemn Beef & Chicken Patty 3 Oz Ckd $114.87 509403 54/3oz Beko Beef Salisbury Steak Cooked $43.06 510193 240/10z Kin cmnd Beef Steak Finger Brd Ckd Wg $64.17 290306 6/8ct Mrsbaird Bun Crustini Sandwich 4.5 In $10.18 455030 1/151b Harvest Catfish Nugget Breaded 2-40z $38.67 799855 4/32oz MOM Cereal Bulk Crispy Rice $26.09 799116 4/45oz M 0 M Cereal Bulk Frosted Flakes $34.78 799127 4/50oz Kelloggs Cereal Bulk Granola Lowfat $56.29 799080 4/44oz MOM Cereal Bulk Hone nut Scooters $48.09 132429 100/loz Gldhrvst Cheese Cream PC Cu $18.67 134206 2/5Ib Tyson Chicken Breast Diced Griled $37.27 110640 2/51b Tyson Chicken Breast Pulled Cooked $42.08 104890 2/51b Tyson Chicken Meat Diced 1/2In $40.29 487529 4/Slb Tyson Chicken Thigh Diced Raw $43.18 115169 36/3oz Minh Egg Roll Pork & Veg Roller GO $27.79 380264 80/2oz Le Gourm Egg Roll Vegetable $23.77 401205 5/21b Farmrich French Toast Stick $24.07 600116 6/1110 Celebrty Mandarin Orange Whole Segments $46.37 149335 37/4.25oz Dr rae r Meatless Black Bean Burger $44.07 372073 48/4.25oz Mornstar Meatless Black Bean Burger $75.58 372090 200/.75oz Mornstar Meatless Chicken Nugget $60.88 172464 2/51b Beyond Meatless Chicken Tender $68.38 165031 4/2.51b Hormel Meatless Chorizo Crumble $60.57 372084 48/3.4oz Gardnbrg Meatless Garden Burger Blk Bn $58.58 372081 48/3.4oz Gardnbrg Meatless Garden Patty $58.58 372100 312/1.3oz IMornstar Meatless Sausage Pa $55.47 372067 4/8ct Ratners Meatless Veggie Griller 5 Oz $35.49 100855 14/15oz Kin cmnd Meatloaf Pull Apart $59.28 151786 2/101b Bellacib Pasta Penne Rigate $20.39 145785 1/101b Trident Pollock Stick Brd 1 Oz $36.67 532421 80/3oz Kin cmnd Pork Rib Patty W/Bbq Sauce $58.27 107369 2/51b Gransabr Pork Tip For Taco Especial $3.37/lb 157429 4/31b Gidntigr Rice Vegetable Fried $41.07 111495 180/loz Schubert Roll Dinner Par -Baked $26.07 660122 1/1gal Kikkoman Sauce Teri aki $11.97 164128 200/1.76oz Gokouju Spring Roll Vegetable 1.760z $40.07 167053 400/.88oz Gokou u Spring Roll Vegetable Mini $37.78 385792 120/1.5oz Rodri uz Tamale Beef In Husk 1.5 Oz $35.87 385179 341/.75oz Posada Ta uito Shredded Beef $71.29 451914 1/101b Sea Best Tilapia Fillet 3-5 Oz $28.89 128990 1/101b Westedge Tila is Fillet Iqf 5.5-6 Oz $25.59 105126 1/101b Perdue Turkey Burger Homesle $32.89 492254 30/5.33oz Butterbi Turkey Burger Mediterranean $30.89 492949 2/51b Butterbi Turkey Diced White $30.59 492990 2/101b Butterbi TurkeV Ground Bulk Chub $36.67 492954 12/11b Butterbi TurkeyLunchmeatCombo $32.18 150188 1/401b Shendoah Turkey Thighs Bnls Skinless $97.78 349245 1/201b Mrkn/Fc Vegetable Blend California $22.88 349350 1/201b Mrkn/Fc Vegetable Blend Capri Mix $26.67 349450 1/201b Mrkn/Fc Vegetable Blend Oriental Mix $28.57 349609 12/2lbs Mrkn/Fc Vegetable Blend Scandinavian $29.69 349650 1/201b Mrkn/Fc Vegetable Blend Winter Mix $22.88 Attachment to Invitation to Bid Form- Additional Bid Items 164989 1/81b Whitemtn Yogurt Greek Plain $24.78 285775 6/32oz Dannon Yogurt Plain Original Lowfat $17.38 108099 4/61b Dannon Yogurt Vanilla Dannon Pro $36.27 283934 6/32oz Dannon Yogurt Vanilla Low Fat $17.38 113016 48/4oz Yoplait Yogurt Variety Pack Light $23.19 283861 48/4oz Li ht&Ft Yogurt Variety Pack $20.37 283256 48/4oz Yo lait Yogurt Variety Rasp/Peach Ori $22.30 STATE OF ILOV,1 C {} t r AFFIDAVIT COUNTY OF �JScTrr l {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared En,,' i G L „"CA known to me to be the person whose name is subscribed to the following, who, upon ath sa s: I am the Manager, Secretary, or other Agent or Officer or the Principal of the Bidder in the matter of the bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 o `cial, employee or age t of Calhoun County prior to the official opening of this Bid. i r. Sales Ma Printed Name and Title of Aff!ant Name of Bidder (Company) Ben E Keith Address 17635 Ben E Keith Way, Selma TX 78154 Phone Number 361-205-4070 Fax Number Email Address esiynch@benekeith.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 -2 day of go o-cm d er- 20�. DOROTHY M. WOOD _ Notary Public, State of Texas Notary Public, State of / C)c ek I —. ..:P Comm. Expires 11-21.2022 'o,r1',",, Notary ID 131804350 ZZ Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Address: 17635 Ben E Keith Way Selma, TX 78154 Remittance Address: Telephone: 361-2 05-4070 Fax: �� Signature of Authorized Representative: Printed name of Authorized Rep: Emily Lynch ORDER — CONTACT INFORMATION Order Contact Name & Title: Rachel Judd, Sales Representative Order Contact Telephone: Order Contact Fax: 361-655-7914 Order Contact Email: rljudd@benekeith.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Emily Lynch, District Sales Manager Contact Telephone: 361-205-4070 Contact Fax: Contact Email: Eslynch@benekeith.com CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 Complete Nos. i - 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: 2021.811205 Date Filed: 10/11/2021 Date Acknowledged: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Ben E Keith Selma, TX United States 2 Name of governmental entity or state agency that is a party to the contract forwh ch the form is being filed. Calhoun County, Texas 3 Provide the Identification number used by the govemmental entity or state agency to track or identity the contract, and provide a description of the services, goads, or other property to be provided under the contract. Bid Number 2022.04 Annual Supply Contract for Inmate Food Services- January 1, 2022 thru December 31, 2022 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. ❑ 6 UNSWORN DECLARATION My name is Emily Lynch and my date of birth i My address is 'I USA, (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Aransas county, State of Texas , on the 1 %y of October 20 21 (month) (year) Signature of authorized agent of d3noacting business entity (Dedaram) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc ACORTO® CERTIFICATE OF LIABILITY INSURANCE `� DA1E(MMIDDAYYYI I I IISQ021 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 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 Marsh & McLennan Agency, LLC 301 Commerce St., Ste. 2201 Ft Worth TX 76102 Cindy Williams PNONE FAX —81 - , •. 817-286.3907 ac Ne:617-2883857 u qsr oindy.Wllliams(Mmarshmms.com INSURERS) AFFORDING COVERAGE INSURERA: Travelers Property Casualty Co of Amer INSURED SENEKEITH INsuRERB: AOCident Fund General Ins. CO, Ben E. Keith Company 601 E. 7th St. INSURER c: ACE PropertyPmperty & Casualty Insurance Cc Iy INSURER D: Gemini Insurance CompanyIill ii, Fort Worth TX INSURERE: Safety National Casualty Corporation IN811RERF: COVERAGES CERTIFICATE NUMBER: 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. I�TR TYPE OFINSUMNCE POLICYNUMBER MMN��) PDIUCYEXP (MMDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 411=1 4I1MV EACH OCCURRENCE $2.0w,wo M OCCUR DAMAGE TO RENTED EMI m S500000 HCLAIMS-MAOE X MED EXP (Arry are eram _ $Eow 25,000 PERSONAL& ADV INJURY S2.0w.wD GEN'L AGGREGATE LIMIT APPUES PER: GENERALAGGREGATE S20.000,000 X POLICY ❑ JECT MLOC PRODUCTS-COMP/OPAGG 52,000,WD S OTHER: A AUTOMOBILE LIABILITY 4/12021 4112022 COMBINED SINGLE LIMIT(Ea 20d'Ibral S BODILY INJURY(Parpersan) $ ANY AUTO BODILY INJURY (Peraadtlont) S AfLRI.00NMED AUTEODULED HIRED AUTOS X NAOONOYINED S Ix PROPERTY DAMAGE iftr�ml S $ C X UMBRELLA UAe X OCCUR 4I12021 VI= EACH OCCURRENCE slo'wo000 AGGREGATE S10000,000 EXCESS UAB CLAIMS.MADE DED I X I RETENTIONmrI n. $ B WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY N ANY PROpRISTORIPARTNER/EXEC1rNE YI OFHrEPJMEMBER EXCLUDED? (Mandatoryln NH) 1/1/2021 111YATT1 X I PEAT TE I I ETµ EL EACH ACCIDENT $1,000,000 EL DISEASE -EA EMPLOYEE $1,M000 E.1- DISEASE -POLICY LIMIT 31000000 If yea, describe um. DESCRIPTION OF OPERATIONS below D E Excess Auto Uab OK Swift. Excess WC& EmpbyarsUab VW021 12112019 4/12022 12n2021 Eacb ominfence 55,000,0W EL Max porOce Si,000,0W SeX lmured Retento S1,W0,0D0 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ADDED 101,AddKlonal Rsmarb Sdwdul& may be affaciced Nmom apace Is rsqulmdl WORKERS COMPENSATION: All States Except Texas Auto Excess Liability provides limits between Primary Auto Liability and Umbrella Liability policies. Additional Insured form #CGD144 edition 02119 applies to the General Liability policy. Additional Insured form #CGT700 edition 02/19 (lessor of leased equipment) applies to the General Liability policy. Additional Insured form #CGD126 edition 10195 applies to the General Liability policy. Waiver of subrogation form #CG2404 edition 05/09 ap lies to the General Liability policy. Primary & Non -Contributory General Liability form �T100 edition 02119. See Attached... Calhoun County Detention Center County Judge Richard H. Meyer Calhoun County Jail 302 W. Live Oak St. 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. -1�14-7- ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: SENEKEITH LOG #: ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NANEDINSURED Marsh & McLennan Agency, LLC Ben E. Keith Company 601 E. 7th St. PouCY NUMBER Fort Worth TX CARRIER I NAIL CODE EFFECTIVE DAZE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF Votice of Cancellation form #ILT400 applies to the General Liability nal Insured form #CAT437 edition 02116 applies to the Automobile Liability policy. of subrogation form #CAT340 edition 02f15 applies to the Automobile Liability policy. of Cancellation form #ILT400 applies to the Automobile Liability policy. of subrogation form #W0000313 edition 04184 applies to the Workers Compensation policy. : General Liability policy includes a blanket additional insured endorsement to the certificate holder only when there is a written contract between the named fired and the certificate holder that requires such status. : General Liability policy contains an endorsement with "Primary and NonContributory" wording that may apply only when there is a written contract between named insured and the certificate holder that requires such wording. General Liability policy contains a blanket waiver of subrogation endorsement that may apply only when there is a written contract between the named Ned and the certificate holder that requires such wording. : Automobile Liability policy contains language that provides additional insured status to the certificate holder only when there is a written contract between named insured and the certificate holder that requires such status. Automobile liability policy includes waiver of subrogation wording that may apply only when there is a written contract between the named insured and the Ificate holder that requires such wording. : Worker's Compensation policy includes a waiver of subrogation endorsement that may apply only when there is a written contract between the named Ired and the certificate holder that requires such wording. General Liability Automobile Liability and Worker's Compensation policies include a blanket notice of cancellation to the certificate holder endorsement, iding for (30) days' advance written notice Ifthe policy is canceled by the company, or 10 days' written notice before the policy is canceled for nonpayment emium. Notice is sent to certificate holders with mailing addresses on file with the agent or the company. The endorsement does not provide for notice of :eilation to the certificate holder if the named insured requests cancellation. ® 2008 AI 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. OFFiCEUSEONLY 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 Govemment Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. Ben E Keith 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 officerabout 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 IS 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 ® 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 IM71 A I No a 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 ^ 10111/21 Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/3012016 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. Emily Lynch, District Sales Manager Name and Title of Authorized Agent Signature of Authorized Agent 10/11/21 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, Ben E Keith , 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 ofContractor's Authorized Official Emlty Lynch, District Sales Manager Printed Name and Title of Contractor's Authorized Official 10/11/21 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. bidloffer/application NA a. initial filing NA b. grant 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 Sabawardee, Enter Prime _ Subawardee Name and Address of Prime: _ Tier. if Known: NA NA Congressional! Dkstrict, if known: Congressional Distri if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: NA NA CFDA Number, if applicable: 8. Federal Action Number, ffknawn: 9. Award Amount, tfknown: NA $ NA 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (inchrding address ff (if individual, last name, first name, MI): different from No. 10a) (last name, first name, M!): NA NA 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: Emily Lynch by the tier above when this transaction was made or Manager District Sales M entered into. This disclosure is required pursuant to 31 Title: U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public 361-205 4070 WNU21 Telephone No.: Date: inspection. Any person who fails to file the required disclosure shalt 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, Emily Lynch the undersigned representative of Representative Ben E Keith (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-proftt 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 Emily Lynch, DSM Print Name & Title 10/11/21 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 (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) B I certify that Ben E Keith is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Emily Lynch, District Sales Manager Printed Name and Title of Authorized Agent 10/1112021 Date ® Request for Taxpayer Give Form to the E°"n identification (dumber and Certification requester. Do not (Rev. October 9016) Ilepartmanl of IhoTreasury send to the IRS. (marmot Revenue service ►Go to fvww.irs.gov/FormWB for instructions and the latest information. 1 Name (as shown on your income tax return). Name Is required m this Me: do not leave this fine blank. Ben E. Keith Company 2 Business nameldisregarded entity name, If dafeent from above m 8 Check appropriate box for federal tax classification of the person whose name Is entered online 1. Check only arcs of are 4 Exemptions (codes apply only to rz fallowing seven boxes, certain entities, not indhdduals; see instructions on page 3): c ❑ Indivkluallsole proprietor or 0 CCorporation ❑ SCorporation ❑ Partnership ❑ Tmsvestate is single -member LLC Exempt payee code (if any) H❑Limited liabtliH company. Enter the tax clessificaaon(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 rat check Exemption from FATCA reporting lg 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 code (it any) another LLC that Is not disregarded from the owner for U.S. fetlerel tax purposes. Otherwise, osingle-member a a Is disregarded from the owner should check the appropriate box for the tax classification of its owner. ai Other wss fnslructions)► raro�2. ro.amr.,: m.i,emaom�xa me usl �j 5 Address (number, street, and apt. or suite nos Sea Instructions, Requesters name and address (optur as s PO Box 1570 CALHOUN COUNTY ro 202 S ANN ST, PORT LAVACA TX 77979 6 City, stale, and ZIP code Fort Worth,. TX 76101 361-553-4610 FAX: 361-553-4614 7 List amount number(s) here (optional) JEH Taxpayer Identification Number IN Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid III amun securrry nmmoer II backup withholding. For Individuals,etororthis this Is generally your social security number (SSNr. However, far a L—L_LJ - m -LLW 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 e TM, later. or NOW. If the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification nunrear Number 7o Give the Requester for guidelines on whose number to enter. r-.T-.-1 o -y� 7 1) �T�-1 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am wafting 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. HeI Signature At4N e,Controller for 10/11/21ere US. 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 www1rs.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 ((TIN), adoption taxpayer identification number (ATikp, or employer identification number (ElN), 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 (intere it 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), I898-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Farm W-9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN. It 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 Form W-9 (Rev. 10-2018) #14 NOTICE OF MEETING— 11/24/2021 14. Consider and take necessary action to award the bid for the Annual Supply Contract for Delivered Fuel, Bid Number 2022.01 for the period beginning January 1, 2022 and ending December 31, 2022 with an option for renewal for an additional three — one (1) year periods, if agreeable with both the successful bidder and Calhoun County. (RHM) Peggy Hall explained Bids. Richard Meyer abstained from voting. Bid from New Distributing awarded. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Commissioner Hall, Lvssv, Behrens, Reese Page 10 of 28 November 18, 2021 To: Judge Meyer From: The office of the County Auditor Please place the following item on the Commissioners Court Agenda for November 24, 2021: Consider and take necessary action to award the bid for the Annual Supply Contract for Delivered Fuel, Bid Number 2022.01 for the period beginning January 1, 2022 and ending December 31, 2022 with an option for renewal for an additional three — one (1) year periods, if agreeable with both the successful bidder and Calhoun County. 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DELIVERED FUEL ANNUAL SUPPLY CONTRACT BID NUMBER: 2022.01 BEGINNING JANUARY 1, 2022 AND ENDING DECEMBER 31, 2022 With an option for renewal for an additional three —one (1) year periods, if agreeable with both the successful bidder and Calhoun County CALHOUN COUNTY, TEXAS INVITATION TO BID FORM AMENDED WITH ADDENDUM NO. 1 Approved by Commissioners Court October 20, 2021 Annual Supply Contract for Delivered Fuel Bid Number: 2022.01 January 1, 2022 thru December 31, 2022 With an option for renewal for an additional three -one (1) year periods, if aggreeable with both the successful bidder and Calhoun County BIDDER'S NAME AND ADDRESS: New Distirbuting 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 1-1 • Estimated quantities are not guaranteed for the year. Amounts will vary by need. • ALL Transportation Cost s.and Other Fees must be included in the ""d plus or minus mark-up pergallon or clearly stated on the bid • 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 • ALL OTHER FEES NOT INCLUDED IN PLUS OR ;;NUS THE MARK-UP PER GALLON MUST BE LISTED AND CLEARLY STATED ON THE INVITATION TO BID FORM. If extra space is needed to list Other Fees, attach a separate page stating the fee and amount of the fee. This separate page must be signed and dated by an authorized respresentative. Make note of this separate page under the Other Fees column. Only Fees listed on the bid returned by the bidder and awarded as such to the successful bidder will be allowed to be included on the invoice when the awarded bidder submits the invoice for payment. List Method or Source that will be used throughout the bid period and provide a copy: OPIS Victoria Citgo Unbranded / Corpus Citgo Branded for Ethanol -Free ONLY Page 1 of 7 Invitation to Bid Form - Annual Supply Contract for Delivered Fuel --Continued OTHER FEES NOT INCLUDED IN PLUS OR41 MINUS THE MARK-UP PER GALLON If No Charge OR Not Applicable, Mark NA Plus er Texas List Any Other Minus Environmental Fee(s) AND Mark -Up Texas OSLTF- Fee Per Delivery (See Texas Petroleum Amount of Per State LUST Federal Oil Products Delivery Fee Fee(s) Schedule for 5,000 Gallons Ex: After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee ormore) Service Fee Gasoline Less than 2,500 Precinct 1 Gallons the Fee is Unleaded $.0012 Fuel Tank(s) Location: 87 Octane $ .07 $0.20 .001 .00193 2,500 Gallons but N/A 305 Henry Barber Way Brand Name: Less than 5,000 Port Lavaca TX77979 Citgo UNB Gallons the Fee is $ .0012 Gasoline Less than 2,500 ••870etane Is Et haveveavailable•` Unleaded Gallons the Fee is $ a all we Pricing basis l be Up Branded 930ctane $ .14 $0.20 .001 .00193 .0012 2,SOO Gallons but N/A Corpus Chnstl•` Non -Ethanol Less than 5,000 Brand Name: Gallons the Fee is Citgo Branded $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ .08 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons the Fee is $ .0012 Gasoline Less than 2,500 Precinct 2 Gallons the Fee is Unleaded $ .0012 Fuel Tank(s) Location: 87 Octane $ •07 $0.20 .001 .00193 2,500 Gallons but N/A 5812 FM 1090 Brand Name: Less than Port Lavaca TX 77979 Citgo UNB Gallons the Fee is Fee $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ . 88 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons the Fee is $ .0012 Page 2 of 7 Invitation to Bid Form -Annual Supply Contractfor Delivered Fuel --Continued OTHER FEES NOT INCLUDED IN PLUS t rS R ",,,NUS THE MARK-UP PER GALLON If No Charge OR Not Applicable, Mark NA Nus eF Texas List Any Other err Environmental Feels) AND Mark -Up Texas OSLTF- Fee Per Delivery (See Texas Petroleum Amount of Per State LUST Federal Oil Products Delivery Fee Fee(s) Schedule for S,ODO Gallons Ex: After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee or more) Service Fee Precinct Gasoline Less than 2,500 Gallons the Fee is Fuel Tanks) Location: Unleaded $ .0012 24627 State Hwy 172 87 Octane $ .07 $0.20 .001 .00193 2,500 Gallons but N/A Port Lavaca TX77979 Brand Name: Less than 5,000 (Precinct 3 is in Olivia) CItgo UNB Gallons the Fee is $ .0012 Gasoline Less than 2,500 •87 octane Ethanol-Freais Unleaded Gallons the Fee is $ all we have avallable" Pricing basis will 93 Octane $ .14 $0.20 .00193 .0012 2,500 Gallons but N/A Coplu:cn Branded Non -Ethanol .001 Less than 5,000 Brand Name: Gallons the Fee is Citgo Branded $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ -08 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons the Fee is $ .0012 Precinct 4 Gasoline Less than 2,500 Gallons the Fee is (Port O'Connor) Unleaded $ .0012 Fuel Tank(s)Location: 87Octane $ .07 $0.20 2,500 Gallons but N/A 93 Trevor Street Brand Name: .001 .00193 Less than 5,000 (Off of Hwy185) Cltgo UNB Gallons the Fee is Port O'Connor TX 77982 $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ .08 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 CItgo UNB Gallons the Fee is $ .0012 Page 3 of 7 Invitation to Bid Form - Annual Supply Contract far Delivered Fuel -- Continued OTHER FEES NOT INCLUDED IN P61JS OR MINUS THE MARK-UP PER GALLON If No Charge OR Not Applicable, Mark NA Plus er Texas List Any Other Minus Environmental Fee(s) AND Mark -Up Texas OSLTF- Fee Per Delivery (see Texas Petroleum Amount of Per State LUST Federal Oil Products Delivery Fee Feels) Schedule for 5,000 Gallons Me After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee or more) service Fee Precinct Gasoline Less than 2,500 Gallons the Fee is (Seadrift) Unleaded $ .0012 Fuel Tank(s) Location: 87 Octane $ .07 $0.20 .001 .00193 2,500 Gallons but N/A 104 E Dallas Brand Name: Less than 5,000 Seadrift TX77983 Citgo UNB Gallons the Fee is $ .0012 Gasoline Less than 2,500 "87 Octane Unleaded Gallons the Fee is Ethanol -Freels all we have available" Pricing hasiswill 93 Octane $ .14 $0.20 .001 .00193 $ .0012 2,500 Gallons but N/A be Citgo Branded Corpus Chdsti" Non -Ethanol Less than 5,000 Brand Name: Gallons the Fee is Citgo Branded $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ '08 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons the Fee is $ .0012 Precinct Gasoline Less than 2,500 Gallons the Fee is (Seadrift) Unleaded $ .0012 Fuel Tank(s) Location: 87 Octane $ .07 $0.20 .001 .00193 2,500 Gallons but N/A 448 Harbor Road Brand Name: Less than 5,000 Seadrift TX77983 Citgo UNB Gallons the Fee is $ .0012 Diesel Less than 2,500 Gallons the Fee is Low Sulfur $ .0012 (Clear Diesel) $ .08 $0.20 .001 .00214 2,500 Gallons but N/A Brand Name: Less than 5,000 Citgo UNB Gallons the Fee is $ .0012 Page 4 of 7 Invitation to Bid Form -Annual Supply Contract for Delivered Fuel --Continued OTHER FEES NOT INCLUDED IN PLUS CVTOR MINUS THE MARK-UP PER GALLON If No Charge OR Not Applicable, Mark NA PIUS eF Texas List Any Other Minus Environmental Feels) AND Mark -Up Texas OSLTF- Fee Per Delivery (See Texas Petroleum Amount of Per State LUST Federal Oil Products Delivery Fee Fee(s) Schedule for 5,000 Gallons Ex: After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee or more) service Fee Skid Fuel Tank Skid Location for Fuel Diesel Less than 2,500 Gallons the Fee is Delivery: Low Sulfur $ .0012 Within Close Proximity (Clear Diesel) $ .21 $0.20 .001 .00214 2,500 Gallons but N/A to the Calhoun County Brand Name: Less than 5,000 Courthouse Citgo UNB Gallons the Fee is 211 S Ann Street $ .0012 Port Lavaca TX 77979 Generator - CalhounCounty Diesel Less Gallons the Fee is Gallon the Courthouse Low sulfur $ .0012 Generator Fuel Tank (Red Diesel) $ '21 NA .001 .00214 2,500 Gallons but N/A Location for Fuel Brand Name: Less than 5,000 Delivery: ItgO CUNB Gallons the Fee is 2115 Ann Street $ .0012 Port Lavaca TX 77979 Generator - Calhoun County Less than 2,500 Adult Detention Diesel Gallons the Fee is Low Sulfur $ .0012 Center JAIL ) (Red Diesel) $ .21 NA .001 .00214 2,500 Gallons but N/A Generator Fuel Tank Brand Name: Less than 5,000 Location for Fuel Citgo UNB Gallons the Fee is Delivery: $ .0012 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 PLUS OR MINUS THE MARK-UP PER GALLON If No Claarge OR Not Applicable, Mark NA Plus er Texas List Any Other Minus Environmental Feels) AND Mark -Up Texas OSLTF- Fee Per Delivery (see Texas Petroleum Amount of Per State LUST Federal Oil Products 0eNeryFee Fee(s) Schedule for 5,000 Gallons Ex: After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee ormore) Service Fee Generator - EMS Central Station Less than 2,500 (Emergency Diesel Gallons the Fee is Low Sulfur $ .0012 Management (Red Diesel) $ 21 NA .001 .00214 2,500 Gallons but N/A Services) Brand Name: Less than5,000 Generator Fuel Tank Citgo UNB Gallons the Fee is Location for Fuel $ .0012 Delivery: 705 Henry Barber Way Port Lavaca TX 77979 Generator - EMS South Station Less than 2,500 (Emergency Diesel Gallons the Fee is Low Sulfur $ .0012 Management (Red Diesel) $ 21 NA .001 .00214 2,500 Gallons but N/A Services) Brand Name: Less than5,000 Generator Fuel Tank Citgo UNB Gallons the Fee is Location for Fuel $ .0012 Delivery: 6084 State Hwy 185 E Seadrift TX 77983 Page 6 of 7 Invitation to Bid Form -Annual Supply Contract for Delivered Fuel --Continued OTHER FEES NOT INCLUDED IN PNUS OR MINUS THE MARK-UP PER GALLON If No Charge OR Not Applicable, Mark NA Pkts el Texas List Any Other Minus Environmental Fee(s) AND Mark -Up P Texas OSLTF- Fee Per Delivery (see Texas Petroleum Amount of Per State LUST Federal Oil Products Delivery Fee Fee(s) Schedule for s000 Gallons Ex: After Hours Call Out Department Fuel Type Gallon Excise Tax FEE Spill Fee armors) Service Fee Generators - Memorial Less than 2,500 Medical Center Diesel Gallons the Fee is (Hospital) Low Sulfur $ .0012 (Red Diesel) $ .08 NA .001 .00214 2,500 Gallons but N/A Generators Fuel Tank Brand Name: Less than5,000 Location for Fuel Citgo UNB Gallons the Fee is Delivery: $ .0012 815 N Virginia Street Port Lavaca TX 77979 Generator - Memorial Diesel Less than 2,500 Gallons the Fee is Medical Clinic Low sulfur $ .0012 Generator Fuel Tank (Red Diesel) $ •21 NA .001 .00214 2,500 Gallons but N/A Location for Fuel Brand Name: Less than5,000 Delivery: Cltgo UNB Gallons the Fee is 1016 N Virginia Street $ .0012 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 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 any official, employee, or agent of Calhoun County in connection with 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: 10/11 /2021 Authorized Signature & Title: Vice President Printed Name & Title of Authorized Signature: Devin New - Vice President Phone Number: (361) 575-1981 Email: devin@newdistributing.com REMARKS: Page 7 of 7 10/11/21, 9:30 AM Customized OPTS City Rack Report C.tS1SMnf°LCt1GRkl��r'ar �� ;L.;)f'J't"S VICTORIA/PLACEDO, TX 2021-10-11 10:00:12 EDT **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS CBOB ETHANOL(10°/.) PRICES** 9.0 RVP Move Terms Unl Move Mid Move Pre Move Date Time Valero b 1-10 246.38 + 1.01 262.34 + .80 295.47 + .40 10/08 18:00 Citgo u 1-10 247.25 + 2.52 262.40 + 2.52 294.73 + 2.53 10/08 18:00 76-Mot b 125-3 247.69 + 2.74 262.88 + 2.74 296.80 + 2.73 10/08 18:00 Shell -Mot b 125-3 247.83 + 2.74 266.06 + 2.74 300.49 + 2.74 10/08 18:00 Citgo b 1-10 247.93 + 3.00 263.59 + 3.00 295.40 + 3.00 10/08 18:00 Cenex b 1-10 249.60 + 3.15 -- -- -- -- -- -- -- -- 10/08 18:00 PSX b 1-10 249.79 + 3.00 264.94 + 3.00 297.26 + 3.00 10/08 18:00 XOM b 125-3 249.83 + 3.11 267.05 + 3.11 300.47 + 3.11 10/08 19:00 LOW RACK 246.38 262.34 294.73 HIGH RACK 249.83 267.05 300.49 RACK AVG 248.29 264,18 297.23 OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 239.17 -- -- 251.77 BRD LOW RACK 246.38 262.34 295.40 BRD HIGH RACK 249.83 267.05 300.49 BRD RACK AVG 248.44 264.48 297.65 UBD LOW RACK 247.25 262.40 294.73 UBD HIGH RACK 247.25 262.40 294.73 UBD RACK AVG 247.25 262.40 294.73 CONT AVG-10/11 249.29 - 264.18 297.23 CONT LOW-10/11 246.38 262.34 294.73 CONT HIGH-10/11 249.83 267.05 300.49 VICTORIA, TX LOW RETAIL 279.48 AVG RETAIL 287.55 LOW RETAIL EX -TAX 240.71 AVG RETAIL EX -TAX 248.79 VICTORIA/PLACEDO, TX -- 2021-10-11 10:00:12 EDT **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS ULTRA LOW SULFUR LED DISTILLATE PRICES** Move Terms No.2 Move No.1 Move Pre Move Date Time Cenex b 1-10 262.29 + .65 -- -- -- -- -- -- -- -- 10/08 18:00 PSX b 1-10 263.11 + 1.00 -- -- -- -- -- -- -- -- 10/08 18:00 Citgo b 1-10 263.19 + 1.50 -- -- -- -- -- -- -- -- 10/08 18:00 Citgo u 1-10 263.19 + 1.50 -- -- -- -- -- -- -- -- 10/08 18:00 Valero b 1-10 263.35 + 1.70 -- -- -- -- -- -- -- -- 20/08 18:00 Motiva b 125-3 263.64 + 1.46 -- -- -- -- -- -- -- -- 10/08 18:00 76-Mot b 125-3 263.80 + 1.47 -- -- -- -- -- -- -- -- 10/08 18:00 Shell -Mot b 125-3 263.85 + 1.47 -- -- 10/08 18:00 LOW RACK 262.29 -- -- -- -- HIGH RACK 263.85 -- -- -- -- RACK AVG 263.30 -- -- -- -- OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 245.99 -- -- -- -- BRD LOW RACK 262.29 -- -- -- -- BRD HIGH RACK 263.85 -- -- -- -- BRD RACK AVG 263.32 -- -- -- -- UBD LOW RACK 263.19 -- -- -- -- UBD HIGH RACK 263.19 -- -- -- -- UBD RACK AVG 263.19 -- -- -- -- CONT AVG-10/11 263.30 -- -- -- -- CONT LOW-10/11 262.29 -- -- -- -- CONT HIGH-10/11 263.85 -- -- -- -- https://webracks.oplsnet.com/Default.aspx 1/2 10111121. 9:30 AM VICTORIA/PLACEDO, TX 2021-10-11 10:00:12 EDT **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 Cenex b 1-10 262.69 + .65 -- -- -- -- -- -- -- -- 10/08 18:00 Citgo b 1-10 263.59 + 1.50 -- -- -- -- -- -- -- -- 10/08 18:00 Citgo u 1-10 263.59 + 1.50 -- -- -- -- -- -- -- -- 10/08 18:00 PSX b 1-10 264.12 + 1.00 -- -- -- -- -- -- -- -- 20/08 18:00 LOW RACK 262.69 -- -- -- -- HIGH RACK 264.12 -- -- -- -- RACK AVG 263.50 -- -- -- -- OPIS GULF COAST DELIVERED SPOT (SRI) FOB VICTORIA/PLAC 246.34 -- -- -- -- BRD LOW RACK 262.69 -- -- -- -- BRD HIGH RACK 264.12 -- -- -- -- BRD RACK AVG 263.47 -- -- -- -- UBD LOW RACK 263.59 -- -- -- -- UBD HIGH RACK 263.59 -- -- -- -- UBD RACK AVG 263.59 -- -- -- -- CONT AVG-10/11 263.50 -- -- -- -- CONT LOW-10/11 262.69 -- -- -- -- CONT HIGH-10/11 264.12 -- -- -- -- VICTORIA/PLACEDO, TX 2021-10-11 10:00:12 EDT **OPIS CONTRACT BENCHMARK FILE** **OPIS GROSS WHOLESALE BS SME BIODIESEL PRICES** ULS2 ULS20 Move Terms LED LED Date Time XOM b 125-3 260.75 -- -- 1e/08 19:00 PSX b 1-10 263.11 -- -- 10/08 18:00 Citgo b 1-10 263.19 263.59 10/08 18:00 Citgo u 1-10 263.19 263.59 10108 18:00 Valera b 1-10 263.35 -- -- 10/08 18:00 Motiva b 125-3 263.64 -- -- 10/08 18:00 76-Mot b 125-3 263.80 -- -- 10/08 18:00 Shell -Mot b 125-3 263.85 -- -- 10/08 18:00 LOW RACK 260.75 263.59 HIGH RACK 263.85 263.59 RACK AVG 263.11 263.59 BRD LOW RACK 260.75 263.59 BRD HIGH RACK 263.85 263.59 BRD RACK AVG 263.10 263.59 UBD LOW RACK 263.19 263.59 UBD HIGH RACK 263.19 263.59 UBD RACK AVG 263.19 263.59 CONT AVG-10/11 263.11 263.59 CONT LOW-10/11 260.75 263.59 CONT HIGH-10/11 263.85 263.59 Copyright, Oil Price Information Service https://webracks.opisnet.com/Defaull.aspx 2/2 § !I<§■|!§| \(()((\(\ ; m:mlElm . /|§§GBeBe $rrmrarrr ; r �- � 8S STATE OF Texas IV, AFFIDAVIT COUNTY OF Victoria 0 The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, 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 bid to which this affidavit is attached, and I have full knowledge of the relations of the bidder with the otherfirms in this same line of business, and the bidder is not a member of any trust, pool or combination to control the price of leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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. Affi nt Davin New - Vice President Printed Name and Title of Affiant Name of Bidder (Company) New Distirbuting.Co., Inc. Address PO Box 1247 Victoria, TX 77902 Phone Number Fax Number (361) 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 11th day of October DME STONE MYN0IvyID#5M4423 `•...... . E*ms May 28, 2D23 Stamp/Seal 2021 . Notary Public, State of 1-S !-DIagla3 My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: New Distirbuting Co., Inc. 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 Signature of Authorized Representative: Printed name of Authorized Rep: Devin New ORDER — CONTACT INFORMATION Order Contact Name&Title: DevinNew-VicePresdient/TerryFoster-Dispatcher Order Contact Telephone: (361) 575-1981 Order Contact Fax: N/A Order Contact Email: orders@newdistributing.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Tiffany Williams -Billing Contact Telephone: (361) 575-1981 Contact Fax: (361) 575-2602 Contact Email: tiffany@newdistributing.com CERTIFICATE OF INTERESTED PARTIES FORM IL295 lofl 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. 2021-815045 New Distributing Co., Inc. Victoria, TX United States Date Filed: 10/20/2021 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 he provided under the contract. 2022-01 Fuel distributor 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 My name is Dc'yf d and my date of birth is ow My address is _ (street) (city) (state) (zip coda) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in V(yr P'IA- County, Slate of IeXki , on the (t'1, day of bGT 06A— , 20_1.1. (month) (year) t Signat w of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc 4Ike D CERTIFICATE OF LIABILITY INSURANCE nA�02/13 021 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(tes) 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 FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 GONTgGT ME: CLIENT CONTACT CENTER RgICN110 eye: 888-3334949 alc Ne:507-446-4664 OWATONNA, MN 56060 ADDRESS: CLIENTCONTACTCENTER FEDINS.COM INSURER(S) AFFORDING COVERAGE NAIL INSURER A: FEDERATED MUTUAL INSURANCE COMPANY INSURED 034-113-1 INSURER B: NEW DISTRIBUTING CO INC PO BOX 1247 _ _ INSURER 0: INSURER 0: VICTORIA, TX 77902-1247 NSURER E: NSURER F: NUMBER- n 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. ILTR TYPEOFINSURANCE AODL INSR SUBR VNO POUCYNUMBER POLICY EFF MMIDDIYYYYI POLICY EXP (MMIDDIYYYYJ LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR FACHOCCURRENCE $1,000,000 PA�Mffl SO RENTE.Dam, $100,000 BLED UP(Anydne person) EXCLUDED A N N 04/01/2021 04/01/2022 PERSONAL R ADV INJURY $1,000,000 GEWL X AGGREGATE LIMIT APPLIES PER: POLICY ❑PNO- ❑ JECT LOC CENERALAGGREGATE $2,000,000 PRODUCTS - COMPIOP AGO $2.000,000 OTHER: A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY SAUTOSCHEDULED N N 04/01M021 04/01/2022 COMBINED SINGLE LIMIT Eee Itlenl $1,000,000 BODILY INJURY (For person) BODILY INJURY IPer aaidmi) HIRED AUTOS ONLY NON -OWNED AUTOS ONLY PROPERTY AMAGE Paraadd.D m X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $10,000,000 A EXCESS LIAR CUUMS-MADE N N 04/01/2021 04/01/2022 AGGREGATE $10,000,000 ' DSO I I RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFIGERIMEMBEA EXCLUDED? NIA N 04/01/2021 04/01/2022 X PERSTATUTE OTH- ER E.LEACHACCIDENT $1.000,000 EL DISEASE - EA EMPLOYEE $1,00D,000 (Mandatory in NH) N yes. dmedbe under EL DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS ImIew DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AEdldonrl Remarks Schedule, may Be adeched If more apace Is required) THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES. -- -_— 00 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 reserved. AOUHU Zb (ZUTUIUB) The ACORD name and logo are registered marks of ACORD i-> Insured Copy 0 FEDERAZED INSURANCE FEDERATED MUTUAL INSURANCE COMPANY 121 East Park Square, Owatonna, MN 55060 (507)455-5200 DECLARATIONS COMMERCIAL UMBRELLA LIABILITY POLICY MUTUAL COMPANY PARTICIPATING NONASSESSABLE POLICY Item 1. Named Insured and Address: NEW DISTRIBUTING CO INC PO BOX 1247 VICTORIA TX 77902 Item 2. Policy Period: (Mo. Day Yr.) From 04-01-2021 to 04-01-2022 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: Item 3. $10 , 0 0 0, 0 0 0 Occurrence Limit Item 4. 010,000,000 Aggregate Limit • Item 5. As Billed Annual Premium CERTIFIED ACTS OF Item 6. Schedule of Underlying Insurance Policies. TERRORISM PREMIUM: 140 Type of Insurance Limits of Liability Per Occurrencel Aggregate Insurer - Federated unless otherwise indicated. GENERAL LIABILITY X�Commercial General Liability $1,000,OOC $2,000,00 Businessowners ❑ Dwelling ❑ Dwelling Dwelling AUTO LIABILITY XQ Business Auto 01,000,00 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) Transaction Effective Date: 04-01-2021 Insured Copy EMPLOYERS LIABILITY Limits of Liability XQ Employers Liability $1000000/1000000/1000000 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 virtue of this 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. 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) Policy NuINEMEMTransaction Effective Date: 04-01-2021 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. OFFICEUSEONLY 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. New Distributing z Check box if you are filing an update to a previously filed questionnaire. (The law requires that 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.) -IJ 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 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 Fx-� 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 FOND 51 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 10/11 /2021 Signatu vendor 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. Devin New - Vice President Name and Title of Authorized Agent _rL)� 'J ignature of Authorized Agent 10/11 /2021 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.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signature of Contractor's Authorized Official Davin New -Vice President Printed Name and Title of Contractor's Authorized Official 10/11 /2021 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) 0349-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: N/A a. contract N/A a. bid/offer/application N/A 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: N/A N/A Congressional District, if (mown: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: N/A N/A CFDA Number, ifapplicable: S. Federal Action Number, ifknown: 9. Award Amount, ifknown: N/A N/A S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, MI): dierent from No. 10a) (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: disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Devin 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:10/11/2021 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 Davin New the undersigned representative of Representative 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 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. L4 alai—® Signa�ture of Representative Davin New - Vice President Print Name & Title 10/11 /2021 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 V I certify that (city and state) New Distributing is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Davin New -Vice President Printed Name and Title of Authorized Agent 10/11/2021 Date W®9 Request for Taxpayer Give Form to the Form (Rev. October2D18) Identification Number and Certification 1 requester. Do not Department of theTreasury send to the IRS. Intemal Revenue Service ► Go to www.1rs.gov/F0mnM for instructions and the latest Information. t Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. New Distirbuting Co., Inc. 2 Business name/disregarded entity name, If different from above w 3 Check appropriate box for federal tax classification of the one of the person whose name is entered on line 1. Check only 4 Exemptions codes to sae followinseven boxes. certain entities, not Indivilduais; a cc❑ / VS IndivtduaVwlo proprietor or ❑ CCorporation SCorporation ❑ Partnership ❑ TmsVestate instructions on page 3): m ai = single -member LLC Exempt payee code (f any) o � Umked liability. cam an Enter the tax classification C C ❑ p y. (= corporation, S=S corporation, P=Padnership)► `0 2 Note: Checkthe appropriate box in the line above for the tax classification of the single -member owner. Donotcheck Exemption from FATCA reporting Yn t c LLC if the LLC Is classed as a aingte-member LLC that is disregarded from the ownerunless the owner of the LLC Is another LLC that is not disregarded from the ownerfor U.S. federal tax purposes. Otherwise, a single -member LLC that (if codeeny) o-� Is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (am Instructions)► Wnr b..Me ,=awmau.as/ h 5 Address (number, street, and apt or suite no.) See instructions. Requester's name and address (optional) y PO Box 1247 CALHOUN COUNTY 202 S ANN ST, PORT LAVACA TX 77979 s City, state, and ZIP code Victoria, TX 77902 361-553-4610 FAX: 361-553.4614 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 youthsocial security number (SSN). However, for a backup withhalien, sole For Inter, or is this d d entity, resldeMalien, sole proprietor, or disregarded entity, see the Instructions for Part 1, later. For other - m - entities, h Is your employer identification number (EIM. 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 Employerlderdification number Number To Give the Requester for guidelines on whose number to enter. 7 4 - 1 1 8 3 8 3 1 2 Under penalties of perjury,) certify that: 1. The number shown on this forth is my correct taxpayer identification number (or 1 am waiting for a numberto 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 subjeat to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(a) 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 falled 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. Sea the Instructionsfor Part II, later. ai9n Signature of ,L Here I U.S. person► ' L Date► to 11 'Lo I 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/FarmW9. 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 (EBB, to report on an Information return the amount paid to you, or other amount reportable on an Information retum. 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 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 aWN, you might be subject to backup withholding. See what is backup withholding, later. Cat. No. 10231X Form W-9 (Rev.10-2018) #15 NOTICE OF MEETING — 11/24/2021 15. Consider and take necessary action to award the bids for the Annual Supply Contract for Insecticides for Mosquito Control, Bid Number 2022.02 for the period beginning January 1, 2022 and ending December 31, 2022. (RHM) Peggy Hall explained Bids. Low Bids that met specifications awarded. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 11 of 28 November 18, 2021 To: Judge Meyer From: The office of the County Auditor Please place the following item on the Commissioners Court Agenda for November 24, 2021: Consider and take necessary action to award the bids for the Annual Supply Contract for Insecticides for Mosquito Control, Bid Number 2022.02 for the period beginning January 1, 2022 and ending December 31, 2022. RE: Annual Supply Contract for Insecticides for Mosquito Control Bid Number 2022.02 Period beginning January 1, 2022 and ending December 31, 2022 Bids were opened at 2:00 PM, Tuesday, November 9, 2021. 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 ONLY TWO BIDS MET SPECIFICATIONS: 1. Clarke Mosquito Control Products, Inc. 2. ES OPCO USA LLC, dba Veseris Two (2) Bids did not meet specifications: 1. ADAPCO LLC ■ Disclosure of Lobbying Activities was marked "None" at the top of the form BUT was not signed as per the instructions (this requirement for the signature even if not applicable is listed 5 times in the Invitation to Bid Packet, including the specifications) 2. Rentokil North America, Inc., dba Target Specialty Products ■ Did Not Sign their Bid Based on the information that only 2 bids met specifications: Low Bids Appear to be as follows: Mineral Oil 5 Gallon Pail: Clarke Mosquito Control Products, Inc. 50 Gallon Drum: ES OPCO USA LLC, dba Veseris 55 Gallon Drum: ES OPCO USA LLC, dba Veseris 275 Gallon Tote: ES OPCO USA LLC, dba Veseris Malathion 2 x 2.5 Gallon Case: ES OPCO USA LLC, dba Veseris 5 Gallon Pail: No Bids Received 55 Gallon Drum: Only 1 Bid Received —Specifications Not Met 260 Gallon Tote: Only 1 Bid Received —Specifications Not Met Added by Bidder: Bulk (1000Gallon Minimum): ES OPCO USA LLC, dba Veseris Malathion EW 2 x 2.5 Gallon Case: Only 1 Bid Received —Specifications Not Met 30 Gallon Drum: Only 1 Bid Received — Specifications Not Met Page 1 of 2 0111Si1m1VA 2 x 2.5 Gallon Case: ES OPCO USA LLC, dba Veseris 5 Gallon Pail: Only 1 Bid Received —Specifications Not Met 30 Gallon Drum: ES OPCO USA LLC, dba Veseris 55 Gallon Drum: ES OPCO USA LLC, dba Veseris 275 Gallon Tote: ES OPCO USA LLC, dba Veseris 31-66 ULV 4 x 1 Gallon Case: Only 1 Bid Received —Specifications Not Met 2 x 2.5 Gallon Case: ES OPCO USA LLC, dba Veseris 30 Gallon Drum: ES OPCO USA LLC, dba Veseris 275 Gallon Tote: ES OPCO USA LLC, dba Veseris 31-67 ULV 4 x 1 Gallon Case: No Bids Received 2 x 2.5 Gallon Case: ES OPCO USA LLC, dba Veseris 30 Gallon Drum: ES OPCO USA LLC, dba Veseris 275 Gallon Tote: ES OPCO USA LLC, dba Veseris 4-4 ULV 2 x 2.5 Gallon Case: ES OPCO USA LLC, dba Veseris 30 Gallon Drum: ES OPCO USA LLC, dba Veseris 55 Gallon Drum: ES OPCO USA LLC, dba Veseris 275 Gallon Tote: ES OPCO USA LLC, dba Veseris 4-8 ULV 2 x 2.5 Gallon Case: 2 Bids Received — Specifications Not Met 30 Gallon Tote: 2 Bids Received — Specifications Not Met 55 Gallon Drum: No Bids Received 275 Gallon Tote: 2 Bids Received —Specifications Not Met Altosid 30 Day Briquets 400 Per Case: Low Bid appears to be Current 2021 prices —Clarke Mosquito Control Products, Inc. Altosid XR Extended Residual Briquets—Altosid XR Briquets 220 Per Case: Low Bid appears to be Current 2021 prices— Clarke Mosquito Control Products, Inc. DeltaGard or Equivalent 2 x 2.5 Gallon Case: Only 1 Bid Received — Specifications Not Met 30 Gallon Drum: Only 1 Bid Received —Specifications Not Met 250 Gallon Drum(Tote): Only 1 Bid Received —Specifications Not Met Fourstar Sustained Release 45 Dav Microbial Briquets 200 Per Case: Clarke Mosquito Control Products, Inc Fourstar Sustained Release 90 Day Microbial Briquets 200 Per Case: Clarke Mosquito Control Products, Inc. Fourstar Sustained Release 180 Day Microbial Briquets 200 Per Case: Clarke Mosquito Control Products, Inc. Page 2 of 2 RE: Annual Supply Contract for Delivered Fuel Bid Number 2022.01 Period beginning January 1, 2022 and ending December 31, 2022 With an option for renewal for an additional three — one (1) year periods, if agreeable with both the successful bidder and Calhoun County Bids were opened at 2:00 PM, Tuesday, November 9, 2021. Three (3) bids were received: 1. New Distributing Co., Inc. 2. Oil Patch Petroleum, Inc. 3. Sun Coast Resources, Inc. ONLY ONE BID MET SPECIFICATIONS: New Distributing Co., Inc. Bid has all of the required forms and all of the forms are complete and have the required signatures. Two (2) Bids did not meet specifications: -Both Bidders were still higher than the bid that met specifications — See Bid Tabulation Oil Patch Petroleum, Inc. 1. Method or Source was not listed at bottom of page 1 of the Invitation to Bid Form 2. Affidavit was not returned with their bid 3. Form 1295: Line 1 and Line 2 were filled out incorrectly Line 1 is the Bidder's Name and they listed Calhoun County Line 2 should be Calhoun County and they listed Oil Patch Petroleum, Inc. 4. Copy of Certificate of Insurance was incomplete -only listed Worker's Compensation 5. Disclosure of Lobbying Activities Form was marked "NA" but was not signed as stated in the instructions Sun Coast Resources, Inc. 1. Affidavit was not notarized or signed by a notary 2. Sun Coast Resources, Inc. asked for revisions to the County's General Conditions CLARKE MOSQUITO CONTROL PRODUCTS, INC. INSECTICIDES FOR MOSQUITO CONTROL ANNUAL SUPPLY CONTRACT BID NUMBER 2022.02 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2022.02 January 1, 2022 thru December 31, 2022 Bidders's Name & Address Clarke Mosquito Control Products, Inc. 675 Sidwell Court • 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 bidder 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 - MC30 OR Equivalent COCOBEAR I List Name of Mineral Oil 5 Gallon Pail $ 105.48 /per 5 Gallon Pail 50 Gallon Drum $ no bid /per 50 Gallon Drum 55 Gallon Drum $ 1,125.14 /per 55 Gallon Drum 275 Gallon Tote $ 5492.00 /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 —List Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ no bid /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ n0 bid /per 30 Gallon Drum 30-30 ULV 1310MIST 30+30 � List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Galion $ 826.36 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ no bid /per 5 Gallon Pail 30 Gallon Drum $ 4,880.64 /per 30 Gallon Drum 55 Gallon Drum $ 8,875.68 /per 55 Gallon Drum 275 Gallon Tote $ 35.228.60 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form -Annual Supply Contract for 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 $ 102928 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 4.456.56 /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 Galion 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 $ 110.00 /Per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ 660.00 /Per 30 Gallon Tote 55 Gallon Drum $ 1,210.00 /Per 55 Gallon Drum 275 Gallon Tote $ 61325.00 /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 $ n0 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 . -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 «—List Insecticide Name Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ 759.00 /per case DeltaGard OR Equivalent F List insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ no bid /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ n0 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 FOURSTAR A Equivalent List Insecticide Name Bacillus sphaericus 6%; subspecies israelensis 1% 45 Day ----- 200 Per Case $ 290.00 /per case 90 Day ----- 200 Per Case $ 482.00 /per case 180 Day-----200 Per Case $ 752.00 /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 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 any official, employee or agent of Calhoun County in connection with 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: Printed Name & Title of Author d signa e: Julie Reiter, VP FIR & Sustainable Development Phone Number: 800-323-5727 Email: customercare@clarke.com Exceptions and/or Variations from Specifications and/or additional Notes: Page 5 of 5 STATE OF Illinois {} AFFIDAVIT COUNTY OF Kane {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Julie Reiter 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 bid to which this affidavit is attached, and I have full knowledge of the relations of the bidder with the otherfirms in this same line of business, and the bidder is not a member of any trust, pool or combination to control the price of leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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. Printed Name and Title of Affiant Name of Bidder (Company) Clarke Mosquito Control Products, Inc. Address 675 Sidwell Court St. Charles, IL 60174 Phone Number 800-323-5727 Fax Number 630-443-3070 Email Address customercare alclarke.com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the fads contained in the above are true and correct, this 1st day of November . 2o21 :Notary IMBERLy J HELMS OFFICIAL SEAL public, State of IllinoisCommission Expires eptember 16, 2024 Public, State of Stamp/Seal My dommission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Clarke Mosquito Control Products, Inc. Address: 675 Sidwell Court St. Charles IL 60174 Remittance Address: 16277 Collections Center Drive Telephone: 800-323-5727 Fax: 630-443-3070 Email: customercare(@clarke.com Signature of Authorized Representative: Printed name of Authorized Rep: Julie eiter ORDER — CONTACT INFORMATION Order Contact Name & Title: Douq Carroll, Control Consultant Order Contact Telephone: 817-600-5353 Order Contact Fax: 630-443-3070 Order Contact Email: dcarrollaklarke.com• customercare(a)clarke.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Carrie Aitken Contact Telephone: 630-671-3139 Contact Fax: 630-443-3070 Contact Email: caitken(a),clarke.com 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. 2021-816853 Clarke Mosquito Control Products, Inc. St. Charles, IL United States Date Filed: 10/26/2021 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. Bid Number 2022.02 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 5 Check only if there is NO Interested Party. X 6 LINSWORN DECLARATION -RkMy name is Stdkt24-,and my date of birth is �. My address is Mm (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Y Executed in VA'n Ne— County, State of 1—L_ , on the �5 day ofIJDJe , 20 7—( (month) (year) i ignature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission \,—000av:efhics.state.tx.us Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 10/27/2021 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 riahts to the certificate holder in lieu of such endorsement(s). PRODUCER HUB International Midwest Limited 55 East Jackson Boulevard Chicago IL 60604 INSURED Clarke Mosquito Control Products, Inc. 159 N. Garden Ave. Roselle, IL 60172 COVERAGES CERTIFICATE NUMBER:EBIWAMKNNSVRMM REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTE 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. INSR LTR ADOLTYPEOFINSURANCE JM WVD SUER POUCYNUMBER MM/ODY� MMI�D/YYYYY LIMITS a X COMMERCIALGENERAL LIABILITY CLAIMS -MADE MOCCUR Pollution Legal 3/1/2021 3/1/2022 EACH OCCURRENCE $1,000,000 PREMISES Ea occurrence $300.000 X MED EXP (Anyone person) S 25,000 Liability PERSONAL B ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY[fl JET LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OP AGG $2,000,000 Pollution Legal Use $1,000,000 C AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED )( NON -OWNED AUTOS ONLY AUTOS ONLY 3/1/2021 3/1/2022 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Par person) $ BODILY INJURY (Per accident) S PROPERTYDAMAGE Per accident $ $ B X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE 3/1/2021 3/1/2022 EACHOCCURRENCE S10.00D.000 AGGREGATE $10,000,000 DED I X I RETENTION q $ A A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE M OFFICER/MEMBEREXCLUOED7 IMandatery in NH) If es, descdbe antler DESCRIPTION OF OPERATIONS below N/A 3/1/2021 3/1/2021 3/1/2022 3/1/2022 X STATUTE ERH E.L. EACH ACCIDENT $1.000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 _7 DESCRIPTION OF OPERATIONS I 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. RE: Calhoun County Bid 2022.02 Calhoun County 211 South Ann Street 3rd floor - Suite 301 Part 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. AUTHORIZEDREI Azl< ACORD 25 (2016103) 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. OFFICEUSEONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Cade, 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. 1J Name of vendor who has a business relationship with local governmental entity. Clarke Mosquito Control Products, Inc. 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.) -IJ 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? ElYes 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 E7 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. 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). Si alure o ndor doing business with the governmental entity Date Form provided y Texas Et ' s 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. Julie Reiter VR HR & Sustainable Development Nnvpmhpr 1st 9091 Name and Title of Authorized Agent Date 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, Clarke Mosquito Control Roducls,Inc. 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. Name and Title of Contractor's Authorized Official November 1st. 2021 Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for oublic 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 Reporting Entity in No. 4 is Subawardee, 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 rif individual, last name, first name, M/): dii erentf om No. 10a) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signatur . disclosure of lobbying activities is a material representation of fact upon which reliance was placed Pri Name: by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: SOO-323-5727 Date: 11 /1 /2021 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, Julie Reiter 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 owned subsidiary, majority -owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit. Signature if Representative ulie Reiter VP HR & Sustainablei�velopment Print Name & Title November 1st, 2021 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. J❑ I 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) ❑ I certify that is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Printed Name and Title of Authorized Agent November 1st 2021 Date ,. 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. Inlemal Revenue Semite ► Go to www.1m.gov1FormW9 for instructlons 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. Clarke Mosquito Control Products, Inc. 2 Business name/disregarded entity name, if different from above M yperson 3 Check appropriate box for federal tax classification of the whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain ent0ies, not individuals; see a. p ❑ Individuallsole proprietor or ❑ C Corporation 21 S Corporation ❑ Partnership ❑ Trust/estate instructions on page 3): single -member LLC Exempt payee coda (f any) o Untied liability company. Enter the lax classification C=C corporation, S=S ❑ y y. (- rp corporation, P=Partnership)► c, Note: Check the appropriate fox In the line above for the tax of the owner. Do not check Exemption from FATCA reporting c 7n 'C � disregarded from owner LLC If the LLC Is Is not disregarded as a ded from the o LLC that Is disregarded from the owner unless the owner of the LLC Is another LLC that is not dlsregemed horn the owner for U.B. federal tax purposes. Otherwise, asingle-member LLC that h wtle if 4 y) a Is disregarded from the owner should check the appropriate box for the tax classification of Its owner. y ❑ Other (sea Instructions)► Nanr.. ro.m.me..Ofm.d.mdd.t.. us/ y 5 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional y 675 Sidwell Court fi City, state, and ZIP code St. Charles, IL 60174 7 Ust account numberfs) here (optional) Taxpayer Identiflcation 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, for a resident alien, sole proprietor, or disregarded entity, see thea 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. 3 6- 3 6 7 2 4 F FB 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 noted 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, hem 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 then 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. 01VIS Signature of Here I us. person► /4. Date► U / 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.gov1FonnW9. 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 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 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), I DII&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. 1f 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) ES OPCO USA, LLC dba VESERIS INSECTICIDES FOR MOSQUITO CONTROL ANNUAL SUPPLY CONTRACT BID NUMBER 2022.02 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2022.02 January 1, 2022 thru December 31, 2022 Bidders's Name & Address ,i -VIaYk btVV 4-- 30a • 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 bidder 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 - MC30 OR Equivalent List Name of Mineral Oil 5 Gallon Pail $ N /per 5 Gallon Pail 50 Gallon Drum $ 3 &0 , QQ /per 50 Gallon Drum 55 Gallon Drum $ ,� �0 /per 55 Gallon Drum 275 Gallon Tote $ �� (� /per 275 Gallon Tote Page 1of5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED Malathion ListInsecticide Name Active Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ 35 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ N g /per 5 Gallon Pail 55 Gallon Drum $ f f }F /per 55 Gallon Drum 260 Gallon Tote $ /per 260 Gallon Tote 4tAik 1000 5*11oNs S q-. ao /pea � llo.� t000 g�11oNs �:� Rdetc Malathion EW F List insecticide Namel Active Ingredients: Malathion 2 x 2.5 Gallon $ /J14 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ N /} /per 30 Gallon Drum 30-30 ULV List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 30 1 . 0 oZ /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ NA /per 5 Gallon Pail 30 Gallon Drum $ ( Q Yj . 0 ?) /per 30 Gallon Drum 55 Gallon Drum $ 0 0 /per 55 Gallon Drum 275 Gallon Tote $ J & Q F /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form- Annual Supply ContractforinsecticidesforMosquito Control — CONTINUED 31-66 ULV — ListInsecticideName Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ M /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $ S� , OQ /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 3, 276_ (e 0 /per 30 Gallon Drum 275 Gallon Tote $ 30.0025.50 /per 275 Gallon Tote 31-67 ULV List Insecticide Name Active Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ IN Ilk /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $ 5 0 0 , Q /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 3, 0 0 (), 00 /per 30 Gallon Drum 275 Gallon Tote $ oZ f 0 t)0. 00 /per 275 Gallon Tote 4-4 ULV List Insecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ V. D 0 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ 615.00 /per 30 Gallon Tote 55 Gallon Drum $ 1 „ 0 it). 00 /per 55 Gallon Drum 275 Gallon Tote $ 0 , 00/per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED 11-8-ULV —List Insecticide Name Active Ingredients: Permethrin 3.985/; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ NA /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ N A /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 Listlnsecticide Name Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ �Q d , Q /per case Altosid XR Extended Residual Briquets OREquivalent List lnsecticideName Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ �jp Q /per case DeltaGard OR Equivalent E List Insecticide Name : Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon r $ (y A /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ N /per 30 Gallon Drum 250 Gallon Tote yA�� $ NA /per 250 Gallon Tote Page 4 of 5 Invitation To Bid Form- Annual Supply ContractforinsecticidesforMosquito Control — CONTINUED FourStar Sustained Release 4$/90/180 Day Microbial Briquets OR Equivalent F List Insecticide Name Active Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecies israelensis 1% 45 Day ----- 200 Per Case $ N P /per case 90 Day ----- 200 Per Case $ aV !q —/per case 180 Day-----200 Per Case $ 'V A- /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 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 any official, employee or agent of Calhoun County in connection with 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: 1 l © Gt o? O a t Authorized Signature & Title: Printed Name & Title of Authorized Signature: Phone Number: -7 13 - 2 0 3- 0y3 fie Email: LCQ,4.L� �aas(� tie 6efie Ls'_LV)n Exceptions and/or Variations from Specifications and/or additional Notes: Page 5 of 5 STATE OF _� X 5 {} AFFIDAVIT COUNTY OF The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. I I BEFORE ME, the undersigned authority, on this day personally appeared ce s known tome 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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. � 7 n , Printed Name and Title of Aff!ant Name of Bidder (Company) ES ©OCO 4S 14 l_ LC b B A ✓eye CS Address I O G10 o e c ykr-� Vd 3 D Phone Number l 3- Z b 3- d LA 3 Cn Fax Number Email Address V, e • + L h a. c� -s (-� ✓e Se 62 k S . C 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 0 C7 n A .L-t- . 20?-1 . AMARESH ATRI �P.fff 9 .gyp °�' �,% Notary Public, State of Texas =_ z. �1-�-.. lye Comm. Expires 02-26-2025 v ,.:.. k ` Notary ID 126818103 Stamp/Seal Notary Public, State of e ) fL%� t�— 5 02—/2 G /2,6 ZS: My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: F- 5 Address: Remittance Address: ES ORC L1-C NA I%5 eye; a-C P0. box-7110131c�oo l L 60671-013T Telephone: 1 2- 0 3- OLI 3 6P Fax: CIF Signature of Authorized Representative: 59�� j U`�- oI, %V a-o-0 Printed name of Authorized Rep: K e ,`-I L I- - �4 0. a S ORDER - CONTACT INFORMATION Order Contact Name & Title: Order Contact Telephone: -4 13 - 20 3 - 64 3 (e Order Contact Fax: Order Contact Ema INVOICES - CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Contact Telephone: �7-1 3 - Z O 3 - Oy 3 � Contact Fax: Contact Email: ICe +L aa S (�) Vese2► 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. 2021-814515 ES OPC LLC, DBA Veserls Corpus Christi , TX United States Date Filed: 10/19/2021 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 identitythe contract, and provide a description of the services, goods, or other property to be provided under the contract. Bid Number 2022.02 Annual Supply of Insecticides for Mosquito Control Januaryl, 2022 thru December 31, 2022 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Fintermedlary Garcia, Nico Corpus Christi, TX United States X Theriot, Mark Corpus Christi, TX United States X Gibbs, Doug Houston, TX United States X Haas, Keith Houston, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION 1 1' My name is It . is L I . t7 Q a .5 and my date of birth is My address Is q(z1pcoFde)kl (street) (city) (state) I declare under penalty of perjury that the foregoing is true and correct. j �t Executed in 0 AR c s County, State of Y Q IC A S , on the J i day of v�, 20-2L. (month) (year) /✓/// ,(,(^/_//��//// signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191DSC , CERTIFICATE OF LIABILITY INSURANCE DATE7/20 NYYY) zns/2ozz 9i2v2o21 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(tes) 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 Lockton Companies 1185 Avenue of theAmericas, Suite 2010 New York NY 10036 646-572-7300 INSURED ES OpCo USA LLC 1484396 10800 Pecan Park Blvd Austin TX 78759 I INSURER(S) AFFORDING COVERAGE I —NAIC# I INSURER ANavigators Specialty Insurance CompawI' �I, INSURER B:HarlfoId Casual Insurance Company INSURER c:Hartford Underwriters Insurance Compam INSURER D:Twin CityFire Insurance Comp—, COVERAGES CERTIFICATE NUMBER: lINJEJEW REVISION NUMBER: x3ocxx ,'X 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. IN7fl TYPEOFINSURANCE ABOL SUBR POLICY NUMBER MM3nrYYYYF NIMIDDYYYYP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS.MADE � OCCUR N N - 2/15/2021 2/15/2022 EACH OCCURRENCE - $ 1000000 MAED PREMDAISGEESTOEa occurrence s 300,000 MED UP (Any oneparson) s 25,000 PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECf LOC OTHER: GENERAL AGGREGATE PRODUCTS-COMPIOPAGG B C2/15/2021 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED ONLY AUTOSHIRED NON -OWNED AUTOS ONLY AUTOS ONLY N N 2/15/2021 2/15/2022 2/15/2022 COMBINED SINGLE LIMIT Ea aLY Rs2,000,000 �. INJl BODILY INJURY (Perperson) BOOILV INJURY (Peraaldent)AUTOS PROPERTY DAMAGE Per accident s X3OOCX3O{ A X UMBRELLA LIAB XCESS LIAB j{ OCCUR CLAIMS -MADE N N - - 2/15/2021 -' 2/15/2022 EACH OCCURRENCE s 15,000,000 AGGREGATE $ 15 00O 000 7 DED RETENTION S XXiCL' '�fX�C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY OFFICER/MEMBEHIPE%CLUDEEXECUTIVE (Mandatory In NH) der Iibe OF DESCRIPTIONOPERATIONS below N/A N 2/15/2021 2/15/2022 it - X STATUTE ER E.L. EACH ACCIDENT s 1000000 E.L. DISEASE - EA EMPLOYEE $ 1000000 E.L. DISEASE -POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) 17896190 ES Opco USA LLC 3075 Highland Parkway, Suite 200 Downers Grove IL 60515 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 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, 64th Leg., Regular Session. OFFICEIISEONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Recelmd 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 hater 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. 1J Name of vendor who has a business relationship with local governmental entity. NW 2 Check this box If you are filing an updateto a previouslyiiled 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 M1I /V p, 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 anyfamily relationship with the local government officer. Complete subparts A and IS 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? tN 4 F—] 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 govemmental entity? a „ f A � Yes � No 6 Describe eac�hemployment orbusiness relationship that the vendor named InSection Imaltdalnswlthacorporation 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. N ►4 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 AAJo !9 ocf 2002 -Sigilatallf of vendor oing usmess with the governmental entity Data Farm 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. Vie'4A L,11&4s 0V%A.L[, L [Aeai�, Name and Title of Authorized Agent Signature of Authorized Agent 5r-C' Oct goal 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 land 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, V e5Q✓L,.S , 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/ .S.^3801 et seq., apply to this certification and disclosure, if any. Name and C( O C_+ 2 D,2 I Date P42 C A 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. cons a. bid/offer/application a. initial filing — b. an c. oop t ve agreement an b initi 1 award n c(�pos and 1v m al change For 'al L'hange only: e. an 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: V�� N� Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: qQA NA CFDA Number, if applicable: 8. Federal Action Number, ifknown: �J 9. Award Amount, ifknown: N ►- $ 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, MI): di(Jerent front No. 10a) W (last nine,first name, MI): I v Iv 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: G disclosure of lobbying activities is a material fact Print Name: i} aO, S representation of upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Q a II II �15� Title:�� I i G P e a I *4 SnP U.S.C.1352. This information will be reported to the Congress semi-annually and will be available for public (� Telephone No.: I t3-20D'Og3bate: Oe t 202 I 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, & t+k L ht 0.Q s the undersigned representative of Representative kI2 5 Q 2 ; .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 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. gna ure of Representative (� //a464 I L K2:+k I-- - C',*0,�iST Print Name & Title 0 c+ o 2 I 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. CERTIFICATION Pursuant to Texas Government Code §2252.001 etseq., 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. ❑ Icertifythat (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) €S Opco LLL w5A t QAF B I certify that VQ S e K . Cj is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. 0-4 Signature of Authorized (Agent g 2 4 L L. ++_,S . �u b l. C � 2 t� I sP Q c�� I• S� Printed Name and Title of Authorized Agent c\ © C_- ' 2 Date � Request for Taxpayer Calve Form to Form (Rev. October 2ola) Identification Number and Certification the requester. Do not Oepaunant of the Treasuy IntertW Revmua Savke - - - t+.Go to www.lrsgav/FormW9 for Instructions and the latest Information. send to the IRS. 1. Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank ES OPCO USA LLC 2 Business nameldisregarded entity name, if different from above - Veseris m 3 Check appropriate box for federal tax classification of the person whose name Is entered on lint. Check only one of the 4 Exempllore (codes apply only to an (allowing seven boxes. - certain entities, not Individuals; am a c Q Individuallsole proprietor or ❑ -C Corporation ❑ S Corporation ❑ Partnership ❑ TrusVestate instructions an. page 3): d single•memberLLO. ..Exempt payee code Of any)..... c �. ❑ Umited liability company. Enter the tax classification(C=C corporation, S=S corporation, P=Partnership)► `o Nate: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting w a = LLC if the LLC is classified as a singWmember LLC that is disregarded from the owner unless the owner of the LLC is another LLCOf that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC Unit code f any) a.. 0 IS Is disregarded from the owner should check the appropriate box for the lax classification of Its owner. Other (am instructions) ► Np a.rro.mnamrea.'MaamAr. e.usl 5 Address (number, street, and apt. or suite no.) See Instructions, Requestees name and address (optional) H 18808 Pecan Park Blvd #308 a City, state, and ZIP code Austin TX 78750 7-Ust accountbumber(s) here (optional) Taxpayer Identification Number IN Note.• If the Number To In the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number J tiding. For proprietor, r ls,disregarded this Is d entity,see t social security number (SSNr. However, fora sole proprietor, or disregarded entity, see the Instructions for Part I, later. For other _ m _ fur employer identification number (EIN). If you do. not have a number, see How to get a or count is in: more than one name, seethe Instructions for line 1. Also see What Name and I Employer Identification number 1. The number 2.1 am not subj Service (IRS) no longer sul 3.1 ama.U.S. c 4. The FATCA c he Requester for guidelines on whose number to enter. 18141131SIBL9I5I3I1I ertiftcation f perjury, I certify that: - awn on this form Is my correct taxpayer identification number (or I am waiting for a number to be Issued to me): and a tobackup withholding because: (a) I am exempt from backup withholding,: or (b) I have not been notified by the Internal Revenue IatI 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 Icl to backup withholding; and ten or other U.S. person (defined below); and de(s) entered on this form Of any) Indicating that I am exempt from FATCA reporting is correct. uctlons. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because report all interest and dividends on your lax return. For. real estate transactions, item does not aooly. For mortoane Interest paid. 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 Sign Here St natursof Vj1 I US. persons ►. V 1Y/t Data* 3/13/20Zp c General Instructions • Form 1099-DIV (dividends, Including those from stocks or mutual ..funds) Section references are to the Internal. Revenue Code unless otherwise noted. • Form 1099-MISC (various types at Income, prizes, awards, or. gross proceeds) Future developments. For the latest Information about developments related to Form W-9 and Its instructions, such as legislation enacted - Form 1099•8 (stock or mutual fund sales and certain other after they were published, go. to www.irs.gov/FormW9. transactions by brokers) • Form 1099-S (proceeds from real estate transactions) Purpose Of Form • Form 1099-K (merchant card and third party network transactions) An Individual or entity (Form W-9 requester) who Is required to file an • Form 1098(home mortgage Interest),1098-E:(student loan Interest), . Information return with the IRS must obtain your correct taxpayer 1093-T(luftion) .Identification number MR which maybe your: social security number a Form 1099-C (canceled debt) (SSN), individual taxpayer identification number (iTIN), adoption taxpayer Identification number (ATIN), or employer Identification number ..Form 7099•A (acquisition or abandonment of secured property) (EIR, to report on an information return the amount paid to you, or other Use Form W-9 only 9 you are a U.S. person (Including a resident amount reportable on an Information return. Examples of information alien). to provide your correct TIN. returns include, but are: not limited to, the following. If you do not return Form W-9 to the requester with a TIN, you might •. Font 1099•INT (Interest earned or paid) be subject to backup withholding, See What is backup Withholding, later, Cat. No. 10231X Form w-9 (Rev. 10-2019) ADAPCO, LLC 'IVJct�V nv� ANNUAL SUPPLY CONTRACT BID NUMBER 2022.02 Beginning January 1, 2022 and Ending D 31, 2022 ` CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2022.02 January 1, 2022 thru December 31, 2022 Bidders's Name & Address ADAPCO,LLC 100 Colonial Center Parkway, Suite 170, Lake Mary, FL 32746 • 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 bidder 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 BVA13 or Calpar Mineral Oil - BVA Mosquito Larvicide Oil - MC30 OR Equivalent ULV Mineral oil'- List Name of Mineral oil 5 Gallon Pail $ 78.10 /per 5 Gallon Pail BVA13 50 Gallon Drum $ 651.00 /per 50 Gallon Drum BVA13 55 Gallon Drum $ 610.50 /per 55 Gallon Drum Calpar 80 275 Gallon Tote $ 3,264.25 /per 275 Gallon Tote Calpar 80 Page 1 of 5 Invitation To Bid Form -Annual Supply ContractforinsecticidesforMosquito Control --CONTINUED Malathion Fyanon_ULV __ List Insecticide Name Active Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ 386.72 /per Case (Case = 2x2.5 Gal Jugs) 5 Galion Pail $ No Bid /per 5 Gallon Pail 55 Gallon Drum $ 4,050.59 /per 55 Gallon Drum 260 Gallon Tote $18,482.10 /per 260 Gallon Tote Malathion EW Fyanon EW —List Insecticide Name Active Ingredients: Malathion 2 x 2.5 Gallon $ 316.42 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 1,806.53 /per 30 Gallon Drum 30-30 ULV PermaSeaSe 30-30 List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 344.75 /per Case (Case = 2x2.5 Gal lugs) 5 Gallon Pail $ No Bid /per 5 Gallon Pail 30 Gallon Drum $ 2,072.10 /per 30 Gallon Drum 55 Gallon Drum $ No Bid /per 55 Gallon Drum 275 Gallon Tote $ 18,733.00 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form- Annual Supply ContractforinsecticidesforMosquito Control -- CONTINUED 31-66 U LV No Bid — List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; Please see below item due to Actives listed above. 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 lugs) 30 Gallon Drum $ No Bid /per 30 Gallon Drum 275 Gallon Tote $ No Bid /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 Jugs) 2 x 2.5 Gallon $ 494.30 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 3,600.00 /per 30 Gallon Drum 275 Gallon Tote $ 33,000.00 /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 $ 155.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ No Bid /per 30 Gallon Tote 55 Gallon Drum $ 1054.35 /per 55 Gallon Drum 275 Gallon Tote $ 4,983.00 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form - Annual Supply Contract for Insecticides for Mosquito Control -- CONTINUED 4-8 ULV Alternate: PermaSease 3-15 — List Insecticide Name Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% Bidding Alternate: Permethrin 3.0%; Piperonyl Butoxide 15.0% 2 x 2.5 Gallon $ 154.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ 924.00 /per 30 Gallon Tote 55 Gallon Drum $ No Bid /per 55 Gallon Drum 275 Gallon Tote $ 8,470.00 /per 275 Gallon Tote Altosid 30 Day Briquets OR Equivalent Mist Insecticide Name Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ No Bid /per case Altosid XR Extended Residual Briquets OR Equivalent , List Insecticide Name Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ No Bid /per case 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 )R Equivalent Alternates, not exact substitutes: Vectomax WSP and Metalary XRP List Insecticide Name Lctive Ingredients: Bacillus sphaericus.6%; Bacillus thuringiensis subspecies israelensis 1% Vectomax WSP: Bs 2.7%; Bti 4.5%; Metalary XRP: (S) Methoprene 4.25% 45 Day ----- 200 Per Case $ /per case 90 Day ----- 200 Per Case $ /per case 180 Day-----200 Per Case $ /per case Vectomax WSP 800/case $1,310.00/case; Metalary XRP 800/case $1,760.00/case; Metalary XRP 200/case $450.00/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 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 any official, employee or agent of Calhoun County in connection with 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: Authc Printed Name & Title of Authorized Signature: Julie Ann Lemke Phone Number: (407) 328-6519 Email: bids@myadapco.com Exceptions and/or Variations from Specifications and/or additional Notes: 4-8 ULV and Fourstar Briquets; please see notes for alternate products. Please see attached labels. Worldwide pemethrin shortage may come into play for Permethrin products in 2022. Page 5 of 5 STATE OF Florida {} AFFIDAVIT COUNTY OF Seminole {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Julie Ann Lemke 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, terms or conditions of said bid have not been communicated by the undersi ned nor by a y employee or agent to any other person engaged in this type of business or to official, employe or agent o alhoun County prior to the official opening of this Bid. Affiant Julie Ann Lemke Printed Name and Title of Affiant Name of Bidder (Company) ADAPCO, LLC Address 100 Colonial Center Parkway, Suite 170, Lake Mary, FL 32746 Phone Number (407) 328-6519 Fax Number (866) 330-9888 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 1st day of November , 2020 �V*r A" Notary Public State of Florida LL `F Kathryn A Russell tea: P� My commission GG 153237 Nota ublic, State of +7y " Expires 12/07/2021 ry 12/07/2021 Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: ADAPCO, LLC Address: : 100 Colonial Center Parkway, Suite Remittance Address: PO Box931574, Atiant, Telephone: (407) 328-6519 Fax: (866)330-9888 Email: bids@myadapco.com Signature of Authorized Representative: Lake Marv. FL 32746 GA 31193-1574 Printed name of Authorized Rep: Julie Ann Lemke ORDER - CONTACT INFORMATION Order Contact Name & Title: Customer Service Joy Edwards Order Contact Telephone: (877) 250-6508 Order Contact Fax: (866) 330-9888 Order Contact Email: orders@myadapco.com INVOICES - CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Customer Service - Joy Edwards Contact Telephone: (877) 250-6508 Contact Fax: (866) 330-9888 Contact Email: orders@myadapco.com CERTIFICATE OF INTERESTED PARTIES FORM 1295 1of1 Complete Nos. i - a and 6 if there are interested parties. OFFICE USE ONLY Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. CERI IFICA71ON 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. 2021.819722 ADAPCO, LLC SANFORD, FL United States Date Filed: 11/03/2021 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. 2022.02 Annual Supply Contract for Insecticides for Mosquito Control January 1, 2022 - December 31, 2022 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. ❑ 6 UNSWORN DECLARATION y Julie Ann Lemke ,and my date of birth is M name is My address is USA MINMENINNEM (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 FL , on the3rd day cNovember , 2d21 A�1 (month) (year) 'Signfiture of authorized agent o contracti buss ss entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE Page 1 of 2 DATE(MM/DDNYYY) 11/12/2020 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($), 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 NAME: Towers Watson Certificate Center Willie Towers Watson Northeast, Inc. PHONE 1-B77-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd AIC No Ert: MM No: P.O. Box 305191 E14AIL S: certificates0willis.com ADDRES Nashville. TN 372305191 USA INSURERA: Indian Harbor Insurance Compa INSURED NURER B: Commerce 6 Industry Insurance Adapco, LLC I 550 Aero Lane _ INSBURER C: Sanford, FL 32771 ivauoco n• COVERAGES CERTIFICATE NUMBER' PFvtclnN m"SiptFR• 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. IITR TYPE OF INSURANCE ADOL SUER POUCYNUMBER POLICY EFF MMIDD PODCY IXP MMA1D LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES We occurrence § 100, 000 MED EXP(Any one person) $ 5,000 A PERSONAL 6ADV INJURY $ 1,000,000 11/14/2020 11/14/2021 GEN-L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ JECT PRC- ❑ LOG GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGO § 2,000,000 $ OTHER: AUTOMOBILELIABILITY COMBINED SINGLE LIMIT Ea a.Idea,) $ 1,000,000 X BODILY INJURY (Per person) $ ANYAUTO H X OWNED SCHEDULEDMEN= AUTOS ONLY AUTOS 11/15/2020 11/15/2021 BODILY INJURY Per ausdent ( ) $ HIRED AUTOSOED AUTOS ONLY AUTOSONLY PROPERTYDAMAGE Per accident) $ $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEO RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUTME YIN OFFICER/MEMBEREXCLUDED7 No (Mandatory In NH) If yes, descdbe under DESCRIPTION OF OPERATIONS below N/A��, 11/15/2020 11/15/2021 X PER OTH- STATUTE ER E.L. EACH ACCIDENT § 1,000,000 E.L. DISEASE -EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 H Automobile Liability 11/15/2020 11/15/2021 Combined Single Limit $1,000,000 Any MA Auto DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Mosquito Control Chemical Distribution SEE ATTACHED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD aR AGENCY CUSTOMER ID: _ LOC #: , L R ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Northeast, Inc. Adapco' LLC 550 Aare Lane Sanford, FL 32771 POLICY NUMBER See Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORDING ommerce 6 Industry Insurance Company POLICY NUMBER: EYE DATE: 11/15/2020 SEE DATE: 11/15/2021 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation & EL Each Accident $1,000,000 Employers Liability - CA EL Disease -Each Emp $1,000,000 Per Statute EL Disease -Policy Let $1,000,000 101 NAIC#: 19410 © 2008 ACORD CORPORATION. All riohts reserved. The ACORD name and logo are registered marks of ACORD SR111111M3111�-0E 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. OFFICEUSEONLY 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. jJ Name of vendor who has a business relationship with local governmental entity. ADAPCO, Ilc 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.) -IJ Name of local government officer about whom the information is being disclosed. Mosquito Control Director 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? E]Yes FEND 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 x—1 No 5 Describe each employmentor business relationship that the vendor named in Section 1 maintainswith acorporation 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. ADAPCO is a distributor of insecticide products, technology, spray and monitoring equipment and surveillance equipment to the professional mosquito control industry. 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 I zd 411/03/2021 i ure o e g bust s W a ov ental entity Date Form pi6vided 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. Julie Ann Lemke Name and Title of Authorized Agent S gnature ofAuthoiized Agent 11/01/2021 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). 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 et seq., apply to this certification and disclosure, If any. g a r ont ctorsAu on Julie Ann Lemke Printed Name and Title of Contractors Authorized Official 11/01/2021 Date Approved by OMB ADAPCO, LLC - None Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nuhlic harden dke.1mura) 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 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, if applicable: S. 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 name, first name, MI): d(fereni front 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: by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: 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 l Julie Ann Lemke the undersigned representative of Representative ADAPCC, 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. /I"- JL d. 4 Signature of Representative Julie Ann Lemke Print Name & Title 11/01/2021 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. ® I certifythat ADAPCO, LLC is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is Lake Marv. FL (City and State) ❑ 1 certify that is a `Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Julie Ann Lemke Printed Name and Title of Authorized Agent 11/01/2021 Date Request for Taxpayer Give Form to the Fenn V�A (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to wwwAs.go n(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. ADAPCO LLC 2 Business name/disregarded entity name, if different from above ro- 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 entitles, not individuals; see a p ❑✓ Individual/sole proprietor or ❑ 0Corporation ❑Scorporation ❑ Partnership ❑Trust/estate instructions on page 3): ai single -member LLC Exempt payee code (it any) 0 , 4'o ❑ 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 N 5 = 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 is code (if any) o' another that 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. W ❑ Other (see instructions)► (lrpli. roettamNmtinfBi HWIsiEe tit U.S.) I N 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 100 Colonial Center Parkway, Suite 170 6 City, state, and ZIP code Lake Mary, FL 32746 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 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 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. 5 9 - 2 1 5 1 7 1 4 1 5 1 2 1 3 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 noted 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 (f 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. Here I U.S. personre n_� g�� Controller Here U.S. person► ��`"` Date► 9-23-2021 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 ww%vJm.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 ISSN), 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 Foam W-9 (Rev. 10-2018) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2022.02 January 1, 2022 thru December 31, 2022 Bidders's Name & Address Rentokil North America, dba Target Specialty Products 1225 N. Post Oak Rd. Houston TX 77055 • 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 bidder 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 Mosauito Larvicide Oil - MC30 OR Eauivalent BVA13 , List Name of Mineral Oil 5 Gallon Pail $ $82.97 /per 5 Gallon Pail 50 Gallon Drum $ $640.00 /per 50 Gallon Drum 55 Gallon Drum $ $690.00 /per 55 Gallon Drum 275 Gallon Tote $ $2,940.00 /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 N/A —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 Permanone 30-30 (5 gal, 30 gal, 275 gal) Perm-X 3030 (2.5 gal, 55 gal) � List Insecticide Name Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ $325.00 /per Case (Case = 2x2.5 Gal Jugs) Perm-X 30-30 5 Gallon Pail $ $305.00 /per 5 Gallon Pail Pe r n an on e 319-3 0 30Gallon Drum $ $1,830.00 /per30GallonDrum Pefm"70" 30 30 55 Gallon Drum $ $3,520.00 /per 55 Gallon Drum Pelm- X 3-9-30 275 Gallon Tote $ $16,775.00 /per 275 Gallon Tote Page 2 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED 31-66 ULV Permanone 31-66 (1 gal, 30 gal, 275 gal) Perm-X UL 31-66 (2.5 gal) � List Insecticide Name Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x l Gallon $ $388.00 /per Case (Case = 4xl Gal Jugs) Per m an one 3f "�/e 2 x 2.5 Gallon $ $485.00 /per Case (Case = 2x2.5 Gal Jugs) P-e Km- 30 Gallon Drum $ $2,910.00 /per30Gallon Drum Perm,�,ne3f-/n(� 275GallonTote $ $26.675.00 /per275Gallon Tote Pa,J1r✓Jq,none3!'�� 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 = 4xl 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 Perm-X UL 4-4 ListInsecticide Name Active Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ $115.65 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ $585.50 /per 30 Gallon Tote 55 Gallon Drum $ $1,010.00 /per55 Gallon Drum 275 Gallon Tote $ $4,568.00 /per 275 Gallon Tote Page 3 of 5 Invitation To Bid Form -Annual Supply Contract for Insecticides for Mosquito Control --CONTINUED 4-8 ULV Permanone RTU — ListInsecticideName Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ $200.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ $1,110.00 /per 30 Gallon Tote 55 Gallon Drum $ N/A /per 55 Gallon Drum 275 Gallon Tote $ $9,762.50 /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 $ $500.00 /per case Altosid XR Extended Residual Briquets Altosid XR Extended Residual Briquets OR Equivalent � List Insecticide Name Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ $787.60 /per case DeltaGard ORE Equivalent q DeltaGard round - Im erium aerial F List Insecticide Name Active Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ $1,120.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ $6,510.00 /per 30 Gallon Drum 250 Gallon Tote $ $53,750.00 /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 qulvalent N/A — ListInsecticideName Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecies israelensis 1% 45 Day ----- 200 Per Case $ /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 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 any official, employee or agent of Calhoun County in connection with 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: 10/13/2021 Authorized Signature & Title: Vector Accounting Representative Printed Name & Title of Authorized Signature: Kristi Viada - Vector Accounting Representative Phone Number:225-200-5007 Email: Kristi.viada@target-specialty.com Exceptions and/or Variations from Specifications and/or additional Notes: Page 5 of 5 STATE OF AY A {} AFFIDAVIT COUNTY OF -- � e The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. )% ) / BEFORE ME, the undersigned authority, on this day personally appeared ii i • S? : rid < 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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. I-A,O An/'fl� �INFE Name of Bidder (Company) Rentokil North America, dba Target. Specialty Products Address 1225 N. Post Oak Rd. Houston TX 77055 Phone Number 225-200-5007 Fax Number Email Address Kristi.viada@target-specialty.com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, above are.true and correct, this J� day of Gia Stamp�Seal `•��Jthli G4iY_i9kk �`'�• 1' Notary Public, State of My Commission Expires that the fads contained in the BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Rentokil North America, dba Target Specialty Products Address: 1225 N. Post Oak Rd. Houston TX 77055 Remittance Address: 210 Corporate Dr Bldg. 7 Berks Corporate Ctr Reading, PA 19605 Telephone: 225-200-5007 Fax: Email: Kristi.viada@target-specialty.com Signature of Authorized Representative: Printed name of Authorized Rep: Kristi Viada ORDER — CONTACT INFORMATION Order Contact Name & Title: Kristi Viada Order Contact Telephone: 225-200-5007 Order Contact Fax: Order Contact Email: Kristi.viada@target-specialty.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Kristi viada Contact Telephone: Contact Fax: 225-200-5007 Contact Email: _ Kristi.Viada@target-specialty.com CERTIFICATE OF INTERESTED PARTIES FORM 1295 loll 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. 2021-818081 Target Specialty Products Houston, TX United States Date Filed: 10/28/2021 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. 2022.02 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 I Intermediary Myers, John Reading, PA United States X Gelling, Bruce Reading, PA United States X Coyle, Jason Reading, PA United States X Heft, David Santa Fe Springs, CA United X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION I Mynameis John Michael Nichols and my date II� My address is USA -.0-�I (street) (CRY) (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 the28thday of October 40 21 , (month) (year) Signature of authorized agent of contracting business entity (Declemnt) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE DATE (MMIODNYYY) 9/17/2021 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(sl. PRODUCER Edgewood Partners Insurance Center 200 Glenridge Point Parkway Suite 400 Atlanta GA 30342 ACE INSURED Rentokil North America, Inc. dba Target Specialty Products (REN210) 1125 Berkshire Blvd., Suite 150 Wyomissing PA 19610 COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER MM/UDYEFF MM/UDY�P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR 10/1/2021 10/112022 EACH OCCURRENCE $5,000,OOD Ea TED PREMIEa VT PREMISESS ( $5,000,000 MED EXP Any one person) $ 5,000 PERSONAL& ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY N JEST LOC OTHER: GENERAL AGGREGATE $5.000.000 PRODUCTS-COMP/OPAGG $5,000,000 $ C AUTOMOBILELIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AU70S HIRED NONOWNED ONLY AUTOS ONLY 10/1/2021 10/1/2021 10/1/2022 10/1/2022 COMBINED SINGLE LIMIT Ea accident $2,OOD,000 X BODILY INJURY (Per person) $ 1AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ B X UMBRELLALIAB EXCESS LIAR X OCCUR CLAIMS -MADE 10/1/2021 10/1/2022 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DEO I X I RETENTION$ in nnn $ C D WORKERS COMPENSATION AND EMPLOYERS'LIABILIY YfN ANYPROPRIETORIPARTNER/EXECUTIVE F `N] OFFICER/MEMBEREXCLUDED7 (Mandatary in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 10/1/2021 10/1/2021 10/1/2022 10/1/2022 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 Emars& Omissions LiabilityMMM 10/1/2021 10/1/2022 Each lncidenVAgg 5,000.000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached if more space is required) 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. Evidence of Insurance AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. 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. 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. !J Name of vendor who has a business relationship with local governmental entity. Kristi Viada - 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. Kristi Viada 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? F]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? Yes W1 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. 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 10/13/2021 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 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. Kristi Viada - Vector Accounting Representative 10/13/2021 Name and Title of Authorized Agent Date �JC 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 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 Contra CYOrRenlaklNorth America, tlbeTarget Specialty , cabbies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that theII Jprovisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature of Contractor's Authorized Official Kristi Viada - Vector Accountinq Representative Printed Name and Title of Contractor's Authorized Official 10/13/2021 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 a. bid/offer/application a. initial filing b. 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 X 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: N/A N/A CFDANumber, ifapplicable: S. Federal Action Number, ifknown: 9. Award Amount, ifknown: N/A $ N/A 10. a. Name and Address of Lobbying Registrant b. individuals Performing Services (including address if if individual, last name, first mute, MQ: different from No. 10a) (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: disclosure of of lobbying activities is a material representation of fact upon which reliance was placed Print Name: Kflstl Viada by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Vector Accounting Representative U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: 225-200-5007 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 Kristi Viada Representative the undersigned representative of Rentokil North America. dba Target Specialty 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 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 Kristi Viada - Vector Accounting Representative 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. ❑ 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) Rentokil North Americas, dba Target Specialty Products 9 1 certify that Is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Kristi Viada - Vector Accounting Representative Printed Name and Title of Authorized Agent 10/13/2021 Date Request for Taxpayer Give Form to the Form V�Q (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www.1m.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your income tax retum). Name is required on this line; do not leave this line blank. Rentokil North America, Inc. 2 Business name/disregarded entity name, if different from above Target Specialty Products y 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 p ❑ Individuallsole proprietor or ✓❑ C Corporation [IS Corporation ❑ Partnership ❑ TrusVestate instructions on page 3): single -member LLC Exempt payee code (if any) 5 a �'g ❑ 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 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 LLC is disregarded code (if any) IL another that not 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)► (Applin to acmunbmarntele w6We the Us) y 5 Address (number, street, and apt, or suite no.) See instructions. Requesters name and address (optionail m CO P.O. Box 14084 6 City, state, and ZIP code Reading, PA 19612 7 Ust account numbers) 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 FM —01 — 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 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. F21 3 — 7 1 5 1 6 1 8 1 3 1 5 1 0 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 II, later. Sign Signature Here U.S. personson►1 Date► 01/01/2021 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) • 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. 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, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) #16 NOTICE OF MEETING— 11/24/2021 16. Consider and take necessary action to award the bids for the Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions, Bid Number 2022.03 for the period beginning January 1, 2022 and ending December 31, 2022. (RHM) Peggy Hall explained Bids. Low Bids that met specifications awarded. The Tie Bid awarded to Quality Hot Mix Inc. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 12 of 28 RE: Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2022.03 Period Beginning January 1, 2022 and ending December 31, 2022 Awards made to the following Bidders: 1. Blades Group, LLC Awarded: Bid Item #11: Item 330 D, Pothole Repair, Limestone Rock Asphalt (LRA) 2. Cleveland Asphalt Products, Inc. Awarded: Bid Item #14: Primer Oil Awarded: Bid Item #15: RC-250 Awarded: Bid Item #16: CRS-2 3. K-C Lease Service, Inc. dba Matagorda Construction & Materials Awarded: Bid Item #1: Limestone-3/4 Inch to Dust —for Only Precinct 4-P Awarded: Bid Item #9: Item 302, Type E, Grade 5, Ice Rock (Non -Coated Limestone Only) 4. Midtex Materials, LLC Awarded: Bid Item #13: Item 432, Riprap, Section 2.3 Stone Riprap, 12" Limestone S. Quality Hot Mix, Inc. Awarded: Bid Item #1: Limestone-3/4 Inch to Dust —for Only Precincts 1, 2, 3 & 4-S Awarded: Bid Item #3: Item 247, Type A Limestone, Grade 3 [1 % Inch] Awarded: Bid Item #5: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Awarded: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Awarded: Bid Item #12: Item 334, Type D, Hot Mix Cold Laid Asphalt Concrete Pavement Tie Bid — to be decided by drawing in Commissioners Court: Bid Item #2=Inc. one, Grade 2 [1 % Inch] A100rc✓e-4 Qua K-C Lease Service, Inc. dba Matagorda Construction & Materials RE: Road Materials and Asphalts, Oils and Emulsions Annual Supply Contract Bid Number 2022.03 Period beginning January 1, 2022 and ending December 31, 2022 Baseline Price for Fuel Adjustment on Delivery Price on November 8, 2021= $3.482 Bids were opened at 2:00 PM, Tuesday, November 9, 2021. Nine (9) bids were received: 1. BLADES GROUP, LLC 2. CLEVELAND ASPHALT PRODUCTS, INC. 3. COLORADO MATERIALS LTD 4. K-C LEASE SERVICE, INC. dba MATAGORDA CONSTRUCTION & MATERIALS 5. MARTIN PRODUCTS SALES, LLC dba MARTIN ASPHALT COMPANY 6. MIDTEX MATERIALS, LLC 7. P SQUARED EMULSION PLANTS, LLC 8. QUALITY HOT MIX, INC. 9. WALLER COUNTY ASPHALT. INC. The following Bids did not Meet Specifications: 1. Colorado Materials, LTD • The Disclosure of Lobbying Activities Form was marked "NA" but was not signed and dated as instructed in five different places in the Invitation to Bid Packet, which includes the specifications. 2. Martin Products Sales, LLC dba Martin Asphalt Company • The Certification Regarding Debarment & Suspension & Other Responsibility Matters Form was checked that they were unable to certify to the statements on the form but they did not attach an explanation as required. Need to review the Additional Information and Charees stated on a separate oaee for: • P Squared Emulsion Plants, LLC a) Delivery over 250 miles subject to additional charges b) Pump Charge (trucking charge) $80.00 c) Push Charge (trucking charge) $80.00 per hour d) Return Loads (trucking charge) subject to charge from delivering freight line The following bidders submitted a bid on Alternate Items — Need to Review: 1. P Squared Emulsion Plants, LLC • Review the bid for Primer Oil (may be the same item) — Bid was for P2 Prime Concentrate Bid P2 CWE-2 for CRS-2 2. Waller County Asphalt, Inc. • Bid ASPPM 9202 Grade IV High Performance Cold Mix for Item 334, Type D, Hot Mix Cold Laid Asphalt Concrete Pavement NOTE: Bids that met specifications and appear to be Low Bids are highlighted in Yellow • Please Review Tie bids for the following (page 2 of 11): • Bid Item #2: Item 247, Type A Limestone, Grade 2 [1 Y4 Inch] No bids on the following: • Bid Item #4: Item 275, Cement • Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) • Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) ■ Bid Item #10: Item 330, Type D (Pre -Mix Limestone) in1 P2 Emulsions VZJ P Squared Emulsion Plants - November 2, 2021 Prices subject to change with written notice P2 Salesman - David Williams Contact Phone - (361) 877-2584 Product Tanker FOB Plant Tanker FOB County Drum/Tote Plant P2 Stabilizer $2.44 $2.69 $2.64 P2S1 $2.44 $2.69 $2.64 P2 CWE-2 $2.74 $2.99 $2.94 (Chip Sea[) P2 ROC $2.57 $2.82 $2.77 (Road Over Coat) P2 Rejuvenator $2.44 $2.69 $2.64 P2 Prime Concentrate $1.79 $2.04 $1.99 P2RTU $1.75 $2.00 $1.95 "All listed prices are per U.S. gallon **Minimum Tanker Delivery: 5,000 Gallons **Delivery over 250 miles subject to additional charges **Demurrage (trucking charge): First 2 hours free, $80.00 per hour thereafter **Pump Charge (trucking charge): $80.00 **Push Charge (trucking charge): $80.00 per hour **Return Loads (trucking charge): Subject to charge from delivering freight line **Smaller Quantities Available, Subject to Freight Differential of $0.25/gal less than 5,000 gal Containers available for smaller product amounts "Tote" Containers (275 gallons size each) cost $100.00 per container "Drum" Containers (55 gallons size each) cost $35.00 per drum Containers are re -usable and can be rinsed out, brought back and re -filled at customer discretion Containers priced individually and sold only with orders for material Than you and we look forward to serving all your emulsion needs! PHmulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 - 254-829-0330 P iP2 Emulsions pJ Date: November 02, 2021 To: Calhoun County Subject: P Squared Emulsion Plants LLC Sole Source Products This communication serves as certification that all products listed below are produced in accordance with the State of Texas' Sole Source requirements according to the proprietary formulas and specifications of P Squared Emulsion Plants LLC. Our proprietary products conform to the formal definition of "a confidential formulation usually containing two or more ingredients and about which information is not in the public domain" and as such, P Squared Emulsion Plants LLC is the only manufacturer and distributor of said products. P Sauared Emulsion Plants LLC Products: 11P2 Stabilizer" Our P2 Stabilizer is an asphalt emulsion that is incorporated into existing soil or base material to provide increased base strength and stability. P2 Stabilizer eliminates the need for additional material such as aggregates, lime, cement or other additives. The utilization of P2 Stabilizer results in increased base density and hardness without sacrificing the flexibility and waterproof properties of asphalt. "P2 Rejuvenator" Our P2 Rejuvenator is engineered to rejuvenate old asphalt roads, RAP and other millings with residual asphaltic content. A one-time application will rejuvenate the existing material through softening oxidized pavement materials and re -binding asphalt to revitalize the road base. "P2 ROC" Our P2 ROC is engineered to seal and protect existing road surfaces. Our "Road Over Coat" is a proven sealing solution that locks down loose chip seal aggregate while sealing oxidized and cracked surfaces. ROC is designed to be traffic safe in under an hour resulting in a uniform, black road surface. "CWE-2-No Bleed Chip Seal" Our unique chip seal formula exhibits superior performance when compared to commodity type CRS-2 emulsions CWE-2 can be applied in a broader range of temperatures (10-20 degrees below other products) and WILL NOT BLEED under extreme summer temperatures. "CWP — Pothole Patch" This emulsion is specifically formulated to work in ALL patch machines, ALL year round with the exact same results. Smooth consistency, no bleed finish and extremely low clog rates differentiate CWP from all other patch materials. "P2 Prime Concentrate" We have several proprietary "ready -to -use" formulas that include prime, tack and dust control products that all derive from our P2 Prime Concentrate. Based on application, customer needs and dilution rates; we have something for literally every road across the state of Texas. **All P Squared Emulsion Plants LLC proprietary products fulfill the formal requirements found in Texas Local Govemmeut Codes regarding county purchasing. Section 262.024.9.A. (Available upon request) --All P Squared Emulsion Plants LLC proprietary products are fully TCEQ and EPA compliant All of us at P Squared thank you for the opportunity and we look forward to serving all your emulsion needs! P2Emulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 CALHOUN COUNTY, TEXAS BID TABULATION ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT, BID NUMBER: 2022.03 For the Period Beginning January 1, 2022 and Ending December 31, 2022 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE: $3.482 on November 8, 2021 (www.eia.gov/petroleum/gasdiesel) (Gulf Coast Area) Bids that met specifications and appear to be Low Bid are highlighted in Yellow - Please Review Tie Bids: In the event of Tie Bids, the winning bid is determined per Texas Local Government Code 262.027(b). ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch to Dust LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct Ton $12.00 $18.40 $30.40 24TONS QUALITY HOT MIX, INC. NOTE: ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct Ton $12.00 $18.40 $30.40 24TONS Precinct Ton $12.00 $18.40 $30.40 24TONS Precinct 4-P Ton $12.00 $19.00 $31.00 24TONS Precinct 4-S Ton 1 $12.00 $18.40 $30.40 24TONS Precinct 1 Ton $5.50 $25.00 $30.50 25 TONS K-C LEASE SERVICE, INC. dba MATAGORDA CONSTRUCTION & MATERIALS Precinct 2 Ton $5.50 $25.00 $30.50 25 TONS Precinct 3 Ton $5.50 $25.00 $30.50 25 TONS Precinct 4-P .Ton $5.50 $25.00 $30.50 - 25 TONS Precinct 4-S Ton $5.50 $25.00 $30.50 25 TONS Precinct Ton $6.00 $28.00 $34.00 24 TON MIDTEX MATERIALS, LLC Precinct 2 Ton $6.00 $28.00 $34.00 24 TON Precinct 3 Ton $6.00 $28.00 $34.00 24 TON Precinct 4-P I Ton 1 $6.00 1 $30.00 1 $36.00 1 24 TON Precinct 4-S Ton 1 $6.00 1 $28.00 $34.00 24 TON Page 1 of 11 Tie Bldg: In the event of Tie Bids, the winning bid is determined per Texas Local Government Code 262.027(b). Bid Item #2: ITEM 247, TYPE A LIMESTONE, GRADE 2 [1 3/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $12.00 $18.00 $30.00 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 $12.00- $18.00 $30.00 24 TONS Precinct 3 Ton $12.00 - $18.00 $30.00 24 TONS Precinct 4-P Ton $12.00 $18.00 $30.00 24 TONS Precinct 4-S Ton $12.00 ` $18.00 $30.00 24 TONS Precinct 1 Ton $5.00 $25.00 $30.00 25 TONS K-C LEASE SERVICE, INC. dba MATAGORDA CONSTRUCTION & MATERIALS Precinct 2 Ton $5.00 $25.00 $30.00 25 TONS Precinct 3 Ton $5.00 $25.00 $30.00 25 TONS Precinct 4-P Ton $5.00 $25.00 1 $30.00 1 25 TONS Precinct 4-S Ton $5.00 $25.00 $30.00 25 TONS Precinct Ton $6.00 $28.00 $34.00 24 TON MIDTEX MATERIALS, LLC Precinct 2 Ton $6.00 $28.00 $34.00 24 TON Precinct 3 Ton $6.00 $28.00 $34.00 24 TON Precinct 4-P Ton $6.00 $30.00 $36.00 24 TON Precinct 4-S Ton $6.00 $28.00 $34.00 24 TON Precinct 1 Ton Did Not Meet Specifications $19.75 Did Not Meet Specifications $8.84 Did Not Meet Specifications $28.59 24 COLORADO MATERIALS, LTD Material Location: Nursery, TX DID NOT MEET SPECIFICATIONS Disclosure of Lobbying Activities Form was marked "NA" BUT was not signed and dated as instructed in 5 different places in the Invitation to Bid Packet, which includes the specifications. Precinct 2 Ton Did Not Meet Specifications $19.75 Did Not Meet Specifications $8.84 Did Not Meet Specifications $28.59 24 Precinct 3 Ton Did Not Meet Specifications $19.75 Did Not Meet Specifications 1 11.68 Did Not Meet Specifications $31.43 24 Precinct 4-P Ton Did Not Meet specifications $19.75 Did Not Meet Specifications $11.05 Did Not Meet Specifications $30.80 24 Precinct 4-S Ton Did Not Meet Specifications $19.75 Did Not Meet Specifications $9.82 Did Not Meet Specifications $29.57 24 Page 2 of 11 Bid Item #3: ITEM 247, TYPE A LIMESTONE, GRADE 3 [1 3/4 INCH] LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton $12.00 $19.00 $31.00 24TONS QUALITY HOT MIX, INC. Precinct Ton $12.00 $19.00 $31.00 24TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct Ton $12.00 $19.00 $31.00 24TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $12.00 $19.00 $31.00 24TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $12.00 $19.00 $31.00 24 TONS Precinct Ton $6.00 $28.00 $34.00 24TONS MIDTEX MATERIALS, LLC Precinct Ton $6.00 $28.00 $34.00 24TONS Precinct 3 Ton $6.00 $28.00 $34.00 24 TONS Precinct 4-P Ton $6.00 $30.00 $36.00 24TONS Precinct 4-S Ton $6.00 $28.00 $34.00 24TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $19.75 $8.84 $28.59 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Location: Nursery, TX Precinct 2 Ton $19.75 $8.84 $28.59 24 ------------------------------------------------- DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $19.75 1 $11.68 $31.43 24 marked "NA" BUTwas not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Ton $19.75 $11.05 $30.80 24 specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $19.75 $9.82 $29.57 24 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 Lb Bags on Pallet Page 3 of 11 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 $53.00 $9.00 $62.00 25 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $53.00 $9.00 $62.00 25 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $53.00 $9.00 $62.00. 25 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $53.00 $9.00 $62.00 25 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $53.00 $9.00 $62.00 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $40.00 $24.96 $64.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $40.00 $24.63 $64.63 24 _________________________________________________ DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 3 Ton $40.00 $25.64 $65.64 24 Disclosure of Lobbying Activities Form was marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Precinct 4-P Ton $40.00 $28.17 $68.17 24 Invitation to Bid Packet, which includes the specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $40.00 $26.14 $66.14 24 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 $53.00 $9.00 $62.00 25 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $53.00 $9.00 - $62.00 25 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 1 Ton 1 $53.00 1 $9.00 1 $62.00 1 25 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct4-P Ton $53.00 $9.00 $62.00 25 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $53.00 $9.00 $62.00 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $40.00 $24.96 $64.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $40.00 $24.63 $64.63 24 ------------------------------------------------- DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 3 Ton $40.00 $25.64 $65.64 24 Disclosure of Lobbying Activities Form was Did Not Meet Did Not Meet Did Not Meet marked "NA" BUT was not signed and dated Specifications Specifications Specifications as instructed in 5 different places in the Precinct 4-P Ton $40.00 $28.17 $68.17 24 Invitation to Bid Packet, which includes the specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $40.00 $26.14 $66.14 24 Page 4 of 11 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 NO BIDS RECEIVED Precinct 2 Ton Precinct Ton Precinct4-P Ton Precinct 4-S Ton Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material source out of LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton NO BIDS RECEIVED Precinct 2 Ton Precinct 3 Ton Precinct 4-P Ton Precinct 4-S Ton Intentionally Left Blank - Continued on next page Page 5 of 11 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 $17.00 $25.00 $42.00 25 TONS K-C LEASE SERVICE, INC. dba Precinct 2 Ton $17.00 $25.00 $42.00 25 TONS Precinct 3 Ton $17.00 $25.00 $42.00 25 TONS MATAGORDA CONSTRUCTION Precinct4-P Ton $17.00 $25.00 $42.00 25TONS &MATERIALS Precinct 4-S Ton $17.00 $25.00 $42.00 25 TONS Precinct 1 Ton $26.50 $23.50 $50.00 24 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $26.50 $23.50 $50.00 24 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $26.50 $23.50 $50.00 24 TONS TRAILERSS.. Precinct 4-P Ton $26.50 $23.50 $50.00 24 TONS BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 4-S Ton $26.50 $23.50 $50.00 24 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct i Ton $30.00 $24.96 $54.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $30.00 $24.63 $54.63 24 ------------------------------------------------- DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $30.00 $25.64 $55.64 24 marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Ton $30.00 $28.17 $58.17 2q specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $30.00 $26.14 $56.14 24 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 NO BIDS RECEIVED Precinct 2 Ton Precinct 3 Ton Precinct 4-P Ton Precinct 4-S Ton Page 6 of 11 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 l Ton $71.17 $47.45 $118.62 24 TONS BLADES GROUP LLC Yard $83.98 $55.99 $139.97 22 CU YDS r50 I Bag $14.00 $0.00 $14.00 1 PALLET - 62 BAGS Precinct 2 Ton $70.97 $47.31 - $118.28 24 TONS Yard $83.74 $55.83 $139.57 22 CU YDS 50 lb Bag $14.00 $0.00 $14.00 1 PALLET- 62 BAGS Precinct 3 Ton $72.62 $48.41 $121.03 24 TONS Yard $85.69 $57.13 $142.82 22 CU YDS FSO lb Bag $14.00 $0.00 $14.00 1 PALLET-62 BAGS Precinct 4-P Ton $73.13 $48.76 $121.89 24 TONS Yard $86.30 $57.53 $143.83 22 CU YDS 50lb Bag $14.00 $0.00 $14.00 1 PALLET-62 BAGS Precinct 4-S Ton. $71.17 $47.45 $118.62 24 TONS Yard $83.98 $55.99 $139.97 22 CU YDS 50lb Bag $14.00 $0.00 $14.00 1 PALLET 62 BAGS Intentionally Left Blank - Continued on next page Page 7 of 11 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: Precinct 2 Ton $75.00 $9.00 $84.00 25 TONS Precinct 3 Ton $75.00 $9.00 $84.00 25 TONS ALL DELIVERIES ARE IN END DUMP TRAILERS. Precinct 4-P Ton $75.00 $9.00 $84.00 25 TONS BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 4-S Ton $75.00 $9.00 $84.00 25 TONS Precinct 1 Ton $88.00 $30.59 $118.59 25 TONS WALLER COUNTY ASPHALT, INC. BID ALTERNATE ITEM: Precinct 2 Ton $88.00 $31.51 $119.51 25 TONS Precinct 3 Ton $88.00 $27.83 $115.83 25 TONS BID FOR ASPPM 9202 GRADE IV Precinct 4-P Ton 1 $88.00 1 $35.19 1 $123.19 1 25 TONS HIGH PERFORMANCE COLD MIX Precinct 4-S Ton $88.00 $34.96 $122.96 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $69.00 $24.96 $93.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Precinct 2 Ton Specifications $69.00 specifications $24.63 Specifications $93.63 24 Material Source: New Braunfels, TX DID NOT MEET SPECIFICATIONS Disclosure of Lobbying Activities Form was marked "NA" BUT was not signed and dated as instructed in 5 different places in the Invitation to Bid Packet, which includes the specifications. Precinct 3 Precinct 4-P Ton Ton Did Not Meet Specifications $69.00 1 Did Not Meet Specifications. $69.00 Did Not Meet Specifications $25.64 Did Not Meet specifications $28.17 Did Not Meet Specifications $94.64 Did Not Meet Specifications $97.17 24 24 Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $69.00 $26.14 $95.14 24 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 $26.00 $58.00 $84.00 24 TON MIDTEX MATERIALS, LLC Precinct 1 Ton $26.00 $58.00 $84.00 24 TON Precinct 3 Ton 1 $26.00 1 $58.00 1 $84.00 1 24 TON Precinct 4-P Ton $26.00 $60.00 $86.00 24 TON Precinct 4-S Ton $26.00 $58.00 $84.00 24 TON Page 8 of 21 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 Per Hour Precinct 1 Gallon $2.20 $0.20 $2.40 After 2 Free Hours CLEVELAND ASPHALT $80 Per Hour Precinct 2 Gallon $2.20 1 $0.20 $2.40 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80 Per Hour load, for smaller quantities please call Precinct 3 Gallon $2.20 $0.20 $2.40 After 2 Free Hours 800-334-0177. $80 Per Hour Diluted material can not be returned for Precinct 4-P Gallon $2.20 $0.20 $2.40 After 2 Free Hours credit. $80 Per Hour Precinct 4-S Gallon $2.20 1 $0.20 $2.40 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour MARTIN PRODUCTS SALES LLC Precinct 1 Gallon $2.85 $0.18 $3.03 After 2 Free Hours dba MARTIN ASPHALT COMPANY Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 2 Gallon $2.85 $0.18 1 $3.03 After 2 Free Hours MC-30 5000 gallon minimum Did Not Meet Did not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour ------------------------------------ Precinct 3 Gallon $2.85 $0.16 $3.01 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specification Specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-P Gallon $2.85 $0.21 $3.06 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.85 $0.19 1 $3.04 After 2 Free Hours P SQUARED EMULSION $80 Per Hour PLANTS LLC Precinct 1 Gallon $2.04 n/a $2.04 After 2 Free Hours P2 PRIME CONCENTRATE $80 Per Hour ** Please see attached equivalent Precinct 2 Gallon $2.04 n/a $2.04 After 2 Free Hours and/or superior product information and Sole Source Affidavit. ** P Squared is proudly recognized and accepted $80 Per Hour by Tarrant County Co-op. Precinct 3 Gallon $2.04 n/a $2.04 After 2 Free Hours SEE ATTACHED INFOROMATION FOR ADDITIONAL CHARGES $80Per Hour Minimum Tanker Delivery: 5,000 Gallons; Precinct 4-P Gallon $2.04 n/a $2.04 After 2 Free Hours Delivery over 250 miles subject to additional charges; Pump Charge (trucking charge) $80.00; $80PerHOUr Push Charge (trucking charge) $80.00 per hour; Return Loads (trucking Charge) Subject to charge Precinct 4-S Gallon $2.04 n/a $2.04 After 2 Free Hours from delivering freight line Page 9 of 11 Bid Item #25: RC-250 LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $3.45 $0.20 $3.65 After 2 Free Hours CLEVELAND ASPHALT $80.00 Per Hour Precinct 2 Gallon $3.45 1 $0.20 $3.65 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80.00 Per Hour load, for smaller quantities please call Precinct 3 Gallon $3.45 $0.20 $3.65 After 2 Free Hours 800-334-0177. Diluted material can not be returned for $80.00 Per Hour credit. Precinct 4-P Gallon 1 $3.45 $0.20 1 $3.65 lAfter 2 Free Hours $80.00 Per Hour Precinct 4-S Gallon $3.45 $0.20 $3.65 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 1 Gallon $2.75 $0.18 $2.93 After 2 Free Hours MARTIN PRODUCTS SALES LLC dba Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour MARTIN ASPHALT COMPANY PYBCIDCt 2 Gallon $2.75 $0.18 $2.93 After 2 Free Hours 5000 gallon minimum Did Not Meet Did not Meet Did Not Mee[ Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 3 Gallon $2.75 $0.16 $2.91 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications specification specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-P Gallon $2.75 $0.21 $2.96 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Uld Not Meet Specifications Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.75 $0.19 $2.94 After 2 Free Hours Intentionally Left Blank - Continued on next page Page 10 of 11 f Bid Item #16: CRS-2 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 CLEVELAND ASPHALT $80.00 Per Hour Precinct 2 Gallon $2.00 $0.20 $2.20 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80.00 Per Hour load, for smaller quantities please call Precinct 3 Gallon $2.00 $0.20 $2.20 After 2 Free Hours 800-334-0177. $80.00 Per Hour Diluted material can not be returned for Precinct 4-P Gallon $2.00 $0,20 $2.20 After 2 Free Hours credit. $80.00 Per Hour Precinct 4-S Gallon $2.00 1 $0.20 $2.20 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 1 Gallon $2.00 $0.18 $2.18 After 2 Free Hours MARTIN PRODUCTS SALES LLC dba Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications specifications $70 Per Hour MARTIN ASPHALT COMPANY Precinct 2 Gallon $2.00 $0.18 $2.18 After 2 Free Hours 5000 gallon minimum Did Not Meet Did not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 3 Gallon $2.00 $0.16 $2.16 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specification Specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-1p Gallon $2.00 $0.21 $2.21 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications P Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.00 1 $0.19 1 $2.19 After 2 Free Hours $80.00 Per Hour P SQUARED EMULSION Precinct 1 Gallon $2.99 n/a $2.99 After 2 Free Hours PLANTS LLC P2 CWE-2 $80.00 Per Hour ** Please see attached equivalent Precinct 2 Gallon $2.99 n/a $2.99 After Free Hours and/or superior product information and Sole Source Affidavit. $80.00 Per Hour '* P Squared is proudly recognized and accepted by Tarrant County Co -Op. Precinct 3 Gallon $2.99 n/a $2.99 After 2 Free Hours SEE ATTACHED INFOROMATION FOR ADDITIONAL CHARGES $80.00 Per Hour Minimum Tanker Delivery: 5,000 Gallons; Precinct 4-P Gallon $2.99 n/a $2.99 After 2 Free Hours Delivery over 2SO miles subject to additional charges; Pump Charge (trucking charge) $80.00; Push Charge (trucking charge) $80.00 per hour; $80.00 Per Hour Return Loads (trucking Charge) Subject to charge Precinct 4-S Gallon $2.99 n/a 1 $2.99 lAfter 2 Free Hours from delivering freight line Page 11 of 11 BLADES GROUP, LLC ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address Uv�\;TX • 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 PER UNIT 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 i I i i Precinct 3 I Ton I I i I Precinct Ton I ', I I I I Precinct 3 Ton I I I Precinct4-P I Ton I Precinct4-S : 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 I I I I Precinct 1 ; Ton I I Precinct 2 I Ton I I I I Precinct Ton I Precinct4-P; Ton Precinct 4-S ; Ton I 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/ORDE 1 I I I I Precinct 1 1 Ton I 1 f 1 Precinct Ton Precinct 3 I Ton I 1 1 1 1 Precinct 4-P ; Ton 1 Precinct4-S Ton I I I I lRemarks: 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 Ton 1 1 _of 47161 1 1 I 1 Bags on Pallet 1 1 1 1 i i Precinct Ton I I I 1 of 47 lb. Bags on Pallet 1 1 1 1 Precinct3 1 Ton f 1 _of47lb i Bags on Pallet i Precinct4-P 1 Ton 1 1 1 1 1 _of471b Bags on Pallet j Precinct4-S ; Ton _of47lb; 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 #S: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATIO I MATERIAL I DELIVERY I TOTAL I I Precinct 1 Ton I Precinct 2 Ton Precinct 1 Ton I Precinct4-P; Ton Precinct4-S I Ton 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 Precinct 1 Ton I I I I Precinct 2 I Ton i I ; I I i I Precinct Ton I I I Precinct 4-P ' Ton I I I I Precinct4-S 1 Ton 1 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 LOCATION Unit MATERIAL DELIVERY Precinct 1 ; Ton I Precinct 2 I Ton I I I I Precinct 3 ; Ton I I I I Precinct4-P I Ton I I I Precinct4-S 1 Ton 1 1 I Remarks: TOTAL TOTAL MINIMUM LOAD/ORDER 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 1 Precinct 1 Ton I I I I I I Precinct Ton I Precinct 3 I Ton i i i i i i Precinct4-P 1 Ton I 1 I 1 I i Precinct 4-51 Ton 1 1 1 1 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 I Precinct 1 Ton 1 1 1 I 1 Precinct 2 Ton Precinct 3 Ton 1 1 1 I Precinct 4-P I Ton I Precinct4-S 1 Ton Remarks: Bid Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY 1 1 i Precinct 1 Ton 1 1 1 1 1 Precinct 2 1 Ton 1 1 1 Precinct 3 1 Ton 1 1 1 Precinct4-P i Ton I Precinct 4-51 Ton MINIMUM TOTAL LOAD/ORDER 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 I �, \' 7 Yard pr 'O J x4-G� 45 1 50 lb Bag . VA L y . d'0 - 6• . G • S Precinct Ton 1 l d 1 e,.,S �'1-( T•pn� Yard' $'3,-1`k 1 SSM /��I1 �st7 t1a 50 lb Bag + l A, — 1 v-A i (M 1 1,i Precinct 1 Ton 1 �� oa 1 ,�� I `v�.Q3 0� \t ro Yard' f 50lbBag 1 ,� 1 '—' I�y,Q-CJ b �({ Precinct 4-1 Ton Yard' c:�r� I 7• J as Cw 1 1 1 Iy P 1 50lbBag I\L' ,00 1 — 1 Q4�c Precinct4-S Ton 1 1\�e7 c 1 4� r� J 14, q�0c) b d 1 �-� �a•-o 1 , Yard' 50 lb Bag \A. UN) _ 1 \ C. \A .00 1 nP. } Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2IMF 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 =MATERIALDELIVERY TOTAL LOAD/ORDER I 1 I I Precinct 1 Ton 1 Precinct 2 Ton 1 I i Precinct 3 Ton 1 Precinct 4-P ; Ton Precinct 4-S I 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 LOCATION Unit MATERIAL DELIVERY TOTAL Precinct 1 Ton 1 I I I i I Precinct 2 1 Ton I I I I I I I I I I I Precinct I Ton I I I I Precinct4-P 1 Ton I I I I I Precinct4-S ; Ton I I rks: 300, Asphalts, Oils and Emulsions Item #14: Primer Oil Price per gallon / delivery LOCATION I Unit I 1 1 Gallon 2 1 Gallon 3 I Gallon 4-P 1 Gallon 4-S i Gallon to County Stockpile and/or Jobsite MATERIAL I DELIVERY I TOTAL MINIMUM LOAD/ORDER 3 1i[9 i`,7_TCL —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 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 I Unit I MATERIAL I DELIVERY Precinct 1 I Gallon ; Precinct { Gallon i ; Precinct 3 Gallon ; I Precinct4-P 1 Gallon ; Precinct 4-S Gallon TOTAL Item #16: CRS-2 Temperature must be no lower than 1500 and no higher than 180a Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL I I Precinct 1 ; Gallon ; , ; Precinct Gallon I Precinct3 Gallon I ; Precinct4-P; Gallon ; 17 Precinct 4-S Gallon I I I - Remarks: 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 i Free Hours _ Per Hour j Free Hours Per Hour, Free Hours Per Hour j Free Hours Per Hour j 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 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 any official, employee or agent of Calhoun County in connection with 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: N -3— F Authorized Signature & Type Name & Title of Authorized Signature: \ ilor r.c�<✓ �N�rl s tef N(�ei�y Phone Number: �� — l �� Email: �,D0o tiTO c`6„ci.S 1 N\ Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 9 STATE OF 772 is {} " � AFFIDAVIT COUNTY OF V/A,1 {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared I YlD%YIG.Sil / I7 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 bid to which this affidavit is attached, and I have full knowledge of the relations of the bidder with the otherfirms in this same line of business, and the bidder is not a member of any trust, pool or combination to control the price of leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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, emplo ee or agent of Calhoun County prior to the official opening of this Bid. r Printed Name and Title of Affiant Name of Bidder (Company) M{ AZIO Address ++�� Phone Number cyst(`- Fax Numberi`3�'S Email Address SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant,r_who, on oath, states that the facts contained in the above are true and correct, this 16f day of AVi°i/YI &-,P . 20 91 •Y' ti Unica y9j•.,ApF�`' oMIDvy NoCaoOrz. Notary Public, State of Mp n/ / % .4 /' Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Address: 3 V M \1L\ID3 VVe\9e_u iqR"8C,\ Remittance Address: -:� FM �y0 J Telephone: :a 1 O. 1\ b-"vVCC1'A Lc Fax: g30- SA \- YIQ6 ` Email: �Y�pNtiNY��oe. c��11(kcar� Signature of Authorized Printed name of Authorized Rep: . �C5'�'� N ORDER — CONTACT INFORMATION ; a ICrOrder Contact Name &Title: r% CON, Order Contact Telephone: S\b "\B Q\ Order Contact Fax: 930•-5A\ -1��i\ Order Contact Email: INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Zs��,�� Contact Telephone: %�i0- his- Contact Fax: Contact Email: 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: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2021-818884 Blades Group LLC Uvalde, TX United States Date Filed: 11/01/2021 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. 2022.03 Packaged Asphalt for road repair. 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 ) 0 rYh Qt S \ O to t tv and my date of birth is My address is , �� (.tree (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 15r* day of NOV , 20�. (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc ACC>RDO CERTIFICATE OF LIABILITY INSURANCE liw� DATE(MMIDD/YYYY) 5/14/2021 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 Marsh Wortham, a division of Marsh USA, Inc. 131 Interpark Blvd. San Antonio, TX 78216 ACT NAME. Leslie Burleson PHONE —"— — FAX E61NLP. ,tk—210-307-4732 ._ (ac, Na_ 210-920-2007 ADDRESS_ leslie.burleson0marsh.com INSURERL) AFFORDING COVERAGE NAIC# www.worthaminsurance.com _ INSURER A: Ohio Security Insurance Company INSURED Blades Group, LLC 3 FM 1403 INSURER a: Great American E $i S Insurance Company/ -- INSURER c: _____------....------_--- INSURERD Uvalde TX 78801 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: IRWIN@= REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 'BETOMM 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 TYPE OF INSURANCE SU9R pOUCY NUMBER MMIOOrYYEYYF'! MMIOO/YYYY LIMITS B C�OIMMERCIALGENERALLIABILRY � ✓ I VNEW 2/28/2021 2/2812022 LEACH OCCURRENCE $1.000.000 _,,j CWMS-MADE OCCUR I j 1 DAMAGSS(Eao TEiS PREMISEB (Ea o¢ulren J. $500,000 i MEDEXP(A onepemon) I$20,000 PERSONAL S ADV INJURY $1 000.000 GEN'LAGGREGATE LIMIT —APPLIES PER: _ GENERAL AGGREGATE s2,000,000 j PRO- ✓ POLICY JECT L— LOC PHODUCTS•COIdPIOP AGGGGGG�52,000 OOD OTHER: { $ A AUTOMOBILE LIABILITY 12130/2/120 12/30/2021 COMBINED SINGLE LIMIT nt)!, S 1,000,000 ANY AUTO BODILY INJURY(Por person) OWNED —I SCHEDULEDAUTOS ONLY ✓ AUTOS 1 ^S BODILY INJURY (Per arcidcnl) S ✓ HIRED NON -OWNED AUTOS ONLY . ✓ AUTOS ONLY PROPERTYDAMAGE S Lr accitlonl)___.. $ B UMBRELLA LIAB ,� OCCUR 12/2812021 2/28/2022 11EgCH OCCURRENCE - — — S3 OOO,COO ✓ EXCESSUAB CLAINIS-MADE ~--- (_AGGREGATE t 3 0001 OOO CEO RETENTIONS __ _ S — WORKERS COMPENSATION I PER ER _ORTM I STATUTE _�_"__.____ AND EMPLOYERS'LIABILITY AN YPROPRIETORIPARTNERIENECUTWE : OFFICERIMEMBER EXCLUDED? NIA( E.L. EACH ACCIDENT Is ________ (Mandatory In NH) E.L. DISEASE -EF EMPLOYEE 1----- $ It yyo�uu dosuitro undm OESCRIPTIONOFOPERATIONShot. ( E.L. DISEASE -POLICY LIMIT $ I ( I I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 1111.Additional Romarlss Schodula, may be attschod if mom spaco is mquired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Marsh Wortham, a division of Marsh USA. Inc. ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD LL/A9i WiY 1mom I in., 20::J t1:59:41 An ICrl I ^age 1 a 1] 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. 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 of vendor who has a business relationship with local governmental entity. 2 —heck 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 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 RZfNo 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 WNo 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 ignature of vendor d ' e governmental entity Date Form provided by exas 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 igna ure -of Agent \\—\ _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 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, &%An t1a `Cr 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. $19 ure of Contractors Authorize icial Printed Name and Title of Contractor's Authorized Officiff 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 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, ifknown: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (iindividual, last name, first name, MI): diereni firm No. 10a) (last name, first name, MI): 11. Information requested through this form is ' authorized by title 31 U.S.C. section 1352. This Signa - disclosure of lobbying activities is a material f representation of fact upon which reliance was placed Print Name: QV(\w- by the tier above when this transaction was made or \ entered into. This disclosure is required pursuant to 31 Title: 61 Telephone No.:'YO'31b- NX4AJDate: -�a 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 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, -0 %'NS ilcJ�a1�''�� the undersigned representative of Representative (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 sn 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. (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 defined in Government Code §2252.001 and our principal place of business is (City and State) Mr I certify that �� J�� W� L is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent tiomas �N'`� Printed Name and Title of Authorized Agent \\-\' Date -9 Request for Taxpayer Give Form Form (Rev. October 2013) Identification Number and Certification to the requester. Do not Depamment of the Treasury send to the IRS. Internal Ravenue Service ► Go to www.irsgov/FormW9 for instructions and the latest information. t Name (as shown on your Income tax return). Name Is required onthls line: do not leave this line blank. BLADES GROUP, LLC 2 Business nametdisregarded 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 M following seven boxes. certain entities, not individuals; see a o ❑ Individuaysofe proprietor or ❑ C Corporation ❑ 8 Corporation ❑ Partnership ❑ TrusUestate instructions on page 3): .. m 4i single -member LLC Exempt payee code fit my) o 2.2 ❑✓ Limited liability company. Enter the tax classification (C=0 corporation, S=S corporation, P=Partnership) ► P `o Note: Check the appropriate box in the fine above for the tax classification ofthe single -member owner. Donotcheck Exemption from FATCA reporting eLLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is cede (if any) a m not disregarded from the ownerfor 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 (see instructions)► m•osl N 5 Address (number, street, and apt. orsufte no.) See instructions. I Requester's name and address (optional) N 3 FM 1403 6 City, state, and ZIP code UVALDE, TX 78801 7 Ust account number(s) here (optional) Taxpayer Idenfification 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 (SS. However, fora -m _ 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 fo 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 guidelines on whose number to enter. rn 3l�C�tlilFl[i©� 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 1 am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (deigned 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 hem 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, conbibutions to an individual retirement arrangement (IRA), and generally, payments Giber 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. 019tt Signature of < 1 s� Here U.S.'Person). e• Date ► t � i — CaD a i General 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 afterthey were published, go to wwwJirs.gov1FcrmW9. 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 (11N) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIM, 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-rAISC (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-9 (Rev. 10-2018) CLEVELAND ASPHALT PRODUCTS, INC. ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address Cleveland Asphalt Products, INC. PO Box 1449 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. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT 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 NB 1 NB 1 NB 1 NB I Precinct 2 1 Ton 1 NB I 1 NB I 1 NB NB I I Precinct 3 1 Ton NB NB I 1 NB I 1 NB Precinct4-P Ton NB NB NB NB Precinct4-51 Ton NB 1 NB 1 NB 1 NB 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 1 1 Ton NB NB NB 1 NB Precinct 2 1 Ton 1 NB 1 NB 1 NB 1 NB Precinct 3 1 Ton NB 1 NB 1 NB ' 1 NB Precinct4-P 1 Ton 1 NB 1 NB 1 NB 1 NB 1 NB Precinct4-51 Ton I 1 NB 1 NB � NB Remarks: Page 1 of 8 Invitation To Bid Form -Annual Supply Contractfor 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 MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton NB 1 NB I NB I NB Precinct Ton NB NB I NB NB ' 1 Precinct 3 I Ton I NB NB NB NB Precinct 4-P ; Ton NB NB NB NB I I I I Precinct 4-S Ton NB I NB I NB I i NB 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton NB NB NB NB ' of 47 1 NB 1 NB 1 NB 1 NB I Bags on Pallet I 1 Precinct 2 Ton NB I NB NB NB _of471b� NB NB NB NB ' Bags on Pallet I Precinct 3 1 Ton 1 NB 1 NB 1 NB 1 NB of 47 lb Bags on Pallet I NB I I NB I 1 NB NB NB NB I NB I NB Precinct4-P I Ton i of 47 lb Bags on Pallet I NB I NB I NB NB Precinct 4-S I Ton i NB I NB ; NB NB - i —of 47 lb Bags on Pallet j NB I NB I NB NB Page 2 of 8 Invitation To Bid Form - Annuol Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #S: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton N13 NB NB NB i 1 I Precinct Ton NB NB NB I NB 1 I I Precinct3 Ton i NB NB NB I NB I NB NB I Precinct4-P 1 Ton NB I NB I ' I I Precinct4-S ; TonI NB I NB I NB 1 1 NB 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 Precinct 1 1 Ton i NB I NB NB NB Precinct 2 Ton 1 NB 1 NB I i NB 1 ; NB NB NB NB NB Precinct 3 Ton j NB 1 NB NB NB Precinct 4-P I Ton I I I I 1 NB 1 NB 1 NB I NB Precinct 4-5 1 Ton I I I I rks: 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 Ton NB NB NB NB I I Precinct 2 f Ton NB I NBI I NB I NB 1 1 NB Precinct 3 Ton I NB 1 I NB 1 I NB i i ' NB Precinct 4-P I Ton I i 1 NB I I NB i I NB NB Precinct 4-S : Ton NB _ NB NB rks: 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 lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE Precinct 1 ', Ton NB NB NB NB ' Precinct Ton i NB 1 NB I i NB i NB i NB 1 NB 1 NB 1 NB Precinct 3 1 Ton I 1 NB NB 1 NB 1 NB Precinct4-P I Ton Precinct 45 ; Ton NB 1 NB 1 NB 1 NB 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 i, Ton I NB NB NB 1 NB Precinct 1 Ton j NB NB NB NB 1 NB NB NB NB Precinct i Ton i I 1 1 NB 1 NB 1 NB 1 NB Precinct 4-13 ; Ton i NB I NB i NB i NB Precinct4-S Ton 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 Precinct 1 1 Ton NB NB NB NB Precinct 2 1 Ton I NB NB NB NB i i NB 1 NB 1 NB 1 NB Precinct 3 1 Ton 1 I i i I NB NB NB 1 NB Precinct 4- P 1 Ton 1 i 1 1 NB 1 NB 1 NB 1 NB Precinct4-S I Ton I I rks: 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 I Precinct 1 1 I Ton NB I 1 NB I NB I NB I I Yard NB I I NB I I NB I NB 1 50 lb Bag NB I NB I B I NB I I NB NB NB NB Precinct Ton I I NB NB 1 NB 1 NB Yard' I ' 50 lb Bag ; NB I I NB I I NB NB Precinct 3 Ton 1 NB1 NB NB NB Yard' NB NB NB 1 NB 50 lb Bag 1 NB 1 NB NB NB Precinct4-P Ton NB NB NB NB I Yard' NB I NB I NB I NB SO lb Bag NB NB NB 1 NB I Precinct4-S I Ton 1 NB I 1 NB I 1 NB I 1 NB 1 Yard' 1 NB I NB I NB I NB 1 I SO lb Bag 1 NB I 1 NB I I NB I = 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 I Precinct 1 1 I Ton 1 NB t NB I NB I NB Precinct 2 1 Ton NB NB NB NB Precinct 3 Ton NB NB NB NB Precinct4-P; Ton NB NB 1 NB NB I Precinct4-S ; I Ton NB I 1 NB I 1 NB I 1 NB 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/ORDE NB NB NB NB Precinct 1 Ton NB NB NB j NB Precinct 2 1 Ton I I Precinct i Ton I NB 1 NB I NB I NB I I NB I I NB I NB I I NB Precinct 4-1)1 Ton I Precinct 4-S I I Ton I NB 1 NB N13I I NB rks: 300, Asphalts, Oils and Emulsions Item #14: Primer Oil Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I I 1 $2.20 I $0.20 I $2.40 1 80.00 Per Hour After Precinct i t Gallon I I I 1Z Free Hours 1 I $2.20 1 $0.20 $2.40 I $ 80.00 per Hour After Precinct 2 1 Gallon I 1 1 1�—Free Hours ' 1 1 1$80.00 Per Hour After Precinct 3 1 Gallon 1 I $2.20 I $0.20 1 1 $2.40 1 12— Free Hours i I 1 I I 1 i 1 1 1 1$ 80.00 Per Hour After 1 Precinct 4-P I Gallon I $2.20 i $0.20 $2.40 12 Free Hours 1 1 $ 80:00 per Hour After Precinct 4-S ! Gallon $2.20 I $0.20 $2.40 ! 2. _Free Hours Diluted material can not be returned for credit. Page 6 of 8 Invitation To Bid Form -Annual Supply Contractfor Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #15: RC-250 Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE i i ' i i i 80 '$ .00 Per Hour After $3.45 Precinct 1 I Gallon $0.20 1 1 $3.65 12 Free Hours i i i , i i i $80.00 Per Hour After $3.45 1 $0.20 i $3.65 12 Precinct 2 Gallon 1 Free Hours 1 1 $3.45 1 1 $0.20 1 $3.65 $ 80.00 Per Hour After Precinct 3 1 Gallon 1 1 1 1 2 Free Hours i i 1 1 $3.45 i 1 $0.20 i 1 $3.65 j$ 80.00 Per Hour After Precinct 4-P 1 Gallon 1 1 1 2 Free Hours i i 1 , $ 80.00 Per Hour After 1 $3.45 Precinct 4-5 1 Gallon i 1 $0.20 1 $3.65 1 2 Free Hours Remarks: Prices based on minimum 5000 gallon load, 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 150° and no higher than 180° Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE $W.00 Per Hour After 1 1 $2.00 1 Precinct 1 1 Gallon 1 1 $0.20 1 I $2.20 1 2 Free Hours 1 ;$1 .00 Per Hour After Precinct 2 I Gallon I $2.00 $0.20 $2.20 ; 2 Free Hours 1 1 $2.00 1 $0.20 1 $2.20 1$80.00 Per Hour After 2 Precinct 3 1 Gallon I 1 1 Free Hours i 1 1 1 1 1 1$80.00 Per Hour After Precinct 4-P 1 Gallon $2.00 ; $0.20 1 $2.20 ; 2 Free Hours 1 1 $2.00 1 $0.20 1 $2.20 1$ 80.00 Per Hour After Precinct 4-S 1 Gallon 1 1 1 2 Free Hours Remarks: Prices based on minimum 5000 gallon load, 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 Rid Form -Annual Supply Contract for Rood 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 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 any official, employee or agent of Calhoun County in connection with 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: 11/312021 Authorized Signature & Title: Type Name & Title of Authorized Signature: Clayton Moore, Sales Rep. ccmcapco@msn.com Phone Number: 800-334-0177 Email: clayton.moore@clevelandasphaltproducts.com Exceptions and or Variations from Specifications and/or additional Notes: All prices based on minimum 5000 gallon load. For smaller quantities please call 800-334-0177. Diluted material can not be returned for credit. Page 8 of 8 STATE OF Texas 0 COUNTY OF Calhoun M AFFIDAVIT The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 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 clayton.moore@clevelandasphaltproducts.com SWORN TO AND SUBSCRIBED BEFORE ME�ay the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this t,;l day of November 2021 •^ ��.� BUNA JONES Notary ID #2328056 My Commission Expires May 30, 2023 Stamp/Seal My Commission Expires ILI]»Will fel111Ti/eI1[00 Please Type. If handwritten, must be in ink and legible Bidder's Name: Cleveland Asphalt Products, INC. Address: PO Box 1449 Shepherd, Texas 77371 Remittance Address: Department # 936 PO Box 4652, Houston, Texas 77210-4652 Telephone: 800- Fax: 936-628-6602 Email: ccmcapco(a)_msn.com clayton.moore(cbclevelandasphaitproducts.com Signature of Authorized Representative: Printed name of Authorized Rep: Clayton Moore ORDER — CONTACT INFORMATION Order Contact Name & Title: Leeann Ails, Office Manager Order Contact Telephone: 800-334-0177 Order Contact Fax: 936-628-6602 Order Contact Email: capcoasphalt@msn.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Leeann Ails Office Manager Contact Telephone: 800-334-0177 Contact Fax: 936-628-6602 Contact Email: capcoasphalt@msn.com 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: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2021-819862 Cleveland Asphalt Products, INC. Shepherd, TX United States Date Filed: 11103/2021 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. Bid Number 2022.03 Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions January 1, 2022 thru December 31, 2022. 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 _ ClaytonMoore and my date of birth is My address is lllillillommommimm MKINHEINNEMM, . USA . (street) (city) (stale) (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 3rd day of November, 20 21 (month) (year) Tnatuff , 6T authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIODmn1 7127/2021 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 Bowen, Miclette &Britt Insurance Agency, LLC 1111 North Loop West, #400 Houston TX 77008 CO TACT NAME: $tBCI Dufresne X PHONE FNo. ac Na Eae: 713-802-6159 ac No: AIL ADDRESS: sdufresne bmbinc.com INSURER(S) AFFORDING COVERAGE NAIC4 INSURER A: Admiral Insurance CO INSURED Cleveland Asphalt Products, Inc. P O Box 1449 INSURER B: Clearblue Insurance Company INSURER C: Texas Mutual Insurance Company INSURER D : Shepherd TX 77371 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER'.111FAM REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTE LOW 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 TYPE OF INSURANCE A UBR POLICYNUMBER MM/UOYI1'YYFY MM/D�/YEXP l'" LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 8/112021 BIIM022 EACH OCCURRENCE $1.000.000 CLAIMS -MADE a OCCUR PREMISES Ea occurrence S300,000 MED EXP(My one person) $25,000 PERSONAL& ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,00D,000 %( POLICY JECT LOC PRODUCTS-COMP/OPAGG S2,00D,000 S OTHER: B AUTOMOBILE LIABILITY Y Y 8/12021 0/1/2022 COMBINED SINGLE LIMIT Ee accident S 0000o0 %( BODILY INJURY (Per person) S ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per dent) S HIRED AUTOS NON -OWNED AUTOS 5 A UMBRELLA LIAB X OCCUR Y N FE(EX52185OD6 011/2021 8112022 EACH OCCURRENCE S3,00D,00D X AGGREGATE S3,00D,000 1 EXCESS UAB CLAIMS -MADE DELI RETENTIONS S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Y 8/12021 8/12022 X I STATUTE I I ERH E.L. EACH ACCIDENT 51,000,000 ANY OFFICEWMEM ER EXCLUDED ECUTIVE NIA E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S1.000.00D DESCRIPTION OF OPERATIONS I 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 Smalling: certificates@bmbinc.com General Liability: Blanket additional insured Ongoing Operations per form #CG 2026 07 04 Blanket additional insured Completed Operations per form #CG20371001 Blanket waiver of subrogation per form #ECC-320-0712 See Attached... Lsla C11111a I"I'll r a itki YJ a C7 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 (2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: A� ® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Bowen, Micletle & Britt Insurance Agency, LLC NAMED INSURED Cleveland Asphalt Products, Inc. P O Box 1449 Shepherd TX 77371 POLICYNUMSER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 26 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Blanket additional insured per form #Q-ADLIN-B-0814 Blanket waiver of subrogation per form #Q-WAIVER-B-0814 Blanket primary/non-contributory per form # CA 04 49 1116 per form #WC 42 03 04 B additional insured perform #EXS-200-0712 primary/non-contributory perform #EXS-200-0712 AL:UKU TUT (LUUS/U1) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number. Effective Date: 8/1/2021 to 8/1/2022 Cleveland Asphalt Products, Inc. Endorsement Number., 25 Additional Insured — Designated Person or Organization This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of LO, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to name as an Additional Insured. to 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 Numbe Effective Date: 8/1/2021 to 8111202 Cleveland Asphalt Products, Inc. Endorsement Number: 26 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS BLANKET It modifies insurance provided under this Policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to name as an additional insured. However, this status exists only for the project specified in that contract. Location And Description of Completed Operations: Those project locations where this endorsement is required by contract. 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 liability arising out of "your worIC' 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 3710 01 0 ISO Properties, Inc., 2000 Page 1 of 113 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 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. 1J 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 F-x-] 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-1 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 11/3/2021 Signature of vendor ing 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. Clayton Moore, Sales Rep. 11/3/2021 Name and Title of Authorized Agent Date ignature 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 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, Cleveland Asphalt Pmducts, INC., 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 Contractor's Authorized Official Clayton Moore, Sales Rep. Printed Name and Title of Contractor's Authorized Official 11 /3/2021 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 Submvardee, 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, ifopplicable: S. Federal Action Number, ifknown: 9. Award Amount, ifknown: NA $ NA 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if rf individual, last name, first name, MQ: differentfrom No. IOa) (last name, first name, MI): NA NA 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature:—�--��z disclosure 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: 11 /3/2021 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, Clayton Moore the undersigned representative of Representative 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 11 /3/2021 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. ❑ I 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) IS I certify that Cleveland Asphalt Products, INC. is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Clayton Moore, Sales Rep. Printed Name and Title of Authorized Agent 11/3/2021 Date VAR A YYWV Kequest tor Taxpayer October 2018) Identification Number and Certification Give Form to the tment of the Treasury requester. Do not al Revenue service ► Go to www-irs-gov1F0MW9 for instructions and the latest information. send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do net leave Ihis line blank. Cleveland Asphalt Products, INC. 2 e s ss name/tl sregardetl hilly name. if different I,_ 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 ❑ Indivi le proprietor or ❑ C Corporation El Corporation ❑Partnership ❑ TmsUestate instructions on page 3): single -member LLC Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► Note: Check the appropriate box in the line 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 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. ❑ Other'a-instructions)► Waprm roxcwm:„dmarcuauaoo rm usf 5 Address (number, street, and apt. or suite no.) See instructions. Requesters name antl atldress (optional) PO Box 1449 Calhoun County 6 City, state, and 21P code 202 S Ann St, Port Lavaca, TX 77979 She herd, Texas 77371 361-553-4610 FAX 361-553-4614 7 List account num6er(s) here (aptionap Taxpayer Identification Number (TIN) 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, 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 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 Requester for guidelines on whose numberto enter. Form (Rev. Depai him Under penalties of perjury, I or 2oon©oonn© 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)1 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 (f any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above'4 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. oryn I SU.S.ignature Here person► / �/y/ _!`�_ Date► 11/3/2021 General lnstructio Section references are to the emat 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.gov1Formvvg. 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 1099-6 (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-9 (Rev. 10-2018) K-C LEASE SERVICE, INC. �. • MATAGORDA CONSTRUCTION & MATERIALS I:ZiL1�l► /_ti1:1:1/_1�►� AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address we Lease Se-4se Inc nRn Matagorda Construction & Materials /7/Z S// ff Jou//, go,wd,{y 734 77YIV • 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 PER UNIT ROAD MATERIALS -` Bid Item #1: `Limestone-3/41nch To Dust Price per ton / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton00 I .30. 50 i ,?,f Kv Precinct Ton S:SIP ITS•00 t 1 30•5-0 t t at�i.,l Precinct 3 Ton I S.SO I 0?f: o o 30. so ,?S P-",J Precinct 4-P ' Ton I S-, �^0 I aS: a o 3p.S0 t o?r�ns t i i i t Precinct4-S Ton I ,f fo I aS oo I •?O.SO Remarks: Bid Item #2: Item 2471 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 .i-00 o?S•OD ', 20.00 Precinct I Ton t r.o0 I ,0o i I ,3D. 00 t .tr t Precinct t Ton I 5-.00 t t j`. DO I 30, 00 t Precinct4-P; Ton 'r 00 i,is.0a ; 30.0D ar 7hj Precinct4-SI Ton 0 ;,30.00 Remarks: Page 1 of 8 Invitation To Bid Form -Annual Supply Contractor 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/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY T AL LOAD/ORDER I I I l Precinct 1 Ton 1 I l 1 l 1 1 Precinct 2 Ton i i i i 1 0 I I Precinct 3 1 Ton I I i l l 1 � 1 l Precinct 4-P ; on I l Pr ct 4-5 I Ton I I l 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 ags on a Pallet Price per unit / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 1 l I i i i i Precinct 1 I Ton 1 l l i I I of 47 lb 1 - I I Bags on Pallet Precinct 2 1 Ton l 1 l I I _of47lb1 I Bags on Pallet I d 1 1 i i i i i i Precinct 3 1 Ton l I I i i i i I _of47lb1 I I 1 I I Bags on Pallet 1 I I I l 1 Precinct 4-P I Ton 1 I l I I f47lb 1 1 I 1 I B s on Pallet I I 1 I Ton I I 1 I I 1 :71i I _of47lbl Bags on Pallet I I I I Remarks: Page 2 of 8 Invitation To Bid Form - Annual Supply Contract/or Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Bid 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 i I I I I Precinct 1 Ton I Precinct 2 I Ton I I i I Precinct 3 1 Ton I I I I Precinct 4-P ; on I I I Preci 4-S ; Ton 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 TAL LOAD/ORDER I Precinct 1 Ton I Precinct 2 Ton At b I I I I I Precinct 3 Ton I i I I I I I i Precinct 4-P I Ton I I I I I I I I I Pr nct 4-S I Ton I I I 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 DELIVERY TAL LOAD/ORDER Precinct 1 Ton I i I i Precinct 2 1 Ton i I I I I Precinct 3 1 Ton I I I I i i i i i i i i i Precinct 44 I Ton I I I i I Pre a ct 4-S ; Ton i 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY T LOAD/ORDER Precinct 1 Ton Precinct 2 ; Ton I Precinct 3 I Ton f Precinct 4-P I on Ton Remarks Bid Item #9: Item 302, Type E, Grade;5, Ice Price per ton / delivery price to County Sto LOCATION Unit MATERIAL I i Precinct 1 I Ton 117.00 I Precinct Ton I Precinct 3 I Ton I / . D'a I Precinct 4-P ; i Ton Precinct4-S 1 I Ton 1 /7.00 Remarks: Bid Item #10: Item 330, Type (Pre -Mix Li Price per ton / delivery price to County S LOCATION Unit MATERII Precinct 1 Ton I I I Precinct 2 I Ton I I I Precinct 3 1 Ton 1 Precinct 4-P ; To 1 i I Precinct 4- Ton I Remarks: k (Non -Coated limestone Only) and/orJobsite MINIMUM DELIVERY TOTAL LOAD/ORDER I I 00 as As I �s.oa 14y.00 I 1 Rr I �s.oa I I Z/.2.00 1 of OV 1 C12, 0 a .& '/on, estone) kpile and/or Jobsite MINIMUM DELIVERY T LOAD/ORDER 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 LO /ORDER I I I Precinct 1 1 Ton I I I I I I Yard 3 ; 1 I I I ' 50 lb Bag I � Precinct 2 1 Ton I 1 I I I I I Yard' I I I I I I I 50lb Bag I I I I I i I I Precinct I Ton I I I I I Yard' I I I I I I I I 50lb Bag I I I I I I I Precinct 4-P I Ton 1 I I I I I ' 5,01la Bag Precinct4-5vv, Ton I 1 Yard I- 50lb Bag Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pav Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Prol Standard Specifications for Construction and Maintenance of Highways, Streets and Bridge bsite 7 Price per ton/ delivery price to County Stockpile and/or lo in the I MINIMUM LOCATION Unit MATERIAL DELIVE TOTAL LOAD/ORDER Precinct 1 I Ton I t 1 I I Precinct 2 Ton i I I I I Precinct 3 i To i I i Ton Ton 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 Precinct 2 Ton r I i i i i i Precinct 3 I Ton I I Precinct 4-P I Ton ' I cinct4-S ; Ton I )HALTS, OILS AND EMULSIONS 300, Asphalts, Oils and Emulsions Item #14 Primer Oil Price per gallon / delivery price to County Stockpil LOCATION I Unit I MATERIAL Precinct 1 I Gallon I I I VPrecinct 2 ; Gallon I I ' I I Precinct 3 Gallon , I I Precinct 4-P I Gallon I PZI I I I I I inct ; Gallon (Remarks: e and/or Jobsite DELIVERY TOTAL 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 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/orJobsite LOCATION I Unit I MATERIAL DELIVERY I OTAL I DEMURRAGE 1 I 1 1$ Per Hour After Precinct 1 1 Gallon I A 1 Free Hours I I I 1 1 ' i ;$ Per Hour After Precinct 2 1 Gallon IAfy' 1 1 Free Hours I i I 1 1$ Per Hour After Precinct 3 Gallon ;_Free Hours I I 1 I I Per Hour After Precinct 4-P 1 allon I ; ; Free Hours 1 I$ Per Hour After Pr inct4-S; Gallon I I Free Hours Remarks: Bid Item #16: CRS-2 ` Temperature must be no lower than 150' and no higher an 1800 Price per gallon / delivery price to County Stockpile and/or lobsit LOCATION Unit MATERIAL DELI Y TOTAL DEMURRAGE I I l$ Per Hour After Precinct 1 Gallon I ' I 1 Free Hours I 1 Per Hour After Precinct 2 1 Gallon 1 I I I Free Hours I 1 I i I ,$ Per Hour After Precinct 3 1 Gallo Free Hours 1 1 1 1 1 1 1 1 1 1$ Per Hour After Precinct 4-P ' Gallon 1 , 1 , 1 , 1 Free Hours I I I , I I I$ Per Hour After P cinct 4-S i Gallon 1 i , 1 I Free Hours 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 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 any official, employee or agent of Calhoun County in connection with 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 b Signature: III yp g ienu, 4m61els Caner+/f%7onarPl Phone Number: q7q— 3.13— gqI I Email: 1P pAjFk) w,e,,, loos e14tr - co.n Exceptions and or Variations from Specifications and/or additional Notes: &A Page 8 of 8 STATE OF T xus {} AFFIDAVIT COUNTY OF'NArt-fa o. cr— {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Gle4n C ket-61 PSS' 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 n/ �r Printed Name and Title of Affiant K-C Lease Service, Inc DBA Matagorda Construction & Materials Name of Bidder (Company) Address l')12 S A 3 s Soudjt &V C14, -rzL 77 Y 1 y Phone Number 3.23- 9411 Fax Number /V/ii Email Address 4(e1A� �, �*— Co'n SWORN TO AND SUBSCRIBED BEFORE �nME by the above yA_ffiant, who, on oath, states that the facts contained in the i(� above are true and correct, this � day of 6 / l'/"t U i9P—V� , 20PN I . •=o{;wj;ayac• DENISEMONTAGUE NOTARY PUBLIC + I.. ..*..6.. 73 `:'�•. ' State of Texas '''•.'F''oFh'••'• Comm. Exp. 04.08-2025 Stamp/Seal Notary Public, State of Texas V My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible K-C Lease Service, Inc DBA Bidder's Name: Matagorda Construction & Materials Address: I`712 SN 35 Sou4h 13nv L'+�f TiC lllgi,/ Remittance Address: 10112 5143Ssow-il, Telephone: I'W- 3l3- 4911 Fax: NIA Email: a')c e;4-e--% Signature of Authorized Representative: Printed name of Authorized Rep: �Ienn 6\4, 6lesf ORDER — CONTACT INFORMATION Order Contact Name & Title: 4W\Ondd SG6rsw1a. Nspakhe/- OrderContact Telephone: cl%'1q-313-4911 o-FF;« 361-57I-Y23,3 cell Order Contact Fax: Order Contact Email: mczn rn p „&61)- coM INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name &Title: f)ebbie_ kale„;k FFC.eown-is Aye,66-4- Rec%Q"6/sf Contact Telephone: q74- 5-YI -- 61 Y y Contact Fax: N/,,l Contact Email: de66r40<al o„ilc60 %o4o -eo,-" 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. 2021-814547 K-C Lease Service, Inc. DBA Matagorda Construction & Materials Bay City, TX United States Date Filed: 10/19/2021 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. 2022.03 Annual Supply for Road Materials & Asphalts, Oils, & Emulsions January 1, 2022 thru December 31, 2022 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary Krauskopf, Bruce Louise, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION ^^ II My name is Co Iew\ e-SS and my date of birth is iIN=My address is J 'I� W5 (street) (city(state) (zip code) (country) I declare under pennaby of perjury that the foregoing is true and correct. Executed in Ma 7u Cora_ County, State of 011.45 , on the I q day of OeIA61V , 20 dl . (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc KCLEA-1 OP ID: JB .acorzD` CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/18/2021 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 endorsements . PRODUCER 832-449-3232 Energy Insurance Group LLC P.O. Box 963 CONTACT Janice Bloise PHONE 832-449-3232 FAx 832-449-3061 JAIC, No, EXl : E-MAIL Ess:janlOe energy nsgroup.com Richmond, TX 77406 Scott Kulcak INSURERS AFFORDING COVERAGE CIf INSURER A: Everest Indemnity Ins. Co. Lease Service, Inc. dba Me Matagorda Construction & Materials P.O. Box 428 Louise, TX 77455 INSURER B : Everest National Ins. Comp. INSURER C:Texas Mutual Insurance Co Hartford Fire InsuranceCom an INSURER D: P y INSURER E: INSURER F CnVPRA1:PR r:FRTIFICATF NIIMRFR• 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. INSR TYPE OF INSURANCE OOL lum UBR POLICY NUMBER POLICY EFF POLICY UP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X OSI15/2021 08/15/2022 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED aoccu ence 100,00 5 A X PrimaryNonContrib 08/1512021 08/15/2022 MED UP An ene parson I $ 5,000 A X Pollution/Sud&Acc 08/15/2021 08/15/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ jECT LOC GENERALAGGREGATE $ 20,000,000 PRODUCTS -COMPIOPAGG I $ 2,000,000 Pollution 1,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT au e 1,000,000 $ BODILY INJURY Per person)S X ANYAUTO X X 08/15/2021 08/15/2022 BODILY INJURY Per accident S X AUTEOE��S ONLY !� AICITOSWULED 1 AMAGE PeOracCRan $ X HOIED ONLY X AUTOS ONLD A X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAIMS -MADE X X 08/15/2021 08/15/2022 AGGREGATE $ 5,000,000 DEC) RETENTIONS C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY CERIMEMBTEXCLUDEIEXECDTIVE ❑NIA InN RE%CLUDEDT (Mantlatory lnN) (Mandatory X 08/15/2021 08115/2022 �( PER OTH- STAT TE E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE -EA EMPLOYE 1,000,000 $ E.L. DISEASE- POLICY LIMIT 1,000,000 Iryes, describe under DESCRIPTION OF OPERATIONS below D EquipmenVlM 08/15/2021 08115/2022 LIMIT 500,000 RentLease 50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attached if more space is required) Blanket Additional Insured & Waiver of Subrogation on the General Liability, Business Auto & Umbrella Liability with a Blanket Waiver of Subrogation on the Worker's Compensation where their interest may appear by a written contract. 30 Day NOC. Umbrella Policy Follows Form. Calhoun County 202 S Ann St. STE B 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 ACORD 25 (2016103) ©19BU-2015 ACORD CORPORA I ION. All rights reserved. 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. OFFICEUSEONLY 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. jJ Name of vendor who has a business relationship with local governmental entity. K-C Lease Service, Inc DBA mstggorda Construction & Materials 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. 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? 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? FlYes 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 i'� Ao /f-Z / 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 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. Gt�en. bwm6less Genero/ Mc,,� Name and Title of Authorized Agent i��4 /iZ" Signature of Authorized Agent /o 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). K-C Lease Service, Inc DBA The Contractor, Matagorda Construction & MateriArtifies 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. 14 444XV- Signature of Contractors Authorized Official wton e 4mblest 4 &"04!!24 *e Printed 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 t. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial Fling _ b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan F material change only: e.loan guarantee ear quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If eporting Entity in No. 4 is Subawardee, Enter _ Prime Subawardee ame and Address of Prime: Tier , if Known: 0/ Congressional District, if known: / Congressional District, if known: 6. Federal Department/AZenc 7. Federal Program Name/Descriptiou: CFDA Number, ijapplicable: 8. Federal Action Num 9. Award Amount, ifkr:own: 10. a. Name an Address of Lobbying Registrant b. Individuals Performing Services (including address iJ' (rjindividu ,last name, first name, M1): dierenifi-an No. 10a) (last name, first name, M1): i 11. information requested through this form is // authorized by title 31 U.S.C. section 1352. This Signature: ,1�i•-- disclosure of lobbying activities is a material /t ,, aam 6leJf representation of fact upon which reliance was placed Print Name: lb �i?nn by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: l� tnto/ Mena�r� U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.:gi9-3 z3' %9// 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, Uphr% (2 akgm lwjs the undersigned representative of Representative K•C Lease Service, Inc DSA Matagorda Construction x 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 or business associations that exist to make a profit. Signature of Representative lean, 6atblers bn. —1 Print Name & Title /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. (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) K-C Lease Service, Inc DBA I I certify that Matagorda Construction & Materials is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. �1 41% - Signature of Authorized Agent Nlernn l '6r^6IesS NpAea o/ MOnacP/ Printed Name and Title of Authorized Agent 10- 19-z► Date WM 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 www.1rs.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 v 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 o. o ❑ Individual/sole proprietor or ❑ C Corporation ❑`' S Corporation ❑ Partnership ❑ Trustlestate instructions on page 3): ai single -member LLC Exempt payee code (if any) 0 '� ❑ 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 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 another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code if any) o' w is disregarded from the owner should check the appropriate box for the tax classification of its owner. $ ❑ Other (see instructions)► Mppras to a av„e mwWn•d•awdv the U.S.) rn 5 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) rn 1712 SH 35 south 6 City, state, and ZIP code Bay City TX 77414 7 List account numbers) here (optional) giMn 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 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 identifica0on number Number To Give the Requester for guidelines on whose number to enter. 7 4— 2 1 2 1 8 1 7 1 6 1 4 1 5 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 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. Here of Here IU.S.ppersonl► Date ►10 —A7'd1 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/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), 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-W (Rev.10-2018) MIDTEX MATERIALS, LLC ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address ///�OTe1C /�'%!�.�/,✓BLS /_GG 802 ,c�/�oK 167 Z�w2re,xIlle, ZX • 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 PER UNIT 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 OP Precinct 1 I Ton I DO 0 ' 00 ; Precinct Ton 1 �f 4 3 /,9 I C7 Precinct 3 Ton ;. 1 p0 e , / Precinct 4-P ; Ton I 6. i 8d I I 0 3 �, 1 I i O Precinct4-S I Tan I f7• 1 n0 1 00 ' 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 ' 00 Precinct 1 I Ton ; ; �j, f Precinct I Ton ; I 13 Ioa I , Od Precinct 3 1 Ton '.1Aoe pp0 ; I I I0 Precinct 4-P 1 Ton 1 6, !P ; 70®o J I 1 pp U 3`� I 1 001 Precinct 4-S 1 Ton 6 r , 1 oo v 3 9 a 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 oe I 1 1 O av 1 'a0� ; 1 3 y ad a y re, Precinct Ton Precinct 2 Ton a o Precinct 3 1 Ton 16 � � ao Gr6 1 i : t7� ; i © ra 0 (� Precinct 4-P Ton ,. I I pp 1 ad ��. I a� 1 Precinct 4-S 1 Ton I b .• I 13 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 471b Bags on a Pallet Price per unit / delivery price to County Stockpile and/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 Precinct 1 1 Ton 1 I 1 —of 47 lb 1 i Bags on Pallet 1 1 1 1 I 1 1 Precinct 1 Ton 1 I 1 1 1 I 1 1 1 of47lb I 1 1 � 1 1 1 1 Bags on Pallet 1 1 1 1 Precinct 1 Ton 1 1 1 1 1 1 _of47161 1 I 1 1 1 1 Bags on Pallet 1 1 1 1 1 1 Precinct 4-P 1 Ton 1 i 1 1 1 1 1 1 1 _of47lb 1 1 1 1 1 Bags on Pallet 1 1 1 1 1 Precinct4-s 1 Ton 1 1 1 1 1 _of 47lb1 1 1 1 1 Bags on Pallet 1 1 1 1 Remarks: Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid 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 i i i i I I I Precinct 2 1 Ton I I I i I 1 I I I I Precinct 3 1 Ton I 1 I 1 1 I 1 I I I I Precinct4-P 1 Ton I 1 1 1 I 1 1 1 Precinct4-S ; Ton Remarks: a Q� 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 I Precinct 1 Ton I 1 Precinct 2 1 Ton 1 I I I I Precinct 3 Ton I 1 I 1 I Precinct4-P 1 Ton 1 1 1 1 1 I I I i 1 Precinct 4-S,; _ I /Ton d 13, 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 DELIVERY TOTAL LOAD/ORDER 1 I I I I Precinct 1 Ton 1 1 I 1 Precinct 2 1 Ton I 1 1 I I I Precinct 3 Ton c Precinct 4-P 1 Ton I I 1 1 Precinct4-S ; Ton Remarks: p O nI 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 LOCATION Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDER Precinct 1 Ton I , I , I I Precinct z I Ton i I Precinct 3 i To I I I I Precinct 4-13 I Ton I I I i ; i Precinct4-S 1 Ton i I I I I I 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 Remarks: ON Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDER I I I 1 I LPrec!nct Ton I I I , 2 I To I I 3 I To I I i I Precinct 4-P I ; Ton i ' ; I I I I Precinct 4-S I Ton I I I I rF Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery nrirp rn rn. .nr., ct..w..a„ LOCATION�UnitMATERIAL DELIVERY TOTAL =LOAD/ORDER Precinct 1 I I Ton I I I Precinct2 1 I Ton I I I I I Precinct I Ton I I I Precinct4-P I Ton i , I I I I Precinct4-S I Ton i Page 4 of a 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 1 I 1 Precinct 1 I Ton I 1 Yard 1 50lb Bag I Precinct 2 I Ton 1 I Yard' I 1 1 I 50lb Bag 1 1 I I I Precinct 3 1 Ton 1 1 1 1 Yard' I I 1 I I 50lb Bag I I 1 I I 1 1 Precinct4-P 1 Ton I I 1 1 I 1 I Yard' I I I I i i i 50 lb Bag 1 i 1 i 1 I I I I 1 Precinct4-S 1 Ton 1 1 1 1 1 Yard' 1 1 1 1 I 50lb Bag I I I I G 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 1 Ton I I I I Precinct 2 1 Ton 1 I i 1 1 Precinct 3 1 Ton I I I Precinct4-P I Ton I I I I Precinct4-S I Ton Remarks: Pages 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 LOAD/ORDE GO GD �TTOTTAL O o a y el Precinct 1 Ton (� , ��. I I Precinct 2 Ton Q ` /• / 0 0 6. �(y, Precinct I Ton I I Precinct4-P; Ton ° 10 Precinct 4-S ; Ton ! 0 Remarks: Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil Price per gallon / delivery price to County! LOCATION I Unit I MATERIAL Precinct 1 I Gallon Precinct 2 i Gallon Precinct 3 I Gallon Precinct4-P I Gallon Precinct 4-S I Gallon e and/or Jobsite DELIVERY I TOTAL 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 6 of 8 Invitation To Bid Form -Annual Supply Contractfor 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 f I I 1 ; !$ Per Houn Precinct 1 I Gallon ;_ Free Hours Precinct 2 1 Gallon I I i Free Hours 1 Per Hour After Precinct Gallon �$ Free Hours Precinct4-P 1 Gallon I I 1 , I 1 ;$ I Per Hour After ,_Free Hours ' i IS Per Hour After Precinct4-S 1 Gallon I I I I Free Hours Item #16: CRS-2 Temperature must be no lower than 150a and no higher than 1800 Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I ' 1 ;$ Per Hour After Precinct 1 Gallon I ; ;_Free Hours 1 1 �$ Per Hour After Precinct 2 I Gallon I I ' 1_ Free Hours I ' I 1 ' 1$ Per Hour After Precinct 1 Gallon 1 1 Free Hours 1 I 1$ Per Hour After Precinct4-P 1 Gallon I 1 1 1_ Free Hours i i :$ Per Hour After Precinct4-S I Gallon I _ I I —Free Hours Remarks: 0J 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 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 any official, employee or agent of Calhoun County in connection with 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: 44Z / J Authorized Signature & Title: / Lrdt�7— �,w4'- F"-,- Type Name & Title of Authorized Signature: az,4ek Sc 6tpr� %%/j2 Phone Number: '?71?-5 --&94(l �/ Email: �2rc(tPYit��•feiie•�S�o�, �oo c'oo e Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF P)40S {} AFFIDAVIT COUNTY OF -� e R— {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared i.I,,'7� 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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) /h-/�j7 6feyG� �/ -7 9 Address f�i> aC_7oy6 /c'y�� Fg,eille 7) 7W G Phone Number 7fI — fb 6 O ,i Fax Number q71 .376-r?19e--' Email Address SWORN TO AND SUBSCRIBED BEFO E ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this Q day of �An&k�� 20 %� io` P MEGAN COOPER k COMM. EXPIRES B-28-2022 NOTARY ID 12681384-1 Notary Public, Stamp/Seal My Commisslon Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Address: 190 &yx /ZS7 17W Remittance Address: ec d3ooe- /87 Telephone: 6777- 5?161-- 8�y� Fax: !777- 376-L-9-1d-U Email: 4 .0 ya"ioo, cc� Signature of Authorized Representative: ZY:K--_ Printed name of Authorized Rep: ORDER- CONTACT INFORMATION Order Contact Name & Title: %%%rb k sch,• , 17— /,�/1 Order Contact Telephone: 96"y/ Order Contact Fax: 971- M�- d-/2-0 Order Contact Email: yN,�� ,,�4�`�y is d��o�- INVOICES - CONTACT INFORMATION For Invoice Inquiries: // Contact Name & Title: Y/l X, Sc Contact Telephone: % 79-- 3Zf - a 6 io Contact Fax: Contact Email: � f1E/c / e rM /a1fex P G/R hoo- C fir`" 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: 2021-819490 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: 11/02/2021 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. 2022-03 Annual Supply Contract for Road Materials and Asphalts, Oils, and Emulsions 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Midtex Materials, LLC Fayetteville, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is AAeC141,77 and my date of birth My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. i Executed in t -'E ve County, State of Q1�4-.i , on the d� day of IlKletJ119. 20 a i (month) (year) Signatifre of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc MID-MAT-01 EVELYN CERTIFICATE OF LIABILITY INSURANCE DAT121'12D211 1/21/2021 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(tes) 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 W , CT Evelyn Stein, ACSR Ancoinsurance PO Box 3889 Bryan, TX 77805 PHONE FAX ac, No. Eat : (979) 774-0212 AIC, Nd :(979) 774.5372 E S: stein@anco.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: EMC Insurance Cos INSURED INSURERB:Texas Mutual Insurance Company '4 Mid -Tex Materials LLC K3 Transport LLC INSURER C - PO Box 187 INSURER D: INSURERS: Fayettevllle, TX 78940 INSURER F' COVERAGES CERTIFICATE NUMBER- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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 L TYPEOFINSURANCE ADDL USR VIVD POUCYNUMBER POUC EFF POLWEIW LIMIrS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 2/5/2021 215/2022 EACHOCCURRENCE S 1,000,000 DAMAGETO PREMISES I,REMED $500,000 MED EXP M one n S 10,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ Ye LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMP/OP AGG S 2,000,000 § A AUTOMOBILE LIABILITY ANYAUro A�p�Os ONLY X ACppTOOSWVULNJE��D AUTOS ONLY AIITOj ONLDD MINIM 2/5/2021 V5/2022 CEOMBINdEDSINGLELIMIT $ 1,000,000 BODILY INJURV(par arson S BODILY INJURY erecddwt S PeOPiERenl AMAGE $ § A X UMBRELLA UAB EXCESS UAB X OCCUR CLAIMS -MADE 2/5/2021 2/512022 EACHOCCURRENCE S 3,000,000 AGGREGATE § 3,000,000 CEO X RETENTIONS 10,000 S B WORKERSCOMPENSATXJN ANY YIN ANY PROPRIEORIPARTNERIEXECLIINE QQ� CCEn�ME g Imantla of ryln NFTr2j EXCLUDED? I yyes, describe under DE5CRIPTION OF OPERATIONS below NIA 2/612021 21612022 )( I STERTUTE Off", A EL EACH ACCIDENT § 1,000,000 EL DISEASE -EA EMPLOYE S 1.000,000 ELDISEASE-POUCYUMIT S 1,000,000 A A Equipment Floater Motor Truck Cargo 2/5/2021 2/5/2021 2/5/2022 W5/2022 Equipment Cargo 46,442 102,500 - OPERATONS ILOCAMONSIVEHICLES (ACORD101,Addmonal Remadm Schedule.m hea chedlfmomspawfsrequlred) AI sees or Contractors -Automatic Status When required �n a written construction nerel Lability Elite Extension - a I; itional insured -Designated Person or Organization Vicarious Liability; ce a-Wer of Subrogation when required in a wnttan agmeme s Waiver of our Rights to Recover from Others Endom rm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. D REPRESENTATIVE -,vv,w ca, Tcv,mwr V Iiee LYIRNHVRV 4VRYVIV\ IIVIV. All mgm s reservea. 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. 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. 1J Name of vendor who has a business relationship with local governmental entity. ^)Te 7 j-,06 S Lam` 2 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 41%- 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? 1-1 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? E]Yes FIND AA ft 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 `L bignedure 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 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 Aifthorized Agent YSignature of Authorized 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). The Contractor, 06110T, l/U *M5 , 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. Sign ture of Contractor's Authorized Official Printed Name and Title of ontractor'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 feu rmhlie hnrdPn 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 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, ifknown: 10. a. Name and Address of Lobbying Registrant b. individuals Performing Services (including address if (if individual, last name, first name, Ml): dierenifrom 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 t representation of fact upon which reliance was placed Print Name: 12W/4 ,Sc1w.i 7,-- by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: /11,f t Az-' irA- U.S.C.1352. This information will be reported to the Congress semi-annually and will be available for 717 Telephone MV1-86v/ public No 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, AWg ScF/aJ;/% the undersigned representative of Representative A14 ZeK''✓rile £,eU46S, LL � (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. SignatuK6 of Representative Print Name & Title /i/ /,X-/ 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) E I certify that 1,Yta Test �1Ar�2i,yGS. L« 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 II // 4- Date -ctober Request for Taxpayer Form (Rev. 2018) (Rev.O Identification Number and Certification requester. D no t Department of me rressury Imemel Revenue service ► do to www.frs gov/FortnM for instructions and the latest Information. send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leavothts line blank toe ei L GL c 2 ousinessnemefdisregardedenatyneme,Hdigerent mmabove m 3 Check appropriate box furfederal tax classification of the person whose name is entered online 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entities, not Individuals; am a p ❑ CCo ElIntllvitluaysole proprietor or rporstion SCorporetion ❑ partnership ❑TmsVestate Instructions on page 3): 10 single -member LLC Exempt payee code Of my) L—d�O defied 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 forme tax classification of the single -member owner. Donotcheck Exemption from FATCAreporung �i Z LLC if the LLC Is classified as a single -member LLC mat is disregarded from the owner unless the owner of the LLC Is another LLCmm m at Is not disregardedfroe ownerfor U.S. federal tax purposes. Otherwise, a singla-member LLC that a (if any) ag is disregarded from the owner should check the appropriate box for the tax classification of its owner. Y. ❑ Other (am instructions)► rgonemm.:•,wmmn;eaowa, s,.us� N a Address (number, street, and apt or sulfa no.) gee insWctions. Requester's name and address (optional) O ,CSax. / �� CALHOUN COUNTY 6 city, state, and z1P code 202 S ANN ST, PORT LAVACA TX 77979 Fa Cd %E 7e JVe% 361-553.4610 FAX:361-553-4614 7 Ust account numbed.) here (optional) identification Enter your TIN In the appropriate box. The TIN provided must match the name given online 1 to avoid backup withholding. For individuals, this Is generally your social security number (SEN. However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other entitles, R 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 sae What Name and Number To Give the Requester for guidelines on whose number to enter. Under penalties of perjury,) certify that: 1. The number shown on this forth 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 S. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA codes) entered on this form (If any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out Rem 2 above R 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. Signature of U.S. Person ► General Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Forth W-9 and its instructions, such as legislation enacted after they were published, go to www.irs gcv1FotmW9. 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 we not limited to, the following. • Forth 1099-INT (Interest earned or paid) Date► // / / /0%- - 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-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 networkt arsactions) • Forth 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 R you are a U.S. person (Includlng a resident Wien), to provide your correct TIN. if you do notratum Form W-9 to the requesterwith a TIN, you might be subject to backup withholding. See What Is backup withholding, later. Cat No. ID231X Form W-J (Rev. 18-2018) W QUALITY HOT MIX, INC. ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address P a Pc� faNy FJ C4i,,po 1-x 77y37 • 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 PER UNIT ROAD MATERIALS Bid Item #1: ,Limestone-3/4 Inch To Dust Price per ton/ delivery price to county Stockpileand/or Jobsite LOCATION UNIT MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER Precinct I Ton ; �a-,G% ; I 0 1 30-L10 1 qq Oy Precinct Ton ( ,W '$.qo �0.qo f—ih Precinct Ton JIAS Precinct4-P 1 Ton 1 (a -Oil lq,Gfl '? �,GU aq fr,,, S Precinct4-S I Ton I ia.rti 3o.ae aK�3 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 LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER 1 ' , ; Precinct Ton .Cu 1 Ip I o ; I� Precinct 2 Ton I . ul �, c{J ; Precinct 1 Ton (a.W oU ;zy� Precinct 4-P ; Ton j f a, (A 1 18.01 Precinct45 1 Ton (j,(/I ($ UO 3d.QU 1 al., Remarks: Page 1 of 8 Invitation To Bid Form -Annual Supply Contract for Food Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #3: Item247, 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/ORDER I � Precinct Ton 1 .W 1 ( -C/i 1 ,(/U I )q 1�,hS 1 i Precinct I Ton C .E,{1 �q,Od J ,a i Precinct 3 I Ton 1 ( ,C6 Precinct 4-P 1 Ton ; ( 1 ( ; -� I � q I ,cU ,W liO ✓ � Precinct4-S I Ton (_ ,G(j Lq.W j.(/D Ih) 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 1 Precinct 1 I Ton Na ' _ of 47 lb I 1 Bags on Pallet 1 1 I 1 I Precinct 2 Ton 1 of 47 lb� Bags on Pallet I Precinct 3 I Ton I i of 47 lb 1 1 Bags on Pallet ( I 1 1 I I I Precinct4-P I Ton I I 1 I of 47 lb Bags on Pallet i i I 1 Precinct 4-S ; Ton i of 47 lb 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 #S: Item 302, Type PB, Grade (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER l Precinct 1 Ton Precinct Ton �_ 3,(i(J 9.w o .cd Precinct Ton 1 S 3,(,U I.co Q.0 .9T- Precinct 4-P ; Ton ; J 3,GL ; 1. ; p�., oo i I Precinct4-S l Ton 13,C� I Remarks: Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile a nd/o r Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton S 3, ai , w 6 -,a J-P,. ) Precinct i Ton S3,GiJ q`,00 W Precinct Ton S 3,ou c,oQ 6S,W tv,j I I l I I Precinct 4-P l Ton I I I I I Precinct 4-S l Ton ; G 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 Ton I lr ; I I Precinct 2 Ton Precinct 3 ; Ton Precinct 4-P Ton I I l I Precinct4-S ; Ton I Remarks: 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 , I I , Precinct 1 I Ton I � Precinct 2 ; Ton ; I I Precinct 3 I Ton I I I I I I Precinct 4-P I Ton I I I Precinct4-S 1 Ton 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I , Precinct 1 I Ton , 71 I I 3 5, \7/ I �d , CtJ y7 ny Precinct ; - Ton I I Precinct Ton I w I gy tr�'1S I � Precinct 4-P ; Ton 1E a 3 Y(j I 3,0,(/ji Precinct4-S �_.._ Ton Remarks: 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 I I A`1 I I Precinct 1 I Ton I Iv , i I I I Precinct 2 1 Ton Precinct 3 1 Ton I Precinct 4-P I Ton I Precinct 4-S I 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/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 Ton I I I T Yard I 50 lb Bag Precinct 2 1 Ton I I I Yard I 50 lb Bag I I Precinct 3 1 Ton I I I I I I I Yard' I I I I I I 50 lb Bag I I I I I � Precinct I I I I , I 4-P Ton I Yard' I I I I i I 50 lb Bag I I I I I Precinct 4-S ' Ton I I I I I I I i Yard3 I I I I I 50 lb Bag I I I arks: Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMFTable #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 I j. t(J I Q. c0 I �.C(1 Io s I I I I Precinct 2 I Ton 17 S`. (¢/ I r(,0U I I I Precinct I Ton I 7 a I 9.w I Precinct 4-13 I Ton I 7S, cG I •6(f I �y1 I J i.[r�t$ Precinct4-S I Ton �� a-(�) ,Yp�� 0'(� I. a"S I>✓AC rks: Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Aspholts, 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 l I I Precinct 1 Ton ( ; 1 Precinct 2 I Ton I Precinct 3 I Ton Precinct4-P; Ton -------- l Precinct' 4-5 ; Ton', rks: ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil Price per gallon /delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE l I I I I 1 I I I$ Per Hour After Precinct 1 E Gallon I / VU ` ll I I Free Hours - 1 1 1$ Per Hour After Precinct 2 ; Gallon I ; Free Hours 1$ Per Hour After Precinct 3 1 Gallon I 1 1 I— FreeHours i I I I I l$ Per Hour After Precinct4-P I Gallon I l I Free Hours I I I , I $ our After \Hor Precinct 4-5 ; Gallon ;_Fres 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/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE 1 , 1 � $ Per Hour After Precinct 1 Gallon U lj Free Hours i i i i i !$ Per Hour After Precinct 2 1 Gallon I I I Free Hours i i i j i I i 1$ Per Hour After Precinct 3 ; GallonFree Hours I I 1 Per Hour After Precinct4-P 1 Gallon i I Free Hours I I I I I I I ;$ Per Ho fter Precinct 4-S 1 Gallon 1 1 1 1 Free Hours 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/or Jobsite LOCATION Unit MATERIAL DELIVERY I TOTAL DEMURRAGE 1 I 1 Per Hour After Precinct 1 1 Gallon 1 �V (� I I Free Hours I 1 1 , 1 1 I I I$ Per Hour After Precinct 2 I Gallon 1 I_ Free Hours i 1 �$ Per Hour After Precinct 3 I Gallon 1 1 I Free Hours 1 I i$ Per Hour After Precinct4-P 1 Gallon 1 I I I Free Hours I 1 ' Per Hour After Precinct4-S Gallon 1 1 1—Free Hour Be sure to complete next page (page 8) Page 7 of 8 Invitation To Bid Form - Annual Supply Contract for Rood 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 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 any official, employee or agent of Calhoun County in connection with 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: S,V Jcr Phone Number. Q?� 543 qqn Email: 1�tQr5)doUl � D 4 @ 7 Q ?Wr Exceptions and or Variations from Specifications and/or additional Notes: *NOTE* ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Page 8 of 8 STATE OF {} AFFIDAVIT COUNTY OF {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 9I S 2 Su1�(il( Q reSiLl k�f' Printed Name and Title of Affiant Name of Bidder (Company) c�lXV�I i� C, Address �� t�G1G f �N _1 C4 njla ij 7?40 Phone Number Q li Sti3 i4gO Fax Number R7 9 S(i 3 V Email Address Q � ) Y. cew SWORN TO AND SUBSCRIBED BEFORE ME by the above Afffia„ntt,,who, on oath, states that the facts contained in the above are true and correct, this o�� day of V v- �20n a, )n . ^ VIC10E AR I / MM.ERPIIIE8t2.11.20YL Notary Public, Sta e of le x6s NOTARY ID 1134552-6 N6 IZ- Zn2Z Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Address: Q 6 igcx 14 Ny �� ( c4ytin0 Remittance Address: 1:,:� cl yin p Telephone: 117q '3-43 LINub Fax: CP Sub J dXR Email: ) e (19k/I16, 1M1)G cowl Signature of Authorized Representative: — �* ,Jy \� Printed name of Authorized Rep: rp-a S-Vyder ORDER — CONTACT INFORMATION Order Contact Name &Title: YUss Acrr k D;smtG�ne� Order Contact Telephone: c(7 � SN I 'l3 s1 Order Contact Fax: 2i 5 70 V I? Order Contact Email: _ 1 55 ppSu 1761 mflK, cw� INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name &Title: CgnRiG 'r- Ike hR CIePK Contact Telephone: St, `% 5(k3 uN66 Contact Fax: �C�I�' �-43 S-6tR Contact Email: Cy iA)� a9(i1v�1o� ✓1IiX, c�,M 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. 2021-317577 Quality Hot Mix, Inc. El Campo, TX United States Date Filed: 10/27/2021 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. 2022.03 Annual Supply Contract for Road Materials and Asphalts, Oils, and Emulsions. January 1, 2022 thru December 31, 2022 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Snyder, Jeff El Campo, TX United States X 6 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION c My name is and my ' date of birth is � � �� p� My address is , q.J—• (street) (city) (state) (zip code) (country) I declare under penalty of pequry that the foregoing is true and correct. Executed in gSV'-t V\ County, State of. c ,on lhe�L—dayof Ocro ker,20IL. (month) (year) ��Ij1\ f'(�I1 �/�\\ -hI`I�p1 I 4\I ll Signature of authorlzdd ag int of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us version v1.i.laio5cdc QUALHOT-01 CERTIFICATE OF LIABILITY INSURANCE DATE(MMAXIM Y) 6/29/2021 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 ri hts to the certificate holder in lieu of such endorsemen s . PRODUCER co r cT Kristle L Rodriguez, ACSR Texas Associates Insurors 1120 Capital of TX Hwy South Bldg 3.300 PHONE FA% ac, No, Eal : 979 475-1773 ac, No I stie txassoc.com Austin, TX 78746 INSUREFUSI AFFORDING COVERAGE N 1 r INSURER A: The Charter Oak Fire Insurance Company INSURED INSURER B: The Phoenix Insurance Company INSURER c: Travelers Property Casualty Company of America Quality Hot Mix, Inc. Quality Hot Mix Trucking, Inc. P.O. Box 1244 INSURER D:Texas Mutual Insurance Com an INBURER E: El Campo, TX 77437 NSURER F: COVFRAf9FS CPRTIFICATF NHMRFR- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVESEEN ISSUEDTOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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 TYPE OF INSURANCE INSADOBR LSU POLICY NUMBER POLICY EFF POLICY UPOEBL LIMBS A X COMMERCIAL GENERAL LIABILITY CLAIM&MADE El OCCUR 7/912021 7/9/2022 RENCE 3 1,000,00O PREM,EEENTED 309,000 one arson S 5,00D GV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jECT LOC OTHER: REGATE S 2,000,000 PRODUCTS AGO S 2,000,000 1100-0,000 B AUTOMOBILE X LIABILITYS ANYAUTO OWNED SCHEGULED AUTOS ONLY ANa1UTOSWWNNEEop ALTO6 ONLY AIDITNO3 NNLY 7/9/2021 719/2022 COMBINED SINGLEUMIT 1,000,000 BODILY INJURY Per arson S BODILY INJURY Peracdtlenl S PeOP�E� DAMAGE C X UMBRELLALIAB EXCESS UAB N OCCUR CLAIM&MADE 7/9/2021 71912022 EACHOCCURRENCE S 5,1100,000 AGGREGATE S 5,000,000 DELI I X I RETENTIONS 10,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIE%ECUTIVE YIN OFandFICEWMF)MB�N EXCLUDED? 1 alaryn H�) If as, desaibe under DESCRIPTION OF OPERATIONS below NIA 7/912D2t 71912D22 )t PER OTH- E.L.EACHACCIDENT $ i,999,D9D E.L. DISEASE -EA EMPLOYE $ 1,000,00 E.L. DISEASE -POLICY LIMIT S 1,000,00g A Scheduled Equipment 7/912021 71912022 Varies per Item DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORDi01,AddiBanSl RenurksSchedule,meybseasehedBmorespaeeialequlred) rFRTIFInATF uni rrFR CANCPI 1 AmnIJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Calhoun County Auditors Office 211 S. Ann Street Suite 301 THE ACCORDANCE WITH THE POLICY THERETION DATE O, ONTIICE WILL BE DELIVERED IN Port Lavaca, TX 77979 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. 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. OFFICEUSEONLY 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. 1J Name of vendor who has a business relationship with local governmental entity. 'Y Pz 4 S n I &cr QZu ; N 4� 41 X 2 Checkthisboxifyouarefilinganupdatetoapreviouslyfiledquestionnaire.(Thelawrequiresthatyoufileanupdated 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 G Ak 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. IUo nQ- 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 1-1 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? 1-1 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. Mc t4Q- 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 NJ Signature of vend i _d b sid ss With the governmental entity Dale 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 Signat4l of Ku horized Agent /()b7Li 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 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, (3ovljjr;1 4;X1r. 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 t1britractors Authorized Official Te4 Sb, l( r QrPs)L4 Printed Name and Title of Contractor's Authorized Official �ol�zl�c Date Approved by OMB N �6 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: S. 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: S. 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 name, first name, Ml): d ffetvnt front No. 10a) (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 T Print Name: •.1 ('- i- V FI` by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Q !'p S ) je,0 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.; V S�-U liy 66 Date: G d Zi 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, Ski Sriy u�Cf the undersigned representative of Representative GL-dI N o— 41 , C , (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 orin 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 Re se t ive S�1?� ��,4`l�r b)restd�int Print Name & Title 10��7�.aI 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) \ I certify that Qgc)1 ff i f 6+ Am I a t, is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature ofAutho' ed ent g I nn 1- &t rl r y�esdeot Printed Name and Title of Authorized Agent J Date W'9 Request for Taxpayer Give Form to the Form (Rev. October2(1B) Identification Number and Certification requester. Do not Doparanerd of thoT ea:ry send to the IRS. intemel Revenue S. ► Go to www.Irs gov/FormM for Instructions and the latest information. 1 Name (es shown on your Income tax return). Nam a is required on this line; do not issue this line blank. / V ` 2 Business name(disregar ad entity name, if different tram above m S Check appropriate box for federal lax classification of the person whose name Is entered online 1. Check only one of the 4 Exemptions (codes apply any to m a following seven boxes. certain entities, not individuals; am c ❑ Individuallsola proprietor or CCorpomtion ❑ SCorporation ❑ Partnership ❑ Trusvastete Instructions on page 3): $ to single -member LLC Exempt payee -do Of any) yJ� ❑ United liability company. Enter the tax clamilkaiion(O=C corporation, S=S corporation, P=Partnership)► `o Note: Check the appropriate box in the line above forthe tax classification ofthe single-memberovmer. Donotchack Exemption from FATCA reporting LLC if the LLC la classified as a single -member LLC that is disregarded from the owner unless the avmer of the LLC Is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLCihet code Of any) tl� Is disregarded from the owner should check the appropriate box for the tax classlfication of its owner. ❑ Other (am Instructions)► tt•ou*ro•mamo-maaxetl•varam•esi s Address (number. street, and apt. or suite no.) See instructions. Requester's name and address (optional) m - 1 G (' CALHOUN COUNTY 202 S ANN ST, PORT LAVACA TX 77979 6 City, state, and Zip code 0 ` ! 7``/ 1 t J 7 361-553-4610 FAX: 361-553.4614 7 Usteccountnumbeds)here (o IonaQ 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, r this this Is generally youthsocial security number (Sant. However, fora resident alien, sole proprietor, or disregarded entity, sae the Instructions for Pert I, later. For other entities, it Is your employer Identification number (EIM. 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 sea What Name and I Employer Identification number Number To Give the Requester for guidelines on whose number to enter. 17-7-71 F--T-T—. T-'1- 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)1 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 forth 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 pmperty, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you aR not reggied to sign the certification, but you must provide your correct 11N. Sea the Instructions for Part II, later. aryrl signature of Here US.personl General Instr Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Forth W-9 and Its Instructions, such as legislation enacted afterthey were published, go to www.Irsgov1FormW9. 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 coned taxpayer Identification number (TIN) which may be your social security number (SSM, Individual taxpayer identification number (RIM, adoption taxpayer Identification number (ATIM, or employer Identification number (EIM, 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. • Forth 1099-INT (Interest earned or paid) Date ► • 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-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) • Forth 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tuition) • Forth 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 Fonn illf-9 (Rov.10-2018) COLORADO MATERIALS, LTD ROAD MATERIALS I_1►101 ASPHALTS, OILS AND EMULSI ANNUAL SUPPLY CONT BID NUMBER 2 Beginning January 1, 2022 and d=':ng-ecember 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address CoW VLF AAVeAwS , CTO . . o . q7t* Z" • 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 PER UNIT ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch To Dust Ak �iV) Price ner ton / delivery orice to County Stockpile and/or Jobsite MINIMUM LOCATION I UNIT I MATERIAL I DELIVERY I TOTAL I LOAD/ORDER Precinct 1 1 Ton I 1 1 1 Precinct 2 I Ton I 1 Precinct 3 I Ton I I I Precinct 4-P I Ton I I I 1 Precinct4-S I Ton I I 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 MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precincts I Ton Precinct 2 I Ton 1 19 .16 1 d lg 1 .5 1 1 2, 1 Precinct 3 I Ton I I I ir,S 1(06 I I Precinct4-P I Ton�1,.p� I �G� I Z� •� Precinct 4-S I Ton ' 1 I� i �f1 IRemarks: 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 1 1 Ton 1 �°( • 1 e •� 1 2S. 1 �� Precinct 2 Ton 1 1 •�� a, Qj� ; 7i'2i . ��1 ; L� 1 Precinct 3 1 Ton 1 (� . �� 1 1 (o� (• �; 1 Precinct 4-P ; Ton Precinct 4-S I In 1 ` ' •ZS 1 vZ 1 z4 . ,1 1 Remarks: AA4Yfl'Ad4•t, T—ic Bid Item #4: Item 275, Cement A,2j � 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i i Precinct 1 ; Ton ; i 1 i i 47lb1 i 1 —of 1 Bags on Pallet i i i i Precinct 2 1 Ton 1 i i 1 i i 1 i i I i of 47 lbi i 1 1 Bags on Pallet 1 1 I 1 i i i i i Precinct 3 1 Ton 1 1 I 1 I I —of47lb 1 I 1 Bags on Pallet j i i i i I i i i Precinct 4-P 1 Ton 1 ' I _of471b j Bags on Pallet i i Precinct 4-S ; Ton i i i of 47 lb 1 — 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 LOCATION Unit MATERIAL DELIVERY Precinct 1 ; Ton ; CIO, 4D ; •�� Precinct Ton I 0.L)L I I Precinct 3 Ton 0. 0� I ' �. I zs7 6 I I Precinct4-P I Ton I go -OD I ; I •�7 I Precinct4-S ! Ton 1 CiO.DJ I I ("f Remarks: Ak4%t"-i-Rw ` mavug ' New 64Awl*c s Bid Item #6: Item 302, Type PB, Grade 4 (Pre -Coated Rock) TOTAL b Rfo �f .63 (05- .64 MINIMUM LOAD/ORDER Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 2"� (O� b Precinct 1 ; Ton tAo. ; l 17 ! • l Precinct 2 ' Ton a. tgp I , Fi I (Oct . (o, I ?A i i Precinct ; Ton i i ; LSp �S i Q, •�� .(p� Precinct4-P 1 Ton I I Precinct4-S I Ton ; O.QJ I ; L(c.( ; (p(� •( I Z Remarks: ;bLoce . h%ow K wouc-� Item 302, Type PE, Grade 3 (Pre -Coated Rock) Bid Item #7: *Material Source out of * itlo Q, L4 Price perton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton j Precinct 2 Ton 1 I I I Precinct 3 ; Ton I t I Precinct4-P I Ton I I I I Precinct4-S 1 Ton Page 3 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions -- CONTINUED Item 302, Type PE, Grade 4 (Pre -Coated Rock) Bid Item #8: *Material Source out of * ./190 b' Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE I 1 Precinct 1 Ton I Precinct 2 Ton Precinct 3 Ton j Precinct4-P 1 Ton 1 I 1 1 1 1 1 Precinct 4-S I Ton 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 Precincts Ton �5/•✓)7 lr�. Ie 1 1•q� Z`� Precinct 2 Ton ; `32 .,02 ` IA .J;3 15 . 6 ; L Vl Precinct 3 ; Ton ; Zi4 Z.Ci (o`I-r' ; S� (0cA I �( 1 "L'1 • , , Precinct 4-P ; Ton 1 O .00 Z+�. �7 I s • el Z Precinct 4-S Ton • 0 t7 ' . (� I �� • (M I `^ f Remarks: �PeC� �R t 7�+�crr iIJZ �N `�M�+►rZ�S, Bid Item #10: Item 330, Type D (Pre. -Mix Limestone) /Va Price per ton / delivery price to County Stockpile and/or Jobsite LOCATIO I MATERIAL I DELIVERY I TOTAL 1 Precinct 1 1 Ton 1 1 Precinct 2 1 Ton 1 Precinct 3 ; Ton I Precinct4-P ; Ton I Precinct 4-S I Ton MINIMUM 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. / Y gaa Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton I 1 I Yard I I 1 I 50 lb Bag ; l l Precinct 2 1 Ton I I 1 I Yard' I I 50 lb Bag l Precinct 3 1 Ton I I 1 l Yard' I I 1 1 1 50 lb Bag I I I 1 1 Precinct4-P 1 Ton I I I 1 l Yard' I I l 50 lb Bag l I 1 Precinct 4-S I Ton I I I 1 I 1 1 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 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 Ton l b l 43. b ` 2' ,Qo 1 Precinct 2 Ton I I I 6n. co I ro of 3 .63 I L Precinct 3 ; Ton ; (.9. oQ ; -L,S , (ocA 2- Precinct4-P ; Ton l (-,qG, Oz. 1 q-7- r? ` 24 Precinct 4-S Ton I • �� 26 1t%1 { C(G7 . Remarks: ">n pA�. S AAGa, w VV.4V, re ft-1.5 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 /to 127�D Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I I I I Precinct 1 ; Ton I I I I I Precinct 2 I Ton I I I I I I I I I I I Precinct 3 1 Ton I I I I Precinct4-P I Ton I I I Precinct 4-S Ton rks: ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil Ab RIP 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 I i i i i Precinct 1 I Gallon I I I ;_ Free Hours (Remarks: I i i I I$ Per Hour After Precinct 2 Gallon I _Free Hours i i i I i i i I $ Per Hour After Precinct 3 I Gallon I I ;_ Free Hours I I I I I$ Per Hour After Precinct 4-P I Gallon Free Hours i I I I `$ Per Hour After Precinct4-S I Gallon I I I I —Free Hours 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 NO Temperature must be no lower than 140' Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION I Unit I MATERIAL I DELIVERY Precinct 1 Gallon 1 1 Precinct 1 Gallon 1 i Precinct Gallon i i Precinct4-P 1 Gallon i i Precinct 4-5 I Gallon Remarks: TOTAL I DEMURRAGE I 1$ Per Hour After 1_ Free Hours i 1 1$ Per Hour After i_ Free Hours 1 1$ Per Hour After Free Hours I I$ Per Hour After i Free Hours i S Per Hour After I Free Hours I Bid Item #16: CRS-2 NC1 I1W Temperature must be no lower than 1500 and no higher than 180° Price per gallon / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE Per Hour After Precinct 1 I Gallon I I I_ Free Hours I 1 1$ Per Hour After I Precinct 2 I Gallon I I I 1 I Free Hours 1 I ' I 1 I ,$ Per Hour After Precinct 3 1 Gallon I I I Free Hours I Per Hour After Precinct 4-13 1 Gallon I I I 1$ I_ Free Hours 1 i 1 t I i I$ Per Hour After Precinct 4-S 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 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 any official, employee or agent of Calhoun County in connection with 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: �1— Type Name & Title of Authorized Signature: � ,y_00AA `-RiSkwVjj+ S*Lo% 1AZp' Phone Number: C516 �9(0^ [I_S _ Email: gyriWPo.v Q. (4yn/revLM0. C.D . Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF TEKo.5 {} AFFIDAVIT COUINTYOF HA85 0 The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. Pe BEFORE ME, the undersigned authority, on this day personally appeared f>%W0pN `rAidy%)1(; 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 officiyloyee rag nt of Calhoun County prior to the official opening of this Bid. Printed Name and Title of Affiant Name of Bidder (Company)\ o�W Nh�/J� A/V+WA%7A(S_( TO Address �•-0- %1�F� ?(CP1 PhoneNumber Fax Number Email Address 1-�-vu,"O.W (•{VN!'2ycA%Jb- oo� 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 3" day of No%/v-"e,,r 20 2.1 . THERESAJ. DAVIS ow..� - ?;pw?�`;f Mowry Public, State of Texas e` W`- Notary ID# 12632735-8 ... pie M/ ConzNssbn Expires '`- W " NOVEMBER 19, 2023 MII Notary Public, State of /(-/9-Z3 My Commission Expires Stamp/Seal BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: Address: '? • o . V,-.p ZcDS C n*y AA44 -v 5 Remittance Address: S44-tcZ Telephone:( stz) 3%- Fax: ( <-12, ) 5`1v - Email: Signature of Authorized Representative: Printed of Authorized ORDER — CONTACT INFORMATION Order Contact Name &Title: 9VAY ov C--!y- "VL, 4-v. Order Contact Telephone: \\Csl2� -5yy& Order Contact Fax: (5l `) 3f16 - t ,� Order Contact Email: 9vtWP0VGWUW-&-K%VNln. (b^ INVOICES - CONTACT INFORMATION For Invoice Inquiries: ((�� Contact Name & Title: _F>n� `�-t-W4 C,,� �--o . Contact Telephone:\1�-� Contact Fax: ( fir.. 196 (S Contact Email: (#JVZe"V r(r�` CERTIFICATE OF INTERESTED PARTIES FORM 1295 lafl 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. 2021-819652 Colorado Materials, Ltd San Marcos, TX United States Date Filed: 11/03/2021 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. BID NUMBER 2022-03 ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND APHALTS, OILS AND EMULSION, JANUARY 1, 2022 THRU DECEMBER 31, 2022 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. A Executed in pet- ( County, State of 1 on the 3=day of S0 L, (month) (year) ur /^� Signat a of h gent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc Client#: 73628 14HUNTEIND ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYYY) 11/0312021 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 ORALTERTHE 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 any rights to the certificate holder in lieu of such endorsement(s). Marsh Wortham 221 West 6th Street, Suite1400 Austin, TX 78701 512 453-0031 CONPRODUCER NAME: cT Mary Beth Campos PHONE 512 453-0031 FA't 512 453-0041 A/C No Esl: AIC No: E-MAIL ma beth.cam os //l1marsh.com ADDRESS: rY V P INSURERS AFFORDING COVERAGE American Family Home Insurance Company INSURER A: Y Y INSURED INSURER B: Berkshire Hathaway Specialty Ins Compan Colorado Materials, Ltd Texas Mutual Insurance Company INSURER C: P Y P. O. Box 2109 San Marcos, TX 78667-2109 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 ADUL INSR SUER MD POLICY NUMBER POLICY EFF MMIDD POLICYEXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 7/19/2021 0711912022 1 EACH OCCURRENCE $2 g0600D PREMI6E5 Es oNiurrcnce $1 000000 MED EXP (Any one person) $15,000 PERSONALSADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F X1 JECOT FX I LOC OTHER: GENERALAGGREGATE $4,000,000 PRODUCTS -COMPIOPAGG $4,000,000 $ A AUTOMOBILE LIABILITY X ANY AUTO OWNED ULED AUTOS ONLYHSCUTHOES0,HIRED NON-ONED X AUTOS ONLY AUTOS ONLY X Cs90 7/19/2021 07119/2022 EeeBINEDSINGLE LIMIT $2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccident $ $ B UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE I 7/19/2021 0711912022 EACH OCCURRENCE $5000000 AGGREGATE $5 000 000 DED I I RETENTIONS $ c WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEMEXECUnVE YIN OFFICEMMEMBER EXCLUDE07 � (Mandatoryin NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 7 7/19/2021 0711912022 X IPTERTuTE OTH- E.L. EACH ACCIDENT S1,000,000 _ E.L. DISEASE -EA EMPLOYEE $1,000000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) (See Attached Descriptions) To be Used For Information Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Marsh Walham 796E-2U115 ACURU CURFUHAI IUN. All rlgnts reserves. ACIDD 25 20161U3) 1 of 2 The ACORD name and logo are registered marks of ACORD I I 14MBC DESCRIPTIONS (Continued from Page 1) The General Liability policy includes a blanket additional insured endorsement that provides additional insured status to the certificate holder when there is a written contract between the named insured and the certificate holder requiring additional insured status. The General Liability Policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. The General Liability policy contains a special endorsement with "Primary and Noncontributory" wording. The Business Auto Policy includes a blanket automatic additional insured endorsement (provision) that provides additional insured status to the certificate holder only when there is a written contract between the named insured and the certificate holder that requires such status. The Business Auto Policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. The Workers Compensation Policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. The General Liability, Business Auto and Workers Compensation Policies includes a blanket notice of cancellation to certificate holders endorsement, providing for [30] days advance notice if the policy is cancelled by the company other than for nonpayment of premium, [10] days notice after the policy is cancelled for nonpayment of premium. Notice is sent to certificate holders with mailing address on the file with the agent or the company. The endorsement does not provide for notice of cancellation if the named Insured requests cancellation - SAGITTA 25.3 (2016103) 2 of 2 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. OFFICEUSEONLY 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. jJ Name of vendor who has a business relationship with local governmental entity. oN " 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 aboutwhom the information is being disclosed. Nw1� 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 CIa 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? ED Yes 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? F]Yes El 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. AD 6 Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts El as described in Sect' 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 =J�A Z Signature endor doing bustriess with the governmental entity Dat 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. ?.. c sftg�.Vzv Name and Title of Authorized Agent dq IT) 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 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, _`uWoa A ML C1rs Vi W6certifies 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 provi ns of U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Sig fdaQjrodors Authorized Official 1�+rw„rk�v (,In" A4- ��Xa (r22�• Printed Name and Title of Contractor's Authorized Official ��I� IZ, 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 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, Enter _ Prime _ Subawardee Name and Address of Prime: Tier. if Known: Congressional District, if known: Congressional District, if ]mown: 6. Federal DepartmentlAgency: 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 name, first name, MI): different from 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: by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: Date: inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than 510,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) n / I--- NrJI\N HOUSE BILL 89 VERIFICATION CERTIFICATION REQUIRED BY TEXAS GOVERNMENT CODE SECTION 2270.001 I, &Mpolu O 114 Vww the undersigned representative of Representative &vt000 grem hls M. (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 gatides or business associations that exist to make a profit. Signature Print Name & Title u1AI-Il 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. (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) -0 I certify that M j/ - G�tcs , L'20 is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. <-- I ((�' Signat hor z/4A nt IP ^ C• ,�40,�>, c 12��. Printed Name and Title of Authorized Agent l l 'Z \ Date MARTIN PRODUCTS SALES, LLC RM MARTIN ASPHALT COMPANY ROAD MATERIALS AND ASPHALTS, OILS AND E ANNUAL SUPPL I I'll 0 1 ki 0 Beginning January 1, 2022 any$ .. , ding December 31, 2022 MARTIN PRODUCTS SALES, LLC ff MARTIN ASPHALT COMPANY ROAD MATERIALS FAR►1FE ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT BID NUMBER 2022.03 Beginning January 1, 2022 and Ending December 31, 2022 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address AdlQr�hQ G� Zr}2o_ Pi co bn ► �"l o5(o • 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 PER UNIT ROAD MATERIALS Limestone-3/4 Inch To Dust Bid Item #1: Price perton / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I Precinct 2 Ton Precinct 3 Ton Precinct 4-P I Ton I I Precinct 4-S 1 Ton Remarks: Bid Item #2: Item 247, Type,A Limestone, Grade 2, [1I3/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIALJ DELIVERY TOTAL LOAD/ORDER 1 I Ton I 2 Ton I 3 I Ton I 4-P ; Ton 4-S I Ton Page 1 of 8 Invitation To Bid Form -Annual supply Contractfor Road Materials and Asphalts, Oils and Emulsions -- CONTINUED d Item #3: Item 247, Type A Limestone, Grade 3 [13/4 Inch] Price per ton / delivery price to County Stockpile and/orJobsite LOCATIO I MATERIAL I DELIVERY TO i 'recinct 1 Ton ! recinct 2 ! Ton 'recinct 3 ! Ton ! recinct 4-P ; Ton recinct 4-S I Ton MINIMUM L LOAD/ORDER 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 I ! ( ! ! Precinct 1 Ton Precinct 2 Precinct 3 Precinct 4-P Precinct 4-5 Remarks: of 47 lb Bags on Pallet Ton of 47 lb Bags on Pallet Ton of 47 lb Bags on Pallet Ton _of47lb Bags on Pallet Ton of 47 lb Bags on Pallet Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid Item #S: Item 302, Type PB, Grade 3 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I 1 1 1 Precinct 1 ; Ton 1 i i i i Precinct 2 1 Ton 1 I 1 i I 1 I I I I Precinct 3 1 Ton i 1 1 1 I 1 I 1 i Precinct 4-P ; Ton 1 i Precinct 4-S ; Ton Remarks: Bid Item #6: Item 302, Type`PB, Grade 4 (Pre -Coated Rock) Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 1 1 Precinct 1 ; Ton 1 I 1 I I 1 Precinct 2 1 Ton 1 1 1 I 1 I 1 I I Precinct 3 Ton v Precinct4-P 1 Ton 1 I I 1 1 1 1 I Precinct4-S 1 Ton 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/orJobsite _F MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I 1 I 1 Precinct 1 Ton i c Precinct 2 1 Ton I 1 1 I I Precinct 3 1 Ton 1 1 1 1 i i i i i Precinct 4-P 1 Ton I I I I I 1 1 1 Precinct 4-5 1 Ton 1 I 1 1 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 Precinct 1 Ton I , Precinct 2 Ton I Precinct 3 Ton i Precinct 4-P ! Ton Precinct 4-S I Ton 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 I Ton I I I I I I I i I Precinct 2 Ton I I I I I I Precinct 3 Ton I i i i i i Precinct4-P I Ton I I ii I I I Precinct 4-S I Ton I I I I I Bid Item #10:'Iter Price LOCATION Precinct 1 Precinct 2 Precinct 3 Precinct 4-P Precinct 4-S Remarks: ape D (Pre -Mix Limestone) =.livery price to County Stockpile and/or Jobsite MINIMUM Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Ton I I I Ton Ton Ton Ton 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 1 1 I Precinct 1 1 Ton 1 I I 1 1 1 Yard 1 I I 1 I I 50 lb Bag I 1 I I I I Precinct 2 1 Ton I I 1 1 1 I 1 Yard' i I i i 50 lb Bag 1 1 1 Precinct 3 1 Ton 1 1 1 1 1 1 1 Yard' 1 1 I 1 1 50 lb Bag 1 I 1 1 1 1 I Precinct 4-13 1 Ton I I 1 1 1 1 Yard' 1 1 1 1 I 50 lb Bag i I 1 1 1 Precinct 4-S 1 Ton 1 1 1 1 1 1 1 1 Yard' 1 1 50 lb Bag 1 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 Precinct 1 Ton i i i Precinct 2 Ton i i I I I I I Precinct 3 Ton Precinct 4-13 ; Ton i i i Precinct 4-S ; Ton i i Remarks: Page 5 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED d 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 Precinct 1 Ton I I I I Precinct 2 Ton I I I i Precinct 3 1 Ton I I I ; Precinct 4-P ; Ton Precinct 4-5 1 Ton I I I ASPHALTS, OILS AND, EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil — M& p Price per gallon / delivery price to County Stockpile and/orJobsite Remarks: LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE ; Q% is10 Hour After Precinct 1 I Gallon iI { I Free Hours I I a�s CJ 3j03 I$ —//Fr —tOPerHour After Precinct Gallon ; "�� 1 Free Hours a� ; o nh Per Hour After :$ Precinct Gallon Free Hours C7 �. `(� rfD Per Hour After $ I Precinct 4-P 1 Gallon I I I I_9� Free Hours r � / ; � � OLF-. �$ to Per Hour After Precinct 4-S ; Gallon I l L'2, Free Hours n . . 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 140° Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE is -70 Per Hour After Precinct 1 Gallon r///`��`f ; Free Hours J q3 I$ /o Per Hour After Precinct 2 1 Gallon I I r U I I i 2 Free Hours , I 1 { / � I Z �/ I$�Q Per Hour After Precinct Gallon 2 Free Hours I ; /1S � • / i ,2, I Lti/„ is Per Hour After Precinct 4-13 1 Gallon Free Hours , , ' / '1 (c I ✓ ' �//� / ' t,/ l a '$ Per Hour After Precinct4- ' Gallon i I / I r l� Free Hours Remarks: 50W mhantarm Bid Item #16: CRS-2 1 Temperature must be no lower than 150' and no higher than 1800 Price per gallon / delivery price to County Stockpile and/orJobsite LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE I I mm �'�v i I ,jQ ��/" i I$ lfl Per Hour After Precinct I Gallon I I ,�(� I I%Free Hours JQ / (1 i Per Hour After Precinct I Gallon i i i I Free Hours O/D '$�O Per Hour After ' 12 Precinct I Gallon I • Free Hours Per Hour After Precinct4-P I Gallon 1�Free Hours I a ®p 9 i$�� Per Hour After Precinct4-S ; Gallon i v1 , I [ ?,,Free Hours Remarks: Khoo He sure to complete next page (page 8) Page 7 of 8 Invitation To. Bid Farm -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 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 any official, employee or agent of Calhoun County in connection with 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: ) l I 1 12,0?, I Authorized Signature & Type Name & Title of At PhoneNumber:11 J 3,5-0 ` 6� - Email: I�149aA. gP1Y.Ol': DIAo We, co r' Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF r09& C {} AFFIDAVIT COUNTY O The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared V,C. op 19 �Ouno 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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_ Name of Bidder (i Address Phone Number Fax Number Email Address SWORN TO AND SUBSCRIBED BEFORE ME by the above ffiant, who, on oath, states that the facts contained in the above are true and correct, this �, day of / 20_g STEPHANIE AGUIRRE Notary Public, State of Texas Comm. Expires 02-06-2024 Notary ID 730373086 Stamp/Seal v Notary Public, State of- p z, - 0 0 - 2,0 2-V . My Commission Expires Please Type. If handwritten, must be in ink and legible Bidder's I Address: Remittance Address: PVAZI QQp_ I Telephone: ' // 9- Z)OU- Fax: -713 --55-0 - A D Email: Signature of Authorized /Y Aa c,&m Printed name of Authorized Rep: VCC Aok�,d 60 ORDER — CONTACT INFORMATION Order Contact Name & w6u Order Contact Telephone: 1-3 3b-p — (4 5"/ Order Contact Fax: 71 3- z6o —(p ()/ /� � � y Order Contact Email: 1%ph(t • ,S� 0 MIL J717 MIPj W/77 INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: �1-Ordjvl Contact Telephone: Contact Fax: Contact Emal 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: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2021-818832 Martin Asphalt Company SOUTH HOUSTON, TX United States Date Filed: 11/01/2021 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 #2022.03 ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS JANUARY 1, 2022 - DECEMBER 31, 2022 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 {7 My name is V L and my date of birth is INNMy address is `mow (street) (city) (slate) (zip code) (country) I declare under penalty of perjury ythat the foregoing is true and correct. IdExecuted in 6 1yw" L County, State of [ , on the ay of JtW20 (month) (year) Signature of adQZ?or11,zA agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE 1 DATE00 YYYY) 5/1/2022 4/26/2/2021 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 riqhts to the certificate holder in lieu of such endarsement(s). 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 * CERTIFICATE NUMBER: INNE011111111i REVISION NUMBER: XXXXXXX 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. ILTR TYPE OF INSURANCE DIED ADDL SUER , POLICYNUMBER MMIDDY� MMIODf YYY LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE C X OCCUR POLLUTION LIABILITY Y N BOREN= 5/1/2021 5/1/2022 EACH OCCURRENCE S 4000000 DAMAGE TO RENTED PREMISES We occurrence S 100000 X MEDEXP(Anyenepersan) S Not Applicable X I $1 M-SIR PERSONAL B ADV INJURY S 4.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY❑JECT DLOC OTHER: GENERAL AGGREGATE S 4000000 PRODUCTS -COMP/OPAGG S4000000 S A AUTOMOBILE LIABILITY ANYAUTO OWNED AUTOS ONLY SCHEDULED AUTOS HIRED AUTOS ONLY X AUTOS ONLOY N N 5/1/2021 5/1/2022 COMBINED tSINGLE LIMIT S 5000000 X BODILY INJURY (Par Person) S X)MXXX X BODILY INJURY (Per accident) S XXXXXXX X Pena cider DAMAGE S XXXXXXX SXXXXXXX B UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE N N 5/l/2021 5/1/2022 EACH OCCURRENCE S 10000000 X AGGREGATE S 10,000,000 DED X RETENTIONS $0 S XXXXXXX C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER E%CLUDED'1 ❑N (Mandatory in NH) If yes, describe ur DESCRIPTION OF OPERATIONS below N/A N See Attached 5112021 5/1/2022 PER OTH- X STATUTE ER E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE -POLICY LIMIT S 1,000,000 D F EXCESS AUTOMOBILE LIABILITY EXCESS LIAB. N N 5/1/2021 5/1/2021 5/1/2022 5/I/2022 LIMIT$5,000,000 LIMIT$10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORDIBI,Additional Remarks Sehedula,maybeattachedifmorespace is required) 16403438 Calhoun County 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �yS Producer: Lockton Companies, LLC 2100 Ross Ave., Suite 1400 Dallas, TX 75201 WORKERS' COMPENSATION POLICIES OTHER STATES Policy Number: 9111110INIM . Insurer: Indemnity Insurance Co. of North America California Policy Number: SHMEMMEM Insurer: Ace American Insurance Co. 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 ENERGY SERVICES LLC 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. PRISM GAS SYSTEMS I L.P. PRISM GAS SYSTEMS, INC. PRISM GULF COAST SYSTEMS, L.L.C. TRANSMAR, INC. TALEN'S MARINE & FUEL LLC MARTIN MIDSTREAM 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 MARTIN PRODUCT SALES LLC D/B/A PARASTIM ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Number Martin Resource Management Corporation 4 Policy Symbol Poli Policy Period Effective Date of Endorsement XSL O5/01/2019 to 05/01/2020 Issued By (Name of Insurance Company) ACE American Insurance Company insert the po cy number. I he remainder oa information is to be compieted on y when this endorsement is issued subsequent o We preparation or the policy. 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 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. !J Name of vendor who has a business relationship with governmental entity. /local � h mAlepl A t& Vp 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.) �!J 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? Yes 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? E]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. 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 o Ivendor ing buslne s with the governmental entity I I at7 e - Form provided by Texas Ethics Commission www.ethics.slate.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. "do os." AJt6 R . ! Wa Name and Title of Authorized Agent ate 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,.Pdjfkit j&,y Pj4 certifies or affirms the truthfulness and accuracy of each statement of its certificat- d disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 UV S pj 3801 at seq., apply to this certification and disclosure, if any. Official Printed Name and Title of Contractor's Authorized Official dl 1 i I%Rr 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 Dublic 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 e. loan guarantee t ` // n _ For material change only: 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, ifknown: 9. Award Amount, ifknown: $ 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, MI): dif erenifrrnn 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 V representation of fact upon which reliance was placed Print Name: {�, O by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 C Title: ✓ glirCJ U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.:713-: -WS7i Date: I I Zl 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, �� ('1 oo)l_ IZO the undersigned representative of MReprresentativ AAA �(hereafter referred to as Company) being an Company or Busi ess 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. 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) 21 certify that digt i ayk1iff '"n1/11s a "Resident Bidder" of Texas as (Company Name) J defined in Government Code §2252.001. SignaturlofAuthoriz Agent Printed" a an Title oY Authorized Agent L Date Vie-9 Request for Taxpayer Give Form Far, (Rev. October 2018) Identification Number and Certification to the requester. Do not Department of the Treasury, send to the IRS. em Inla Revenue Service ► Go to wwwdrs.gov/For1nW9 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. MARTIN PRODUCT SALES, LLC 2 Business nameldisregarded entity name, if different from above MARTIN ASPHALT CO. m 3 Check appropriate box for federal tax classification 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: sea tip ❑ C Co ❑ Individuallsole proprietor or Corporation ❑ S Corporation ❑ Partnership ❑ TrusVestate Instructions on page 3); ai single member LLC Exempt payee code fir any) a. o ,� 16 ❑✓ Umited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnorship) ► S `o jz Note: Check the appropriate box in the line above for the tax classification or the single -member owner. Do not check Exemption from FATCA reporting w 'C� LLC If the LLC is classified as a single -member LLC that Is dlsrogardad from the owner unless the owner or the LLC Is en code df y) IL another LLC that is not disregarded from the owner for U.S. federal lax purposes. Otherwise, a single -member LLC that Is disregarded gram the owner should check the appropriate box for the tax classification of Its owner. 0 El Other (see Instructions)► rMPr'rtl•rccvunemir xdouWa W asv be 5 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) 3 RIVERWAY, STE 400 6 City, state, and ZIP code HOUSTON, TX 77056 7 Ust account numbers) here (optional) IM 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 -m -� 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 Now to get a TIN, later. or Note: If the account Is In more than one name, see the Instructions for line 1. AJso see What Name and I Employer Identification number Number To Give the Requester for guidelines on whose number to enter. 7 5 - 1 2 1 0 1 8 1 1 1 0 1 5 1 3 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 crass 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. Sea the instructions for Part 11, later. Jryrr Signature of l Here I U.S. person► ci 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.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 (SSM, 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) • Forts 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Forts 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), 1096 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-U (Rev.10-2018) P SQUARED EMULSION PLANTS, LLC ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONPq ANNUAL SUPPLY CONTRA cember 31, 2022 BID NUMBER 202 Beginning January 1, 2022 and EndjT7 �;v CALHOUN COUNTY TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address P Squared Emulsion Plants, LLC 516 South McLennan Loop Elm Mott, Texas 76640 • 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 PER UNIT ROAD MATERIALS Bid Item #1: Limestone-3/4 Inch To Dust Price perton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct l I Ton I I I I I Precinct 2 I Ton I I I I I ' Precinct 3 Ton I I I I I Precinct4-P Ton I I Precinct4-S I Ton I I I 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/orJobsite FDELIVERY MINIMUM LOCATION Unit MATERIAL TOTAL LOAD/ORDER I I I Precinct 1 Ton I i i i i Precinct 2 1 Ton I I i I i I I i Precinct 3 I Ton I I I I I Precinct-P; Ton I Precinct 4-S ; Ton II I 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 1 1 Ton I 1 I Precinct Ton Precinct 3 1 Ton 1 1 BID I I Precinct4-P ; Ton 1 Precinct4-S 1 Ton 1 1 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 Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 I Precinct 1 Ton 1 of 47 lb 1 I 1 Bags on Pallet 1 1 1 1 1 I 1 1 I Precinct 2 1 Ton 1 NO RLD _ of 47 lb � 1 Bags on Pallet 1 I i i i i Precinct 1 Ton 1 1 i 1 1 of 47161 Bags on Pallet Precinct4-P 1 Ton it fill No I of 47 lb Bags on Pallet j i 1 1 1 i Precinct 4-S ; Ton j _of47lb; j 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 #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 I I I Precinct 1 Ton I I I Precinct 2 Ton I i0 IT fit) Precinct 3 1 Ton I I i 1 Precinct4-P I Ton I I I Precinct4-5 ; Ton 1 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 TOTAL LOAD/ORDER Precinct 1 Ton 1 i Precinct 2 Ton I I Precinct { Ton I I Precinct4-P I Ton I I I I I I I Precinct4-S i 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 LOCATION Unit MATERIAL DELIVERY TOTAL AMINIMUM LOAD/ORDER I i I I Precinct 1 Ton 1 I I I I I I Precinct I Ton I Precinct3 Ton j i i Precinct4-P I Ton I I I I I I Precinct4-S I Ton ; i I 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 Ton 1 i i I I i Precinct 2 Ton I I Precinct 3 Ton 1 1 1 Precinct4-P i Ton i I I I Precinct4-S 1 Ton 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/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precincts 1 Ton 1 1 1 Precinct 1 Ton 1 1 1 Precinct 3 1 Ton 1 1 1 1 I I I I I Precinct 4-P i Ton i 1 1 1 1 1 i Precinct 4-5 1 Ton I I ; Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATIO I MATERIAL I DELIVERY TOTAL i (recinct 1 i Ton 1 'recinct 2 i Ton i I 'recinct 3 I Ton i 'recinct4-P 1 -- Ton - I recinct4-S I Ton MINIMUM LOAD/ORDER 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/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER , Precinct 1 I Ton 1 I ; 1 I 1 Yardallo 50lb Bag 1 1 , Precinct Ton I 1 I I ' Yard' 1 ' I 1 1 ' 50lb Bag 1 1 Precinct 3 1 Ton ' Yard' NO I 11y" I 50lb Bag 1 ; Precinct4-P Ton I 1 Yard' I NO-l" I ' I SO lb Bag ; Precinct 4-S I Ton I I I 1 1 1 -DI"', I Yard' 1 1 1 50 lb Bag I I I I Remarks: Bid Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2 JMF Table #5 Laboratory Mixture Design Properties found in the Standard Specifications for Construction and Maintenance of Highways, Streets and Bridges. Price perton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i 1 1 I Precinct 1 1 Ton 1 I I I Precinct 2 1 Ton 1 1 1 I Precinct 3 I Ton i Precinct 4-P I Ton , I I I Precinct4-51 Ton I I 1 1 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 LOCATION Unit MATERIAL DELIVERY TOTAL I Precinct 1 Ton 1 I Precinct 1 Ton 1 , I ' i i Precinct3 I Ton Precinct4-P 1 Ton 1 1 I I , i i Precinct4-S 1 Ton I I I ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions Bid Item #14: Primer Oil (P2 Prime Concentrate) Price per gallon / delivery price to County St LOCATION Unit MATERIAL 1 1 Precinct 1 1 Gallon $2.04 Gallon 1 $2.04 3 1 Gallon 1 $2.04 Precinct 4-1) ` Gallon 1 $2.04 I 1 Precinct4-S 1 Gallon I $2.04 see attached equivalent and/or sr e and/or Jobsite MINIMUM LOAD/ORDER DELIVERY TOTAL DEMURRAGE i 80.00Per Hour After n/a 1 $2.04 1$ 2 , Free Hours $ 80.00PerHour After n/a $2.04 1 2 Free Hours I l$ 80.00 Per Hour After n/a 1 $2.04 1 2 Free Hours 1 I ' 1$ 80.00 Per Hour After n/a 1 $2.04 12 Free Hours 1 80.00 Per Hour After n/a $2.04 1$ I_ Free Hours product information and Sole Source Affdai 't 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/orJobsite LOCATION I Unit I MATERIAL I DELIVERY I TOTAL Precinct 1 I Gallon 1 i Precinct 2 I Gallon 1. : Precinct Gallon t 1 1 Precinct 4-P I Gallon 1 Precinct4-S Gallon (Remarks: Bid Item #16: CRS-2 W2 CWE-2) Temperature must be no lower than 1500 and no higher than 1800 Price per gallon / delivery price to County Stockpile and/or Jobsite 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 LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE 1 I I I I I I 1 1$ 80.00 per Hour After Precinct 1 1 Gallon 1 $2.99 n/a 1 $2.99 1 2 Free Hours $ 80.00 Per HourAfter Precinct 1 Gallon 1 $2.99 : n/a 1 $2.99 12 Free Hours I I I I I $ 80.00 Per Hour After Precinct 3 1 Gallon 1 $2.99 1 n/a 1 $2.99 1 2 Free Hours 1 I 1 1 1$ 80. 00 Per Hour After Precinct4-P 1 Gallon 1 $2.99 1 n/a i $2.99 12 Free Hours $ 80.00 Per Hour After Precinct 4-S 1 Gallon 1 $2.99 1 n/a 1 $2.99 1 2 Free Hours Remarks`*Please see attached equivalent and/or superior product information and Sole Source Affrrla 't **P Squared is proudly recognized and accepted by Tarrant County Co -Op. 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 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 any official, employee or agent of Calhoun County in connection with 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: 46t Type Name & Title of Authorized Signature: j neMCGfnnis, Partner/CFO Phone Number: (254) 829-0330 Email: ofi<ce(iDp2emulsions.com Exceptions and or Variations from Specifications and/or additional Notes: **Please see attached equivalent and/or superior product information and Sole Source Affidavit. **P Squared is proudly recognized and accepted by Tarrant County Co -Op. Page 8 of 8 n P2 Emulsions �1J P Squared Emulsion Plants - November 2, 2021 Prices subject to change with written notice P2 Salesman - David Williams Contact Phone - (361) 877-2584 Product Tanker FOB Plant Tanker FOB County Drum/Tote Plant P2 Stabilizer $2.44 $2.69 $2.64 P2S1 $2.44 $2.69 $2.64 (Chip Seal) P2 CWP $2.74 $2.99 $2.94 (Cold Weather Patch) P2 ROC $2.57 $2.82 $2.77 (Road Over Coat) P2 Rejuvenator $2.44 $2.69 $2.64 P2 Prime Concentrate $1.79 $2.04 $1.99 P2RTU $1.75 $2.00 $1.95 'All listed prices are per U.S, gallon **Minimum Tanker Delivery: 5,000 Gallons **Delivery over 250 miles subject to additional charges **Demurrage (trucking charge): First 2 hours free, $80.00 per hour thereafter **Pump Charge (trucking charge): $80.00 **Push Charge (trucking charge): $80.00 per hour **Return Loads (trucking charge): Subject to charge from delivering freight line **Smaller Quantities Available, Subject to Freight Differential of $0.25/gal less than 5,000 gal Containers available for smaller product amounts "Tote" Containers (275 gallons size each) cost $100.00 per container "Drum" Containers (55 gallons size each) cost $35.00 per drum Containers are re -usable and can be rinsed out, brought back and re -filled at customer discretion Containers priced individually and sold only with orders for material Thank you and we look forward to serving all your emulsion needs! P2Emulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 P2 Emulsions Date: November 02, 2021 To: Calhoun County Subject: P Squared Emulsion Plants LLC Sole Source Products This communication serves as certification that all products listed below are produced in accordance with the State of Texas' Sole Source requirements according to the proprietary formulas and specifications of P Squared Emulsion Plants LLC. Our proprietary products conform to the formal definition of "a confidential formulation usually containing two or more ingredients and about which information is not in the public domain" and as such, P Squared Emulsion Plants LLC is the only manufacturer and distributor of said products. P Squared Emulsion Plants LLC Products: "P2 Stabilizer" Our P2 Stabilizer is an asphalt emulsion that is incorporated into existing soil or base material to provide increased base strength and stability. P2 Stabilizer eliminates the need for additional material such as aggregates, lime, cement or other additives. The utilization of P2 Stabilizer results in increased base density and hardness without sacrificing the flexibility and waterproof properties of asphalt. "P2 Rejuvenator" Our P2 Rejuvenator is engineered to rejuvenate old asphalt roads, RAP and other millings with residual asphaltic content. A one-time application will rejuvenate the existing material through softening oxidized pavement materials and re -binding asphalt to revitalize the road base. "P2 ROC" Our P2 ROC is engineered to seal and protect existing road surfaces. Our "Road Over Coat" is a proven sealing solution that locks down loose chip seal aggregate while sealing oxidized and cracked surfaces. ROC is designed to be traffic safe in under an hour resulting in a uniform, black road surface. "CWE-2-No Bleed Chip Seal" Our unique chip seal formula exhibits superior performance when compared to commodity type CRS-2 emulsions. CWE-2 can be applied in a broader range of temperatures (10-20 degrees below other products) and WILL NOT BLEED under extreme summer temperatures. "CWP — Pothole Patch" This emulsion is specifically formulated to work in ALL patch machines, ALL year round with the exact same results. Smooth consistency, no bleed finish and extremely low clog rates differentiate CWP from all other patch materials. "P2 Prime Concentrate" We have several proprietary "ready -to -use" formulas that include prime, tack and dust control products that all derive from our P2 Prime Concentrate. Based on application, customer needs and dilution rates; we have something for literally every road across the state of Texas. **AII P Squared Emulsion Plants LLC proprietary products fulfill the formal requirements found in Texas Local Government Codes regarding county purchasing. Section 262.024.7.A. (Available upon request) **All P Squared Emulsion Plants LLC proprietary products are fully TCEQ and EPA compliant All of us at P Squared thank you for the opportunity and we look forward to serving all your emulsion needs! P2Emulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 17Z P2Emulsions SOLE -SOURCE PURCHASE AFFIDAVIT KNOW ALL MEN BY THESE PRESENTS THAT: Before me, the undersigned authority duly authorized to take acknowledgements and administer oaths on this day personally appeared Seth McGinnis, on sworn oath stated the following: My name is Seth McGinnis and I serve as the Chief Executive Officer of P Squared Emulsions Plants, LLC. I respect the required compliance of Calhoun County to the competitive bidding requirements outlined under Chapter 262 of the Texas Local Government Code; however, the purchase of an item that can be obtained from only one source is exempted from said statutory competitive bidding provisions. The authority to purchase P Squared Emulsion Plants, LLC's proprietary products as defined as "Sole -Source" may be found under Texas Local Government Code § 262.024a (7)(A). a) A contract for the purchase of any of the following items is exempt from the requirement established by Section 262.023 if the commissioners court by order grants the exemption: (7) an item that can be obtained from only one source, including: (A) items for which competition is precluded because of the existence of patents, copyrights, secret processes" I represent and assert to the Purchasing Department of Calhoun County and hereby warrant that P Squared Emulsion Plants, LLC is the sole -source manufacturer and supplier of the following item(s): P2 Stabilizer, P2 Rejuvenator, ROC, CWE-2, CWP & all P2 Road Primes. Each of our asphalt emulsion products is manufactured on site to the specifications of our proprietary formulas which are solely owned and manufactured by P Squared Emulsion Plants, LLC. I likewise assert that should P Squared Emulsion Plants, LLC cease to be the sole -source supplier of these proprietary products; I shall immediately make full disclosure in writing of all relevant facts and circumstances. IN WITNESS WHEREOF, the undersigned has executed this Affidavit on the 2nd day of November 2021. Seth McGinnis, C.E.O. (Signature) (Printed Name) (Title) SWORN TO AND SUBSCRIBED before me on November 02, 2021 by Seth McGinnis. -A<�—ralu 00 E f" LINDATEAKELL TSNotary Public, State of Texas °yr Comm. Expires 04-30.2024,:�� Notary ID 124782921 Notary Pu lic, State of Texas My Commission expires on April 30, 2024 P2Emulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 STATE OF Texas {} AFFIDAVIT COUNTY OF McLennan {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared Dane McGinnis 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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 Ihoun County prior to the official opening of this Bid. Affiant Printed Name and Title of Affiant Name of Bidder (Company) PSquared Emulsion Plants, LLC Address 516 South McLennan Loop, Elm Mott, TX 76640 Phone Number _[254) 829-0330 Fax Number 254 829-0337 Email Address �frce(u)w2emulsions com SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts above are true and correct, this 2nd contained in the day of November 20 ZI , — ,`"p'r"o"•• LINDATEAKELL Notary Public, State of Texas 14 Comm. Expires 04-30.2024 °•'i"" Notary '•,,,�;„" Notary ID 12478292t Public, State of ex, Apri130, 2024 Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: PSquaredEmulsion Plants, LLC Address: 516 South McLennan Loon Elm Mott, TX 76640 Remittance Address: 516 South McLennan Loop Elm Mott, TX 76640 Telephone: (254) 829-0330 Fax: (254) 829-0337 Email: Signatt Printec ORDER — CONTACT INFORMATION Order Contact Name & Title: David Williams. Area Sales Representative Order Contact Telephone: (361) 877-2584 Order Contact Fax: (254) 829-0337 Order Contact Email: david(a)p2emulsions.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: LindeeTeakell.Office Manager Contact Telephone: (254) 829-0330 Contact Fax: (254) 829-0337 Contact Email: lindeeAp2emulsions.com/office(a)p2emulsions.com 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: 2021-819257 Date Filed: 11/02/2021 Date Acknowledged: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. P Squared Emulsion Plants, LLC Elm Mott, 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. Calhoun County, Texas 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 NO. #2022.03 Annual Supply Road Materials and Asphalts, Oil and Emulsions, January 1, 2022 thru December 31, 2022 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 Lindee Teakell and my date of birth is My address is illillillimigmONE=, (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in McLennan County, State of Texas on the2nd day ofNovember2o21 . (month) (year) (A , I 1191a - ignature of authorizffi agent of contracting b6smess entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE DATE (MWODIYYYY) 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). TACT PRODUCER NAME: Blake Fribourg Arthur Blake Insurance PHONE No,Eat: (972)336-4115 pc No: (972)633-0477 850 Central Parkway East Ste 108 ADDRESS: blake@abigtexas.com Plano, TX 75074 INSURERISI AFFORDING COVERAGE NAIC# INSURED P Squared Emulsions, LLC & EMT Properties, LLC, INSURERS: Mercury Count Mutual Insurance Cc an Tlt' J Start at 55, LLC DBA P2 Emulsions INSURERC: Texas Mutual Insurance Com an 516 S Mclennan Loop INSURER D: Elm Mott, TX 76640-3586 INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 49 THIS )S 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. INSR LTR rypE OF INSURANCE ADDL INSD SUER POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE NIOCCUR 12/3112020 12131/2021 EACH OCCURRENCE S 1000000 DAMAGE TO RENTED PREMISES Ea..unence 5 100,000 MED EXP(Any one person) S 5000 PERSONAL It ADV INJURY 5 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JECT1:1 LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGGVS2,000,000 B AUTOMOBILE LIABILITY AUTO OWNED SCHEDULED ONLY X AUTOSXAUTOS ONLY X IRED AUTOS ONL� 01/03/2021 0110312022 OMBINEDSINGLELIMIT ffil000000_ANY BODILY INJURY (Per person) BOOILV INJURY (Per eccitlenl)XAUTOS PeOacErlRdenIDAMAGE A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 1213'1/2020 1213112021 EACH OCCURRENCE ,000,000 X AGGREGATE S 1,000,000 DED I X I RETENTIONS 10000 S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? FYI(Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 01/0312021 0110312022 X STATUTE ERH E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1e1, Additional Remarks Schedule, maybe attached If more space Is required) 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. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by CBF on 11/04/2021 at 11:06AM Tlevxasmutu , WORKERS' COMPENSATION INSURANCE Workers' Compensation and Employer's Liability Policy NCCI Canier Item 1 Insured name and address Producer 43564 Item 2 Item 3 Item 4 Information Page Insured copy P Squared Emulsion LLC r DBA: P2 Emulsions 516 S MCLENNAN LOOP ELM MOTT TX 76640-3585 Federal tax ID Entity Other workplaces not shown above 270114986 LLC See Schedule of Operations attached. Interim adjustment Annual FRIBOURG LLC Branch DBA: ARTHUR BLAKE INSURANCE GROUP 850 CENTRAL PKWY E STE 108 Dallas PLANO TX 75074.5561 Renewal of The policy period is from: 1/4121 To: 1/4122 12:01 a.m. standard time at the insured's mailing address A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Texas B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The Limits of our Liability under Part Two are: Bodily Injury by Accident $1,000,000.00 Each Accident Bodily Injury by Disease $1,000,000.00 Policy Limit Bodily Injury by Disease $1,000,000.00 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: None D. This policy includes these endorsements and schedules: see Schedule of Endorsements attached. The premium for this policy will be determined by our manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Payroll Premium Total payroll and estimated manual premium $700,000.00 $5,576.00 Description Factor Amount Waiver of Subrogation 112.00 Increased Limits Factor 1,000,000/1,000,00011,000,000 0.014 78.00 Increased Limits Balance to Minimum Premium ($150) 72.00 Schedule Modifier 0.670 (1,927.00) Healthcare Network Option 0.120 (469.00) Expense Constant 150.00 Total estimated annual premium $3,592.00 Minimum premium $250.00 Issue date: 12/31/20 Countersigned by Indudes copyright material of the National Council on Compensation Insurance, Inc used'W h Its permission &Copyright 2021 National Council of Compensation insurance, Inc. All rights reserved. PO Box 12058, Austin, TX 78711-2058 1 of 1 texasmutual.com 1 (800) 859-5995 1 Fax (800) 359-0650 WC 00 00 01 B 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. P Squared Emulsion Plants, LLC FORM CIO OFFICE USE ONLY Date Received 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.) Name of local government officer about whom the information is being disclosed. N/A 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? F]Yes XMNo 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 E�] 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. N/A Check this box if the vendor has given the local as described in Section 176.003(a)(2)(B), exc : officer or a family member of the officer one or more gifts described in Section 176.003(a-1). Form provided by Texas Ethics Commission www.ethics.state.tz.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. Dane McGinnis, Partner/CFO Name and Title of Authorized Agent November 02, 2021 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 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 Contractorf Squared Emulsion Plants, tcCcertifies 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 provisional U.S.C.,0801 at seq., apply to this certification and disclosure, if any. Of Dane McGinnis, Partner/CFO Printed Name and Title of Contractor's Authorized Official November 02, 2021 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 AVA b. grant N/A b. initial award N/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 N/A 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: Congressional District, if known: 6. Federal Department(Agency: 7. Federal Program Name/Description: N/A N/A CFDA Number, if applicable: N/A 8. Federal Action Number, ifknown: NIA 9. Award Amount, ifknown: N/A 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (f individual, last name, first name, MI): different frmn No. l0a) N/A (last name, first name, MI): N/A 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: Dan Ginnfs by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Partner/CFO U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: ,(254)829-0330Date:11/02/21 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, Dane McGinnis the undersigned representative of Representative P LYquared Emulsion Plants 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 associ�wns that exist to make a profit. Signature of Dane McGinnis, Partner/CFO Print Name & Title November 02 2021 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) 18 I certify that P Squared Emulsion Plants LLC is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized nt Dane McGinnis Partner/CFO Printed Name and Title of Authorized Agent November 02 2021 Date Form W-9 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.frs.gov/FormW9 for instructions and the latest information. send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. P Squared Emulsion Plants, LLC 2 Business name/dismgarded entity name, if different from above m3 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 a following seven boxes. certain entities, not individuals; see o ❑ Individual/sole proprietor or ❑ C Corporation p ❑ S Corporation ❑ Partnership ❑ TrusVestate instructions on page 3): ao single -member LLC Exempt payee code (if any) :79 ❑✓ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) 0-P o Note: Check the appropriate box in the line 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 the Exemption from FATCA reporting owner unless 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) •y is disregarded from the owner should check the appropriate box for the tax classification of its owner. o' ❑ Other (see instructions) ► (pples to accaunitmainlelneC wMide Me U.S.) v1 5 Address number, street, and apt. or suite no. See Instructions. ( P � ) Requester's name and address (optional) m to South McLennan LoopCalhoun 6 C 6 City, state, and ZIP coda County, Texas 211 S. Ann Street, 3rd Floor, Ste. 301 Elm Mott, Texas 76640 Port Lavaca, TX 77979 7 List account numbers) here (optionaQ •anpayOl rYCpulluduun Imurnoer giN) 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 1, 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 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 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, A are not required to sign the Rvifirntion, bA yyAmust provide your correct TIN. §gee the instructions for Part 11, later. Signature of Here I 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.irs.gov/Fcmfw9. 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 ► • 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), 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-9 (Rev. 10-2018) t WALLER COUNTY ASPHALT, INC. vrw lvlrl l LI\1/'iLJ N AND ASPHALTS, OILS AND EMULSIONS - ANNUAL SUPPLY &Nop BID NUMBER 202 Beginning January 1, 2022 and Enecember 31, 2022 N CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS Bid Number: 2022.03 January 1, 2022 thru December 31, 2022 Bidder's Name & Address WALL Pnf ►.rTc(pSPH�L_�i' �O In FAI uEb AjoS Ike-7viFZcAD —tx -nc�uc • 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 Pmrr oco IIRII� Page 1 of 8 Invitation To Bid Form -Annual Supply Contractfor 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/orJobsite LOCATION Unit MATERIAL DELIVERY MINIMUM TOTAL LOAD/ORDE Precinct 1 I Ton ' I I I , , i Precinct2 ; Ton I Precinct 3 Ton I I , Precinct 4-P ( Ton i I I I I [Precinct 4-5 i Ton i I 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 LOCATION Unit MATERIAL DELIVERY MINIMUM , I TOTAL LOAD/ORDER Precinct 1 ; Ton ' : _of 47 lb; I ' I , I I Bags on Pallet , I , • I i I I Precinct 2 I Ton I I I I I of 47 lb I I I Bags on Pallet , I I Precinct 3 I Ton iI I I I I _ of 47 lb 1 I , I Bags on Pallet I I , I I Precinct 4-P Ton I —of471b Bags on Pallet ? I i I i Precinct 4 Ton i i I , __of 471bi I i i i Bags on Pallet 1 I I 1 Page 2 of 8 Invitation To Bid Form -Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions --CONTINUED Bid 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 ToI I I I Precinct 2 Ton I ' , i I Precinct I Ton I I ' I I Precinct4-P I Ton ; I I I Precinct 4-5 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 TOTAL LOAD/ORDER I ' Precinct 1 I Ton I I ' I I I Precinct Ton , Precinct I Ton I I Precinct4-P i Ton I I Precinct4-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 I MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 I Ton I I Precinct 2 Ton I I I , Precinct I Ton ' I I I I , Precinct4-P I Ton I I I ' PrecinctL4-S I Ton , 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 MATERIAL I DELIVERY I TOTALI MINIMUM LOAD/ORDER 1 I Ton I i 2 ; Ton 1 3 Ton i 4-P I Ton 7-S Ton 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 LULA11UN Unit I Precinct_ I I Ton I Precinct 2 Ton I 'recinct 3 on 'recinct4P Ton I 'recinct 4-SI Ton MATERIAL I DELIVERY Item #10: Item 330, Type D (Pre -Mix Limestone) Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit i recinct 1 I I Ton recinct2 Ton •ecinct 3 � Tin ecincf4ecincf4PTon I ecinct 4-S I Ton MATERIAL I DELIVERY MINIMUM TOTAL I MINIMUM TOTAL LOAD/ORDER Page 4 of g 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 MATERIAL DELIVERY TOTAL InAnrnDne ct 1 I Ton Yard So lb RA I t2 i Ton i Yarda 501b Bai t3 Ton I Yarda I 1 50lh Fla, 4-P I Ton 1 Ynr,4a 1 501b Ban 4-S 1 Ton I I Yarrla 501b Bag Item #12: Item 334, Type D Hot Mix Cold Laid Asphalt Concrete Pavement Material must meet or exceed Item 334, 4.1.2JMF 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 I Unit I MATERIAL I DELIVERY TOTAL I MINIMUM LOAD 'recinct 1 Ton 30.S9 TovJS recinct 2 Ton q25 I 80 W I 5 is 9 ou 125 -roNs recinct 3 _— Ton { $ I Zi $3 I i f �3 ' -rotas recinct4-P Ton g$,w it f J 25 'ecinct4-S ; Ton 1. QQ 'P GV,� ; b Zie 'ZZ 96 TonlS 25 Tons 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 Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 i Ton Precinct 2 1 Ton Precinct 3 1 Ton 'recinct 4-P 1 Ton 'recinct 4-51 Ton Remarks: 300, Asphalts, Oils and Emulsions Item #14: Primer Oil Price per Rallon / delivery nrire to r�, int., c.mn^ Remarks: LOCATION Unit MATERIAL DELIVERY f::�T�OTALDEMURRAGE 1 Precinct 1 Gallon 1 1 1 1 ;$ Per Hour After ' '_ Free Hours Precinct 2 ; Gallon ' 1 1 1 i Per Hour After , i 1 Free Hours 1 Precinct 3 Gallon i 1 1 1 1 1$ Per Hour After Free Hours Precinct4-P Gallon � I �$ Per Hour After i 1_ Free Hours 1 1 1 1 i 1 1 Precinct4-S 1 Gallon ;$ Per Hour After F,QoW�,,,� Page 6 of 8 Invitation To Bid Form -Annual supply Contract for Rood 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 :;J;;RIAL:EDELIVERYTOTAL 1 1 Gallon i i i Gallon i Gallon i I -P I Gallon i I I S i Galion 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 I $ - Precinct 1 ' _1 Gallon I � r , 2 Gallon 4_P 'I Gallon 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 Aker Free Hours DEMURRAGE Free Hours Per Hour After Free Hours Per Hour Aker Free Hours I_ Free Hours I$ Per Hour After Free Hours Page 7 of 8 Invitation To Bid Form -Annual Supply Contract far 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 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 any official, employee or agent of Calhoun County in connection with 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: 1012-%12OZ1 Authorized Signature & Title: Type Name & Title of Authorized Signature: RE I D DAVV—CoM Y I Cc Vgeu Di4( Phone Number: Qg7—i5ri?%-7O%S Email: I/lr-09 eASP"UrWAI Exceptions and or Variations from Specifications and/or additional Notes: Page 8 of 8 STATE OF 'TiC {} AFFIDAVIT COUNTY OF WALUwR {} The undersigned certifies that the bid price contained in this bid has been carefully checked and is submitted as correct and final and if bid is accepted, agrees to pay for said lease upon the conditions contained in the Agricultural Lease, Specifications and General Conditions. BEFORE ME, the undersigned authority, on this day personally appeared lZeo Dftso J 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 bid 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 leases bid on, or to influence any person to bid or not to bid thereon. I affirm that I am duly authorized to execute this bid, 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 any official, employee or agent of Calhoun County in connection with the submitted bid. The contents of this bid as to price, 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. 2� Aff ant RE 1® DJAWS04 V 1 Ca ?Re511 aXr Printed Name and Title of Affiant Name of Bidder (Company) W ALLEY COUNTY ^SPdML� T f 1AX Address 22010 FAIRAIPWIPS ?4> e HQ%4M42P%b f'lY -nggS Phone Number 9W —92(o "%O%S' Fax Number Email Address IN A C WNS"J—T 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 o2 % day_o f'-��P - 20 21 . GLENDA DEGAGNE,Notary Public, State of TexasComm. Expires 02-15-2023 LE1111 NotaryPublic, State o� Notary ID 11174365 C Stamp/Seal My Commission Expires BIDDER INFORMATION Please Type. If handwritten, must be in ink and legible Bidder's Name: WAUZ-k douggY As?WLT, /AIC. Address: 22010 FiAWAIZoWiNS RZ ' ' 16 i' Remittance Address: -2oto FAIit. Uu.-iDS12D Telephone: 9'19 -8250 -702C Fax: Email: MI&E VVC4SPAALTebM Signature of Authorized Representative: Printed name of Authorized Rep: 20b DArr5a.1 ORDER -CONTACT INFORMATION Order Contact Name & Title: SAMDRA QM912EK OWIGE MAIJAF,a Order Contact Telephone: 97q-M-70—Js Order Contact Fax: Order Contact Email: Wfb @ WCASPHALT.Cor►'Q INVOICES -CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: S wbpA oAagg QPFICe MAMA&ZZ_ Contact Telephone: 6W - $Zfo-707S Contact Fax: Contact Email: JA1fb&_ NCASPKAL_r.dDWt 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. 2021-816969 Waller County Asphalt, Inc. Hempstead, TX United States Date Filed: 10/26/2021 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. 2022.03 Road Materials 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only N there is NO Interested Party. X 6 UNSWORN DECLARATIONI •�7��^1.w, My name Is RED U Jf, sO� and my date of birth Is it My address Is (street) (city) (state) (zip code) (country) 1 declare under penalty of perjury that the foregoing is true and correct. Executed in W A LLE-1- Cou V. state of on the _day of 6CM 20-7 _. (month) (year) GLE44DA DEGAGNE o:' G_Notary Pub116, State of Texas .:0Z Comm. Expires 02-15-2023 9',9iF••• ignature of au rized agent o business Notary ID 11174365 eclarant) NN- Forms provided by Texas Ethics Commission www.ethics.stateums Version V1.1.191b5cdc CERTIFICATE OF LIABILITY INSURANCE DATEtMMIDDIYyYY) 04/07/2021 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. If ------ '—"---^—•�• ••••° r••••�Y\•��1 ruues "-a' ""I IUNAL INSURED provisions or be endorsed. 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 Baty Worldwide NAME: ""Y'.+,ou,cy PHONE a/c Nu Exl : (713) 468-0700 9575 Katy Freeway ADDRIESS: 9ayl@batyins.con Suite N 450 INSURERS) Houston TX 77024 wsuRERa: Charter Oak Fire INSURED Waller County Asphalt, Inc., DBA: Waller County Asphalt INBURER E: Travelers Proped INBURER C: Toklo Marine S e p Waller County Construction, LLC.: Proline Materials, Inc. INSURER D: 22010 Fairground Rd. INSURER E: Hempstead TX 77415 INBURER F: COVERAGES CERTIFICATE NUMB • REVISION NUMBER: INDICATED, DINGANY REQUI M ER. THIS IS TO CERTIFY THAT ISTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY BE NOTWIT SUREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH PISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, INSR OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE NSo WVD POLICYNUMBER POLICY EFF POLICY EXP X COMMERCIAL GENERAL LIABILITY MMIDDIYYW MMIDDNYri LIMITS CLAIMS -MADE /� v OCCUR EACH OCCURRENCE $ 1,000,000 PREMISES Ea ocwlrence $ 300.000 A Wn MEDEXP(Any Onepersan) $ 5,000 GEN'LAGGREGATE LIMITAPpLI04/01/2021 04/01/2022 ER: PERSONAL aADVINJURY § 1.000,000 POLICY � PRO. LOC GENERALAGGREGATE $ 2,000,000 OTHER: PRODUCTS.COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY COM$ X ANYAUTO Ea accdeIDSINGLE LIMIT § 1,000,000 OWNED BODILY INJURY(Perpersan) $ B AUTOS ONLY AUTOSULED 04/01/2021 04/01/2022 BODILY INJURY (Per accltlen0 $ X HIREO NON -OWNED AUTOS ONLY X AUTOS ONLY PROPERTYPDAMAGE P$ X UMBRELLA LIAB X OCCUR $ B E%CESS LIAB EACH OCCURRENCE § 1,000,000 CLAIMS -MADE 04/01/2021 04/01/2022 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY YIN STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUOEDy ❑ NIA E.L. EACH ACCIDENT $ (Mandatary in NH) If yes, describe under E.L. DISEASE -EA EMPLOYEE S DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ C Pollution Liability MEN Contractors Pollution $1,000,000 03/15/2021 03/15/2022 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlflonal Remarae Schedule, may be allached if more space Is required) CERTIFICATE HOLDER .....__.. -_._-- Insured's Copy 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 ©1988-2016 ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD All rights reserved. Insured's Copy 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 ©1988-2016 ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD All rights reserved. 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. OFFICEUSEONLY 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 71h 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. 1J Name of vendor who has a business relationship with local governmental entity. NONG 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. JJbN E Name of Officer .ffJ 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? 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? ElYes r J o 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. AIOMGe 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 2-r'�- Sign ture oLlE;ndor doing business with the governmental entity1 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. VIaRaEsibeXIT Name and Title of Authorized Agent Signature of Authorized Agent 0 27 ZOZ1 We 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, W U� VoW A-WWt 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 o" f Contractor's Authorized Official RIFID.7 AWSCO VIlr P;!1E5ftx*rr Printed Name and Title of Contractor's Authorized Official / o /`Z7/2 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 oublic burden disclosure) 0348.0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: (8Ocontmct (rbid/ot%r/application d;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: S. If Reporting Entity in No. 4 is Subawardee, Enter _ Prime Subawardee Name and Address of Prime: Tier , if Known: WALIAL 40,jAnY ASPHALT, /wK - 2201��TfGuODS S "i'7t{41 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 name, first name, M& dierentfrom No. 10a) (last tame, 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 7 {—�� RWi representation of fact upon which reliance was placed Print Name:. D ter+Mt/$O� by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title:yA cr pocsf o&-r U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: qn M-707S Date: (O 2 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, RE)b bAK5cJ the undersigned representative of Representative IA/AIIAM 6010Y ASPiA T, Nc (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 far -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 n' ofof Representative RRiab bAvys&JI V ICc PusiDer rr Print Name & Title /O /Z7 ®ZO24 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. ❑ I 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) III certifythat.WAL1.ELCW91Y 45PMCG JOC is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Si nature of Authorized Agent BET b bAWSc J V I W ?R;-S'Wmrr Printed Name and Title of Authorized Agent /0127 /`?Az I Date W-9 Request for Taxpayer Give Form to the Form (Rev. October2018) Identification Number and Certification requester. Do not IOein�Revenus Service ry ► Go to www.lrs.gav1FannW9 for instructions and the latest information. send to the IRS. 1 Name tum).. Name is required on this line; do not leave this line blank (ass sham on your Income tax reet.S WALLGR Wt%n r 1 ^MIAL-14C.. 2 Business nameldisragardedentity nameifdiftemntfrom above m 3 Check appropriate boxlorfederel tax classification ofthe person whom name is entered online 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain enift1m, not IndMduals; No a c - ,--, ❑ Individuaysole proprietor or 130 Corpnretion ❑ SCorporatlon ❑ Partnership ❑ Trusvestate Instructions on page 3): I single -member LLC Exempt paym code(dany) Be ❑ Umfied liability company. Enter the lax classification (C=C corporation. 5=S corporation, P=Pednerehip)► `0 2 Note: Chockthe appropriate box in the line above forthetexclasaiflce8on ofthe single-memberoxmer. Donotcbwk Exemption from FATCA reporting 1: a LLC if the LLC is classified as a single- member LLC that is dlsragardecifram the owner unless 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 o g Is disregarded from the owner should check the appropriate box for the tax classification of its owner. 4y ❑ Other (am Instructions) ► f^ccrmw.avwms,aw•�,ua, N•aaJ y 5 Address (number, street, and apl. orsuite no.) See instructions. Requester's name and address (optional) 7220i9 CALHOUN COUNTY ur 202 S ANN ST, PORT LAVACA TX 77979 a City, state, and ZIP code Hem mmb I—m —n449 361-553-4610 FAX: 361-553.4614 7 Ust account numbers) here (optional) ggan Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on line Ito avoid Social security number stsecurity number (SSM. However, fora backup alien, sole For Individuals, this Is d entity, resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, Teter. For other se the Instructions _ m -� entitles, x Is your employer Identification number (EIhM- If you do not have a number, see How to gat a TIN, later, or Note: If the account is in more than one name, see the Instructions for line 1. Also sea What Name and I Employer Identification number Number To Give the Requester for guidelines on whose number to enter. n7 jar Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer Identification number (or I am wafting for a numberto 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 mass 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, acqulsttlon or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you ere not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. algn Signature of i Here UA.pereon► / ® Date► /® ,27 /2�®'ZI 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.gov1FbrmW9. 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 identification number (FfIN), adoption taxpayer Identification number (ATIM, or employer identification number (EIM, 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), 109E-E (student loan Interest), 1098-T (tuNon) • 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) November 18, 2021 To: Judge Meyer From: The office of the County Auditor Please place the following item on the Commissioners Court Agenda for November 24, 2021: Consider and take necessary action to award the bids forthe Annual Supply Contract for Road Materials and Asphalts, Oils and Emulsions, Bid Number 2022.03 for the period beginning January 1, 2022 and ending December 31, 2022. RE: Road Materials and Asphalts, Oils and Emulsions f %_ Annual Supply Contract t l(J Bid Number 2022.03 Period beginning January 1, 2022 and ending December 31, 2022 Baseline Price for Fuel Adjustment on Delivery Price on November 8, 2021= $3.482 Bids were opened at 2:00 PM, Tuesday, November 9, 2021. Nine (9) bids were received: 1. BLADES GROUP, LLC 2. CLEVELAND ASPHALT PRODUCTS, INC. 3. COLORADO MATERIALS LTD 4. K-C LEASE SERVICE, INC. dba MATAGORDA CONSTRUCTION & MATERIALS 5. MARTIN PRODUCTS SALES, LLC dba MARTIN ASPHALT COMPANY 6. MIDTEX MATERIALS, LLC 7. P SQUARED EMULSION PLANTS, LLC 8. QUALITY HOT MIX, INC. 9. WALLER COUNTY ASPHALT, INC. The following Bids did not Meet Specifications: 1. Colorado Materials, LTD • The Disclosure of Lobbying Activities Form was marked "NA" but was not signed and dated as instructed in five different places in the Invitation to Bid Packet, which includes the specifications. 2. Martin Products Sales, LLC dba Martin Asphalt Company • The Certification Regarding Debarment & Suspension & Other Responsibility Matters Form was checked that they were unable to certify to the statements on the form but they did not attach an explanation as required. Need to review the Additional Information and Charges stated on a separate page for: P Squared Emulsion Plants, LLC a) Delivery over 250 miles subject to additional charges b) Pump Charge (trucking charge) $80.00 c) Push Charge (trucking charge) $80.00 per hour d) Return Loads (trucking charge) subject to charge from delivering freight line The following bidders submitted a bid on Alternate Items — Need to Review: 1. P Squared Emulsion Plants, LLC • Review the bid for Primer Oil (may be the same item) — Bid was for P2 Prime Concentrate Bid P2 CWE-2 for CRS-2 Waller County Asphalt, Inc. • Bid ASPPM 9202 Grade IV High Performance Cold Mix for Item 334, Type D, Hot Mix Cold Laid Asphalt Concrete Pavement NOTE: Bids that met specifications and appear to be Low Bids are highlighted in Yellow Please Review Tie bids for the following (page 2 of 11): • Bid Item #2: Item 247, Type A Limestone, Grade 2 [1 % Inch] No bids on the following: • Bid Item #4: Item 275, Cement • Bid Item #7: Item 302, Type PE, Grade 3 (Pre -Coated Rock) • Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) ■ Bid Item #10: Item 330, Type D (Pre -Mix Limestone) in1 P2 Emulsions V"pf P Squared Emulsion Plants - November 2, 2021 Prices subject to change with written notice P2 Salesman - David Williams Contact Phone - (361) 877-2584 Product Tanker FOB Plant Tanker FOB County Drum/Tote Plant P2 Stabilizer $2.44 $2.69 $2.64 P2S1 $2.44 $2.69 $2.64 �P2CWE-2 $2.74 $2.99 $2.94 (Chip Seal) P2 CWP $2.74 $2.99 $2.94 (Cold Weather Patch) P2 ROC $2.57 $2.82 $2.77 (Road Over Coat) P2 Rejuvenator $2.44 $2.69 $2.64 P2 Prime Concentrate $1.79 $2.04 $1.99 P2RTU $1.75 $2.00 $1.95 'All listed prices are per U.S. gallon **Minimum Tanker Delivery: 5,000 Gallons **Delivery over 250 miles subject to additional charges **Demurrage (trucking charge): First 2 hours free, $80.00 per hour thereafter **Pump Charge (trucking charge): $80.00 **Push Charge (trucking charge): $80.00 per hour **Return Loads (trucking charge): Subject to charge from delivering freight line **Smaller Quantities Available, Subject to Freight Differential of $0.251gal less than 5,000 gal Containers available for smaller product amounts "Tote" Containers (275 gallons size each) cost $100.00 per container "Drum" Containers (55 gallons size each) cost $35.00 per drum Containers are re -usable and can be rinsed out, brought back and re -filled at customer discretion Containers priced individually and sold only with orders for material Thank you and we look forward to serving all your emulsion needs! PHmulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 (PD P2 Emulsions Date: November 02, 2021 To: Calhoun County Subject: P Squared Emulsion Plants LLC Sole Source Products This communication serves as certification that all products listed below are produced in accordance with the State of Texas' Sole Source requirements according to the proprietary formulas and specifications of P Squared Emulsion Plants LLC. Our proprietary products conform to the formal definition of "a confidential formulation usually containing two or more ingredients and about which information is not in the public domain" and as such, P Squared Emulsion Plants LLC is the only manufacturer and distributor of said products. P Sauared Emulsion Plants LLC Products: "P2 Stabilizer" Our P2 Stabilizer is an asphalt emulsion that is incorporated into existing soil or base material to provide increased base strength and stability. P2 Stabilizer eliminates the need for additional material such as aggregates, lime, cement or other additives. The utilization of P2 Stabilizer results in increased base density and hardness without sacrificing the flexibility and waterproof properties of asphalt. "P2 Rejuvenator" Our P2 Rejuvenator is engineered to rejuvenate old asphalt roads, RAP and other millings with residual asphaltic content. A one-time application will rejuvenate the existing material through softening oxidized pavement materials and re -binding asphalt to revitalize the road base. "P2 ROC" Our P2 ROC is engineered to seal and protect existing road surfaces. Our "Road Over Coat" is a proven sealing solution that locks down loose chip seal aggregate while sealing oxidized and cracked surfaces. ROC is designed to be traffic safe in under an hour resulting in a uniform, black road surface. "CWE-2-No Bleed Chip Seal" Our unique chip seal formula exhibits superior performance when compared to commodity type CRS-2 emulsions. CWE-2 can be applied in a broader range of temperatures (10-20 degrees below other products) and WILL NOT BLEED under extreme summer temperatures. "CWP — Pothole Patch" This emulsion is specifically formulated to work in ALL patch machines, ALL year round with the exact same results. Smooth consistency, no bleed finish and extremely low clog rates differentiate CWP from all other patch materials. "P2 Prime Concentrate" We have several proprietary "ready -to -use" formulas that include prime, tack and dust control products that all derive from our P2 Prime Concentrate. Based on application, customer needs and dilution rates; we have something for literally every road across the state of Texas. **All P Squared Emulsion Plants LLC proprietary products fulfill the formal requirements found in Texas Local Government Codes regarding county purchasing, Section 2G2.0247.A. (Available upon requed) *All P Squared Emulsion Plants LLC proprietary products are fully TCEQ and EPA compliant All of us at P Squared thank you for the opportunity and we look forward to serving all your emulsion needs! PHmulsions.com • 516 South McLennan Loop • Elm Mott, Texas 76640 • 254-829-0330 CALHOON COUNTY, TEXAS BID TABULATION ROAD MATERIALS AND ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT, BID NUMBER: 2022.03 For the Period Beginning January 1, 2022 and Ending December 31, 2022 BASELINE PRICE FOR FUEL ADJUSTMENT ON DELIVERY PRICE: $3.482 on November 8, 2021 (www.eia.gov/petroleum/gasdiesel) (Gulf Coast Area) Bids that met specifications and appear to be Low Bid are highlighted in Yellow - Please Review Tie Bids: In the event of Tie Bids, the winning bid is determined per Texas Local Government Code 262.027(b). ROAD MATERIALS 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 $12.00. $18.40 $30.40 24TONS QUALITY HOT MIX, INC. NOTE: ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct Ton $12.00 $18.40 $30.40 24TONS Precinct Ton $12.00 $18.40 $30.40 24TONS Precinct 4-P Ton $12.00 $19.00 $31.00 24TONS Precinct 4-S Ton $12.00 $18.40 $30.40 24TONS Precinct 1 Ton $5.50 $25.00 $30.50 25 TONS K-C LEASE SERVICE, INC. dba MATAGORDA CONSTRUCTION & MATERIALS Precinct 2 Ton $5.50 $25.00 $30.50 25 TONS Precinct 3 Ton $5.50 $25.00 $30.50 25 TONS Precinct 4-P Ton 1 $5.50 $25.00 $30.50 25 TONS Precinct 4-S Ton $5.50 $25.00 $30.50 25 TONS Precinct 1 Ton $6.00 $28.00 $34.00 24 TON MIDTEX MATERIALS, LLC Precinct 2 Ton $6.00 $28.00 $34.00 24 TON Precinct 3 Ton $6.00 $28.00 $34.00 24 TON Precinct 4-P Ton $6.00 $30.00 $36.00 1 24 TON Preclnct4-5 I Ton $6.00 $28.00 $34.00 24 TON Page 1 of 11 Tie Bids: In the event of Tie Bids, the winning bid is determined per Texas Local Government Code 262.027(b). 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 $12.00 $18.00 $30.00 24 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $12.00 $18.00 $30.00 24 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $12.00 $18.00 $30.00 24 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED - Precinct 4-P Ton $12.00 $18.00 $30.00 24 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $12.00 $18.00 $30.00 24 TONS Precinct 1 Ton $5.00 $25.00 $30.00 25 TONS K-C LEASE SERVICE, INC. dba Precinct 2 Ton $5.00 $25.00 $30.00 25 TONS Precinct 3 Ton $5.00 $25.00 $30.00 25 TONS MATAGORDA CONSTRUCTION &MATERIALS Precinct4-P Ton $5.00 $25.00 $30.00 25TONS Precinct 4-S Ton $5.00 $25.00 $30.00 25 TONS Precincts Tan $6.00 $28.00 $34.00 24 TON MIDTEX MATERIALS, LLC Precinct 2 Ton $6.00 $28.00 $34.00 24 TON Precinct 3 Ton $6.00 $28.00 $34.00 24 TON Precinct 4-P Ton $6.00 $30.00 $36.00 24 TON Precinct 4-S Ton $6.00 $28.00 $34.00 24 TON Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $19.75 $8.84 $28.59 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Location: Nursery, TX Precinct 2 Ton $19.75 $8.84 $28.59 24 DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $19.75 1 11.68 $31.43 24 marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Ton $19.75 $11.05 $30.80 24 specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-5 Ton $19.75 $9.82 $29.57 24 Page 2 of 11 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 $12.00 $19.00 $31.00 24 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $12.00 $19.00 $31.00 24 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $12.00 $19.00 $31.00 24 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $12.00 $19.00 $31.00 24 TONS & PROVIDED IF AVAILABLE. Precinct4-S Ton $12.00 $19.00 $31.00 24TONS Precinct 1 Ton $6.00 $28.00 $34.00 24 TONS MIDTEX MATERIALS, LLC Precinct 2 Ton $6.00 $28.00 $34.00 24 TONS Precinct 3 Ton $6.00 $28.00 $34.00 24 TONS Precinct 4-P Ton $6.00 $30.00 $36.00 24 TONS Precinct 4-S Ton $6.00 $28.00 $34.00 24 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $19.75 $8.84 $28.59 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications specifications Material Location: Nursery, TX Precinct 2 Ton $19.75 $8.84 $28.59 24 ------------------------------------------------- DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $19.75 $11.68 $31.43 24 marked "NA" BUTwas not signed and dated as instructed in 5 different places in the Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Ton $19.75 $11.05 $30.80 24 specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $19.75 $9.82 $29.57 24 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 _ of 47 Lb Bags on Pallet Page 3 of 11 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 $53.00 $9.00 $62.00 25 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $53.00 $9.00 $62.00 25 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $53.00 $9.00 $62.00 25 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $53.00 $9.00 $62.00 25 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $53.00 $9.00 $62.00 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $40.00 $24.96 $64.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $40.00 $24.63 $64.63 24 ---------------------- DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 3 Ton $40.00 $25.64 $65.64 24 Disclosure of Lobbying Activities Form was marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Precinct 4-P Ton $40.00 $28.17 $68.17 24 Invitation to Bid Packet, which includes the specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Tan $40.00 $26.14 $66.14 24 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 $53.00 $9.00 $62.00 25 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $53.00 $9.00 $62.00 25 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 1 Ton $53.00- 1 $9.00 1 $62.00 25 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $53.00 $9.00 $62.00 25 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Tan $53.00 $9.00 $62.00 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $40.00 $24.96 $64.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $40.00 $24.63 $64.63 24 _________________________________________________ DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 3 Ton $40.00 $25.64 $65.64 24 Disclosure of Lobbying Activities Form was Did Not Meet Did Not Meet Did Not Meet marked "NA" BUT was not signed and dated Specifications Specifications Specifications as instructed in 5 different places in the Precinct 4-P Ton $40.00 $28.17 $68.17 24 Invitation to Bid Packet, which includes the specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $40.00 $26.14 $66.14 24 Page 4 of 11 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 NO BIDS RECEIVED Precinct 2 Ton Precinct 3 Ton Precinct 4-P Ton Precinct 4-S Ton Bid Item #8: Item 302, Type PE, Grade 4 (Pre -Coated Rock) *Material Source out of LOCATION Unit MATERIAL DELIVERY TOTAL MINIMUM LOAD/ORDER BIDDER AND REMARKS, IF ANY Precinct 1 Ton NO BIDS RECEIVED Precinct 2 Ton Precinct Ton Precinct4-P Ton Precinct 4-S Ton Intentionally Left Blank - Continued on next page Page 5 of 11 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 $17.00 $25.00 $42.00 25 TONS K-C LEASE SERVICE, INC. dba Precinct 2 Ton $17.00 $25.00 $42.00 25 TONS Precinct 3 Ton $17.00 $25.00 $42.00 25 TONS MATAGORDA CONSTRUCTION Precinct 4-P Ton $17.00 $25.00 $42.00 25 TONS & MATERIALS Precinct 4-S Ton $17.00 $25.00 $42.00 25 TONS Precinct Ton $26.50 $23.50 $50.00 24 TONS QUALITY HOT MIX, INC. Precinct 2 Ton $26.50 $23.50 $50.00 24 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton $26.50 $23.50 $50.00 24 TONS TRAILERS. Precinct 4-P Ton $26.50 $23.50 $50.00 24 TONS BELLY DUMP TRAILERS CAN BE REQUESTED & PROVIDED IF AVAILABLE. Precinct 4-S Ton $26.50 $23.50 $50.00 24 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $30.00 $24.96 $54.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $30.00 $24.63 $54.63 24 _________________________________________________ DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $30.00 $25.64 $55.64 24 marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Ton $30.00 $28.17 $56.17 24 specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $30.00 $26.14 $56.14 24 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 NO BIDS RECEIVED Precinct 2 Ton Precinct Ton Precinct 4-P Ton Precinct 4-S Ton Page 6 of 11 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 1 Ton $71.17 $47.45 $118.62 24 TONS BLADES GROUP LLC Yard $83.98 $55.99 $139.97 22 CU YDS r5O I b Bag - $14.00 $0.00 $14.00 1PALLET -62BAGS Precinct 2 Ton $70.97 $47.31 $118.28 24 TONS Yard ` $83.74 $55.83 $139.57 22 CU YDS 50 lb Bag $14.00 $0.00 $14.00 1 PALLET - 62 BAGS Precinct 3 Ton $72.62 $48.41 $121.03 24 TONS Yard $85.69 $57.13 $142.82 22 CU YDS 50 lb Bag $14.00 $0.00 $14.00 1 PALLET-62 BAGS Precinct 4-P Ton $73.13 $48.76 $121.89 24TONS Yard $86.30 $57.53 $143.83 22 CU YDS 50 lb Bag $14.00 $0.00 $14.00 1 PALLET- 62 BAGS Precinct 4-S Ton $71.17 $47.45 $118.62 24 TONS Yard $83.98 $55.99 $139.97 22 CU YDS 50 lb Bag $14.00 - $0.00 $14.00 1 PALLET- 62 BAGS Intentionally Left Blank - Continued on next page Page 7 of 11 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. Precinct 2 Ton $75.00 $9.00 $84.00 25 TONS NOTE: ALL DELIVERIES ARE IN END DUMP Precinct 3 Ton 1 $75.00 1 $9.00 1 $84.00 1 25 TONS TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED Precinct 4-P Ton $75.00 $9.00 $84.00 25 TONS & PROVIDED IF AVAILABLE. Precinct 4-S Ton $75.00 $9.00 $84.00 25 TONS Precinct 1 Ton $88.00 $30.59 $118.59 25 TONS WALLER COUNTY ASPHALT, INC. BID ALTERNATE ITEM: Precinct 2 Ton $88.00 $31.51 $119.51 25 TONS Precinct 3 Ton $88.00 $27.83 $115.83 25 TONS BID FOR ASPPM 9202 GRADE IV HIGH PERFORMANCE COLD MIX Precinct 4-P Tan 1 $88.00 $35.19 1 $123.19 1 25 TONS Precinct 4-S Ton $88.00 $34.96 $122.96 25 TONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 1 Ton $69.00 $24.96 $93.96 24 COLORADO MATERIALS, LTD Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Material Source: New Braunfels, TX Precinct 2 Ton $69.00 $24.63 $93.63 24 _________________________________________________ DID NOT MEET SPECIFICATIONS Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Disclosure of Lobbying Activities Form was Precinct 3 Ton $69.00 $25.64 $94.64 24 marked "NA" BUT was not signed and dated Did Not Meet Did Not Meet Did Not Meet as instructed in 5 different places in the Specifications Specifications Specifications Invitation to Bid Packet, which includes the Precinct 4-P Tan $69.00 $28.17 $97.17 24 specifications. Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Precinct 4-S Ton $69.00 $26.14 $95.14 24 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 $26.00 $58.00 $84.00 24 TON MIDTEX MATERIALS, LLC Precinct 1 Ton $26.00 $58.00 $84.00 24 TON Precinct 3 Ton $26.00 1 $58.00 $84.00 24 TON Precinct4-P Ton $26.00 $60.00 $86.00 24 TON Precinct 4-S Ton $26.00 $58.00 $84.00 24 TON Page 8 of 11 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 Per Hour Precinct 1 Gallon $2.20 $0.20 $2.40 After 2 Free Hours CLEVELAND ASPHALT $80 Per Hour Precinct 2 Gallon $2.20 $0.20 $2.40 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80 Per Hour load, for smaller quantities please call Precinct 3 1 Gallon $2.20 1 $0.20 $2.40 After 2 Free Hours 800-334-0177. $80 Per Hour Diluted material can not be returned for Precinct 4-P - Gallon $2.20 $0.20 $2.40 After 2 Free Hours credit. $80 Per Hour Precinct 4-S Gallon $2.20 $0.20 $2.40 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour MARTIN PRODUCTS SALES LLC Precinct Gallon $2.85 $0.18 $3.03 After 2 Free Hours dba MARTIN ASPHALT COMPANY Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 2 Gallon $2.85 $0.18 $3.03 After 2 Free Hours MC-30 5000 gallon minimum Did Not Meet Did not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour ------------------------------------------------- Precinct 3 Gallon $2.85 $0.16 $3.01 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specification Specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-P Gallon $2.85 $0.21 $3.06 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.85 $0.19 $3.04 After Free Hours P SQUARED EMULSION $80 Per Hour PLANTS LLC Precinct 1 Gallon $2.04 n/a $2.04 After 2 Free Hours P2 PRIME CONCENTRATE $80 Per Hour r. Please see attached equivalent Precinct 2 Gallon $2.04 n/a $2.04 After 2 Free Hours and/or superior product information and Sole Source Affidavit. '• P Squared is proudly recognized and accepted $80 Per Hour by Tarrant County Co -Op. Precinct 3 Gallon $2.04 n/a $2.04 After 2 Free Hours SEE ATTACHED INFOROMATION FOR ADDITIONAL CHARGES $90Per Hour Minimum Tanker Delivery: 5,000 Gallons; Precinct 4-P Gallon $2.04 n/a 1 $2.04 lAfter2Free Hours Delivery over 250 miles subject to additional charges; Pump Charge (trucking charge) $80.00; $80 Per Hour Push Charge (trucking charge) $80.00 per hour; Return Loads (trucking Charge) Subject to charge Precinct4-S Gallon $2.04 n/a $2.04 After 2 Free Hours from delivering freight line Page 9 of 11 Bid Item #15: RC-250 LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE BIDDER AND REMARKS, IF ANY $80.00 Per Hour Precinct 1 Gallon $3.45 $0.20 $3.65 After 2 Free Hours CLEVELAND ASPHALT $80.00 Per Hour Precinct 2 Gallon $3.45 $0.20 $3.65 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80.00 Per Hour load, for smaller quantities please call Precinct 3 Gallon $3.45 $0.20 $3.65 After 2 Free Hours 800-334-0177. Diluted material can not be returned for $80.00 Per Hour credit. Precinct 4-P Gallon $3.45 $0.20 $3.65 After 2 Free Hours $80.00 Per Hour Precinct 4-S Gallon $3.45 $0.20 $3.65 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 1 Gallon $2.75 $0.18 $2.93 After 2 Free Hours MARTIN PRODUCTS SALES LLC dba Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications specifications $70 Per Hour MARTIN ASPHALT COMPANY Precinct 2 Gallon $2.75 $0.18 $2.93 After 2 Free Hours 5000 gallon minimum Did Not Meet Did not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 3 Gallon $2.75 1 $0.16 $2.91 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specification Specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-P Gallon $2.75 $0.21 $2.96 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.75 $0.19 $2.94 After 2 Free Hours Intentionally Left Blank- Continued on next page Page 10 of 11 Bid Item #16: CRS-2 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 CLEVELAND ASPHALT $80.00 Per Hour Precinct 2 1 Gallon $2.00 1 $0.20 $2.20 After 2 Free Hours PRODUCTS, INC. Prices based on minimum 5000 gallon $80.00 Per Hour load, for smaller quantities please call Precinct 3 Gallon $2.00 $0.20 $2.20 After 2 Free Hours 800-334-0177. $80.00 Per Hour Diluted material can not be returned for Precinct 4-P Gallon $2.00 $0.20 $2.20 After 2 Free Hours credit. $80.00 Per Hour Precinct 4-S Gallon $2.00 1 $0.20 $2.20 After 2 Free Hours Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 1 Gallon $2.00 $0.18 $2.18 After 2 Free Hours MARTIN PRODUCTS SALES LLC dba Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour MARTIN ASPHALT COMPANY Precinct 2 Gallon $2.00 $0.18 1 $2.18 After 2 Free Hours 5000 gallon minimum Did Not Meet Did not Meet Did Not Meet Did Not Meet Specifications Specifications Specifications Specifications $70 Per Hour Precinct 3 Gallon $2.00 $0.15 $2.16 After 2 Free Hours DID NOT MEET SPECIFICATIONS The Certification Regarding Debarment & Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications Specifications Specification Specifications $70 Per Hour Suspension & Other Responsibility Matters Precinct 4-P Gallon $2.00 $0.21 $2.21 After 2 Free Hours Form was checked that they were Unable to Certify to the statements on the form BUT Did Not Meet Did Not Meet Did Not Meet Did Not Meet Specifications P Specifications Specifications Specifications $70 Per Hour they Did Not attach an explanation Precinct 4-S Gallon $2.00 $0.19 $2.19 After 2 Free Hours P SQUARED EMULSION $80.00 Per Hour Precinct 1 Gallon $2.99 n/a $2.99 After 2 Free Hours PLANTS LLC P2 CWE-2 $80.00 Per Hour ** Please see attached equivalent Precinct 2 Gallon $2.99 n/a $2.99 After 2 Free Hours and/or superior product information and Sole Source Affidavit. ** P Squared is proudly recognized and accepted $80.00 Per Hour by Tarrant County Co-op. Precinct 3 Gallon $2.99 n/a $2.99 After 2 Free Hours SEE ATTACHED INFOROMATION FOR ADDITIONAL CHARGES $80.00 Per Hour Minimum Tanker Delivery: 5,000 Gallons; Precinct4-P Gallon $2.99 n/a $2.99 After 2 Free Hours Delivery over 250 miles subject to additional charges; Pump Charge (trucking charge) $80.00; Push Charge (trucking charge) $80.00 per hour; $80.00 Per Hour Return Loads (trucking Charge) Subject to charge Precinct 4-5 Gallon $2.99 n/a $2.99 After 2 Free Hours from delivering freight line Page 11 of 11 # 17 c NOTICE OF MEETING— 11/24/2021 17. Consider and take necessary action on a charge made by Judge Alex Hernandez on his County credit card in the amount of $230.40 to Magnum Steno Inc. for a Magnum Steno Beginning Theory, 4t' Edition Steno book. (RHM) Cindy Mueller, Rhonda Kokena and Sara Rodriguez explained their concerns. Commissioners agreed this charge would be approved, but a formal policy needed to be in place for similar situations in the future. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioners Pct 1 SECONDER: Vern Lyssy, Commissioners Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 13 of 28 Consider and take necessary action on the charge made by Judge Hernandez on his County credit card in the amount of $230.40 to Magnum Steno Inc. for a Magnum Steno Beginning Theory, 4`h Edition Steno book. Student Books and Equipment Purchase List Books: Course: Theory You will need this for the first day of class. Magnum Steno Theory book You can purchase this at www.magnumsteno.com, Store You may use the student discount code of stu644 for your book purchase. Course: Medical Terminology You will need this in your second quarter. Medical Terminology: A Short Course (5th edition) by Davi- Ellen Chabner. *MUST BE THE 5th Edition You can purchase this on Amazon, Ebay, or any online book retailer. Price can vary depending on if you buy it new or used. Course: English Terminology This is an optional purchase and not required for the course. If you would like to use it to supplement the course, you will not use it until your second quarter of Theory. How to SU It and Write It Correctly NOW (2" Edition) by Dr. Santo J. Aurelio. **MUST BE THE 2nd Edition You can search the same online retailers for copies of this book. Price may vary. Eauinment: (You will need these for your first day of class.) Laptop: 1. Must NOT be a Mac or a netbook. MUST run on Windows, Vista, 7,8, or 10 2. Should have at least one USB port, 8 GB or more of RAM, at least a 256 GB SSD drive, and a 2.0+ GHz processor. 3. Microsoft Office and PDF reader required. CAT Software: DigitalCAT student software can be purchased at www.stenovations.com Writer: (You may use any make/model of writer as long as it has the required features below; whether it is a professional/student writer and/or new/used, is your preference choice.) Required features: 1. Extended asterisk key to the right; 2. Extended -DZ keys; 3. Realtime cable. Recommend Writer models and purchasing sites: Recommended models: Luminex/Luminex CSE, Wave, Diamante Recommended purchasing sites: www.stenograuh.com www.acculaw.com www.stenoworks.com Kimi's Court Reporter Thrift Shop — Facebook Group Online Non -Live Student A non -live online student is one who cannot attend live class times, and chooses to watch class videos online of the day's previously recorded class. You are held accountable for when you watch them and get the homework done. This is done at your individual convenience. *On Site and Online Live Class term begins in September of each year. If you would like to enroll at any other point in the year and not wait for September, your learning option is to be a Non -Live Online Student. As a non -live online student, you are able to begin the program the beginning of any quarter after completing the enrollment process. Cost of Tuition Tuition is the same across the board regardless of the type of student (online, onsite) you choose to be. Beginning Students $500/month for beginning students who have NOT completed a Theory. ** Please note: this price does NOT decrease once you have completed our Theory classes. The price remains $500 until you have completed the program. ** CALHOUN COUNTY 202 S. ANN STE. A CHECK REQUISITION/ PORT LAVACA, TX 77979 PURCHASE ORDER CITIBANK CORPORATE CARD A S t d' cVvunt tatemm Commerical Card Account ALEX HERNANDEZ Account Inquiries: Toll Free: 1-(800)-248-4553 International: 1-(9D4).954-7314 Account Number: XXXX XXXX_XXXX-4717 TDDITTY: 1-(677)-505-7276 Send Notice of Billing Errors and Customer Service Inquiries to: CITIBANK, N.A., PO BOX 6125, SIOUX FALLS SD 57117-6125 Transactions rvoice. For your records only. $5.000 i:asn Advance Lima $0 Statement Closing Date 11/03/2021 Days In Billing Period 31 Post Tmns Date Date MCC Reference Number Descriptionn-ocation Amount . ........... *'-"" NOTICE MEMO ITEM(S) LISTED BELOW """•"•"'•'•••••• 1QM9 10f19 59W 02-VW41292500213847761 1 MAGNUMSTENOINC 713-837-6595 TX 77095 USA 230A0 Oct-18-2021 11:52 TOTAL AMOUNT OF MEMO ITEM(S): $230At CALHOUN COUNTY TREASURER NOV - 8 2021 DATE RECEIVED NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION CI t' • CITIBANK N.A. PO BOX 6125 SIOUX FALLS SD 57117-6125 ALEX HERNANDEZ STE A 202 S ANN ST PORT LAVACA TX 77979-4204 Page 1 of 2 Account Number Statement Closing Date 00007753246 XXXX-XXXX-XXXX-4717 November 03, 2021 Not an Invoice. For your records only. �ils!!(�IiF ore n .._'ten® Slaw^r - Wrlre Fosr Order Information - Order #9002 Qz y. ill 10W Y' I ae "t 1 ea. Magnum Steno Beginning Theory, 4th Edition $249.00 Status History & Comments Fate Orrtlar 3.tt'W' €.o;'mww 10/18/2021 New Delivery Address Karesh Kartchner 211 Ann St Floor 2 Ste 201 Port Lavaca, Texas 77979 United States Shipping Method Zone Rates (Shipping to US (1 x 4.00lb(s))) Search I Advanced Search Order Date: Monday 18 October, 2021 1 Sub Total: $249.00 Zone Rates (Shipping to US (1 x 4.00lb(s))): $14.99 Discount Coupon: stu644 :-$50.00 Tax: $16.41 Total: $230.40 Billing Address Karesh Kartchner 608 S LAVACA Port Lavaca, Texas 77979 United States Payment Method Credit Card Search_! Advanced Search .._,tempA-:'? ,-r - Write Fosr' Thank You! We Appreciate your Business! Your Order Number Is: 9002 Thank you for shopping. Please click the Log Off link to ensure that your receipt and purchase Information Is not visible to the next person using this computer. You can view your order history by going to the My Account page and by clicking on "View All Orders". 0 Please direct any questions to customer service. Thanks for shopping with us online! v ,,.,,:,, "r1:,1, _ ,..,,,:, ".M.m Call Now: 713-837-5595 Horne Page A'rithig Short Contact Us View Store FAQ Testimonials This is the place where court reporters and students GAIN SPEED AND ACCURACY!! Blessed be the LORD my strength which teacheth my hands to war, and my fingers to fight. - Psalms 144:1 May the favor of the Lord our God rest on us; establish the work of our hands for us -- yes, establish the work of our hands. - Psalms 90:17 Click here for free speedup/slowdown extension for Google Chrome! Click here for free speedup/slowdown extension for Mozilla Firefox! This is THE place to finally start improving your writing!! THOUGHT FOR THE WEEK: "Love is not affectionate feeling but a steady >ish for the loved person's ultimate good as far as it can be obtained." - C. S. Lewis Anagram for "Mark Tod Kislingbury": "My kid, stroking a blur." TODAY'S BRIEFS:11-16-21: Q&A: will you please HRUPSZ; license HR-PBS; licensed HR*PBS; that is orrect THARBG; when I get WH*EUGT; when I got WH*EUGTD; how about HOUB; , uh-huh, *HU; expert witness SPEUPBS; proceedings PROEGZ; practice PRA; has the SHAT; has it SHA*T; I've had AO*EUFD; and actually SKP*LTD; back and forth PWO*RT; basically PWAEUFL; estate STAET; are you familiar with RUFPL; familiar TPAPL; familiar with TPWAPL; health care H-BG; directive TKR*EFBGT; instruments STRAOUPLTS; in your TPH*RBG; convey KWAEU. Struggling to improve? Court reporter or student? The Magnum Steno Club! Only $29.95 per month. Want a free one -week trial? Write Mark Kislingbury at mark@magnumsteno.com to request one! Include your name, whether you are student or reporter, where you attend school (if any), and your current speed and goals. Welcome to Magnum Steno Like 99 I'm Mark Kiel ingbury, and it's great to see you here! [Purpose of this site: ------------- ------------- -------- ----------- ---- ------- —----- —----------------------- --------------------------� For Reporters and Captioners: To become the BEST you can be! For Students: To help you gain speed with faster fingers and shorter strokes! ---- m Three tools that you can achieve your machine shorthand goals: First, there is the book "Magnum Steno: Beginning Theory" This is Mark's latest book on WRITING SHORT! It's $249 in our store, and students and previous customers get a $50 discount. Call 713-837-6595 for the discount code to enter in the store. This 2014 book is the improvement on Mark's best-selling 2008 book "Magnum Steno: Write Short - Write Fast!" This book comes with 100% satisfaction guarantee! (Books may be returned for full refund under following conditions: (1) That recipient has not been sent the free dictionary that comes with the book, (2) the book is in excellent condition, and (3) the return must be within two weeks of receiving the book.) Second, we have the Magnum Steno Club! This amazing club costs only $29.95 a month, with no minimum, cancel any time. It provides hundreds of videos of me dictating three categories of videos: speed building, briefs, and instructional. Practice daily with me and quickly become one of the best reporters and captioners in the country. Check out the hundreds of testimonials for students and reporters alike! Call 713- 837-6595 or write me at mark@magnumsteno.com for a FREE one -week trial of the Magnum Steno Club! Third, 1 am presenting Magnum Steno Seminars around the country (each one is NCRA-approved or pending approval). In addition, I am available for personal consultations. I have helped hundreds via e-mail and telephone to resolve their problems and achieve their goals, at no charge. Also, I personally answer your e-mail questions. I'm here to help you! mark@magnumsteno.com. Every single thing you ever pay for at Magnum Steno, Inc., COMES WITH A 100% SATISFACTION GUARANTEE OR YOUR MONEY BACK! (Books may be returned for full refund under following conditions: (1) That recipient has not been sent the free dictionary that comes with the book, (2) the book is in excellent condition, and (3) the return must be within two weeks of receiving the book. Sincerely, Mark Kislingbury ! Questions? I Call Jordane at 713-837-6595 or write her at sammysteno@aol.com! Or write Mark personally an e-mail: mark@magnumsteno.com. See you soon! ATTENTION Students and previous customers, call in to get your DISCOUNT code when buying the Magnum Steno book) About Magnum Steno Are you a court reporter, captioner or student of either one of these careers and want to become better, faster, more accurate and the best writer you can be? Are you unsure what exactly is holding you back from writing faster and always keeping pace with the speaker, and unclear about how to become faster? 1 Mark Kislingbury Mark Kislingbury has a Guinness World Record in speed writing and is the fastest, shortest writer in the world. Mark is now sharing his speed building and short -writing techniques with court reporters, captioners and students around the world. He has the answers you are looking for to be able to write faster, shorter and take your career to the next level. If you truly want to become one of the best court reporters or captioners in the business, and are willing to practice diligently, you've come to the right place. The biggest problem that most reporters and students have when writing is in being able to get the speaker's words down as quickly, and as accurately, as possible. Mark has found that one of the most effective ways of improving your skills is to learn to 'write short', by using as many abbreviations, or 'briefs,' as possible. This reduces the number of key strokes you need to make, automatically giving you increased speed. Although many successful reporters and students use some briefs, they usually rely on fast fingers, or finger speed alone. However, their ultimate speed will always be limited by how many strokes they need to write. Fewer strokes means greater speed. Also, the continual writing of an excessive number of strokes is stressful and often contributes to hand, wrist, arm, shoulder, back, and/or neck problems from the repetitive strain. Reducing the average number of strokes per word written simply makes the job so much easier, less stressful and better for your health, and you will see yourself improve very quickly. LWritmg.Mechanics _... .....-. ....-.- .-.-.. ....-. __. _ - -- _.__...._ --- __ m._--_ -------------- ----------------- ..... _.......... Let's look at the mechanics of reporting spoken words in a court or lecture situation. As you listen to the speech, there are two factors that limit the speed and accuracy with which you can report them. The first is simply how fast your fingers are moving, or how many strokes you can make per second. You can train and practice speed building to make your fingers move faster, but there will always be an upper limit as to how many strokes you can achieve in one second, on a sustained basis. Secondly, you can abbreviate the words as much as possible, reducing the number of strokes you need per word, allowing you to get more words down without the fingers going faster. Mark has found that by working on both areas: increasing finger speed, and working diligently to shorten writing, you can achieve significantly higher speeds and easily keep up with even super fast speakers. More important, your realtime translation will become cleaner and thus your transcription time will but cut down, such that you will be making more money per hour. Mark Kislingbury is living proof that these skills can result in incredibly fast reporting. Mark has honed his skills to such a level, that in 2004, he set a new Guinness World Record for speed writing. For one minute, he wrote an amazing 360 words per minute, at 97.22% accuracy. (He made only ten errors in that one minute.) To do this, he combined great finger speed, an average 4.8 strokes per second, with dramatically abbreviated words: He used only 289 strokes for those 360 words, averaging 0.8 strokes per word. Many court reporters and captioners realize that these are areas in which they need to improve, but although they are willing to put in the time and effort to practice, they don't know exactly what they should do, nor how to approach speed building so as to be able to write faster and shorter. Without guidance from an expert and the right techniques, practice will unfortunately not produce the desired results. Many well-known techniques for writing faster and shorter only produce slight improvements or are ineffective, causing reporters and students to simply give up and fall back into their old habits. Mark is dedicated to sharing his revolutionary methods (which enabled him to clinch the word speed record, as well as win 11 NCRA speed and realtime contests since 1999) with his fellow reporters, captioners, CART writers, and students. He can teach you both how to train your fingers to move quicker, and how to reduce the number of strokes you need to get each word down accurately and combine strokes to record more shortened words at once. It seems amazing that such shortened words can allow extraordinary accuracy, but it's true. Mark's method will teach you how to memorize briefs for thousands of the most common words and phrases, enabling you, too, to achieve great speed. Mark personally guarantees that you can benefit from his methods. He is 100% certain that they will help anyone whose job or occupation involves having to quickly get down the spoken word, keeping up with the speaker at all times. The Magnum Steno Club is the ideal place to begin your training and start writing faster today! 'Magnum S snot Beginning Theory_ First, there is Mark's book, 'Magnum Steno: Beginning Theory', his new 'Magnum Opus'. This book not only gives you details of all the short -writing techniques that make Mark a ground -breaking world record holder, but they also present them in such a way that you'll learn effortlessly, have plenty of material to practice with, and you will notice yourself being able to write shorter and faster almost immediately, the same day in many cases! Amazingly, this book is just what many people need for speed buildingl That's because writing short automatically confers speed. This incredibly detailed book is really the equivalent of a Master's Degree in writing short, and all returning customers (as well as t`d3w �-$ten° WliWSIMM Wn,e fFY! students) receive a $50 discount. .....__ ____...— ..---- _--------- ----- ._ ----------- _-..-...__- '!The Magnum Steno Club ` If you are more of a visual and aural learner who wants to be able to study and practice with direct video training and guidance from Mark, there is the 'Magnum Steno Club'. Just $29.95 per month gets you unlimited access to hundreds of videos Mark has painstakingly made about his methods and practice techniques, so you can study with new material every day, any time. Mark is so sure that you'll love the club, he'll even give you a week's free trial before you commit! Just email him at mark@magnumsteno.com, or give him a call today at 713-837-6595. Personal Seminars E Finally, Mark regularly gives personal seminars all around the country to select audiences of court reporters and captioners who are eager to learn and. receive personalized advice. Just contact Mark for details of up -coming seminars. Whatever method of learning these revolutionary techniques you choose (Magnum Steno book, and/or Magnum Steno Club), Mark is personally committed to your success. He will always be available by email or telephone for personalized support. Let Magnum Steno and Guinness World Record holder Mark Kislingbury help you get writing shorter and faster today. Discover the great benefits that short writing could bring to your career. Your only regret will be that you didn't do it soonerl Speed Building I Wrtung Short I Contact Us I View Stare I increasing Speed I Testimonials r 112010 - 2021 Magnum Siinn cuid Fund Ad, D,,,11 4. AL Righk Rz.survQd. -, — - — Search Advanced search How is it different from "Magnum Steno: Write Short - Write Fast"? Because it has all his briefs and phrases appearing in the order of how common they are. In other words, the earlier you are in the book, the more common the word/phrase is! This book will soon be in many schools. Students and previous customers! Call 713-837-6595 for a discount on this product! * Shipping rates may vary for international orders, .............................. Add to Cart: :I Add to Cart Thls product was added to our catalog on Monday 02 August, 2021. Customers who bought. this product also p urchased . Wpb neeig,, ny: VentagA web Solutlons.Aii tlgF,r,_ z;.�,Eragd. €.Agin Mae Selle Ci5sell From: cl6.r.ri.atkinson@4;Alh.ounco.tx.org (Clard.ftinson) -<tlarti,atkinso.nCo)calh6untotx.or.g;� Sent: Wedn6sdoy, Septem - bar 8, 202111:54 AM To: M.4,Pbpli.e.casset@cal4puncotx.org Cc: cindy muell6rr,. rhonda kokena;: eichard.MLhyor@calhouritbtx.bt§i David Hall;vern JYSSY; joel:behrens@.c6lhouncotx.org; garyjreese@caIhou.ncotxO.rg Subject; Agenda Item Request - Job -Description Approval Attachments, Court At Law Admin Asst Job Descriptio,n.Eff. Q9j5.202tpdf. Please place the following item On the agenda for September 15, 20k: Consider and take necessary action to approve the Job Description for County Court At Law Administrative Assistant/Court Coordinator,. dardAtkimon Calhoun Coun.ty. :Chief. Deputy. Treasurer — Human Resqp.r;q§ Coordinator 202.S. Ann; Suite A Port Lavaca, TX 7.7979 P. .361,553A618, F:. 361.553.4614 Calhoun County Texas Calhoun County Job Description Court At taw SUMMARY QFP0SrrI0N Performs administrative office management and court coordinating functions. COURT COORDINATOR DUTIES: Monitors court docket and routinely advises Judge of developments. in cases; Frequently consults judge regarding non -routine matters before the courtand handles per Judge's'instruction; Ensures, that all -cases,, motions, etc. are set on a date and purpose certain as defined by local court.rul es; -Ens § that 611 cases on the court's docketare listed on docket properly; Ensures that all attorneys and parties are properly notified of settings; Coordinates civil trials and hearings; Serves as liaison'between attorneys, the public, and the judge in matters I before the court; Ensures that all cases transferred are processed in accordancewith the local court rules; Advises Judge of attorneys and parties who Will be late or have A.conaict;. Coordinates with County Clerk's and District Attorney's.officos, litigators, litigants, and jurors to: schedule ttials,rippointments and resolve other organizational issues - Locates. problem areas, if any, and advises the Judge osu the, problems and make any suggestionsfoxernedy same;. Works with. All agencies in the judicial.environment as they relate to the efficicrit operation of the court; Remains available to the,Judge at all times in order to give assistance when deemed necessary; Handlesjurors':excuses .and: inquiriesin.a0cordanq0with the policies of the court, obtaining instruction from the hulge,ifnecdedp- - Performs research for court as delegated by, the Judge; - Handles:.telephone inquiries as to future. settingssp, ,di os0ionsandotherinformationas required', Monitor appeal cases sothat statutory time limits are met; ESSENTIAL, OFFICE: DUTIES AND RESPONSIBILITIES - Secretarial functionsincluding. filing, answering telephone, taking messages, making appointments for attorneys, sheriff, sheriff deputies, police department, and. public; - Date stamping warrants consecutively,database of warrants, filing scanning and maintain datab arr Ing: warrants, scanning and safeguarding same; - Maintain electronic and hard copy: files and records- - Prepare purchase orders; - Prepare purchase :orders .for attomeys; Order office supplies and materials; - . . . . . . . . M app schedule, - Perform administrative 4 duties such as sorting and distributing mail, work processing, scheduling, filing, copying: and faxing documents; . ng - Perform other duties asassigned; REQUIRED KNOWLEDGE,, SOLLS AND ABILITIES Must be able to handle stressful situations ina professional manner; Knowledge of standard office, bookkeeping and personnel practices and. Procedures-, Mast'be proficient in Microsoft Word, Microsoft Excel, Microsoft Power Point and Xerox; Perform basic mathematical functions; Communicate effectively both. orally and in writing; Understand policies and procedures; -.Establish and maintain effective working relationships with County Clerk's office, other departments,, and the general public; Create Judge's calendar. annually., - Advises Indgeof changes and schedules in. the, calendar,. - Schedules seminars and judicial conferencesfor the Judge; - Prepare travel expense vouchers: and.purchase orders; Anticipate day to day judicial needs, Understand docket management ent techniques, standard office practices and procedures, legal terms and research practices; #18 NOTICE OF MEETING — 11/24/2021 18. Consider and take necessary action to authorize the installation of an emergency key holder for fire and law enforcement agencies at the Calhoun County Library. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 14 of 28 Mae Belle Cassel From: ncruz@cclibrary.org (Noemi Cruz) <ncruz@cclibrary.org> Sent: Wednesday, November 10, 2021 11:20 AM To: MaeBelle.Cassel@calhouncotx.org Subject: Agenda Item 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. Hello MaeBelle, Please add to the next Commissioners' Court Approval to install an emergency key holder for fire and law enforcement agencies at the Calhoun County Library. -Thanks Noeml Cruz, Library Director Calhoun County Public Library 200 W. Mahan Port Lavaca, TX 77979 Phone 361.552.7250. ext. 6 Fax 361.662.4926 Email ncruz@cclibrarv.ore Web www.cclibrarv.ore "A library outranks any other one thing a community can do to benefit its people. It is a never failing spring in the desert." Andrew Carnegie Calhoun County Texas A. y O N lD O C, `C� x 0 O N m A 3 D C. N .+ N (D y �^^ CL n N ' CD w N M N C 2% i.f. c1 -�°ii--- =. �ii a A - -7 -- -- -- - ' S - p -� - =f N G G CD m _. m N C_ n 3 m m to 3 B 2 -� a m vC ,q a d < n o M0 m 0 A '� C to y cD n 44 a CDd . o N C w O N N � C C X P* O �p cD m f C t X C C a a d a a 0 O- W m C. C y 01 N 1 7C d (p !Ci N fn �2.. L1 3 O x w z N 'a y y M C_ y o Ul C. fp 0 n y C. fD C y ` (D 0 C. 0 M y A 3 #19 NOTICE OF MEETING— 11/24/2021 19. Consider and take necessary action to award the bid for drainage and sewage improvements in Alamo Beach for Calhoun County, under Texas General Land Office Contract No. 20-065-064-C182 and Calhoun County CDBG-DR Contract Work Order No. D-1. (DH) Awarded to Lester Contracting, Inc. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissionerpct 1 SECONDER: Vern Lyssy, Commissioner Pct AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 15 of 28 David E. Hall Calhoun County Commissioner, Precinct 41 202 S. Ann Port Lavaca, TX 77979 Honorable Richard Meyer Calhoun County Judge 211 S. Ann Port Lavaca, TX 77979 RE: AGENDA ITEM Dear Judge Meyer, (361)552-9242 Fax(361)553-8734 Please place the following item on the Commissioners' Court Agenda for November 24th, 2021. Consider and take necessary action to award the bid for drainage and sewage improvements in Alamo Beach for Calhoun County, under Texas General Land Office Contract No. 20-065-064-C182 and Calhoun County CDBG-DR Contract Work Order No. D-1. Sincer , Da E. Hall DEH/apt # 20 NOTICE OF MEETING— 11/24/2021 20. Consider and take necessary action on a request from Brigid Berger, Texas Master Naturalist, Mid -Coast Chapter, to utilize the Port O'Connor Community Center as an overflow facility to house turtles in the event of severe winter storms and the turtles need to be rescued. (GR) Brigid Berger gave a report on the importance of additional emergency housing for turtles in the event of a major winter storm. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 16 of 28 1) O V O 1 r h S4 i m C a a' o C ci 0 kD N W a M Gary D. Reese County Commissioner County of Calhoun Precinct 4 November 15, 2021 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 for November 24, 2021. Consider and take necessary action on request from Brigid Berger, Texas Master Naturalist, Mid -Coast Chapter, to utilize the Port O'Connor Community Center as an overflow facility to house turtles in the event of severe winter storms and the turtles need to be rescued. Sincerely, 1(� r� ^j c 1\" '\-I— Gary D. Reese GDR/at P.O. Box 177 —Seadrift, Texas 77983 —email: zarv.reeserlcalhouncotx.ore — (361) 785-3141 —Fax (361) 785-5602 October 28, 2021 Dear Port O'Connor Community Center Board In February 2021 Winter Storm Uri caused extensive damage in Texas including Calhoun County. One of the largest wildlife impacts was to sea turtles who were rendered helpless when the water temperature in our shallow bays dropped to critical levels and was sustained for several days. As a result, the turtles were "cold stunned", floated to the top of the water and were washed ashore. We literally found hundreds of dead sea turtles around the Port O'Connor & Seadrift area because we had no rescue system to help these poor creatures. Kelley Kowal, San Antonio Bay Ecosystem Leader for Texas Parks & Wildlife Department Fisheries here in Port O'Connor, and I are Initiating the MID -COAST COLD STUNNED TURTLE RESCUE PROGRAM. We've had a large response from the community and over 40 people have signed up for training to help our local turtles. It's a wonderful start to an important program. I would like to ask for your approval to use the Port O'Connor Community Center if we have another mass cold stunning event. In a 'normal' cold stunning event we will house the turtles at the TPWD Fisheries office on 16`h Street which can hold about 50 turtles. But if another extreme event occurs that effects hundreds of turtles, we will need additional housing. We are seeking to secure both the Community Center and the POC Elementary School gym so that we can be as prepared as possible. In housing the turtles, we would cover the floor with tarps and contain each turtle in an individual enclosure (tub or plastic pool). The turtles will be monitored 24/7 and their care will have the oversight of a veterinarian. When they are sufficiently warmed, which may take several days, they will be released back into the wild. If a turtle is having any other health issue it will be transported to a rehabilitation center for the appropriate care. Sea turtles are not only iconic symbols of the Gulf Coast and beloved sea creatures but also are endangered species. I hope that you will grant permission for us to use the Community Center and help us help these amazing animals. Please let me know if you have any questions. Thank you, Brigid Berger Texas Master Naturalist, Mid -Coast Chapter brigidberger6l@gmail.com 713-825-1929 #21 NOTICE OF MEETING— 11/24/2021 21. Consider and take necessary action to accept payment of $3,832.55 from The Hartford for damages caused by Victoria Electric Cooperative at Port O'Connor Community Center and place funds in the Port O'Connor Community Center budget to cover costs of damages that have already been paid. (GR) Commissioner Gary Reese explained the reasoning for this payment. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 17 of 28 Gary D. Reese County Commissioner County of Calhoun Precinct 4 November 16, 2021 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 for November 24, 2021. • Consider and take necessary action to accept payment of $3,832.55 from The Hartford for damages caused by Victoria Electric Cooperative at Port O'Connor Community Center and place funds in the Port O'Connor Community Center budget to cover costs of damages that have already been paid. Sincerely, A � �%_ Gary D. Reese GDR/at P.O. Box 177 — Seadrift. Texas 77983 —email: aary reese ri calhouncoix or — (361) 785-3141 —Fax (361) 785-5602 n Western General Liability Center P.O. Box 14265 THE Lexington KY 40512-4265 HARTFORD 8776252652 x2303896 Me 01 000563 68637 8 2 E rhnlrll'III'I II h 411iIIn4llll III IIIII 11u lllhl l PORT O'CONNOR COMMUNITY CENTER Po Box 177 Seaddit TX 77983-0177 Special Handling ID: 99 Payment 1 of 1 Explanation of Benefits Invoice Number Claim Number/ Insured Namer Additional Comments: Paid on behalf of: Hartford Underwriters Insurance Company Claim Handler: MEGAN MOORS Claim Center: WesternGeneral Liability Center 8776252652 x2303896 P.O. Box 14265 Lexington, KY40512-4265 Issue this Please keep the above information for your records. Western General Liability Center P.O. Box 14265 THE "i'lLexington, KY 40512-4265 THE i'r. ,... HARTFORD Pay THREE THOUSAND EIGHT HUNDRED THIRTY-TWO DOLLARS AND 55/100 TO THE PORT O'Cnn ntno �� ...,,.,._. __. _ ORDER Po Box 177 Vv OF Seadrift, TX 77983-0177 Attention: This remittance incorporates 1 Claim payments Uoheck =Number: ,832.55914 0 'age 1 of 2 Amount Paid $3,832.55 Service Dates 122632313 561544 __ Check Number: 115089914 0 --- 441 Issue Date: 11/03/2021 $"******3,832.55 JPMorgan Chase Bank, N.A. Columbus, OH 43085 m a m rl rLj Authorized Signature ru IN M Lielq Val Allaucquelul sum *Bed sitU 99'zc9'9$:lunowv X3843 19101 0 4466909 4 :jeqwnN 40843 Z JO Z OBBd 8MN30 A-LINnymob NONNOOD IN08:88hd # 22 NOTICE OF MEETING— 11/24/2021 22. Consider and take necessary action to approve the final plat of the Jameson Subdivision, Port O'Connor, Texas. (GR) Pass Page 18 of 28 Gary A Reese County Commissioner County of Calhoun Precinct 4 November 16, 2021 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 for November 24, 2021. Consider and take necessary action to approve the Final Plat of the Jameson Subdivision, Port O'Connor, Texas. Sincerely, Gary D' Reese GDR/at P.O. 13ox 177 - Seadrift. Tows 77983 - email: garyseesew,calhouncIx. ore - (361) 785-3141 - Fax (361) 785-5602 OUTLOT 3 OUTBLOCKI 11 �OUTLOT 2 LO p All sxe•za'm'e -O.00' @szwv°• .BBzoO p i�4 & i� m$ 8 @Ag9 a`By r m � O „w O "'p ��r•V °� m O w .J H g'° Z ya � D i IH y aBsn 3.io.vevtt `"�mw. C v.iASL.ers 8y \ Z IN I €nz� Rag F'1-3 g� � iz a !\N �� x is .00651 a.ia.°z.ers c MUM z1 ! xoo'nulo z .L0'1,Ln0 Y A CX YW 0 � Iy Re8 Vd� dg $�q�� moa O rLr/J^R DoCoO O @a ` mtis 7H @ maw gym.. Of c s R@ ,a slid a 'ag Gy NINE A a g n h o U7 z o Z � � z A gig H ��a •s 6 � 55 if g�6a g� !� NO R i Bg��i�r MFg AR qp'oil ri �� G Am d o g W �p £g3a A d M a raa .use m 'a Rig G� wel G & W ENGINEERS, INC. ENGINEERING • SURVEYING • PLANNINGRB5 W. LIVE OAXSLREEi, PORT LAVgCq. iEXgS ]IB]9 ]BPELS FlflM NO.: IOOPYIOC FINAL PLAT `� ` WBq ssz-uOB: vox] 1AVACA (B]a) ]Pl-n0¢ ear cm K # 23 I NOTICE OF MEETING— 11/24/2021 23. Consider and take necessary action to approve the final plat of the Saltwater Haven No. 2 Subdivision, Port O'Connor, Texas. (GR) Scott Mason with G&W Engineers explained the final plat. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 19 of 28 Gary A Reese County Commissioner County of Calhoun Precinct 4 November 16, 2021 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 for November 24, 2021. • Consider and take necessary action to approve the Final Plat of the Saltwater Haven No. 2 Subdivision, Port O'Connor, Texas. S' cerely, Gary D Rees GDR/at P.O. Box 177 - Seadrift. Texas 77983 —email: un, reese it calhouncote org — (361) 785-3141 —Fax (361) 785-5602 S 6 6 5 e dfl� BOGGY BAYOU m� a 2 a a., gae2. n >Q x o > � RV 8� ---- --- m s E d._ _ _ _ — _ _ _ _ _._ _ -. _ _.—._ _.—._ _.—._ _._ -- _.— °r Iw2. _._ _._ _ co )A y -� r - s n ps ue, L� non I( ( x CIO Q [•J N r�.1�. fl my y Cip, 8 ^ fl os q 8� M I[° I fl I c 5 I k N Z ID fl ip39 6 a m 8 yI0 d es — �0 a©o mE e I Hs w6 8 a i A Rid @@ q/ z §Q ] xGq J .W'WI -- --&_Or *99 bS � �A Vq E fI Alisl zor la tiIK 88 N P N G& W ENGINEERS, INC. ° y i ° z o �� o O • ENGINEERING • SURVEYING • PLANNING • m y o i v FINAL PLAT 205 W °YE OAK S1HEEi, PORT IAVACp, lE%p5 77079 "' ' 0C u' m ,.-I'. P E P Z . (361)ss2-aeos: PoeEr AVACAO.: 919) gg�y P� R �a 2B a� 205 W. LIVE OAK , STREET, PORT LAVACA, MUS DPP9 4509: P (MI) 592 P PLS FIRM NO.: 10022100 CRT LAVACA (979) 323-7100. BAT CRY AMOUNTOF LETTER OF LETTER OF Y NUMBER- DATEOF LETTER OF R EFFE P' • • Y P' • P Y P P P r •P •a .r tr,r e rnf rr Richard Meyor (County A*e) 211 South Ann St. Port Lavaca; T>t•rMM called on toitindthe a�ve Letter of ..+aRPOR relief said note VA be on:atendy, Shohttl tho Fftet of.o,�ffPw uy be 7M Credit the rode will be ink (b) For Issuance ofIrrevocable Cocumsatafy etgArofCredhkio.1122?t),�1- Poe Parkl.W,lpoat Natlenalbe* part Levees 3fee of$3,30M00{i,fl%oftAearnooatofUtaayto pInd payrable on the date the later of t elift is OOCUtetl, letter� ipj.Smrctiae Said tae90 Letter Of Credit IsftothersW to the iarowih,gconditona: 1. Letter of Credit is nahanaferahk ar wifhaut.dae con d of Fkst National Sao, PkaFLavaa, Texas. . 2. Bank ee0 he quesdoh andtienetdary. be required to determine of fadof taw atissus betxreen acaow t. party so far as a OXPMWSWK said credit lesubiect to the regulations of the Uoftm CarnmerciatGotle. This agreement- in to entretysbaa be binding upon all parike hereto, their :heirs , e>iewtcrs, administrators,. succ ora and assigns. 1n 7tESTIMONY WIiEREOE, partae to this agreement have 2�1. tmtaurdo Het their hands on theatre 22rki day of NOrembar 22, A- s BORROWER: r` By' • eterBsttrekrre,. Preskterd # 24 I NOTICE OF MEETING— 11/24/2021 24. Consider and take necessary action to approve the following changes to the Calhoun County Library Board: (RHM) a. Charlene Terrell to replace Reese Vaughn b. Mary Rubio to replace Joe Castaneda c. Mike Stroup to replace Susan Bryant RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 20 of 28 Calhoun County Library Board Port Lavaca, Texas November 18, 2021 Judge Richard Meyer: The Calhoun County Library Board presents Charlene Terrell, Mary Rubio and Mike Stroup for approval by Commissioners' Court for appointment to this Board. Charlene is replacing Reese Vaughn, Mary is replacing Joe Castaneda and Mike is replacing Susan Bryant. We would greatly appreciate you Including this on the agenda of your next meeting. Sinc ely, Pam Lambden, President # 25 I NOTICE OF MEETING — 11/24/2021 25. Consider and take necessary action to authorize the Calhoun County Librarian to apply for fifty (50) Hotspots and ten (10) Laptops from the Federal Communications Commission's Emergency Connectivity Fund Program. (RHM) RESULT: [UNANIMOUS] MOVER: ommissioner Pct 2 SECONDER::::: ommissioner Pct 1AYES: Commissioner Hall, Lyssy, Behrens, Reese Page 21 of 28 Mae Belle Cassel From: Sent: To: Subject: Attachments: ncruz@cclibrary.org (Noemi Cruz) <ncruz@cclibrary.org> Thursday, November 18, 2021 12:36 PM MaeBelle.Cassel@calhouncotx.org Agenda item #2 CCLBScan.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. Hello MaeBelle, Please add to the next Commissioners' Court Approval to apply for 50 Hotspots and 10 Laptops from the Federal Communications Commission's Emergency Connectivity Fund Program. Calhoun County Texas Anne Veigle anne.veigle@fcc.gov For Immediate Release FCC ANNOUNCES OVER $5 BILLION IN FUNDING REQUESTS RECEIVED IN EMERGENCY CONNECTIVITY FUND PROGRAM WASHINGTON, August 25, 2021—The Federal Communications Commission today announced that it has received requests for $5.137 billion to fund 9.1 million connected devices and 5.4 million broadband connections as part of the $7.17 billion Emergency Connectivity Fund Program. The first filing window, attracted applications from all 50 states, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, U.S. Virgin Islands and the District of Columbia — including schools and libraries in both rural and urban communities seeking funding for eligible equipment and services received or delivered between July 1, 2021 and June 30, 2022. In view of outstanding demand and the recent spike in coronavirus cases, the FCC will open a second application filing window for schools and libraries to request funding for connected devices and broadband connections for off -campus use by students, school staff, and library patrons for the current 2021-22 school year. "The Emergency Connectivity Fund is the single largest effort to bring connectivity and devices to students who lack them — and this robust response from applicants shows the tremendous need in our communities. This funding is an important down payment in closing the Homework Gap so that all children, regardless of their circumstances or where they live, have access to the tools they need to succeed," said acting Chairwoman Jessica Rosenworcel. "The pandemic highlighted like never before the difference a reliable internet connection can make in a student's education, and we want to make sure that as many schools and libraries can apply for support this school year. The need is there, and the opening of a second application window reflects that. Together with the Emergency Broadband Benefit Program, we are investing more than $10 billion in American students and households, so more Americans can connect, communicate, and more fully participate in modern life." The FCC will open the second application filing window to provide support for the current school year in light of outstanding demand, including applications that were filed after the close of the initial application filing window, and resource challenges some schools faced with a summertime application filing window. Moreover, the rise of the Delta variant means off campus connectivity remains vital to ensuring students, school staff, and library patrons can engage in remote learning as they face challenges and uncertainty amidst the ongoing COVID- 19 pandemic. During the second application filing window, eligible schools and libraries can apply for financial support to purchase eligible equipment and services for students, school staff and library patrons with unmet needs. The acting Chairwoman has long made closing the Homework Gap a priority during her tenure at the Commission. Recent estimathere tes so ggest may be as many as 17 million children struggling without the broadband access they need to fully engage in remote learning. # 26 NOTICE OF MEETING — 11/24/2021 26. Consider and take necessary action to accept the Texas J & J/Janssen Settlement Agreement for $33,681 and authorize the County Judge to sign all relevant documents. (RHM) Sara Rodriguez explained details of the Settlement Agreement. RESULT: MOVER: APPROVED [UNANIMOUS] SECONDER: David Hall, Commissioner Pct 1 Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 22 of 28 IIIPPS ORTIZ TALAFUSE PLLC Via entail Dan Heart Calhoun County District Attorney 211 S Ann Street, Suite 302 Port Lavaca, Texas 77979 dan.heardCa calhouncotx or Hon. Judge Richard Meyer Calhoun County Judge 211 S Ann Street, Suite 301 Port Lavaca, Texas 77979 richard.meyer@calhouncotx.org November 16, 2021 Hon. Vern Lyssy Calhoun County Commissioner, Pct. 2 211 S Ann Street, Suite 301 Port Lavaca, Texas 77979 vern.lyssygealhouncotx ore Hon. Joel Behrens Calhoun County Commissioner, Pct. 3 211 S Ann Street, Suite 301 Port Lavaca, Texas 77979 Joel.BehrenskcalhouncotX org Hon. David Hall Hon. Gary Reese Calhoun County Commissioner, Pct. 1 Calhoun County Commissioner, Pct. 4 211 S Ann Street, Suite 301 211 S Ann Street, Suite 301 Port Lavaca, Texas 77979 Port Lavaca, Texas 77979 david.hall@calhouncotx o>r gary.reese@calhouncotx.org CONFIDENTIAL SETTLEMENT COMMUNICATION ATTORNEY -CLIENT PRIVILEGED Re; Texas J&J Settlement Agreement Offer to Calhoun County; County of Calhoun v. Allergan USA, Inc., Trial Cause No. 2020-CV-3883-DC, in the 267th Judicial District Court, Calhoun County, Texas (Harris County MDL Pretrial Cause s „ No. 2020-17536). Commissioners and District Attorney: Esyou may be aware, Johnson & Johnson and Janssen Pharmaceuticals, Inc. ("J&J") xreee�yx ntered into a Texas -specific settlement that is materially different than the previously ctrulateproposed national J&J settlement agreement. See attached Texas J&J Agreement. We are recommending that our clients take the Texas J&J Agreement for several reasons: First, the Texas J&J Agreement provides for full payment this year, which is materially different than the national settlement which provides for payments spread out over 9 years. That means Calhoun County will receive a direct payment for the full amount owed under the J&J Agreement —a total payment of $33.681—on or immediately after December 31, 2021. Second, unlike the proposed national settlement, the Texas J&J Agreement is not subject to any offsets or reductions and is afforded protections from bankruptcy. The Phipps 1 102 9th Street I San Antonio, Texas 78215 1 P 210.340.9877 1 F 210.340.9899 November 16, 2021 Page 2 of 3 Third, Calhoun County gets to decide how and where the settlement money should be spent. There are no restrictions on Calhoun County's use of direct payment funds. Fourth, in addition to the direct payment, Calhoun County will be able to apply to a regional opioid abatement fund for additional support for local opioid remediation and treatment programs. Fifth, our contractual contingency fees do not come out of Calhoun County's recovery from the Texas J&J Agreement. Under the Texas J&J Agreement, we are required to waive our contractual attorney's fees and apply to a separate fund overseen by the Texas MDL Court in Harris County. How to Participate in the Texas J&J Settlement Agreement Because the Texas J&J Agreement is administered by a Texas Court, there are certain forms that Calhoun County will need to sign off on to participate in the J&J settlement, specifically: 1. Order Authorizing Approval of J&J Settlement; and 2. Political Subdivision Election and Release Form. We have attached a Release and a proposed draft Order (which you may revise as you see fit) for the Commissioner Court's approval. We ask for your help in getting these signed forms back to us as soon as possible, on or before Monday, November 30, 2021. We understand this may be difficult, particularly around the Thanksgiving holiday. Please let us know if this matter cannot be brought before the Commissioners Court before the end of the month, and we will inform the Court that we require additional time to obtain the required written consent and approval. This Agreement Will Resolve Calhoun County's Claims Against J&J Only The County's acceptance of the Texas J&J Agreement will not affect its claims against any other defendant. Calhoun County's lawsuit against other opioid manufacturers and distributors remains pending in the 152d District Court of Harris County, Texas (In Re: Texas Opioid Litigation, MDL No. 2018-63587). The attached forms only concern the J&J Agreement. The details of the Distributor settlement agreement have not been finalized and talks are ongoing. For these reasons, we are unable to make a recommendation as to the proposed Distributor agreement at this time. Lastly, we understand that the State Attorney General's Office may reach out to you directly about the settlement. We ask that you forward any settlement communications to our office. November 16, 2021 Page 3 of 3 Should you have any questions about the attached documents or the settlement generally, we are more than happy to get on a call or schedule a Zoom to discuss. Very Truly Yours, Yko"- J.ipps ' be Ortiz eagan Tal se Attachments: J&J/Janssen Texas Settlement Agreement; Order Authorizing Approval of J&J Settlement; and Political Subdivision Election and Release Form. THE STATE OF TEXAS § COUNTY OF CALHOUN § ORDER AUTHORIZING APPROVAL OF PROPOSED JANSSEN TEXAS STATE-WIDE OPIOID SETTLEMENT AGREEMENT BE IT REMEMBERED, at a regular meeting of the Commissioners Court of Calhoun rCounty, Texas, held on the 0�day offs' 2021, on motion made by Commissioner of Precinct I and seconded by I��,Nu TM Commissioner of Precinct 3 , the following Order (Resolution) was adopted: WHEREAS, Calhoun County obtained information indicating that certain drug companies and their corporate affiliates, parents, subsidiaries, and such other defendants as may be added to the litigation (collectively, "Defendants") have engaged in fraudulent and/or reckless marketing and/or distribution of opioids that have resulted in addictions and overdoses; and WHEREAS, these actions, conduct and misconduct have resulted in significant financial costs in the past to the County and will undoubtedly result in significant financial costs in the future; and WHEREAS, the County brought claims against Johnson & Johnson, Janssen Pharmaceuticals, Inc., Ortho-McNeil-Janssen Pharmaceuticals, Inc., Janssen Pharmaceutica, Inc. (hereinafter Janssen or the Janssen defendants) defendants, and other defendants in the opioid supply chain on behalf of the County in In Re: Texas Opioid Litigation, MDL No. 2018-63587, currently pending in the 152d District Court of Harris County, Texas; and WHEREAS, on Octoberl7, 2021, the Janssen defendants in the opioid litigation brought by the County, the State of Texas, through the Office of the Attorney General, and a negotiation Page 1 of 3 group for Texas political subdivisions entered into an Agreement entitled Janssen Texas State - Wide Opioid Settlement Agreement and Term Sheet (hereafter, "the Janssen Settlement'); and WHEREAS, Special Counsel and the State of Texas have recommended that the Calhoun County Commissioners Court support the adoption and approval the Janssen Settlement in its entirety; and WHEREAS, even though the payments from the Janssen settlement reflects partial compensation to Calhoun County for the past damages it has suffered or the future damages it is likely to incur, given the risks of litigation, the fact that this is a settlement with only one group of Defendants, the fact that it is to the benefit of Texas and the County and its residents, and that it reduces the risks associated with pay -over -time provisions; NOW, THEREFORE, BE IT RESOLVED that we, the Commissioners Court of Calhoun County: 1. Support the adoption and approval the Janssen Settlement in its entirety; and 2. Authorize County and Special Counsel to execute the Release at Exhibit A of the Janssen Settlement; and 3. Finds as follows: a. There is a substantial need for repayment of past opioid-related expenditures and payment to help abate current and future opioid-related harms in and about Calhoun County, Texas; and b. The County Commissioners Court supports in its entirety the Janssen Settlement. The County Commissioners Court understands that the purpose of this Settlement to effectuate resolution of the Opioid Litigation against Janssen entities. We also understand that an additional purpose is to ensure the effective means of Page 2 of 3 distributing any potential settlement funds obtained under this Janssen Settlement in Texas and under the jurisdiction of Texas Courts in a manner and means that would promote an effective and meaningful use of the funds in abating the opioid epidemic in this County and throughout Texas. The County is hereby authorized to approve and accept the Janssen Settlement. The County's Special Counsel is hereby authorized to execute and deliver the settlement agreement recommended for approval by Special Counsel in the above referenced case and to approve such terms and provisions for the full and final settlement of all matters set forth therein. DONE IN OPEN COURT on this tho4Gay of&M/�.{i?�EU21. ATTEST: County Clerk COUN F CALHOUN, TEXAS County J Page 3 of 3 TEXAS SUBDIVISION ELECTION AND RELEASE FORM This Election and Release Form for Texas Participating Subdivisions resolves opioid- related Claims against Janssen under the terms and conditions set forth in the Janssen Texas State - Wide Opioid Settlement Agreement between Janssen, the State of Texas, and the Counties of Dallas and Bexar (the "Agreement"), the provisions of which are here incorporated by reference in their entirety. Upon executing this Election and Release Form, a Participating Subdivision agrees that, in exchange for the consideration described in the Agreement, the Participating Subdivision is bound by all the terms and conditions of the Agreement, including but not limited to the Release found in Section VII of the Agreement and the provisions concerning participation by Subdivisions in Section VIII, and the Participating Subdivision and its signatories expressly represent and warrant on behalf of themselves that they have, or will have obtained on or before the Effective Date or on or before the execution of this Election and Release Form if executed after the Effective Date, the authority to settle and release, to the maximum extent of the Subdivision's power, all Released Claims related to Covered Conduct. If this Election and Release Form is executed on or before the Initial Participation Date, the Participating Subdivision shall dismiss Janssen and all other Released Entities with prejudice from all pending cases in which the Participating Subdivision has asserted Covered Claims against Janssen or a Released Entity no later than the Initial Participation Date. If this Election and Release Form is executed after the Initial Participation Date, the Participating Subdivision shall dismiss Janssen and all other Released Entities with prejudice from all pending cases in which the Participating Subdivision has asserted Covered Claims against Janssen or a Released Entity concurrently with the execution of this form. By executing this Election and Release Form, the Participating Subdivision submits to Page 1 of 2 the jurisdiction of the Court where the Consent Judgment is filed for purposes limited to that Court's role under the Agreement. Dated: 1 Zl COUNTY OF CALHOUN, TEXAS t By: [Name/Title] Martin J. Phipps Gabe Ortiz Meagan Talafuse PHIPPS ORTIz TALAFUSE PLLC 102 91h Street San Antonio, TX 78215 (210) 340-9877 mphippsna,phippsortiztalafuse.com og rtizna,phippsortiztalafuse.com mtalafuse@phippsortiztalafuse.com Outside Counsel for County of Calhoun, Texas Page 2 of 2 JANSSEN SETTLEMENT AGREEMENT This settlement agreement dated as of July 21, 2021 (the `Agreement') sets forth the terms of settlement between and among the Settling States, Participating Subdivisions, and Janssen (as those terms are defined below). Upon satisfaction of the conditions set forth in Sections II and VIII, this Agreement will be binding on the Settling States, Janssen, and Participating Subdivisions. This Agreement will then be filed as part of Consent Judgments in the respective courts of each of the Settling States, pursuant to the terms set forth in Section VIII. I. Definitions Unless otherwise specified, the following definitions apply: 1. "Abatement Accounts Fund" means a component of the Settlement Fund described in subsection VI.E. 2. "Additional Restitution Amount' means the amount available to Settling States listed in Exhibit N of $67,307,692. 3. "Agreement' means this agreement as set forth above, inclusive of all exhibits. 4. "Alleged Harms" means the alleged past, present, and future financial, societal, and related expenditures arising out of the alleged misuse and abuse of opioid products, non-exclusive examples of which are described in the documents listed on Exhibit A, that have allegedly arisen as a result of the physical and bodily injuries sustained by individuals suffering from opioid-related addiction, abuse, death, and other related diseases and disorders, and that have allegedly been caused by Janssen. 5. "Allocation Statute" means a state law that governs allocation, distribution, and/or use of some or all of the Settlement Fund amounts allocated to that State and/or its Subdivisions. In addition to modifying the allocation, as set forth in subsection VI.D.2, an Allocation Statute may, without limitation, contain a Statutory Trust, further restrict expenditure of funds, form an advisory committee, establish oversight and reporting requirements, or address other default provisions and other matters related to the funds. An Allocation Statute is not required to address all three (3) types of funds comprising the Settlement Fund or all default provisions. 6. "Annual Payment' means the total amount payable to the Settlement Fund by Janssen on the Payment Date each year in 2023 and onward, as calculated by the Settlement Fund Administrator pursuant to Section V. For the avoidance of doubt, this term does not include the Additional Restitution Amount or amounts paid pursuant to Section XI. "Appropriate Official"means the official defined in subsection XIII.E. revised July 30, 2021 8. `Attorney Fee Fund" means an account consisting of funds allocated to pay attorneys' fees and costs pursuant to the agreement on attorneys' fees and costs attached as Exhibit R. 9. "Bar" means either (1) a ruling by the highest court of the State or the intermediate court of appeals when not subject to further review by the highest court of the State in a State with a single intermediate court of appeals setting forth the general principle that no Subdivisions or Special Districts in the State may maintain Released Claims against Released Entities, whether on the ground of the Agreement (or the release in it) or otherwise; (2) a law barring Subdivisions and Special Districts in the State from maintaining or asserting Released Claims against Released Entities (either through a direct bar or through a grant of authority to release claims and that authority is exercised in full); or (3) a Settlement Class Resolution in the State with full force and effect. For the avoidance of doubt, a law or ruling that is conditioned or predicated upon payment by a Released Entity (apart from payments by Janssen incurred under the Agreement) shall not constitute a Bar. 10. "Case -Specific Resolution" means either (1) a law barring specified Subdivisions or Special Districts from maintaining Released Claims against Released Entities (either through a direct bar or through a grant of authority to release claims and that authority is exercised in full); (2) a ruling by a court of competent jurisdiction over a particular Subdivision or Special District that has the legal effect of barring the Subdivision or Special District from maintaining any Released Claims at issue against Released Entities, whether on the ground of the Agreement (or the release in it) or otherwise; or (3) in the case of a Special District, a release consistent with Section IV below. For the avoidance of doubt, a law, ruling, or release that is conditioned or predicated upon a post -Effective Date payment by a Released Entity (apart from payments by Janssen incurred under the Agreement or injunctive relief obligations incurred by it) shall not constitute a Case -Specific Resolution. 11. "Claim" means any past, present or future cause of action, claim for relief, cross - claim or counterclaim, theory of liability, demand, derivative claim, request, assessment, charge, covenant, damage, debt, lien, loss, penalty, judgment, right, obligation, dispute, suit, contract, controversy, agreement, patens patriae claim, promise, performance, warranty, omission, or grievance of any nature whatsoever, whether legal, equitable, statutory, regulatory or administrative, whether arising under federal, state or local common law, statute, regulation, guidance, ordinance or principles of equity, whether filed or unfiled, whether asserted or unasserted, whether known or unknown, whether accrued or unaccrued, whether foreseen, unforeseen or unforeseeable, whether discovered or undiscovered, whether suspected or unsuspected, whether fixed or contingent, and whether existing or hereafter arising, in all such cases, including but not limited to any request for declaratory, injunctive, or equitable relief, compensatory, punitive, or statutory damages, absolute liability, strict liability, restitution, subrogation, contribution, indemnity, apportionment, disgorgement, reimbursement, attorney fees, expert revised July 30, 2021 fees, consultant fees, fines, penalties, expenses, costs or any other legal, equitable, civil, administrative, or regulatory remedy whatsoever. 12. "Claim Over" means a Claim asserted by a Non -Released Entity against a Released Entity on the basis of contribution, indemnity, or other claim -over on any theory relating to a Non -Parry Covered Conduct Claim asserted by a Releaser. 13. "Compensatory Restitution Amount" means the aggregate amount of payments by Janssen hereunder other than amounts paid as attorneys' fees and costs or identified pursuant to subsection VI.B.2 as being used to pay attorneys' fees and investigation costs or litigation costs. 14. "Consent Judgment" means a state -specific consent judgment in a form to be agreed upon by the Settling States, Participating Subdivisions, and Janssen prior to the Initial Participation Date that, among other things, (1) approves this Agreement and (2) provides for the release set forth in Section IV, including the dismissal with prejudice of any Released Claims that the Settling State has brought against Released Entities. 15. "Court" means the respective court for each Settling State to which the Agreement and the Consent Judgment are presented for approval and/or entry as to that Settling State, or the Northern District of Ohio for purposes of administering the Attorney Fee Fund and any related fee and cost agreements. 16. "Covered Conduct" means any actual or alleged act, failure to act, negligence, statement, error, omission, breach of any duty, conduct, event, transaction, agreement, misstatement, misleading statement or other activity of any kind whatsoever from the beginning of time through the Reference Date (and any past, present, or future consequence of any such act, failure to act, negligence, statement, error, omission, breach of duty, conduct, event, transaction, agreement, misstatement, misleading statement or other activity) relating in any way to (a) the discovery, development, manufacture, packaging, repackaging, marketing, promotion, advertising, labeling, recall, withdrawal, distribution, delivery, monitoring, reporting, supply, sale, prescribing, dispensing, physical security, warehousing, use or abuse of, or operating procedures relating to any Product, or any system, plan, policy, or advocacy relating to any Product or class of Products, including but not limited to any unbranded promotion, marketing, programs, or campaigns relating to any Product or class of Products; (b) the characteristics, properties, risks, or benefits of any Product; (c) the reporting, disclosure, non - reporting or non -disclosure to federal, state or other regulators of orders for any Product placed with any Released Entity; (d) the selective breeding, harvesting, extracting, purifying, exporting, importing, applying for quota for, procuring quota for, handling, promoting, manufacturing, processing, packaging, supplying, distributing, converting, or selling of, or otherwise engaging in any activity relating to, precursor or component Products, including but not limited to natural, synthetic, semi -synthetic or chemical raw materials, starting materials, finished revised July 30, 2021 active pharmaceutical ingredients, drug substances, or any related intermediate Products; or (e) diversion control programs or suspicious order monitoring related to any Product. 17. "Designated State" means New York. 18. "Effective Date" means the date sixty (60) days after the Reference Date. 19. "Enforcement Committee" means a committee consisting of representatives of the Settling States and of the Participating Subdivisions. Exhibit B contains the organizational bylaws of the Enforcement Committee. Notice pursuant to subsection XII1.O shall be provided when there are changes in membership or contact information. 20. "Global Settlement Abatement Amount' means the abatement amount of $4,534,615,385. 21. "Global SettlementAmount' means $5 billion, which shall be divided into the Global Settlement Abatement Amount, the Additional Restitution Amount, and the Global Settlement Attorney Fee Amount. 22. "Global Settlement Attorney Fee Amount' means the attorney fee amount of $398,076,923. 23. "Incentive A" means the incentive payment described in subsection V.EA. 24. "Incentive B" means the incentive payment described in subsection V.E.S. 25. "Incentive C" means the incentive payment described in subsection V.E.6. 26. "Incentive D" means the incentive payment described in subsection V.E.7. 27. "Incentive Payment Final Eligibility Date" means, with respect to a Settling State, the date that is the earliest of (1) three years after the Effective Date; (2) the date of completion of opening statements in a trial of any action brought by a Subdivision in that State that includes a Released Claim against a Released Entity when such date is more than two (2) years after the Effective Date; or (3) two (2) years after the Effective Date in the event a trial of an action brought by a Subdivision in that State that includes a Released Claim against a Released Entity began after the Initial Participation Date but before two (2) years after the Effective Date. 28. "Initial Participating Subdivision" means a Subdivision that meets the requirements set forth in subsection VILD. 29. "Initial Participation Date" means the date one hundred twenty (120) days after the Preliminary Agreement Date, unless it is extended by written agreement of Janssen and the Enforcement Committee. revised July 30, 2021 30. "Initial Year Payment" means the total amount payable to the Settlement Fund by Janssen on each of the two Payment Dates in 2022, as calculated by the Settlement Fund Administrator pursuant to Section V. For the avoidance of doubt, this term does not include the Additional Restitution Amount or amounts paid pursuant to Section XI. 31. "Injunctive Relief Terms" means the terms described in Section III and set forth in Exhibit P. 32. "Janssen" means Johnson & Johnson, Janssen Pharmaceuticals, Inc., Ortho- McNeil-Janssen Pharmaceuticals, Inc., and Janssen Pharmaceutica, Inc. 33. "Later Litigating Special District' means a Special District (or Special District official asserting the right of or for the Special District to recover for alleged harms to the Special District and/or the people thereof) that is not a Litigating Special District and that files a lawsuit bringing a Released Claim against a Released Entity, or that adds such a claim to a pre-existing lawsuit, after the Preliminary Agreement Date. It may also include a Litigating Special District whose claims were resolved by a judicial Bar or Case -Specific Resolution which is later revoked following the execution date of this Agreement, when such Litigating Special District takes any affirmative step in its lawsuit other than seeking a stay or removal. 34. "Later Litigating Subdivision" means a Subdivision (or Subdivision official asserting the right of or for the Subdivision to recover for alleged harms to the Subdivision and/or the people thereof) that is not a Litigating Subdivision and that files a lawsuit bringing a Released Claim against a Released Entity, or that adds such a claim to a pre-existing lawsuit, after the Trigger Date. It may also include a Litigating Subdivision whose claims were resolved by a judicial Bar or Case - Specific Resolution which is later revoked following the execution date of this Agreement, when such Litigating Subdivision takes any affirmative step in its lawsuit other than seeking a stay or removal. 35. "Later Participating Subdivision" means a Participating Subdivision that meets the requirements of subsection VILE but is not an Initial Participating Subdivision. 36. "Litigating Special District' means a Special District (or Special District official) that brought any Released Claims against any Released Entities on or before the Preliminary Agreement Date that were not separately resolved prior to that date. A list of Litigating Special Districts will be agreed to by the parties and attached hereto as of the Preliminary Agreement Date. 37. "Litigating Subdivision" means a Subdivision (or Subdivision official asserting the right of or for the Subdivision to recover for alleged harms to the Subdivision and/or the people thereof) that brought any Released Claim against any Released Entity prior to the Trigger Date that were not separately resolved prior to that revised July 30, 2021 Trigger Date. A Prior Litigating Subdivision shall not be considered a Litigating Subdivision. Exhibit C is an agreed list of the Litigating Subdivisions. Exhibit C will be updated (including with any corrections) periodically, and a final version of Exhibit C will be attached hereto as of the Reference Date. 38. "National Arbitration Panel" means the panel described in subsection XII.F. 39. "National Disputes" means the disputes described in subsection XII.F. 40. "Non -Litigating Special District" means a Special District that is neither a Litigating Special District nor a Later Litigating Special District. 41. "Non -Litigating Subdivision" means a Subdivision that is neither a Litigating Subdivision nor a Later Litigating Subdivision. 42. "Non -Participating Subdivision" means a Subdivision that is not a Participating Subdivision. 43. "Non -Party Covered Conduct Claim" means a Claim against any Non -Released Entity involving, arising out of, or related to Covered Conduct (or conduct that would be Covered Conduct if engaged in by a Released Entity). 44. "Non -Party Settlement" means a settlement by any Releasor that settles any Non - Party Covered Conduct Claim and includes a release of any Non -Released Entity. 45. "Non -Released Entity" means an entity that is not a Released Entity. 46. "Non -Settling State" means a State that is not a Settling State. 47. "Opioid Remediation" means care, treatment, and other programs and expenditures (including reimbursement for past such programs or expenditures except where this Agreement restricts the use of funds solely to future Opioid Remediation) designed to (1) address the misuse and abuse of opioid products, (2) treat or mitigate opioid use or related disorders, or (3) mitigate other alleged effects of the opioid abuse crisis, including on those injured as a result of the opioid abuse crisis. Exhibit E provides a non -exhaustive list of expenditures that qualify as being paid for Opioid Remediation. Qualifying expenditures may include reasonable related administrative expenses. 48. "Overall Allocation Percentage" means a Settling State's percentage as set forth in Exhibit F. The aggregate Overall Allocation Percentages of all States (including Settling States and Non -Settling States) shall equal 100%. 49. "Participating Special District" means a Special District that executes a release consistent with Section IV below and meets the requirements for becoming a Participating Special District under Section VII. revised July 30, 2021 50. "Participating Subdivision" means a Subdivision that meets the requirements for becoming a Participating Subdivision under Section VII. Participating Subdivisions include both Initial Participating Subdivisions and Later Participating Subdivisions. Subdivisions eligible to become Participating Subdivisions are listed in Exhibit G. A Settling State may add additional Subdivisions to Exhibit G at any time prior to the Initial Participation Date. 51. "Participation Tier" means the level of participation in this Agreement as determined pursuant to subsection VIII.0 using the criteria set forth in Exhibit H. 52. "Parties" means Janssen and the Settling States (each, a "Party"). 53. "Payment Date" means the date on which Janssen makes its payments pursuant to Section V and Exhibit M. 54. "Payment Year" means the calendar year during which the applicable Initial Year Payments or Annual Payments are due pursuant to subsection V.B. Payment Year 1 is 2022, Payment Year 2 is 2023 and so forth. References to payment "for a Payment Year" mean the Initial Year Payments or Annual Payment due during that year. References to eligibility "for a Payment Year" mean eligibility in connection with the Initial Year Payments or Annual Payment due during that year. 55. "Preliminary Agreement Date" means the date on which Janssen gives notice to the Settling States and MDL PEC of its determination that a sufficient number of States have agreed to be Settling States. This date shall be no more than fourteen (14) days after the end of the notice period to States, unless it is extended by written agreement of Janssen and the Enforcement Committee. 56. "Primary Subdivision" means a Subdivision that has a population of 30,000 or more. A list of Primary Subdivisions in each State is provided in Exhibit I. 57. "Prior Litigating Subdivision" means a Subdivision (or Subdivision official asserting the right of or for the Subdivision to recover for alleged harms to the Subdivision and/or the people thereof) that brought any Released Claim against any Released Entity prior to the Trigger Date and all such Released Claims were separately settled or finally adjudicated prior to the Trigger Date; provided, however, that if the final adjudication was pursuant to a Bar, such Subdivision shall not be considered a Prior Litigating Subdivision. Notwithstanding the prior sentence, Janssen and the State of the relevant Subdivision may agree in writing that such Subdivision shall not be considered a Prior Litigating Subdivision. 58. "Product' means any chemical substance, whether used for medicinal or non - medicinal purposes, and whether natural, synthetic, or semi -synthetic, or any finished pharmaceutical product made from or with such substance, that is an opioid or opiate, as well as any product containing any such substance. It also includes: 1) the following when used in combination with opioids or opiates: benzodiazepine, carisoprodol, zolpidem, or gabapentin; and 2) a combination or revised July 30, 2021 "cocktail" of any stimulant or other chemical substance prescribed, sold, bought, or dispensed to be used together that includes opioids or opiates. For the avoidance of doubt, "Product" does not include benzodiazepine, carisoprodol, zolpidem, or gabapentin when not used in combination with opioids or opiates. "Product" includes but is not limited to any substance consisting of or containing buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, naloxone, naltrexone, oxycodone, oxymorphone, tapentadol, tramadol, opium, heroin, carfentanil, any variant of these substances, or any similar substance. "Product" also includes any natural, synthetic, semi - synthetic or chemical raw materials, starting materials, finished active pharmaceutical ingredients, drug substances, and any related intermediate products used or created in the manufacturing process for any of the substances described in the preceding sentence. 59. "Reference Date" means the date on which Janssen is to inform the Settling States and MDL PEC of its determination whether there is sufficient resolution of claims and potential claims at the Subdivision level to go forward with the settlement. The Reference Date shall be thirty (30) days after the Initial Participation Date, unless it is extended by written agreement of Janssen and the Enforcement Committee. 60. "Released Claims" means any and all Claims that directly or indirectly are based on, arise out of, or in any way relate to or concern the Covered Conduct occurring prior to the Reference Date. Without limiting the foregoing, "Released Claims" include any Claims that have been asserted against the Released Entities by any Settling State or any of its Litigating Subdivisions or Litigating Special Districts in any federal, state or local action or proceeding (whether judicial, arbitral, or administrative) based on, arising out of or relating to, in whole or in part, the Covered Conduct, or any such Claims that could be or could have been asserted now or in the future in those actions or in any comparable action or proceeding brought by a State, any of its Subdivisions or Special Districts, or any Releasors (whether or not such State, Subdivision, Special District, or Releasor has brought such action or proceeding). Released Claims also include all Claims asserted in any proceeding to be dismissed pursuant to the Agreement, whether or not such claims relate to Covered Conduct. The Parties intend that "Released Claims" be interpreted broadly. This Agreement does not release Claims by private individuals. It is the intent of the Parties that Claims by private individuals be treated in accordance with applicable law. Released Claims is also used herein to describe Claims brought by a Later Litigating Subdivision or other non-party Subdivision or Special District that would have been Released Claims if they had been brought by a Releasor against a Released Entity. 61. "Released Entities" means Janssen and (1) all of Janssen's past and present direct or indirect parents, subsidiaries, divisions, predecessors, successors, assigns, including Norameo, Inc. and Tasmanian Alkaloids PTY. LTD.; (2) the past and present direct or indirect subsidiaries, divisions, and joint ventures, of any of the foregoing; (3) all of Janssen's insurers (solely in their role as insurers with respect revised July 30, 2021 to the Released Claims); (4) all of Janssen's, or of any entity described in subsection (1), past and present joint ventures; and (5) the respective past and present officers, directors, members, shareholders (solely in their capacity as shareholders of the foregoing entities), partners, trustees, agents, and employees of any of the foregoing (for actions that occurred during and related to their work for, or employment with, Janssen). Any person or entity described in subsections (3)-(5) shall be a Released Entity solely in the capacity described in such clause and shall not be a Released Entity with respect to its conduct in any other capacity. For the avoidance of doubt, the entities listed in Exhibit Q are not Released Entities; and provided further that any joint venture partner of Janssen or Janssen's subsidiary is not a Released Entity unless it falls within subsections (1)-(5) above. A list of Janssen's present subsidiaries and affiliates can be found at https://johnsonandjohnson.ges-web.com/static-files/f6lae5f3-ffo3-46cl-bfc9- 174947884db2. Janssen's predecessor entities include but are not limited to those entities listed on Exhibit J. For the avoidance of doubt, any entity acquired, or joint venture entered into, by Janssen after the Reference Date is not a Released Entity. 62. "Releasors" means (1) each Settling State; (2) each Participating Subdivision; and (3) without limitation and to the maximum extent of the power of each Settling State's Attorney General and/or Participating Subdivision to release Claims, (a) the Settling State's and Participating Subdivision's departments, agencies, divisions, boards, commissions, Subdivisions, districts, instrumentalities of any kind and attorneys, including its Attorney General, and any person in their official capacity whether elected or appointed to serve any of the foregoing and any agency, person, or other entity claiming by or through any of the foregoing, (b) any public entities, public instrumentalities, public educational institutions, unincorporated districts, fire districts, irrigation districts, water districts, law enforcement districts, emergency services districts, school districts, hospital districts and other Special Districts in a Settling State, and (c) any person or entity acting in a parens patriae, sovereign, quasi -sovereign, private attorney general, qui tam, taxpayer, or other capacity seeking relief on behalf of or generally applicable to the general public with respect to a Settling State or Subdivision in a Settling State, whether or not any of them participate in the Agreement. The inclusion of a specific reference to a type of entity in this definition shall not be construed as meaning that the entity is not a Subdivision. In addition to being a Releasor as provided herein, a Participating Subdivision shall also provide the Subdivision Settlement Participation Form or the Election and Release Form referenced in Section VII providing for a release to the fullest extent of the Participating Subdivision's authority, which shall be attached as an exhibit to the Agreement. Each Settling State's Attorney General represents that he or she has or has obtained (or will obtain no later than the Initial Participation Date) the authority set forth in the Representation and Warranty subsection of Section IV. 63. "Revocation Event" means with respect to a Bar, Settlement Class Resolution, or Case -Specific Resolution, a legislative amendment or a revocation, rescission, reversal, overruling, or interpretation that in any way limits the effect of such Bar, revised July 30, 2021 Settlement Class Resolution, or Case -Specific Resolution on Released Claims or any other action or event that otherwise deprives the Bar, Settlement Class Resolution or Case -Specific Resolution of force or effect in any material respect. 64. "Settlement Class Resolution" means a class action resolution in a court of competent jurisdiction in a Settling State with respect to a class of Subdivisions and Special Districts in that State that (1) conforms with that Settling State's statutes, case law, and/or rules of procedure regarding class actions; (2) is approved and entered as an order of a court of competent jurisdiction in that State and has become final as defined in "State -Specific Finality'; (3) is binding on all Non -Participating Subdivisions and Special Districts in that State (other than opt outs as permitted under the next sentence); (4) provides that all such Non - Participating Subdivisions or Special Districts may not bring Released Claims against Released Entities, whether on the ground of the Agreement (or the releases herein) or otherwise; and (5) does not impose any costs or obligations on Janssen other than those provided for in the Agreement, or contain any provision inconsistent with any provision of the Agreement. If applicable state law requires that opt -out rights be afforded to members of the class, a class action resolution otherwise meeting the foregoing requirements shall qualify as a Settlement Class Resolution unless Subdivisions collectively representing more than 1 % of the total population of all of that State's Subdivisions listed in Exhibit G opt out. In seeking certification of any Settlement Class, the applicable State and Participating Subdivisions shall make clear that certification is sought solely for settlement purposes and shall have no applicability beyond approval of the settlement for which certification is sought. Nothing in this Agreement constitutes an admission by any Parry that class certification would be appropriate for litigation purposes in any case. 65. "Settlement Fund" means the interest -bearing fund established under the Agreement into which all payments by Janssen are made other than amounts paid as attorneys' fees and costs or identified pursuant to subsection VLB.2 as being used to pay attorneys' fees and costs. The Settlement Fund comprises the Abatement Accounts Fund, State Fund, and Subdivision Fund. 66. "Settlement Fund Administrator" means the entity that determines the Annual Payments (including calculating Incentive Payments pursuant to Section V) and any amounts subject to suspension or offset pursuant to Sections V and IX), determines the Participation Tier, and administers and distributes amounts into the Settlement Fund. The duties of the Settlement Fund Administrator shall be governed by this Agreement. Prior to the Initial Participation Date, the Parties shall agree to selection and removal processes for and a detailed description of the Settlement Fund Administrator's duties, including a detailed mechanism for paying the Settlement Fund Administrator's fees and costs, all of which shall be appended to the Agreement as Exhibit L. 10 revised July 30, 2021 67. "Settlement Fund Escrow" means the interest -bearing escrow fund established pursuant to this Agreement to hold disputed or suspended payments made under this Agreement. 68. "Settlement Payment Schedule" means the schedule of payments attached to this Agreement as Exhibit M. A revised Settlement Payment Schedule will be substituted for Exhibit M after any offsets, reductions, or suspensions under Sections V and Dt are determined. 69. "Settling State" means any State that has entered the Agreement. 70. "Special District" means a formal and legally recognized sub -entity of a State that is authorized by State law to provide one or a limited number of designated functions, including but not limited to school districts, fire districts, healthcare & hospital districts, and emergency services districts. Special Districts do not include sub -entities of a State that provide general governance for a defined area that would qualify as a Subdivision. 71. "State" means any state of the United States of America, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. Additionally, the use of non -capitalized "state" to describe something (e.g, "state court") shall also be read to include parallel entities in commonwealths, territories, and the District of Columbia (e.g., "territorial court"). 72. "State Fund" means a component of the Settlement Fund described in subsection VLC. 73. "State -Specific Finality" means, with respect to the Settling State in question: a. the Agreement and the Consent Judgment have been approved and entered by the Court as to Janssen, including the release of all Released Claims against Released Entities as provided in this Agreement; b. for all lawsuits brought by the Settling State against Released Entities for Released Claims, either previously filed or filed as part of the entry of the Consent Judgment, the Court has stated in the Consent Judgment or otherwise entered an order finding that all Released Claims against Released Entities asserted in the lawsuit have been resolved by agreement; and C. (1) the time for appeal or to seek review of or permission to appeal from the approval and entry as described in subsection (a) hereof and entry of such order described in subsection (b) hereof has expired; or (2) in the event of an appeal, the appeal has been dismissed or denied, or the approval and entry described in (a) hereof and the order described in subsection (b) hereof have been affirmed in all material respects (to the extent challenged in the appeal) by the court of last resort to which such appeal has been taken and such dismissal or affirmance has become no 11 revised July 30, 2021 longer subject to further appeal (including, without limitation, review by the United States Supreme Court). 74. "State -Subdivision Agreement" means an agreement that a Settling State reaches with the Subdivisions in that State regarding the allocation, distribution, and/or use of funds allocated to that State and to Participating Subdivisions in that State. A State -Subdivision Agreement shall be effective if approved pursuant to the provisions of Exhibit O or if adopted by statute. Preexisting agreements addressing funds other than those allocated pursuant to this Agreement shall qualify if the approval requirements of Exhibit O are met. A State and its Subdivisions may revise, supplement, or refine a State -Subdivision Agreement if approved pursuant to the provisions of Exhibit O or if adopted by statute. 75. "Statutory Trust" means a trust fund established by state law to receive funds allocated to a State's Abatement Accounts Fund and restrict their expenditure to Opioid Remediation purposes subject to reasonable administrative expenses. A State may give a Statutory Trust authority to allocate one or more of the three Settlement Funds, but this is not required. 76. "Subdivision" means a formal and legally recognized sub -entity of a State that provides general governance for a defined area, including a county, parish, city, town, village, or similar entity. Unless otherwise specified, "Subdivision" includes all functional counties and parishes and other functional levels of sub - entities of a State that provide general governance for a defined area. Historic, non-functioning sub -entities of a State (such as Connecticut counties) are not Subdivisions, unless the entity has filed a lawsuit that includes a Released Claim against a Released Entity in a direct, parens patriae, or any other capacity. For purposes of this Agreement, the term Subdivision does not include Special Districts. A list of Subdivisions by state will be agreed to prior to any Subdivision sign -on period. 77. "Subdivision Allocation Percentage" means for Subdivisions in a Settling State that are eligible to receive an allocation from the Subdivision Fund pursuant to subsection VI.0 or subsection VI.D, the percentage as set forth in Exhibit G. The aggregate Subdivision Allocation Percentage of all Subdivisions receiving a Subdivision Allocation Percentage in each State shall equal 100%. Immediately upon the effectiveness of any State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VLD.3 (or upon the effectiveness of an amendment to any State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VI.D.3) that addresses allocation from the Subdivision Fund, or upon any, whether before or after the Initial Participation Date, Exhibit G will automatically be amended to reflect the allocation from the Subdivision Fund pursuant to the State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by Section V.D.3. The Subdivision Allocation Percentages contained in Exhibit G may not change once notice is distributed pursuant to subsection VILA, except upon the effectiveness of any State- 12 revised July 30, 2021 Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VI.D.3 (or upon the effectiveness of an amendment to any State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VLD.3) that addresses allocation from the Subdivision Fund. For the avoidance of doubt, no Subdivision not listed on Exhibit G shall receive an allocation from the Subdivision Fund and no provision of this Agreement shall be interpreted to create such an entitlement. 78. "Subdivision Fund"means a component of the Settlement Fund described in subsection VI.C. 79. "Subdivision Settlement Participation Form" means the form attached as Exhibit K that Participating Subdivisions must execute and return to the Settlement Fund Administrator, and which shall (1) make such Participating Subdivisions signatories to this Agreement, (2) include a full and complete release of any and of such Subdivision's claims, and (3) require the prompt dismissal with prejudice of any Released Claims that have been filed by any such Participating Subdivision. 80. "Threshold Motion" means a motion to dismiss or equivalent dispositive motion made at the outset of litigation under applicable procedure. A Threshold Motion must include as potential grounds for dismissal, any applicable Bar or the relevant release by a Settling State or Participating Subdivision provided under this Agreement and, where appropriate under applicable law, any applicable limitations defense. 81. "Trigger Date" means, in the case of a Primary Subdivision, the Reference Date, or, in the case of all other Subdivisions, the Preliminary Agreement Date. II. Participation by States and Condition to Preliminary Agreement A. Notice to States. On July 22, 2021 this Agreement shall be distributed to all States. The States' Attorneys General shall then have a period of thirty (30) days to decide whether to become Settling States. States that determine to become Settling States shall so notify the National Association of Attorneys General and Janssen and shall further commit to obtaining any necessary additional State releases prior to the Reference Date. This notice period may be extended by written agreement of Janssen and the Enforcement Committee. B. Condition to Preliminary Agreement. Following the notice period set forth in subsection II.A above, Janssen shall determine on or before the Preliminary Agreement Date whether, in its sole discretion, enough States have agreed to become Settling States to proceed with notice to Subdivisions as set forth in Section VII below. If Janssen determines that this condition has been satisfied, and that notice to the Litigating Subdivisions should proceed, it will so notify the Settling States by providing notice to the Enforcement Committee and Settlement Fund Administrator on the Preliminary Agreement Date. If Janssen determines that this condition has not been satisfied, it will so 13 revised July 30, 2021 notify the Settling States by providing notice to the Enforcement Committee and Settlement Fund Administrator, and this Agreement will have no further effect and all releases and other commitments or obligations contained herein will be void. C. Later Joinder by States. After the Preliminary Agreement Date, a State may only become a Settling State with the consent of Janssen, in its sole discretion. If a State becomes a Settling State more than sixty (60) days after the Preliminary Agreement Date, but on or before January 1, 2022, the Subdivisions and Special Districts in that State that become Participating Subdivisions and Participating Special Districts within ninety (90) days of the State becoming a Settling State shall be considered Initial Participating Subdivisions or Initial Participating Special Districts. A State may not become a Settling State after January 1, 2022. III. Injunctive Relief A. Entry of Injunctive Relief. As part of the Consent Judgment, the Parties agree to the injunctive relief terms attached as Exhibit P. IV. Release A. Scope. As of the Effective Date, the Released Entities will be released and forever discharged from all of the Releasors' Released Claims. Each Settling State (for itself and its Releasors) and Participating Subdivision (for itself and its Releasors) will, on or before the Effective Date, absolutely, unconditionally, and irrevocably covenant not to bring, file, or claim, or to cause, assist in bringing, or permit to be brought, filed, or claimed, or to otherwise seek to establish liability for any Released Claims against any Released Entity in any forum whatsoever. The releases provided for in the Agreement are intended by the Parties to be broad and shall be interpreted so as to give the Released Entities the broadest possible bar against any liability relating in any way to Released Claims and extend to the full extent of the power of each Settling State and its Attorney General to release claims. The Release shall be a complete bar to any Released Claim. B. Claim Over and Non -Party Settlement. Statement of Intent. It is the intent of the Parties that: a. Released Entities should not seek contribution or indemnification (other than pursuant to an insurance contract) from other parties for their payment obligations under this Settlement Agreement; b. the payments made under this Settlement Agreement shall be the sole payments made by the Released Entities to the Releasors involving, arising out of, or related to Covered Conduct (or conduct that would be Covered Conduct if engaged in by a Released Entity); C. Claims by Releasors against non -Parties should not result in additional payments by Released Entities, whether through contribution, indemnification or any other means; and 14 revised July 30, 2021 d. the Settlement meets the requirements of the Uniform Contribution Among Joint Tortfeasors Act and any similar state law or doctrine that reduces or discharges a released party's liability to any other parties. e. The provisions of this subsection IV.B are intended to be implemented consistent with these principles. This Agreement and the releases and dismissals provided for herein are made in good faith. 2. Contribution/Indemnity Prohibited. No Released Entity shall seek to recover for amounts paid under this Agreement based on indemnification, contribution, or any other theory from a manufacturer, pharmacy, hospital, pharmacy benefit manager, health insurer, third -party vendor, trade association, distributor, or health care practitioner, provided that a Released Entity shall be relieved of this prohibition with respect to any entity that asserts a Claim -Over against it. For the avoidance of doubt, nothing herein shall prohibit a Released Entity from recovering amounts owed pursuant to insurance contracts. 3. Non -Party Settlement. To the extent that, on or after the Reference Date, any Releasor enters into a Non -Party Settlement, including in any bankruptcy case or through any plan of reorganization (whether individually or as a class of creditors), the Releasor will include (or in the case of a Non -Party Settlement made in connection with a bankruptcy case, will cause the debtor to include), unless prohibited from doing so under applicable law, in the Non -Party Settlement a prohibition on contribution or indemnity of any kind substantially equivalent to that required from Janssen in subsection IV.B.2, or a release from such Non - Released Entity in favor of the Released Entities (in a form equivalent to the releases contained in this Agreement) of any Claim -Over. The obligation to obtain the prohibition and/or release required by this subsection is a material term of this Agreement. 4. Claim -Over. In the event that any Releasor obtains a judgment with respect to Non -Parry Covered Conduct against a Non -Released Entity that does not contain a prohibition like that in subsection IV.13.3, or any Releasor files a Non -Parry Covered Conduct Claim against a non -Released Entity in bankruptcy or a Releasor is prevented for any reason from obtaining a prohibition/release in a Non -Party Settlement as provided in subsection IV.13.3, and such Non -Released Entity asserts a Claim -Over against a Released Entity, that Releasor and Janssen shall take the following actions to ensure that the Released Entities do not pay more with respect to Covered Conduct to Releasors or to Non -Released Entities than the amounts owed under this Settlement Agreement by Janssen: a. Janssen shall notify that Releasor of the Claim -Over within sixty (60) days of the assertion of the Claim -Over or sixty (60) days of the Effective Date of this Settlement Agreement, whichever is later; b. Janssen and that Releasor shall meet and confer concerning the means to hold Released Entities harmless and ensure that it is not required to pay 15 revised July 30, 2021 more with respect to Covered Conduct than the amounts owed by Janssen under this Settlement Agreement; C. That Releasor and Janssen shall take steps sufficient and permissible under the law of the State of the Releasor to hold Released Entities harmless from the Claim -Over and ensure Released Entities are not required to pay more with respect to Covered Conduct than the amounts owed by Janssen under this Settlement Agreement. Such steps may include, where permissible: (1) Filing of motions to dismiss or such other appropriate motion by Janssen or Released Entities, and supported by Releasors, in response to any claim filed in litigation or arbitration; (2) Reduction of that Releasor's Claim and any judgment it has obtained or may obtain against such Non -Released Entity by whatever amount or percentage is necessary to extinguish such Claim -Over under applicable law, up to the amount that Releasor has obtained, may obtain, or has authority to control from such Non -Released Entity; (3) Placement into escrow of funds paid by the Non -Released Entities such that those funds are available to satisfy the Claim -Over; (4) Return of monies paid by Janssen to that Releasor under this Settlement Agreement to permit satisfaction of a judgment against or settlement with the Non -Released Entity to satisfy the Claim - Over; (5) Payment of monies to Janssen by that Releasor to ensure it is held harmless from such Claim -Over, up to the amount that Releasor has obtained, may obtain, or has authority to control from such Non -Released Entity; (6) Credit to Janssen under this Settlement Agreement to reduce the overall amounts to be paid under the Settlement Agreement such that it is held harmless from the Claim -Over; and (7) Such other actions as that Releasor and Janssen may devise to hold Janssen harmless from the Claim Over. d. The actions of that Releasor and Janssen taken pursuant to paragraph (c) must, in combination, ensure Janssen is not required to pay more with respect to Covered Conduct than the amounts owed by Janssen under this Settlement Agreement. e. In the event of any dispute over the sufficiency of the actions taken pursuant to paragraph (c), that Releasor and Janssen may seek review by 16 revised July 30, 2021 the National Arbitration Panel, provided that, if the parties agree, such dispute may be heard by the state court where the relevant Consent Judgment was filed. The National Arbitration Panel shall have authority to require Releasors to implement a remedy that includes one or more of the actions specified in paragraph (c) sufficient to hold Released Entities fully harmless. In the event that the panel's actions do not result in Released Entities being held fully harmless, Janssen shall have a claim for breach of this Settlement Agreement by Releasors, with the remedy being payment of sufficient funds to hold Janssen harmless from the Claim -Over. For the avoidance of doubt, the prior sentence does not limit or eliminate any other remedy that Janssen may have. To the extent that the Claim -Over is based on a contractual indemnity, the obligations under subsection IV.13.4 shall extend solely to a Non -Party Covered Conduct Claim against a pharmacy, clinic, hospital or other purchaser or dispenser of Products, a manufacturer that sold Products, a consultant, and/or a pharmacy benefit manager or other third -party payor. Janssen shall notify the Settling States, to the extent permitted by applicable law, in the event that any of these types of Non -Released Entities asserts a Claim -Over arising out of contractual indemnity against it. C. General Release. In connection with the releases provided for in the Agreement, each Settling State (for itself and its Releasors) and Participating Subdivision expressly waives, releases, and forever discharges any and all provisions, rights, and benefits conferred by any law of any state or territory of the United States or other jurisdiction, or principle of common law, which is similar, comparable, or equivalent to § 1542 of the California Civil Code, which reads: General Release; extent. A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release that, if known by him or her, would have materially affected his or her settlement with the debtor or released party. A Releasor may thereafter discover facts other than or different from those which it knows, believes, or assumes to be true with respect to the Released Claims, but each Settling State (for itself and its Releasors) and Participating Subdivision hereby expressly waives and fully, finally, and forever settles, releases, and discharges, upon the Effective Date, any and all Released Claims that may exist as of such date but which Releasors do not know or suspect to exist, whether through ignorance, oversight, error, negligence or through no fault whatsoever, and which, if known, would materially affect the Settling States' decision to enter into the Agreement or the Participating Subdivisions' decision to participate in the Agreement. D. Res Judicata. Nothing in the Agreement shall be deemed to reduce the scope of the res judicata or claim preclusive effect that the settlement memorialized in the Agreement, 17 revised July 30, 2021 and/or any Consent Judgment or other judgment entered on the Agreement, gives rise to under applicable law. E. Representation and Warranty. The signatories hereto on behalf of their respective Settling States and its Participating Subdivisions expressly represent and warrant that they will obtain on or before the Effective Date (or have obtained) the authority to settle and release, to the maximum extent of the State's power, all Released Claims of (1) their respective Settling States; (2) all past and present executive departments, state agencies, divisions, boards, commissions and instrumentalities with the regulatory authority to enforce state and federal controlled substances acts; (3) any of their respective Settling State's past and present executive departments, agencies, divisions, boards, commissions and instrumentalities that have the authority to bring Claims related to Covered Conduct seeking money (including abatement and/or remediation) or revocation of a pharmaceutical distribution license; and (4) any Participating Subdivisions. For the purposes of clause (3) above, executive departments, agencies, divisions, boards, commissions, and instrumentalities are those that are under the executive authority or direct control of the State's Governor. Also, for the purposes of clause (3), a release from a State's Governor is sufficient to demonstrate that the appropriate releases have been obtained. F. Effectiveness. The releases set forth in the Agreement shall not be impacted in any way by any dispute that exists, has existed, or may later exist between or among the Releasors. Nor shall such releases be impacted in any way by any current or future law, regulation, ordinance, or court or agency order limiting, seizing, or controlling the distribution or use of the Settlement Fund or any portion thereof, or by the enactment of future laws, or by any seizure of the Settlement Fund or any portion thereof. G. Cooperation. Releasors (i) will not encourage any person or entity to bring or maintain any Released Claim against any Released Entity and (ii) will reasonably cooperate with and not oppose any effort by a Released Entity to secure the prompt dismissal of any and all Released Claims. H. Non -Released Claims. Notwithstanding the foregoing or anything in the definition of Released Claims, the Agreement does not waive, release or limit any criminal liability, Claims for any outstanding liability under any tax or securities law, Claims against parties who are not Released Entities, Claims by private individuals and any claims arising under the Agreement for enforcement of the Agreement. V. Monetary Relief and Payments A. Structure of Payments All payments under this Section V shall be made into the Settlement Fund, except that where specified, they shall be made into the Settlement Fund Escrow. The Settlement Fund shall be allocated and used only as specified in Section VI. 2. Janssen shall pay into the Settlement Fund the sum of Four Billion, Five Hundred Thirty -Four Million, Six Hundred Fifteen Thousand, Three Hundred Eighty -Five 18 revised July 30, 2021 Dollars ($4,534,615,385) minus (1) the offsets and credits specified in subsection V.0 below, (2) any unearned incentive payments under subsection V.E below, and (3) any adjustments under Section Dt below. 3. The payments to the Settlement Fund shall be divided into base and incentive payments as provided in subsections V.D and V.E below. B. Payment Process Except as otherwise provided in this Agreement, Janssen shall make two Initial Year Payments and nine (9) Annual Payments. The Initial Year Payments will consist of base payments. The first Annual Payment shall consist of incentive payments and subsequent Annual Payments shall each consist of base and incentive payments. The amount of all Initial Year Payments and Annual Payments shall be determined by the Settlement Fund Administrator applying Section V and Exhibit M. The Payment Date for the first Initial Year Payment shall be no later than ninety (90) days after the Effective Date. The Payment Date for the second Initial Year Payment shall be no later than July 15, 2022. The Payment Date for the first Annual Payment shall be no later than one year and sixty days following the Effective Date; the Payment Date for the second Annual Payment shall be no later than two years and sixty days following the Effective Date, and so forth, until all Annual Payments are made. 2. All data relevant to the determination of each such payment shall be submitted to the Settlement Fund Administrator sixty (60) days prior to the Payment Date for each payment. Prior to the Initial Participation Date, the Parties will include an exhibit to the Agreement setting forth in detail the process for submitting such data to the Settlement Fund Administrator prior to each Payment Date. The Settlement Fund Administrator shall then determine the Initial Year Payment or Annual Payment and the amount to be paid to each Settling State and its Participating Subdivisions, consistent with the provisions in Exhibit L, by: a. determining, for each Settling State, the amount of base and incentive payments to which the State is entitled by applying the criteria in this Section; b. applying any reductions, suspensions, or offsets required by Sections V and D{; and C. determining the total amount owed by Janssen to all Settling States and Participating Subdivisions. 3. The Settlement Fund Administrator shall then allocate the Initial Year Payment or Annual Payment pursuant to Section VI among the Settling States, among the separate types of funds for each Settling State (if applicable), and among the Participating Subdivisions. 19 revised July 30, 2021 4. As soon as possible, but no later than fifty (50) days prior to the Payment Date for each payment and following the determination described in subsection V.13.2, the Settlement Fund Administrator shall give notice to Janssen, the Settling States, and the Enforcement Committee of the amount of the Initial Year Payment or Annual Payment, the amount to be received by each Settling State, the amount to be received by the separate types of funds for each Settling State (if applicable), and the amount to be received by each Settling State's Participating Subdivisions. 5. Within twenty-one (21) days of the notice provided by the Settlement Fund Administrator, any party may dispute, in writing, the calculation of the Initial Year Payment or Annual Payment, or the amount to be received by a Settling State and/or its Participating Subdivisions. Such disputing party must provide a written notice of dispute to the Settlement Fund Administrator, the Enforcement Committee, any affected Settling State, and Janssen identifying the nature of the dispute, the amount of money that is disputed, and the Settling State(s) affected. 6. Within twenty-one (21) days of the sending of a written notice of dispute, any affected party may submit a response, in writing, to the Settlement Fund Administrator, the Enforcement Committee, any affected Settling State, and Janssen identifying the basis for disagreement with the notice of dispute. If no response is filed, the Settlement Fund Administrator shall adjust the amount calculated consistent with the written notice of dispute, and Janssen shall pay the adjusted amount as the Initial Year Payment or Annual Payment on the Payment Date. If a written response to the written notice of dispute is timely sent to the Settlement Fund Administrator, the Settlement Fund Administrator shall notify Janssen of the preliminary amount to be paid, which shall be the greater of the amount originally calculated by the Settlement Fund Administrator or the amount that would be consistent with the notice of dispute, provided, however that in no circumstances shall the preliminary amount to be paid be higher than the maximum amount of base and incentive payments for that payment as set forth in Exhibit M. For the avoidance of doubt, a transfer of suspended payments from the Settlement Fund Escrow does not count toward determining whether the amount to be paid is higher than the maximum amount of base and incentive payments for that payment as set forth in Exhibit M. The Settlement Fund Administrator shall place any disputed amount of the preliminary amount paid by Janssen into the Settlement Fund Escrow and shall disburse any undisputed amount to each Settling State and its Participating Subdivisions receiving direct allocations within fifteen (15) days of the Payment Date or at such later time as directed by each Settling State. Disputes described in this subsection (other than those for which no response is filed under subsection V.13.6) shall be resolved in accordance with the terms of Section XII. 20 revised July 30, 2021 10. The process described in this subsection V.B shall also apply to accelerated payments made pursuant to Incentive A under subsection V.E.4. 11. For the avoidance of doubt, Subdivisions not listed on Exhibit G shall not receive an allocation from the Subdivision Fund. C. Offsets for Non -Settling States and Credits An offset equal to Four Billion, Five Hundred Thirty -Four Million, Six Hundred Fifteen Thousand, Three Hundred Eighty -Five Dollars ($4,534,615,385) times the percentage allocation assigned to each Non -Settling State in Exhibit F shall be deducted from the total amount to be paid by Janssen to the Settlement Fund under subsection V.A.2 above. In addition to the offset, a credit of Two Hundred and Seventy Million Dollars ($270,000,000) shall be deducted from the maximum Settlement Fund amount to be paid by Janssen under subsection V.A.2 above and applied to the payment amounts as specified by Exhibit M. For the avoidance of doubt, the base payments and maximum incentive payment amounts shown on Exhibit M already reflect the deduction of the offset. Notwithstanding any other provision of this Agreement or any other agreement, in the event that: (1) Janssen enters into an agreement with any Settling State that resolves with finality such Settling State's Claims consistent with Section IV of this Agreement and such agreement has an effective date prior to the Effective Date of this Agreement (such agreement, a "State -Specific Agreement") and (2) pursuant to the terms of the State -Specific Agreement, any payments, or any portion thereof, made by Janssen thereunder are made in lieu of any payments (for the avoidance of doubt, including the Additional Restitution Amount), or any portion thereof, to be made under this Agreement and Janssen makes such a payment pursuant to the State -Specific Agreement, then Janssen will reduce any payments allocable to such Settling State (whether made to the Settlement Fund Escrow or the Settlement Fund) made pursuant to this Agreement to the extent such amount was already paid pursuant to the terms of the State -Specific Agreement. This provision includes but is not limited to any corresponding amounts already paid to the Qualified Settlement Fund established under the Agreement between Janssen and the State of New York dated June 25, 2021. Non -Settling States shall not be eligible for any payments or have any rights in connection with this Agreement. Accordingly, the stated maximum dollar amounts of the payments specified in Exhibit M are reduced by the aggregate Overall Allocation Percentage of Non -Settling States as set forth in Exhibit F. D. Base Payments Janssen shall make base payments into the Settlement Fund totaling One Billion, Nine Hundred Forty -Two Million, Three Hundred Forty -Six Thousand, One Hundred Fifty -Five Dollars ($1,942,346,155) minus the offsets and credits 21 revised July 30, 2021 specified in subsection V.0 above. The base payments will be paid in accordance with the payment schedule specified by Exhibit M, subject to potential acceleration and potential deductions as provided herein. 2. The base payments will be allocated by Settling State proportionate to each Settling State's assigned percentages in Exhibit F, adjusted for any Non -Settling States. If a State qualifies for Incentive A (described below), Janssen will accelerate the base payment schedule so that the State receives its Payment Year 1-4 base payment allocations and full Payment Year 1-4 Incentive A payment amounts within ninety (90) days of notice, on or after the Effective Date, of the Bar's implementation. Payment Year 5-10 payments are made annually and cannot be accelerated. 4. The exemplar payment schedule in Exhibit M does not account for deductions for offsets or unearned incentives, which will be separately calculated for each payment. E. Incentive Payments Janssen shall make incentive payments into the Settlement Fund potentially totaling up to Two Billion, Three Hundred Twenty -Two Million, Two Hundred Sixty -Nine Thousand, Two Hundred Thirty Dollars ($2,322,269,230), consisting of $2,109,038,461 for Incentive A (or, alternatively up to $2,109,038,461 for combined Incentives B and C if Incentive A is not achieved) and $213,230,769 for Incentive D, prior to being adjusted for credits if every State is a Settling State and were to satisfy the requirements specified below to earn its maximum incentive amount. The incentive payments will be paid in accordance with the payment schedule in Exhibit M, subject to potential acceleration and potential deductions as provided herein. The maximum incentive amount for any Settling State shall be $2,322,269,230 times the percentage allocation assigned that Settling State in Exhibit F. A Settling State may qualify to receive incentive payments in addition to base payments if, as of the Incentive Payment Final Eligibility Date, it meets the incentive eligibility requirements specified below. Settling States may qualify for incentive payments in four ways. If a Settling State qualifies for "Incentive A," it will become entitled to receive the maximum Incentive A payment allocable to the State as stated in subsection V.E.1. If a Settling State does not qualify for Incentive A, it can alternatively qualify for "Incentive B" and/or "Incentive C." A Settling State can qualify for "Incentive D" regardless of whether it qualifies for another incentive payment. The Incentive Payment Final Eligibility Date is not relevant to Incentive D. 22 revised July 30, 2021 4. Incentive A: Accelerated Incentive Paymentfor Full Participation. a. A Settling State shall receive an accelerated Incentive A payment allocable to the State for full participation as described in subsection V.E.4.b. b. A State qualifies for Incentive A by: (1) complete participation in the form of releases consistent with Section IV above from all Litigating Subdivisions and Litigating Special Districts, Non -Litigating Subdivisions with population over 10,000, and Non -Litigating Covered Special Districts (as defined in subsection V.E.7.e); (2) a Bar; or (3) a combination of approaches in clauses (1)-(2) that achieves the same level of resolution of Subdivision and Special District claims (e.g., a law barring future litigation combined with full joinder by Litigating Subdivisions and Litigating Special Districts). For purposes of Incentive A, a Subdivision or Special District is considered a "Litigating Subdivision" or "Litigating Special District" if it has brought Released Claims against Released Entities on or before the Reference Date; all other Subdivisions and Special Districts are considered "Non -Litigating." For purposes of Incentive A, Non -Litigating Special Districts shall not include a Special District with any of the following words or phrases in its name: mosquito, pest, insect, spray, vector, animal, air quality, air pollution, clean air, coastal water, tuberculosis, and sanitary. C. Qualification for Incentive A entitles the qualifying Settling State to expedited payment of base payments and incentive payments for Payment Years 1-4, which Janssen shall pay into the Settlement Fund within ninety (90) days after receiving notice from the Settlement Fund Administrator that a State has qualified for Incentive A, but in no event less than ninety (90) days from the Effective Date. Base and incentive payments for Payment Years 5-10 will not be expedited. d. If a Settling State qualifies for Incentive A after receiving an incentive payment under Incentives B or C, described below, the Settling State's payments under Incentive A will equal the remainder of its total Incentive A payments less any payments previously received under Incentives B or C. A Settling State that receives all of its maximum incentive allocation under Incentive A shall not receive additional incentive payments under Incentives B or C. C. A Settling State that is not eligible for Incentive A as of the Incentive Payment Final Eligibility Date shall not be eligible for Incentive A for that Payment Year or any subsequent Payment Years. 23 revised July 30, 2021 5. Incentive B: Early Participation or Released Claims by Litigating Subdivisions and Litigating Special Districts. a. If a Settling State does not qualify for Incentive A, it may still qualify to receive up to 60% of its total potential Incentive A payment allocation under Incentive B. b. A Settling State can qualify for an Incentive B payment if Litigating Subdivisions and Litigating Special Districts collectively representing at least 75% of the Settling State's litigating population are either Participating Subdivisions or have their claims resolved through Case - Specific Resolutions. (1) A Settling State's litigating population is the sum of the population of all Litigating Subdivisions and Litigating Special Districts. A Settling State's litigating population shall include all Litigating Subdivisions and Litigating Special Districts whose populations overlap in whole or in part with other Litigating Subdivisions and Litigating Special Districts, for instance in the case of a Litigating Special District, city, or township contained within a county. (2) For example, if a Litigating Special District and a city that is a Litigating Subdivision are located within a county that is a Litigating Subdivision, then each of their individual populations would be added together to determine the total litigating population. Special District populations shall be counted in the manner set forth in subsection XIII.B. If each qualifies as a Litigating Subdivision or Litigating Special District and the county has a population of 10, the City has a population of 8, and the Special District has a population of 1, the total litigating population would be 19. C. The following time periods apply to Incentive B payments: (1) Period 1: Zero to two hundred ten (210) days after the Effective Date. (2) Period 2: Two hundred eleven (211) days to one year after the Effective Date. (3) Period 3: One year and one day to two years after the Effective Date. d. Within Period 1: If Litigating Subdivisions and Litigating Special Districts collectively representing at least 75% of a Settling State's litigating population are Participating Subdivisions or have their claims resolved through Case -Specific Resolutions during Period 1, a sliding scale will determine the share of the funds available under Incentive B, with a 24 revised July 30, 2021 maximum of 60% of the Settling State's total potential incentive payment allocation available. Under that sliding scale, if Litigating Subdivisions and Litigating Special Districts collectively representing 75% of a Settling State's litigating population become Participating Subdivisions or achieve Case -Specific Resolution status by the end of Period 1, a Settling State will receive 50% of the total amount available to it under Incentive B. If more Litigating Subdivisions and Litigating Special Districts become Participating Subdivisions or achieve Case -Specific Resolution status, the Settling State shall receive an increased percentage of the total amount available to it under Incentive B as shown in the table below. Participation or Case -Specific Resolution Levels (As percentage of litigating population) Incentive B Award (As percentage of total amount available to State under Incentive B 75% 50% 76% 52% 77% 54% 78% 56% 79% 58% 80% 60% 85% 70% 90% 80% 95% 90% 100% 100% e. Within Period 2: If a Settling State did not qualify for an Incentive B payment in Period 1, but Litigating Subdivisions and Litigating Special Districts collectively representing at least 75% of the Settling State's litigating population become Participating Subdivisions or achieve Case - Specific Resolution status by the end of Period 2, then the Settling State qualifies for 75% of the Incentive B payment it would have qualified for in Period 1. Within Period 3: If a Settling State did not qualify for an Incentive B payment in Periods 1 or 2, but Litigating Subdivisions and Litigating Special Districts collectively representing at least 75% of the Settling State's litigating population become Participating Subdivisions or achieve Case -Specific Resolution status by the end of Period 3, then the Settling State qualifies for 50% of the Incentive B payment it would have qualified for in Period 1. g. A Settling State that receives the Incentive B payment for Periods 1 and/or 2 can receive additional payments if it secures participation from additional Litigating Subdivisions and Litigating Special Districts (or Case -Specific Resolutions of their claims) during Periods 2 and/or 3. 25 revised July 30, 2021 Those additional payments would equal 75% (for additional participation or Case -Specific Resolutions during Period 2) and 50% (for additional participation or Case -Specific Resolutions during Period 3) of the amount by which the increased litigating population levels would have increased the Settling State's Incentive B payment if they had been achieved in Period 1. h. If Litigating Subdivisions and Litigating Special Districts that have become Participating Subdivisions or achieved Case -Specific Resolution status collectively represent less than 75% of a Settling State's litigating population by the end of Period 3, the Settling State shall not receive any Incentive B payment. i. If there are no Litigating Subdivisions or Litigating Special Districts in a Settling State, and that Settling State is otherwise eligible for Incentive B, that Settling State will receive its full allocable share of Incentive B. Incentives earned under Incentive B shall accrue after each of Periods 1, 2, and 3. After each period, the Settlement Fund Administrator shall conduct a look -back to assess which Settling States vested an Incentive B payment in the preceding period. Based on the look -back, the Settlement Fund Administrator will calculate the incentives accrued under Incentive B for the period; provided that the percentage of Incentive B for which a Settling State is eligible as of the Incentive Payment Final Eligibility Date shall cap its eligibility for that Payment Year and all subsequent Payment Years. 6. Incentive C: Early Participation of Subdivisions a. If a Settling State does not qualify for Incentive A, it may still qualify to receive up to 40% of its total potential Incentive A payment allocation under Incentive C, which has two parts. (1) Part 1: Under Incentive C, Part 1, a Settling State can receive up to 75% of its Incentive C allocation. A Settling State can qualify for a payment under Incentive C, Part 1 only if Primary Subdivisions (whether Litigating Primary Subdivisions or Non -Litigating Primary Subdivisions as of the Reference Date) representing at least 60% of the Settling State's Primary Subdivision population become Participating Subdivisions or achieve Case -Specific Resolution status. (2) A Settling State's Primary Subdivision population is the sum of the population of all Primary Subdivisions (whether Litigating Primary Subdivisions or Non -Litigating Primary Subdivisions as of the Reference Date). Because Subdivisions include Subdivisions whose populations overlap in whole or in part with other 26 revised July 30, 2021 Subdivisions, for instance in the case of a city or township contained within a county, the Settling State's Primary Subdivision population is greater than Settling State's total population. (Special Districts are not relevant for purposes of Incentive C calculations.) (3) A sliding scale will determine the share of the funds available under Incentive C, Part 1 to Settling States meeting the minimum 60% threshold. Under that sliding scale, if a Settling State secures participation or Case -Specific Resolutions from Primary Subdivisions representing 60% of its total Primary Subdivision population, it will receive 40% of the total amount potentially available to it under Incentive C, Part 1. If a Settling State secures participation or Case -Specific Resolutions from Primary Subdivisions representing more than 60% of its Primary Subdivision population, the Settling State shall be entitled to receive a higher percentage of the total amount potentially available to it under Incentive C, Part 1, on the scale shown in the table below. If there are no Primary Subdivisions, and that Settling State is otherwise eligible for Incentive C, that Settling State will receive its full allocable share of Incentive C, Part 1. Participation or Case -Specific Resolution Levels (As percentage of total Primary Subdivision population) Incentive C Award (As percentage of total amount available to State under Incentive C, Part 1 60% 40% 70% 45% 80% 50% 85% 55% 90% 60% 91% 65% 92% 70% 93% 80% 94% 90% 95% 100% b. Part 2: If a Settling State qualifies to receive an incentive under Incentive C, Part 1, the State can also qualify to receive an additional incentive amount equal to 25% of its total potential Incentive C allocation by securing 100% participation of the ten (10) largest Subdivisions by population in the Settling State. (Special Districts are not relevant for purposes of this calculation.) If a Settling State does not qualify for any amount under Incentive C, Part 1, it cannot qualify for Incentive C, Part 2. C. Incentives earned under Incentive C shall accrue on an annual basis up to three years after the Effective Date. At one, two, and three years after the 27 revised July30, 2021 Effective Date, the Settlement Fund Administrator will conduct a look - back to assess which Subdivisions had agreed to participate or had their claim resolved through a Case -Specific Resolution that year. Based on the look -back, the Settlement Fund Administrator will calculate the incentives accrued under Incentive C for the year; provided that the percentage of Incentive C for which a Settling State is eligible as of the Incentive Payment Final Eligibility Date shall cap its eligibility for that Payment Year and all subsequent Payment Years. 7. Incentive D: Release of Payments if No Qualifying Special District Litigation. a. $213,230,769 shall be available for potential Incentive D payments according to the terms specified in this subsection V.E.7. b. If, within five years of the Reference Date, a Covered Special District files litigation against any Released Entity, Janssen shall, within thirty (30) days of Janssen being served, provide notice of the litigation to the Settling State in which the Covered Special District sits, which shall file a motion to intervene in the litigation and use its best efforts to obtain either dismissal of the litigation in cooperation with Janssen, or a release consistent with Section IV of the Special District's Claims. C. A Settling State shall receive its allocation of the Incentive D payment if, within five years after the Effective Date (the "look -back date"), no Covered Special District within the Settling State has filed litigation which has survived a Threshold Motion and remains pending as of the look -back date, unless the dismissal after the litigation survived the Threshold Motion is conditioned or predicated upon payment by a Released Entity (apart from payments by Janssen incurred under the Agreement or injunctive relief obligations incurred by it). d. Prior to the look -back date, a Released Entity shall not enter into a settlement with a Covered Special District unless the State in which the Covered Special District sits consents to such a settlement or unreasonably withholds consent of such a settlement. e. "Covered Special Districts" are school districts, healthcare/hospital districts, and fire districts, subject to the following population thresholds: (1) For school districts, the K-12 student enrollment must be 25,000 or 0.12% of a State's population, whichever is greater; (2) For fire districts, the district must cover a population of 25,000, or 0.20% of a State's population if a State's population is greater than 18 million. If not easily calculable from state data sources and agreed to between the State and Janssen, a fire district's population is calculated by dividing the population of the county or counties a 28 revised July 30, 2021 fire district serves by the number of fire districts in the county or counties. (3) For healthcare/hospital districts, the district must have at least 125 hospital beds in one or more hospitals rendering services in that district. VI. Allocation and Use of Settlement Funds A. Components of Settlement Fund. The Settlement Fund shall be comprised of an Abatement Accounts Fund, a State Fund, and a Subdivision Fund for each Settling State. The payments under Section V into the Settlement Fund shall be initially allocated among those three (3) sub -funds and distributed and used as provided below or as provided for by a State -Subdivision Agreement (or other State -specific allocation of funds). Unless otherwise specified herein, payments placed into the Settlement Fund do not revert back to Janssen. B. Use of Settlement Payments. It is the intent of the Parties that the payments disbursed from the Settlement Fund to Settling States and Participating Subdivisions listed in Exhibit G be for Opioid Remediation, subject to limited exceptions that must be documented in accordance with subsection VI.B.2. In no event may less than 86.5% of Janssen's maximum amount of payments pursuant to Sections V, X, and XI over the entirety of all Payment Years (but not any single Payment Year) be spent on Opioid Remediation. 2. While disfavored by the Parties, a Settling State or Participating Subdivision listed on Exhibit G may use monies from the Settlement Fund (that have not been restricted by this Agreement solely to future Opioid Remediation) for purposes that do not qualify as Opioid Remediation. If, at any time, a Settling State or a Participating Subdivision listed on Exhibit G uses any monies from the Settlement Fund for a purpose that does not qualify as Opioid Remediation, such Settling State or Participating Subdivision shall identify such amounts and report to the Settlement Fund Administrator and Janssen how such funds were used, including if used to pay attorneys' fees, investigation costs, litigation costs, or costs related to the operation and enforcement of this Agreement, respectively. It is the intent of the Parties that the reporting under this subsection VI.B.2 shall be available to the public. For the avoidance of doubt, (a) any amounts not identified under this subsection VI.B.2 as used to pay attorneys' fees, investigation costs, or litigation costs shall be included in the "Compensatory Restitution Amount" for purposes of subsection VI.F and (b) Participating Subdivisions not listed on Exhibit G or Participating Special Districts that receive monies from the Settlement Fund indirectly may only use such monies from the Settlement Fund for purposes that qualify as Opioid Remediation. 29 revised July 30, 2021 C. Allocation of Settlement Fund. The allocation of the Settlement Fund allows for different approaches to be taken in different states, such as through a State -Subdivision Agreement. Given the uniqueness of States and their Subdivisions, Settling States and Participating Subdivisions are encouraged to enter into State -Subdivision Agreements in order to direct the allocation of their portion of the Settlement Fund. As set out below, the Settlement Fund Administrator will make an initial allocation to three (3) state -level sub -funds. The Settlement Fund Administrator will then, for each Settling State and its Participating Subdivisions listed on Exhibit G, apply the terms of this Agreement and any relevant State -Subdivision Agreement, Statutory Trust, Allocation Statute, or voluntary redistribution of funds as set out below before disbursing the funds. Base Payments. The Settlement Fund Administrator will allocate base payments under subsection V.D among the Settling States in proportion to their respective Overall Allocation Percentages. Base payments for each Settling State will then be allocated 15% to its State Fund, 70% to its Abatement Accounts Fund, and 15% to its Subdivision Fund. Amounts may be reallocated and will be distributed as provided in subsection VI.D. 2. Incentive Payments. The Settlement Fund Administrator will treat incentive payments under subsection V.E on a State -specific basis. Incentive payments for which a Settling State is eligible under subsection V.E will be allocated 15% to its State Fund, 70% to its Abatement Accounts Fund, and 15% to its Subdivision Fund. Amounts may be reallocated and will be distributed as provided in subsection VLD. Application of Adjustments. If a reduction, offset, or suspension under Section IX applies with respect to a Settling State, the reduction, offset, or suspension shall be applied proportionally to all amounts that would otherwise be apportioned and distributed to the State Fund, the Abatement Accounts Fund, and the Subdivision Fund for that State. 4. Settlement Fund Administrator. Prior to the Initial Participation Date, Janssen and the Enforcement Committee will agree to a detailed mechanism consistent with the foregoing for the Settlement Fund Administrator to follow in allocating, apportioning, and distributing payments, which shall be appended hereto as Exhibit L. Settlement Fund Administrator Costs. Any costs and fees associated with or arising out of the duties of the Settlement Fund Administrator as described in Exhibit L with regard to Janssen's payments to the Settlement Fund shall be paid out of interest accrued on the Settlement Fund and from the Settlement Fund should such interest prove insufficient. D. Settlement Fund Reallocation and Distribution. As set forth below, within a particular Settling State's account, amounts contained in the Settlement Fund sub -funds may be reallocated and distributed per a State -Subdivision Agreement or other means. If the 30 revised July 30, 2021 apportionment of amounts is not addressed and controlled under subsections VI.D.1-2, then the default provisions of subsection VI.D.4 apply. It is not necessary that a State - Subdivision Agreement or other means of allocating funds pursuant to subsections VI.D.1-2 address all of the Settlement Fund sub -funds. For example, a Statutory Trust might only address disbursements from a Settling State's Abatement Accounts Fund. Distribution by State -Subdivision Agreement. If a Settling State has a State - Subdivision Agreement, amounts apportioned to that State's State Fund, Abatement Accounts Fund, and Subdivision Fund under subsection VI.0 shall be reallocated and distributed as provided by that agreement. Any State -Subdivision Agreement entered into after the Preliminary Agreement Date shall be applied only if it requires: (1) that all amounts be used for Opioid Remediation, except as allowed by subsection VI.B.2, and (2) that at least 70% of amounts be used solely for future Opioid Remediation (references to "future Opioid Remediation" include amounts paid to satisfy any future demand by another governmental entity to make a required reimbursement in connection with the past care and treatment of a person related to the Alleged Harms). For a State -Subdivision Agreement to be applied to the relevant portion of an Initial Year Payment or an Annual Payment, notice must be provided to Janssen and the Settlement Fund Administrator at least sixty (60) days prior to the Payment Date. 2. Distribution by Allocation Statute. If a Settling State has an Allocation Statute and/or a Statutory Trust that addresses allocation or distribution of amounts apportioned to such State's State Fund, Abatement Accounts Fund, and/or Subdivision Fund and that, to the extent any or all such sub -funds are addressed, requires (1) all amounts to be used for Opioid Remediation, except as allowed by subsection VI.B.2, and (2) at least 70% of all amounts to be used solely for future Opioid Remediation, then, to the extent allocation or distribution is addressed, the amounts apportioned to that State's State Fund, Abatement Accounts Fund, and Subdivision Fund under subsection VI.0 shall be allocated and distributed as addressed and provided by the applicable Allocation Statute or Statutory Trust. For the avoidance of doubt, an Allocation Statute or Statutory Trust need not address all three (3) sub -funds that comprise the Settlement Fund, and if the applicable Allocation Statute or Statutory Trust does not address distribution of all or some of these three (3) sub -funds, the applicable Allocation Statute or Statutory Trust does not replace the default provisions in subsection VI.D.4 of any such unaddressed fund. For example, if an Allocation Statute or Statutory Trust that meets the requirements of this subsection VI.D.2 only addresses funds restricted to abatement, then the default provisions in this Agreement concerning allocation among the three (3) sub -funds comprising the Settlement Fund and the distribution of the State Fund and Subdivision Fund for that State would still apply, while the distribution of the applicable State's Abatement Accounts Fund would be governed by the qualifying Allocation Statute or Statutory Trust. 3. Voluntary Redistribution. A Settling State may choose to reallocate all or a portion of its State Fund to its Abatement Accounts Fund. A Participating Subdivision listed on Exhibit G may choose to reallocate all or a portion of its 31 revised July 30, 2021 allocation from the Subdivision Fund to the State's Abatement Accounts Fund or to another Participating Subdivision or Participating Special District. For a voluntary redistribution to be applied to the relevant portion of an Initial Year Payment or an Annual Payment, notice must be provided to the Settling Distributors and the Settlement Fund Administrator at least sixty (60) days prior to the Payment Date. 4. Distribution in the Absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust. If subsections VI.D.1-2 do not apply, amounts apportioned to that State's State Fund, Abatement Accounts Fund, and Subdivision Fund under subsection VI.0 shall be distributed as follows: a. Amounts apportioned to that State's State Fund shall be distributed to that State. b. Amounts apportioned to that State's Abatement Accounts Fund shall be distributed consistent with subsection VI.E. Each Settling State shall submit to the Settlement Fund Administrator a designation of a lead state agency or other entity to serve as the single point of contact for that Settling State's funding requests from the Abatement Accounts Fund and other communications with the Settlement Fund Administrator. The designation of an individual entity is for administrative purposes only and such designation shall not limit funding to such entity or even require that such entity receive funds from this Agreement. The designated entity shall be the only entity authorized to request funds from the Settlement Fund Administrator to be disbursed from that Settling State's Abatement Accounts Fund. If a Settling State has established a Statutory Trust then that Settling State's single point of contact may direct the Settlement Fund Administrator to release the State's Abatement Accounts Fund to the Statutory Trust. C. Amounts apportioned to that State's Subdivision Fund shall be distributed to Participating Subdivisions in that State listed on Exhibit G per the Subdivision Allocation Percentage listed in Exhibit G. Subsection VII.I shall govern amounts that would otherwise be distributed to Non - Participating Subdivisions listed in Exhibit G. d. Special Districts shall not be allocated funds from the Subdivision Fund, except through a voluntary redistribution allowed by subsection VI.D.3. A Settling State may allocate funds from its State Fund or Abatement Accounts Fund for Special Districts. Restrictions on Distribution. No amounts may be distributed from the Subdivision Fund contrary to Section VII, i.e., no amounts may be distributed directly to Non - Participating Subdivisions or to Later Participating Subdivisions in excess of what is permissible under subsection VII.E. Amounts allocated to the Subdivision Fund that cannot be distributed by virtue of the preceding sentence shall be distributed 32 revised July 30, 2021 into the sub -account in the Abatement Accounts Fund for the Settling State in which the Subdivision is located, unless those payments are redirected elsewhere by a State -Subdivision Agreement described in subsection VI.DA or by an Allocation Statute or a Statutory Trust described in subsection VI.D.2. E. Provisions Regarding Abatement Accounts Fund. State -Subdivision Agreement, Allocation Statute, and Statutory Trust Fund Provisions. A State -Subdivision Agreement, Allocation Statute, or Statutory Trust may govern the operation and use of amounts in that State's Abatement Accounts Fund so long as it complies with the requirements of subsection VI.D.1 or VI.D.2 as applicable, and all direct payments to Subdivisions comply with subsections VILE-H. Absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust. In the absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust that addresses distribution, the Abatement Accounts Fund will be used solely for future Opioid Remediation and the following shall apply with respect to a Settling State: a. Regional Remediation. (1) At least 50% of distributions for remediation from a State's Abatement Accounts Fund shall be annually allocated and tracked to the regional level. A Settling State may allow the Advisory Committee established pursuant to subsection VI.E.2.d to define its regions and assign regional allocations percentages. Otherwise, a Settling State shall (1) define its initial regions, which shall consist of one (1) or more Subdivisions and which shall be designated by the State agency with primary responsibility for substance abuse disorder services employing, to the maximum extent practical, existing regions established in that State for opioid abuse treatment or other public health purposes; and (2) assign initial regional allocation percentages to the regions based on the Subdivision Allocation Percentages in Exhibit G and an assumption that all Subdivisions listed on Exhibit G will become Participating Subdivisions. (2) This minimum regional expenditure percentage is calculated on the Settling State's initial Abatement Accounts Fund allocation and does not include any additional amounts a Settling State has directed to its Abatement Accounts Fund from its State Fund, or any other amounts directed to the fund. A Settling State may dedicate more than 50% of its Abatement Accounts Fund to the regional expenditure and may annually adjust the percentage of its Abatement Accounts Fund dedicated to regional expenditures as long as the percentage remains above the minimum amount. 33 revised July 30, 2021 (3) The Settling State (1) has the authority to adjust the definition of the regions, and (2) may annually revise the percentages allocated to each region to reflect the number of Subdivisions in each region that are Non -Participating Subdivisions. b. Subdivision Block Grants. Certain Subdivisions listed on Exhibit G shall be eligible to receive regional allocation funds in the form of a block grant for future Opioid Remediation. A Participating Subdivision listed on Exhibit G eligible for block grants is a county or parish (or in the case of States that do not have counties or parishes that function as political subdivisions, a city) that (1) does not contain a Litigating Subdivision or a Later Litigating Subdivision for which it has the authority to end the litigation through a release, bar, or other action; (2) either (i) has a population of 400,000 or more or (ii) in the case of California has a population of 750,000 or more; and (3) has funded or otherwise managed an established health care or treatment infrastructure (e.g., health department or similar agency). Each Subdivision listed on Exhibit G eligible to receive block grants shall be assigned its own region. C. Small States. Notwithstanding the provisions of subsection VI.E.2.a, Settling States with populations under four (4) million that do not have existing regions described in subsection VI.E.2.a shall not be required to establish regions. However, such a Settling State that contains one (1) or more Subdivisions listed on Exhibit G eligible for block grants under subsection VI.E.2.b shall be divided regionally so that each block -grant eligible Subdivision listed on Exhibit G is a region and the remainder of the state is a region. d. Advisory Committee. The Settling State shall designate an Opioid Settlement Remediation Advisory Committee (the "Advisory Committee") to provide input and recommendations regarding remediation spending from that Settling State's Abatement Accounts Fund. A Settling State may elect to use an existing advisory committee or similar entity (created outside of a State -Subdivision Agreement or Allocation Statute); provided, however, the Advisory Committee or similar entity shall meet the following requirements: (1) Written guidelines that establish the formation and composition of the Advisory Committee, terms of service for members, contingency for removal or resignation of members, a schedule of meetings, and any other administrative details; (2) Composition that includes at least an equal number of local representatives as state representatives; (3) A process for receiving input from Subdivisions and other communities regarding how the opioid crisis is affecting their 34 revised July 30, 2021 communities, their abatement needs, and proposals for abatement strategies and responses; and (4) A process by which Advisory Committee recommendations for expenditures for Opioid Remediation will be made to and considered by the appropriate state agencies. 3. Abatement Accounts Fund Reporting. The Settlement Fund Administrator shall track and assist in the report of remediation disbursements as agreed to among the Parties. F. Nature of Payment. Janssen, the Settling States, the Participating Subdivisions, and the Participating Special Districts, acknowledge and agree that notwithstanding anything to the contrary in this Agreement, including, but not limited to, the scope of the Released Claims: Janssen has entered into this Agreement to avoid the delay, expense, inconvenience, and uncertainty of further litigation; 2. The Settling States, the Participating Subdivisions, and the Participating Special Districts sought compensatory restitution (within the meaning of 26 U.S.C. § 162(f)(2)(A)) as damages for the Alleged Harms allegedly suffered by the Settling States and Participating Subdivisions; 3. By executing this Agreement the Settling States, the Participating Subdivisions, and the Participating Special Districts certify that: (a) the Compensatory Restitution Amount is no greater than the amount, in the aggregate, of the Alleged Harms allegedly suffered by the Settling States and Participating Subdivisions; and (b) the portion of the Compensatory Restitution Amount received by each Settling State or Participating Subdivision is no greater than the amount of the Alleged Harms allegedly suffered by such Settling State or Participating Subdivision; 4. The payment of the Compensatory Restitution Amount by Janssen constitutes, and is paid for, compensatory restitution (within the meaning of 26 U.S.C. § 162(f)(2)(A)) for alleged damage or harm (as compensation for alleged damage or harm arising out of alleged bodily injury) allegedly caused by Janssen; 5. The Compensatory Restitution Amount is being paid as compensatory restitution (within the meaning of 26 U.S.C. § 162(f)(2)(A)) in order to restore, in whole or in part, the Settling States and Participating Subdivisions to the same position or condition that they would be in had the Settling States and Participating Subdivisions not suffered the Alleged Harms; For the avoidance of doubt: (a) no portion of the Compensatory Restitution Amount represents reimbursement to any Settling State, Participating Subdivision, Participating Special District, or other person or entity for the costs of any investigation or litigation, (b) the entire Compensatory Restitution Amount 35 revised July 30, 2021 is properly characterized as described in subsection VI.F, and (c) no portion of the Compensatory Restitution Amount constitutes disgorgement or is properly characterized as the payment of statutory or other fines, penalties, punitive damages, other punitive assessments, or attorneys' fees; and New York, on behalf of all Settling States, Participating Subdivisions, and Participating Special Districts (the "Form 1098-F Filer") shall complete and file Form 1098-F with the Internal Revenue Service on or before February 28 (March 31 if filed electronically) of the year following the calendar year in which the order entering this Agreement becomes binding. On the Form 1098-F, the Form 1098-F Filer shall identify the entire Compensatory Restitution Amount received by the Form 1098-F Filer as remediation/restitution. The Form 1098-F Filer shall also, on or before January 31 of the year following the calendar year in which the order entering this Agreement becomes binding, furnish Copy B of such Form 1098-F (or an acceptable substitute statement) to Janssen. VII. Participation by Subdivisions and Special Districts A. Notice. No later than fifteen (15) days after the Preliminary Agreement Date, the Settling States, with the cooperation of Janssen, shall send individual written notice of the opportunity to participate in this Agreement and the requirements of participation to all Subdivisions in the Settling States of this Agreement that are (1) Litigating Subdivisions or (2) Non -Litigating Subdivisions listed on Exhibit G as eligible to become Participating Subdivisions. Janssen's share of costs of the written notice to such Subdivisions shall be advanced by Janssen and deducted from its initial settlement payment. Notice shall also be provided simultaneously to counsel of record for Litigating Subdivisions and Non - Litigating Subdivisions listed on Exhibit G as eligible to become Participating Subdivisions. The Settling States, with the cooperation of Janssen, will also provide general notice reasonably calculated to alert Non -Litigating Subdivisions listed on Exhibit G in the Settling States to this Agreement, the opportunity to participate in it and the requirements for participation. Such notice may include publication and other standard forms of notification, as well as notice to national state and county organizations such as the National Association of Counties and the National League of Cities. The notice will include that the deadline for becoming an Initial Participating Subdivision is the Initial Participation Date. Nothing contained herein shall preclude a Settling State from providing further notice to or otherwise contacting any of its Subdivisions about becoming a Participating Subdivision, including beginning any of the activities described in this paragraph prior to the Preliminary Agreement Date. B. Requirements for Becoming a Participating Subdivision: Non -Litigating Subdivisions. A Non -Litigating Subdivision in a Settling State that is listed on Exhibit G may become a Participating Subdivision by returning an executed Subdivision Settlement Participation Form specifying (1) that the Subdivision agrees to the terms of this Agreement pertaining to Subdivisions, (2) that the Subdivision releases all Released Claims against all Released Entities, (3) that the Subdivision agrees to use monies it receives, if any, from the Settlement Fund pursuant to the applicable requirements of Section VI, and (4) that the Subdivision submits to the jurisdiction of the court where the Consent Judgment is filed 36 revised July 30, 2021 for purposes limited to that court's role under the Agreement. The required Subdivision Settlement Participation Form is attached as Exhibit K. C. Requirements for Becoming a Participating Subdivision: Litigating Subdivisions/Later Litigating Subdivisions. A Litigating Subdivision or Later Litigating Subdivision in a Settling State may become a Participating Subdivision by returning an executed Subdivision Settlement Participation Form to the Settlement Fund Administrator and upon prompt dismissal of its legal action. A Settling State may require each Litigating Subdivision in that State to specify on the Subdivision Settlement Participation Form whether its counsel has waived any contingency fee contract with that Participating Subdivision and intends to seek fees according to Exhibit R. The Settlement Fund Administrator shall provide quarterly reports of this information to the parties organized by Settling State. Except for trials begun before the Initial Participation Date, a Litigating Subdivision or a Later Litigating Subdivision may not become a Participating Subdivision after the completion of opening statements in a trial of a legal action it brought that includes a Released Claim against a Released Entity. D. Initial Participating Subdivisions. A Subdivision qualifies as an Initial Participating Subdivision if it meets the applicable requirements for becoming a Participating Subdivision set forth in subsections VII.B or VII.0 by the Initial Participation Date. Provided however, all Subdivision Settlement Participation Forms shall be held by the Settlement Fund Administrator until Janssen provides the notice in subsection VIII.B that it intends to proceed with the settlement, at which time the obligations created by such forms become effective. E. Later Participating Subdivisions. A Subdivision that is not an Initial Participating Subdivision may become a Later Participating Subdivision by meeting the applicable requirements for becoming a Participating Subdivision after the Initial Participation Date and agreeing to be subject to the terms of a State -Subdivision Agreement (if any) or any other structure adopted or applicable pursuant to subsections VI.D or VI.E. The following provisions govern what a Later Participating Subdivision can receive (but do not apply to Initial Participating Subdivisions): A Later Participating Subdivision shall not receive any share of any base or incentive payments paid to the Subdivision Fund that were due before it became a Participating Subdivision. 2. A Later Participating Subdivision that becomes a Participating Subdivision after July 15, 2022 shall receive 75% of the share of future base or incentive payments that it would have received had it become a Later Participating Subdivision before that date (unless the Later Participating Subdivision is subject to subsections VII.E.3 or VILE. below). 3. A Later Participating Subdivision that, after the Initial Participation Date, maintains a lawsuit for a Released Claim(s) against a Released Entity and has judgment entered against it on every such Claim before it became a Participating Subdivision (other than a consensual dismissal with prejudice) shall receive 50% 37 revised July 30, 2021 of the share of future base or incentive payments that it would have received had it become a Later Participating Subdivision prior to such judgment; provided, however, that if the Subdivision appeals the judgment and the judgment is affirmed with finality before the Subdivision becomes a Participating Subdivision, the Subdivision shall not receive any share of any base payment or incentive payment. 4. A Later Participating Subdivision that becomes a Participating Subdivision while a Bar or Case -Specific Resolution involving a different Subdivision exists in its State shall receive 25% of the share of future base or incentive payments that it would have received had it become a Later Participating Subdivision without such Bar or Case -Specific Resolution. No Increase in Payments. Amounts to be received by Later Participating Subdivisions shall not increase the payments due from Janssen. G. Ineligible Subdivisions. Subdivisions in Non -Settling States and Prior Litigating Subdivisions are not eligible to be Participating Subdivisions. H. Non -Participating Subdivisions. Non -Participating Subdivisions shall not directly receive any portion of any base or incentive payments, including from the State Fund and direct distributions from the Abatement Accounts Fund; however, a Settling State may choose to fund future Opioid Remediation that indirectly benefits Non -Participating Subdivisions. Unpaid Allocations to Later Participating and Non -Participating Subdivisions. Any base payment and incentive payments allocated pursuant to subsection VI.D to a Later Participating or Non -Participating Subdivision that cannot be paid pursuant to this Section VII, will be allocated to the Abatement Accounts Fund for the Settling State in which the Subdivision is located, unless those payments are redirected elsewhere by a State -Subdivision Agreement or by a Statutory Trust. J. Requirements for Becoming a Participating Special District: Non -Litigating Special Districts. A Non -Litigating Special District may become a Participating Special District by either executing a release consistent with Section IV or by having its claims extinguished by operation of law or released by a Settling State. K. Requirements for Becoming a Participating Special District Litigating Special Districts/Later Litigating Special Districts. A Litigating Special District or Later Litigating Special District in a Settling State may become a Participating Special District by either executing a release consistent with Section IV and upon prompt dismissal of its legal action or by having its claims extinguished by operation of law or released by a Settling State. L. Initial Participating Special Districts. A Special District qualifies as an Initial Participating Special District if it meets the applicable requirements for becoming a Participating Special District by the Initial Participation Date. 38 revised July 30, 2021 M. Later Participating Special Districts. A Special District that is not an Initial Participating Special District may become a Later Participating Special District by meeting the applicable requirements for becoming a Participating Special District after the Initial Participation Date and agreeing to be subject to the terms of any agreement reached by the applicable Settling State with Initial Participating Special Districts. A Later Participating Special District shall not receive any share of any base or incentive payments paid to the Settlement Fund that were due before it became a Participating Special District. VIII. Condition to Effectiveness of Agreement and Filing of Consent Judgment A. Determination to Proceed With Settlement. Janssen will determine on or before the Reference Date whether there has been a sufficient resolution of the Claims of the Litigating Subdivisions in the Settling States (through participation under Section VII, Case -Specific Resolution(s), and Bar(s)) to proceed with this Agreement. The determination shall be in the sole discretion of Janssen and may be based on any criteria or factors deemed relevant by Janssen. B. Notice by Janssen. On or before the Reference Date, Janssen shall inform the Settling States and MDL PEC of its determination pursuant to subsection VIII.A. If Janssen determines to proceed, the Parties will proceed to file the Consent Judgments. If Janssen determines not to proceed, this Agreement will have no further effect and all releases (including those given by Participating Subdivisions) and other commitments or obligations contained herein will be void. C. Determination of the Participation Tier. On the Reference Date, provided that Janssen determines to proceed with this Agreement, the Settlement Fund Administrator shall determine the Participation Tier. The criteria used to determine the Participation Tier are set forth in Exhibit H. Any disputes as to the determination of the Participation Tier shall be decided by the National Arbitration Panel. 2. The Participation Tier shall be redetermined by the Settlement Fund Administrator annually as of the Payment Date, beginning with Payment Year 1, pursuant to the criteria set forth in Exhibit H. After Payment Year 3, the Participation Tier cannot move higher, unless this restriction is waived by Janssen. 4. In the event that a Participation Tier redetermination moves the Participation Tier higher, and that change is in whole or in part as a result of the post -Reference Date enactment of a Bar and there is later a Revocation Event with respect to that Bar, then on the next Payment Date that is at least one hundred eighty (180) days after the Revocation Event, the Participation Tier shall move down to the Participation Tier that would have applied had the Bar never been enacted, unless the Bar is reinstated or all Subdivisions affected by the Revocation Event become Participating Subdivisions within one hundred eighty (180) days of the 39 revised July 30, 2021 Revocation Event. This is the sole circumstance in which, on a nationwide basis, the Participation Tier can move down. 5. In the event that there is a post -Reference Date Revocation Event with respect to a Bar that was enacted in a Settling State prior to the Reference Date, then, on the next Payment Date that is at least one hundred eighty (180) days after the Revocation Event, unless the Bar is reinstated or all Subdivisions affected by the Revocation Event become Participating Subdivisions within one hundred eighty (180) days of the Revocation Event, the Participation Tier shall decrease — solely for the State in which the Revocation Event occurred — to the Participation Tier commensurate with the percentage of Litigating Subdivisions in that State that are Participating Subdivisions and the percentage of Non -Litigating Subdivisions that are both Primary Subdivisions and Participating Subdivisions, according to the criteria set forth in Exhibit H, except that the calculations shall be performed as to that State alone. For the avoidance of doubt and solely for the calculation in this subparagraph, the Settling States Column of Exhibit H shall play no role. This is the sole circumstance in which one Settling State will have a different Participation Tier than other Settling States. 6. The redetermination of the Participation Tier under subsection VIII.C.2 shall not affect payments already made or suspensions or offsets already applied. IX. Potential Payment Adjustments A. Later Litigating Subdivisions. If a Later Litigating Subdivision in a Settling State with a population above 10,000 brings a lawsuit or other legal proceeding against Released Entities asserting Released Claims, Janssen shall, within thirty (30) days of the lawsuit or other legal proceeding being served on Janssen, provide notice of the lawsuit or other legal proceeding to the Settlement Fund Administrator and the Settling State in which the Later Litigating Subdivision sits and provide the Settling State an opportunity to intervene in the lawsuit or other legal proceeding. A Released Entity shall not enter into a settlement with a Later Litigating Subdivision unless the State in which the Later Litigating Subdivision sits consents to such a settlement or unreasonably withholds consent to such a settlement. 2. If no Participation Tier applies and the Later Litigating Subdivision's lawsuit or other legal proceeding survives a Threshold Motion before Janssen makes its last settlement payment to the Settling State, the following shall apply: a. Janssen will, from the date of the entry of the order denying the Threshold Motion and so long as the lawsuit or other legal proceeding is pending, be entitled to a suspension of the following payments it would otherwise owe the Settling State in which the Later Litigating Subdivision is located: (1) all remaining incentive payments to the relevant state; and (2) the last two scheduled base payments, if not already paid (the "Suspended Payments"). 40 revisedduly30, 2021 b. For each Payment Year that Janssen is entitled to a suspension of payments, the Settlement Fund Administrator shall calculate the Suspended Payments applicable to the next Payment due from Janssen. The Suspended Payments shall be paid into the Settlement Fund Escrow account. 3. If a Participation Tier applies at the time the Threshold Motion is denied, Janssen will be entitled to a suspension of the following percentages of Suspended Payments depending on the applicable Tier-75% for Tier 1, 50% for Tier 2, 35% for Tier 3, and 25% for Tier 4. Otherwise, the requirements of subsection IX.A.2 apply. 4. If the Released Claim is resolved with finality without requirement of payment by a Released Entity, the placement of any remaining balance of the Suspended Payments into the Settlement Fund Escrow shall cease and the Settlement Fund Administrator shall immediately transfer amounts in the Settlement Fund Escrow on account of the suspension to the Settling State at issue and its Participating Subdivisions listed on Exhibit G. The lawsuit will not cause further suspensions unless the Released Claim is reinstated upon further review, legislative action, or otherwise. If the Released Claim is resolved with finality on terms requiring payment by a Released Entity (e.g., if the lawsuit in which the Released Claim is asserted results in a judgment against Janssen or a settlement with Janssen), the Settlement Fund Administrator will transfer the amounts in the Settlement Fund Escrow on account of the suspension to Janssen necessary to satisfy 75% of the payment obligation of the Released Entity to the relevant Later Litigating Subdivision. The Settlement Fund Administrator shall immediately transfer any remaining balance in the Settlement Fund Escrow on account of the suspension to the Settling State at issue and its Participating Subdivisions listed on Exhibit G. If the amount to be transferred to Janssen exceeds the amounts in the Settlement Fund Escrow on account of the suspension, Janssen shall receive a dollar -for -dollar offset for the excess amount against its obligation to pay any remaining payments that would be apportioned to the Settling State at issue and to its Participating Subdivisions listed on Exhibit G. B. Settlement Class Resolution Opt Outs. If a Settling State is eligible for Incentive A on the basis of a Settlement Class Resolution, and a Primary Subdivision that opted out of the Settlement Class Resolution maintains a lawsuit asserting a Released Claim against a Released Entity, the following shall apply. If the lawsuit asserting a Released Claim either survives a Threshold Motion or has an unresolved Threshold Motion fewer than sixty (60) days prior to the scheduled start of a trial involving a Released Claim, and is resolved with finality on terms requiring payment by the Released Entity, Janssen shall receive a dollar -for -dollar offset for the amount paid against its obligation to make remaining Incentive A payments that would be apportioned to that State or Participating Subdivisions listed on Exhibit G. For the avoidance of doubt, an offset shall not be 41 revised July 30, 2021 applicable under this subsection if it is applicable under subsection IX.A with respect to the Subdivision at issue. C. Revoked Bar, Settlement Class Resolution, or Case -Specific Resolution. If Janssen made a payment as a result of the existence of a Bar, Settlement Class Resolution, or Case -Specific Resolution in a Settling State, and that Bar, Settlement Class Resolution, or Case -Specific Resolution is subject to a Revocation Event, Janssen shall receive a dollar -for -dollar offset against its obligation to make remaining payments that would be apportioned to that State or Participating Subdivisions listed on Exhibit G. This offset will be calculated as the dollar amount difference between (1) the total amount of incentive payments paid by Janssen during the time the Bar, Settlement Class Resolution, or Case - Specific Resolution subject to the Revocation Event was in effect, and (2) the total amount of Incentive Payments that would have been due from Janssen during that time without the Bar, Settlement Class Resolution, or Case -Specific Resolution subject to the Revocation Event being in effect. The amount of incentive payments that would have been due, referenced in (2) above, will be calculated based on considering any Subdivision that provides a release within one hundred eighty (180) days after the Revocation Event as having been a Participating Subdivision (in addition to all other Participating Subdivisions) during the time that the Bar, Settlement Class Resolution, or Case -Specific Resolution subject to the Revocation Event was in effect. If a Revocation Event causes a Settling State to no longer qualify for Incentive D, the Settling State shall return to Janssen all payments made under Incentive D. 2. Notwithstanding anything to the contrary in paragraph 1 above, if a Bar or Case - Specific Resolution is reinstated by the Settling State, either through the same or different means as the initial Bar or Case -Specific Resolution, Janssen's right to an offset is extinguished and any amounts withheld to offset amounts paid on account of the revoked, rescinded, reversed, or overruled Bar or Case -Specific Resolution shall be returned to the Settling State, less and except any incentive payments that would have been paid during the period in which the Bar or Case - Specific Resolution was revoked, rescinded, reversed, or overruled. X. Additional Restitution Amount A. Additional Restitution Amount. Pursuant to the schedule set forth below and subject to the reduction specified in subsection X.B below, Janssen shall pay an Additional Restitution Amount to the Settling States listed in Exhibit N. Such funds shall be paid on the schedule set forth on Exhibit M on the Payment Date for each relevant Payment Year to such Settling States as allocated by the Settlement Fund Administrator pursuant to Exhibit N. Payment Year 1 $15,384,615.38 Payment Year 2 $26,923,076.92 42 revised July 30, 2021 Payment Year 3 $25,000,000.00 B. Reduction ofAdditional Restitution Amount. In the event that any Non -Settling State appears on Exhibit N, the amounts owed by Janssen pursuant to this Section X shall be reduced by the allocation set forth on Exhibit N for any such Non -Settling States. C. Use of Funds. All funds paid as an Additional Restitution Amount shall be part of the Compensatory Restitution Amount, shall be used for Opioid Remediation, except as allowed by subsection VI.B.2, and shall be governed by the same requirements as specified in subsection VLF. XI. Plaintiffs' Attorneys' Fees and Costs A. The Agreement on Attorneys' Fees, Expenses and Costs is set forth in Exhibit R and incorporated herein by reference. The Agreement on the State Outside Counsel Fee Fund and Agreement on the State Cost Fund Administration are set forth in Exhibit U and Exhibit S, respectively, and are incorporated herein by reference. XII. Enforcement and Dispute Resolution A. Enforceability. The terms of the Agreement and Consent Judgment applicable to or in a Settling State will be enforceable solely by that Settling State and Janssen. Settling States or Participating Subdivisions shall not have enforcement rights with respect either to the terms of this Agreement that apply only to or in other States or to any Consent Judgment entered into by another Settling State. Participating Subdivisions shall not have enforcement rights against Janssen with respect to the Agreement or any Consent Judgment except as to payments that would be allocated to the Subdivision Fund or Abatement Accounts Fund pursuant to Section VI; provided, however, that each Settling State shall allow Participating Subdivisions in that State to notify it of any perceived violations of the Agreement or Consent Judgment. B. Jurisdiction. Janssen consents to the jurisdiction of the court in which the Consent Judgment is filed, limited to resolution of disputes identified in subsection XII.F.2 for resolution in the court in which the Consent Judgment is filed. C. Specific Terms Dispute Resolution. Any dispute that is addressed by the provisions set forth in the Injunctive Relief terms in Exhibit P shall be resolved as provided therein. In the event Janssen believes the 86.5% threshold established in subsection VI.B. is not being satisfied, any Party may request that Janssen and the Enforcement Committee meet and confer regarding the use of funds under subsection VI.B.1. The completion of such meet -and -confer process is a precondition to further action regarding any such dispute. Further action concerning subsection VI.B.1 shall: (i) be limited to Janssen seeking to reduce its Annual Payments by no more than 5% of the difference between the actual amount of Opioid Remediation and the 86.5%threshold established in subsection VI.B.1; (ii) only reduce Annual 43 revised July 30, 2021 Payments to those Settling States and its Participating Subdivisions that are below the 86.5% threshold established in subsection VI.B.1; and (iii) not reduce Annual Payments restricted to future Opioid Remediation. D. State -Subdivision Enforcement. A Participating Subdivision shall not have enforcement rights against a Settling State in which it is located with respect to the Agreement or any Consent Judgment except: (1) as provided for in a State -Subdivision Agreement, Allocation Statute, or Statutory Trust with respect to intrastate allocation; or (2) in the absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust, as to allegations that: (a) the Settling State's use of Abatement Accounts Fund monies were not used for uses similar to or in the nature of those uses contained in Exhibit E; or (b) a Settling State failed to pay funds directly from the Abatement Accounts Fund to a Participating Subdivision eligible to receive a block grant pursuant to subsection VI.E.2.b. 2. A Settling State shall have enforcement rights against a Participating Subdivision located in its territory: (1) as provided for in a State -Subdivision Agreement, Allocation Statute, or Statutory Trust; or (2) in the absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust, as to allegations that the uses of Abatement Accounts Fund monies by Participating Subdivisions listed on Exhibit G were not for uses similar to or in the nature of those uses contained in Exhibit E. 3. As between Settling States and Participating Subdivisions, the above rights are contractual in nature and nothing herein is intended to limit, restrict, change, or alter any other existing rights under law. E. Subdivision Payment Enforcement. A Participating Subdivision shall have the same right as a Settling State pursuant to subsection XII.F.4.a(4) to seek resolution of any failure by Janssen to make its required base and/or incentive payments in a Payment Year. F. Other Dispute Resolution Terms. Except as provided in subsection XII.C, the parties to a dispute shall promptly meet and confer in good faith to resolve any dispute. If the parties cannot resolve the dispute informally, and unless otherwise agreed in writing, they shall follow the remaining provisions of this subsection XILF to resolve the dispute. 2. Except as provided in subsections XII.0 and XII.F.4, disputes not resolved informally shall be resolved in either the court that entered the relevant Consent Judgment or, if no Consent Judgment was entered, a state or territorial court with jurisdiction located wherever the seat of state government is located. State court proceedings shall be governed by the rules and procedures of the forum. For the avoidance of doubt, disputes to be resolved in state court include, but are not limited to, the following: 44 revised July 30, 2021 a. disputes concerning whether expenditures qualify for Opioid Remediation; b. disputes between a Settling State and Participating Subdivisions located in such Settling State as provided by subsection XII.D, except to the extent the State -Subdivision Agreement provides for other dispute resolution mechanisms. For the avoidance of doubt, disputes between a Settling State and any Participating Subdivision shall not be considered National Disputes; C. whether this Agreement and relevant Consent Judgment are binding under state law; d. the extent of the Attorney General's or other participating entity's authority under state law, including the extent of the authority to release claims; e. whether the requirements of a Bar, a Case -Specific Resolution, State - Specific Finality, Later Litigating Subdivision, Litigating Subdivision, or a Threshold Motion have been met; and f. all other disputes not specifically identified in subsections XILC and XII.F.4. Any Parry may request that the National Arbitration Panel provide an interpretation of any provision of the settlement that is relevant to the state court determination, and the National Arbitration Panel shall make reasonable best efforts to supply such interpretation within the earlier of thirty (30) days or the time period required by the state court proceedings. Any Party may submit that interpretation to the state court to the extent permitted by, and for such weight provided by, the state court's rules and procedures. If requested by a Party, the National Arbitration Panel shall request that its interpretation be accepted in the form of an amicus curiae brief, and any attorneys' fees and costs for preparing any such filing shall be paid for by the requesting Parry. 4. National Disputes involving a Settling State, Participating Subdivision, and/or Janssen shall be resolved by a National Arbitration Panel. a. "National Disputes" are disputes that are exceptions to subsection XII.F.2's presumption of resolution in state courts because they involve issues of interpretation of Agreement terms applicable to all Settling States without reference to a particular State's law. Disputes between a State and any Participating Subdivisions shall not be considered National Disputes. National Disputes are limited to the following: (1) the amount of offset and/or credit attributable to Non -Settling States and Tribes; (2) issues involving the scope and definition of "Product'; 45 revised July 30, 2021 (3) interpretation and application of the terms "Covered Conduct" and "Released Entities"; (4) disputes over a given year's payment or the payment of the Additional Restitution Amount to all Settling States (for the avoidance of doubt, disputes between a Settling State and Janssen over the amounts owed to only that State shall not be considered National Disputes); (5) questions regarding the performance and/or removal of the Settlement Fund Administrator; (6) disputes involving liability of successor entities; (7) disputes that require a determination of sufficient Subdivision and Special District participation to qualify for Incentives A, B, C, or D, as well as disputes over qualification for Participation Tiers; (8) disputes that require interpretation of Agreement terms (i) that concretely affect four (4) or more Settling States; and (ii) do not turn on unique definitions and interpretations under State law; and (9) any dispute subject to resolution under subsection XII.F.2 but for which all parties to the dispute agree to arbitration before the National Arbitration Panel under the provisions of this subsection XII.F.4. b. The "National Arbitration Panel" shall be comprised of three (3) neutral arbitrators. One (1) arbitrator shall be chosen by Janssen, one (1) arbitrator shall be chosen by the Enforcement Committee with due input from Participating Subdivisions, and the third arbitrator shall be agreed upon by the first two (2) arbitrators. The membership of the National Arbitration Panel is intended to remain constant throughout the term of this Agreement, but in the event that replacements are required, the retiring arbitrator shall be replaced by the party that selected him/her. (1) The National Arbitration Panel shall make reasonable best efforts to decide all matters within one hundred eighty (180) days of filing, and in no event shall it take longer than one (1) year. (2) The National Arbitration Panel shall conduct all proceedings in a reasonably streamlined process consistent with an opportunity for the parties to be heard. Issues shall be resolved without the need for live witnesses where feasible, and with a presumption in favor of remote participation to minimize the burdens on the parties. (3) To the extent allowed under state law, a Settling State, Participating Subdivision, and (at any parry's request) the National M revised July 30, 2021 Arbitration Panel may certify to an appropriate state court any question of state law. The National Arbitration Panel shall be bound by a final state court determination of such a certified question. The time period for the arbitration shall be tolled during the course of the certification process. (4) The arbitrators will give due deference to any authoritative interpretation of state law, including any declaratory judgment or similar relief obtained by a Settling State, Participating Subdivision, or Janssen on a state law issue. (5) The decisions of the National Arbitration Panel shall be binding on Settling States, Participating Subdivisions, Janssen, and the Settlement Fund Administrator. In any proceeding before the National Arbitration Panel involving a dispute between a Settling State and Janssen whose resolution could prejudice the rights of a Participating Subdivision(s) or Participating Special District(s) in that Settling State, such Participating Subdivision(s) or Participating Special District(s) shall be allowed to file a statement of view in the proceeding. C. Nothing herein shall be construed so as to limit or otherwise restrict a State from seeking injunctive or other equitable relief in state court to protect the health, safety, or welfare of its citizens. d. Each party shall bear its own costs in any arbitration or court proceeding arising under this subsection XII.F. The costs for the arbitrators on the National Arbitration Panel shall be divided and paid equally by the disputing sides for each individual dispute, e.g., a dispute between Janssen and Setting States/Participating Subdivisions shall be split 50% by Janssen and 50% by the Settling States/Participating Subdivisions that are parties to the dispute; a dispute between a Settling State and a Participating Subdivision shall be split 50% by the Settling State and 50% by any Participating Subdivisions that are party to the dispute. Prior to initiating an action to enforce pursuant to this subsection XII.F, the complaining party must: a. Provide written notice to the Enforcement Committee of its complaint, including the provision of the Consent Judgment and/or Agreement that the practice appears to violate, as well as the basis for its interpretation of the disputed provision. The Enforcement Committee shall establish a reasonable process and timeline for obtaining additional information from the involved parties; provided, however, that the date the Enforcement Committee establishes for obtaining additional information from the parties shall not be more than forty-five (45) days following the notice. 47 revised July 30, 2021 The Enforcement Committee may advise the involved parties of its views on the complaint and/or seek to resolve the complaint informally. b. Wait to commence any enforcement action until thirty (30) days after the date that the Enforcement Committee establishes for obtaining additional information from the involved parties. 6. If the parties to a dispute cannot agree on the proper forum for resolution of the dispute under the provisions of subsections XII.F.2 or XII.F.4, a committee comprising the Enforcement Committee and sufficient representatives of Janssen such that the members of the Enforcement Committee have a majority of one (1) member will determine the forum where the dispute will be initiated within twenty-eight (28) days of receiving notification of the dispute relating to the proper forum. The forum identified by such committee shall be the sole forum for determining where the dispute shall be heard, and the committee's identification of such forum shall not be entitled to deference by the forum selected. G. No Effect. Nothing in this Agreement shall be interpreted to limit the Settling State's Civil Investigative Demand ("CID") or investigative subpoena authority, to the extent such authority exists under applicable state law and the CID or investigative subpoena is issued pursuant to such authority, and Janssen reserves all of its rights in connection with a CID or investigative subpoena issued pursuant to such authority. XIII. Miscellaneous A. No Admission. Janssen does not admit liability or wrongdoing. Neither this Agreement nor the Consent Judgments shall be considered, construed, or represented to be (1) an admission, concession, or evidence of liability or wrongdoing or (2) a waiver or any limitation of any defense otherwise available to Janssen. B. Population of Subdivisions. The population figures for Subdivisions shall be the published U.S. Census Bureau's population estimates for July 1, 2019, released May 2020. These population figures shall remain unchanged during the term of this Agreement. C. Population of Special Districts. For any purpose in this Agreement in which the population of a Special District is used, other than the use of "Covered Special District": (a) School Districts' population will be measured by the number of students enrolled who are eligible under the Individuals with Disabilities Education Act ("IDEA") or Section 504 of the Rehabilitation Act of 1973; (b) Health Districts' and Hospital Districts' population will be measured at 25% of discharges; and (c) all other Special Districts' (including Fire Districts' and Library Districts') population will be measured at 10% of the population served. D. Population Associated with Sheriffs. For any purpose in this Agreement in which the population associated with a lawsuit by a sheriff is used, the population will be measured at 20% of the capacity of the jail(s) operated by the sheriff. m revised July 30, 2021 E. Tax Reporting and Cooperation. Upon request by Janssen, the Settling States, Participating Subdivisions, and Participating Special Districts agree to perform such further acts and to execute and deliver such further documents as may be reasonably necessary for Janssen to establish the statements set forth in subsection VI.E.3 to the satisfaction of their tax advisors, their independent financial auditors, the Internal Revenue Service, or any other governmental authority, including as contemplated by Treasury Regulations Section 1. 162-2 1 (b)(3)(ii) and any subsequently proposed or finalized relevant regulations or administrative guidance. 2. Without limiting the generality of subsection VI.C.1, each Settling State, Participating Subdivision, and Participating Special District shall cooperate in good faith with Janssen with respect to any tax claim, dispute, investigation, audit, examination, contest, litigation, or other proceeding relating to this Agreement. The Designated State, on behalf of all Settling States, Participating Subdivisions, and Participating Special Districts, shall designate one of its officers or employees to act as the "appropriate official' within the meaning of Treasury Regulations Section 1.6050X-l(f)(1)(ii)(B) (the "Appropriate Official'). 4. For the avoidance of doubt, neither Janssen nor the Settling States, Participating Subdivisions, and Participating Special Districts make any warranty or representation to any Settling jurisdiction or Releasor as to the tax consequences of the payment of the Compensatory Restitution Amount (or any portion thereof). F. No Third -Party Beneficiaries. Except as expressly provided in this Agreement, no portion of this Agreement shall provide any rights to, or be enforceable by, any person or entity that is not a Settling State or Released Entity. No Settling State may assign or otherwise convey any right to enforce any provision of this Agreement. G. Calculation. Any figure or percentage referred to in this Agreement shall be carried to seven decimal places. H. Construction. None of the Parties and no Participating Subdivision shall be considered to be the drafter of this Agreement or of any of its provisions for the purpose of any statute, case law, or rule of interpretation or construction that would or might cause any provision to be construed against the drafter of this Agreement. The headings of the provisions of this Agreement are not binding and are for reference only and do not limit, expand, or otherwise affect the contents or meaning of this Agreement. I. Cooperation. Each Party and each Participating Subdivision agrees to use its best efforts and to cooperate with the other Parties and Participating Subdivisions to cause this Agreement and the Consent Judgments to become effective, to obtain all necessary approvals, consents and authorizations, if any, and to execute all documents and to take such other action as may be appropriate in connection herewith. Consistent with the foregoing, each Party and each Participating Subdivision agrees that it will not directly or indirectly assist or encourage any challenge to this Agreement or any Consent Judgment revised July 30, 2021 by any other person, and will support the integrity and enforcement of the terms of this Agreement and the Consent Judgments. J. Entire Agreement. This Agreement, its exhibits and any other attachments, including the attorneys' fees and cost agreement in Exhibit R, embodies the entire agreement and understanding between and among the Parties and Participating Subdivisions relating to the subject matter hereof and supersedes (1) all prior agreements and understandings relating to such subject matter, whether written or oral and (2) all purportedly contemporaneous oral agreements and understandings relating to such subject matter. K. Execution. This Agreement may be executed in counterparts and by different signatories on separate counterparts, each of which shall be deemed an original, but all of which shall together be one and the same Agreement. One or more counterparts of this Agreement may be delivered by facsimile or electronic transmission with the intent that it or they shall constitute an original counterpart hereof. One or more counterparts of this Agreement may be signed by electronic signature. L. Good Faith and Voluntary Entry. Each Party warrants and represents that it negotiated the terms of this Agreement in good faith. Each of the Parties and signatories to this Agreement warrants and represents that it freely and voluntarily entered into this Agreement without any degree of duress or compulsion. The Parties state that no promise of any kind or nature whatsoever (other than the written terms of this Agreement) was made to them to induce them to enter into this Agreement. M. No Prevailing Party. The Parties each agree that they are not the prevailing party in this action, for purposes of any claim for fees, costs, or expenses as prevailing parties arising under common law or under the terms of any statute, because the Parties have reached a good faith settlement. The Parties each further waive any right to challenge or contest the validity of this Agreement on any ground, including, without limitation, that any term is unconstitutional or is preempted by, or in conflict with, any current or future law. N. Non -Admissibility. The settlement negotiations resulting in this Agreement have been undertaken by the Parties and by certain representatives of the Participating Subdivisions in good faith and for settlement purposes only, and no evidence of negotiations or discussions underlying this Agreement shall be offered or received in evidence in any action or proceeding for any purpose. This Agreement shall not be offered or received in evidence in any action or proceeding for any purpose other than in an action or proceeding arising under or relating to this Agreement. O. Notices. All notices or other communications under this Agreement shall be in writing (including but not limited to electronic communications) and shall be given to the recipients indicated below: 50 revised July 30, 2021 For the Attorney(s) General: Ashley Moody, Attorney General State of Florida The Capitol, PL-01 Tallahassee, FL 32399 Josh Stein, Attorney General North Carolina Department of Justice Attn: Daniel Mosteller PO Box 629 Raleigh, NC 27602 Dmosteller@ncdoj.gov 2. For the Plaintiffs' Executive Committee: Paul F. Farrell Farrell Law P.O. Box 1180 Huntington, WV 25714-1180 Jayne Conroy Simmons Hanly Conroy LLC 112 Madison Avenue, 7th Floor New York, NY 10016-7416 JConroy@simmonsfirm.com Joseph F. Rice Motley Rice LLC 28 Bridgeside Blvd. Mount Pleasant, SC 29464 jrice@motleyrice.com Peter Mougey Levin Papantonio Rafferty 316 South Baylen St. Pensacola, FL 32502 pmougey@levinlaw.com Paul J. Geller Robbins Geller Rudman & Dowd LLP 120 East Palmetto Park Road Boca Raton, FL 33432 PGeller@rgrdlaw.com 51 revised July 30, 2021 3. For Janssen: Charles C. Lifland O'Melveny & Myers LLP 400 South Hope Street, 18th Floor Los Angeles, CA 90071 Phone: (213) 430-6000 clifland@omm.com Daniel R. Suvor O'Melveny & Myers LLP 400 South Hope Street, 18th Floor Los Angeles, CA 90071 Phone: (213) 430-6000 dsuvor@omm.com Any Party or the Plaintiffs' Executive Committee may change or add the contact information of the persons designated to receive notice on its behalf by notice given (effective upon the giving of such notice) as provided in this subsection. P. No Waiver. The waiver of any rights conferred hereunder shall be effective only if made by written instrument executed by the waiving Party or Parties. The waiver by any Party of any breach of this Agreement shall not be deemed to be or construed as a waiver of any other breach, whether prior, subsequent, or contemporaneous, nor shall such waiver be deemed to be or construed as a waiver by any other Party. Q. Preservation of Privilege. Nothing contained in this Agreement or any Consent Judgment, and no act required to be performed pursuant to this Agreement or any Consent Judgment, is intended to constitute, cause, or effect any waiver (in whole or in part) of any attorney -client privilege, work product protection, or common interest/joint defense privilege, and each Party agrees that it shall not make or cause to be made in any forum any assertion to the contrary. R. Successors. This Agreement shall be binding upon, and inure to the benefit of, Janssen and its respective successors and assigns. Janssen shall not sell the majority of its voting stock or substantially all its assets without obtaining the acquirer's agreement that it will constitute a successor with respect to Janssen's obligations under this Agreement. Modification, Amendment, Alteration. After the Reference Date, any modification, amendment, or alteration of this Agreement by the Parties shall be binding only if evidenced in writing signed by Janssen along with the signatures of at least thirty-seven (37) of those then -serving Attorneys General of the Settling States along with a representation from each Attorney General that either: (1) the advisory committee or similar entity established or recognized by that Settling State (either pursuant to subsection VI.E.2, by a State -Subdivision Agreement, or by statute) voted in favor of the modification, amendment, or alteration of this Agreement including at least one Participating Subdivision -appointed member; or (2) in States without any advisory committee, that 50.1% of the Participating Subdivisions by population expressed approval of the modification, amendment, or alteration of this Agreement in writing. 52 revised July 30, 2021 Provided, however, in the event the modification, amendment, or alteration relates to injunctive relief, interstate allocation between the Settling States, intrastate allocation in a particular Settling State, or fees or costs of Settling States and Participating Subdivisions, then every Settling State and each Participating Subdivision affected by that modification, amendment, or alteration must assent in writing. Provided further that, in the event the modification, amendment, or alteration relates to injunctive relief, then such amendment, modification, or alteration of injunctive relief against Janssen will not be effective unless and until any Consent Judgment is modified by a court of competent jurisdiction, except as otherwise provided by the Injunctive Terms. T. Termination. Unless otherwise agreed to by Janssen and the Settling State in question, this Agreement and all of its terms (except subsection XIII.N and any other non - admissibility provisions, which shall continue in full force and effect) shall be canceled and terminated with respect to the Settling State, and the Agreement and all orders issued by the courts in the Settling State pursuant to the Agreement shall become null and void and of no effect if one or more of the following conditions applies: a. A Consent Judgment approving this Agreement without modification of any of the Agreement's terms has not been entered as to the Settling State by a court of competent jurisdiction on or before one hundred eighty (180) days after the Effective Date; or b. This Agreement or the Consent Judgment as to that Settling State has been disapproved by a court of competent jurisdiction to which it was presented for approval and/or entry (or, in the event of an appeal from or review of a decision of such a court to approve this Agreement and the Consent Judgment, by the court hearing such appeal or conducting such review), and the time to appeal from such disapproval has expired, or, in the event of an appeal from such disapproval, the appeal has been dismissed or the disapproval has been affirmed by the court of last resort to which such appeal has been taken and such dismissal or disapproval has become no longer subject to further appeal (including, without limitation, review by the United States Supreme Court). 2. If this Agreement is terminated with respect to a Settling State and its Participating Subdivisions for whatever reason pursuant to subsection XIII.T.1, then: a. An applicable statute of limitation or any similar time requirement (excluding any statute of repose) shall be tolled from the date the Settling State signed this Agreement until the later of the time permitted by applicable law or for one year from the date of such termination, with the effect that Janssen and the Settling State in question shall be in the same 53 revised July 30, 2021 position with respect to the statute of limitation as they were at the time the Settling State filed its action; and b. Janssen and the Settling State and its Participating Subdivisions in question shall jointly move the relevant court of competent jurisdiction for an order reinstating the actions and claims dismissed pursuant to the terms of this Agreement governing dismissal, with the effect that Janssen and the Settling State and its Participating Subdivisions in question shall be in the same position with respect to those actions and claims as they were at the time the action or claim was stayed or dismissed. Unless Janssen and the Enforcement Committee agree otherwise, this Agreement, with the exception of the Injunctive Relief Terms that have their own provisions on duration, shall terminate as to all Parties as of the Payment Date for Payment Year 9, provided that Janssen has performed its payment obligations under the Agreement as of that date. Notwithstanding any other provision in this Agreement, all releases under this Agreement will remain effective despite any termination under this paragraph. U. Governing Law. Except (1) as otherwise provided in the Agreement or (2) as necessary, in the sole judgment of the National Arbitration Panel, to promote uniformity of interpretation for matters within the scope of the National Arbitration Panel's authority, this Agreement shall be governed by and interpreted in accordance with the respective laws of the Settling State, without regard to the conflict of law rules of such Settling State, that is seeking to enforce the Agreement against Janssen or against which Janssen is seeking enforcement. Notwithstanding any other provision in this subsection on governing law, any disputes relating to the Settlement Fund Escrow shall be governed by and interpreted in accordance with the law of the state where the escrow agent has its primary place of business. 54 revised July 30, 2021 EXHIBIT A Alleged Harms The following export reports that were filed in connection with the case captioned In re National Prescription Opiate Litigation, No. 1-17-and-02804 (N.D. Ohio): 1. Expert report of Professor David Cutler, dated March 25, 2019. 2. Expert report of Dr. Jeffrey B. Liebman, dated March 25, 2019. 3. Expert report of Professor Thomas McGuire regarding damages to Bellwethers, dated March 25, 2019. 4. Report of Professor Thomas McGuire regarding public nuisance, dated March 25, 2019. 55 revised July 30, 2021 EXHIBIT B Enforcement Committee Organization Bylaws ARTICLE I These bylaws constitute the code of rules adopted by the Settling States and Participating Subdivisions for the creation of an Enforcement Committee (the "Committee") to exist and operate during the term of the Agreement in connection with Janssen and shall control the regulation and management of the Committee's affairs. ARTICLE II Purpose The Committee is organized for the sole purpose of evaluating and taking such action as deemed reasonable, necessary, and appropriate by the members of the Committee on the matters delegated to the Committee under that certain Settlement Agreement between the Settling States and Janssen dated July 21, 2021. ARTICLE III Members of the Committee (1) Number of Members The Committee will consist of seventeen (17) members (the "Members"). Upon majority resolution of the Committee, the number of Members may be increased or decreased from time to time, but in no event shall a decrease have the effect of decreasing the total number of Members to less than seven Members. (2) Initial Members The Committee initially will consist of eleven Settling State Members and six Participating Subdivision Members; three of the Participating Subdivisions shall be counties and three shall be municipalities. The initial Settling State Members are representatives from: Connecticut, Delaware, Florida, Georgia, Massachusetts, New York, North Carolina, Ohio, Pennsylvania, Tennessee, and Texas. The initial Participating Subdivision Members are: (a) Bexar County, Texas; (b) Broward County, Florida; (c) Chicago, Illinois; (d) Cincinnati, Ohio; (e) Nashville, Tennessee; and (f) Nassau County, New York. Until the Reference Date contained in the Settlement Agreement, the Participating Subdivisions may designate their outside counsel to serve as their representative. After the Reference Date, an employee or official of the Participating Subdivision must be the designated as the representative of the Participating Subdivision. (3) Term of Members The term of office for Members of the Committee will be until the end of the term of the Settlement Agreement, nine (9) years, unless and until a Member withdraws or resigns from the Committee. 56 revised July 30, 2021 (4) Resignation Any Member may resign at any time by delivering written notice to the Chairperson of the Committee. Such resignation shall take effect upon receipt or, if later, at the time specified in the notice. (5) Removal (a) Any Member may be removed without cause, at any time, by a majority of the entire Committee, at a Regular or Special Meeting called for that purpose. Any Member under consideration of removal must first be notified about the consideration by written notice at least five days prior to the meeting at which the vote takes place. (b) In the event that any Member is not a Settling State or a Participating Subdivision or the Member subsequently becomes a Later Litigating Subdivision, the Member shall be removed immediately without notice or vote of the Committee. (6) Vacancies In the event of a vacancy, the Members of the same type (Settling State or Participating Subdivision) shall select another Settling State or Participating Subdivision to fill that Member's position. (7) Compensation Members shall not receive any salaries or other compensation for their services, but, by resolution of the Committee, may be reimbursed for any actual expenses incurred in the performance of their duties for the Committee, as long as a majority of disinterested Members approve the reimbursement. Any reimbursement shall be sought from the Settlement Fund Administrator. ARTICLE IV Conflicts of Interest and Code of Ethics If a Member, agent, or employee of the Committee has a conflict of interest, he or she may not participate in a vote, discussion, or decision about the matter. Each Member shall follow any applicable state or local law with respect to conflicts, gifts, and ethics. ARTICLE V Committee Meetings (1) Place of Meetings Meetings of the Committee will be held at any place that the Chairperson may designate, including by telephonic or electronic means. (2) Regular Meetings Regular meetings of the Committee shall be held as deemed necessary by the Chairperson or any three members. 57 revised July30, 2021 (3) Notice of Meetings Written notice of the date, time, place and subject of each meeting must be provided to the Members at least 72 hours before the scheduled time of the meeting, except when there is an emergency or urgent public necessity. (4) Quorum A majority of the incumbent Members (not counting vacancies) shall constitute a quorum for the purposes of convening a meeting or conducting business. (5) Voting and Proxy When it is necessary to vote on any matter before the Committee, Members may vote by electronic means as provided in these Bylaws. Proxy voting is permitted. In order for a matter to pass, the matter must have a majority vote of Members present and must have at least one vote from a Settling State Member and a Participating Subdivision Member. In the event that there is a Quorum, but no Settling State or Participating Subdivision Member is present, then a matter may pass with a simple majority vote. (6) Minutes The Committee shall prepare and keep minutes. The minutes must state the subject of each deliberation and indicate each vote, order, decision, or other action taken. ARTICLE VI Officers (1) Roster of Officers The Committee shall have a Chairperson, a Vice Chairperson, and a Secretary. The Committee may have at its discretion, such other officers as may be appointed by the Members of the Committee. One person may hold two or more offices, except those serving as Chairperson. (2) Election and Removal of Officers All officers shall serve two-year terms. The election shall be conducted at the first meeting of the fiscal year. Officers shall remain in office until their successors have been selected. Officers may serve consecutive terms without limit. The election of officers shall be by majority vote of the Members of the Committee attending the meeting. (3) Vacancies If a vacancy occurs during the term of office for any elected officer, the Members of the Committee shall elect a new officer to fill the remainder of the term as soon as practical, by majority vote of Members present. (4) Chairperson The Chairperson will supervise and control the affairs of the Committee and shall exercise such supervisory powers as may be given him/her by the Members of the Committee. The Chairperson will perform all duties incident to such office and such other duties as may be provided in these bylaws or as may be prescribed from time to time by the Committee. The 58 revised July 30, 2021 Chairperson shall preside at all meetings and shall exercise parliamentary control in accordance with Robert's Rules of Order. (5) Vice Chairperson The Vice Chairperson shall act in place of the Chairperson in the event of the Chairperson's absence, inability, or refusal to act, and shall exercise and discharge such other duties as may be required by the Committee. The Vice Chairperson shall serve as the parliamentarian and interpret any ambiguities of the bylaws. (6) Secretary The Secretary will keep and maintain all records related to the Committee and take minutes of all meetings. (7) Records All elected officers and committee chairpersons shall relinquish their records to the Chairperson immediately upon the completion of their term of office or completion of a project. (8) Resignation An officer may resign the office while not resigning membership from the Committee, by submitting a letter to the Chairperson. Vacancies occurring in any office shall be appointed for the remainder of the term. ARTICLE VII Duties (1) Prior to the Reference Date The Committee shall be responsible for any additional negotiations with Janssen, including, but not limited to, negotiating extensions of any periods created by the Settlement Agreement. (2) After the Enforcement Date The Committee shall establish procedures for the receipt of notices that a dispute exists concerning the Agreement and review of such disputes, pursuant to Section XII of the Agreement. Members may engage with Janssen, Settling States, and Participating Subdivisions attempting to resolve any dispute without further action by the Committee. The Committee may request additional information from Janssen, Settling States, and Participating Subdivisions to the extent the Committee believes such information is necessary to understand, resolve, or provide advice related to a dispute. The Committee shall endeavor to provide advice relative to the dispute no later than 60 days after receipt of notice. 59 revised July 30, 2021 ARTICLE VIII Rules of Procedure The proceedings and business of the Committee shall be governed by Robert's Rules of Order unless otherwise waived by the Committee. ARTICLE IX Operations (1) Records The Committee will keep correct and complete records and will also keep minutes of the proceedings of the Committee meetings and Committees. The Committee will keep such records at its principal place of business at a place designated by the Chairperson. All elected officers and committee chairpersons shall relinquish their records to the Chairperson, immediately upon the completion of their term of office. (2) Inspection of Books and Records The minutes of a meeting are public records and shall be available for public inspection and copying on request to the Committee's Chairperson or the Chairperson's designee. (3) Amendments The bylaws may be amended at any time by a vote of a majority of Members present and must have at least one vote from a Settling State Member and a Participating Subdivision Member. In the event that there is a Quorum, but no Settling State or Participating Subdivision Member is present, then a matter may pass with a simple majority vote. 60 revised July 30, 2021 DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES EXHIBIT C Litisatine Subdivision and Special District List' 1. Abbeville (AL), City of, Alabama 2. Albertville (AL), City of, Alabama 3. Alexander City (AL), City of, Alabama 4. Anniston (AL), City of, Alabama 5. Arab (AL), City of, Alabama 6. Argo (AL), City of, Alabama 7. Ashland (AL), City of, Alabama 8. Ashville (AL), City of, Alabama 9. Athens (AL), City of, Alabama 10. Attalia (AL), City of, Alabama 11. Attentus Mouton, LLC d/b/a Lawrence Medical Center (AL), Alabama 12. Auburn (AL), City of, Alabama 13. Autauga (AL), County of, Alabama 14. Baldwin (AL), County of, Alabama 15. Barbour (AL), County of, Alabama 16. Berry (AL), Town of, Alabama 17. Bibb (AL), County of, Alabama 18. Bibb County Healthcare Authority (AL), Alabama 19. Birmingham (AL), City of, Alabama 20. Blount (AL), County of, Alabama 21. Boaz (AL), City of, Alabama 22. Brent (AL), City of, Alabama 23. Bridgeport (AL), City of, Alabama 24. Brookwood (AL), Town of, Alabama 25. Brundidge (AL), City of, Alabama 26. Bullock (AL), County of, Alabama 27. Butler (AL), County of, Alabama 28. Butler (AL), Town of, Alabama 29. Calera (AL), City of, Alabama 30. Calhoun (AL), County of, Alabama 31. Camp Hill (AL), Town of, Alabama 32. Carbon Hill (AL), City of, Alabama 33. Cedar Bluff (AL), Town of, Alabama 34. Center Point (AL), City of, Alabama 35. Centre (AL), City of, Alabama 36. Centreville (AL), City of, Alabama 37. Chambers (AL), County of, Alabama 38. Cherokee (AL), County of, Alabama 39. Cherokee (AL), Town of, Alabama 40. Chickasaw (AL), City of, Alabama 41. Chilton (AL), County of, Alabama 42. Choctaw (AL), County of, Alabama 43. Clanton (AL), City of, Alabama 44. Clarke (AL), County of, Alabama 45. Clay (AL), County of, Alabama 46. Cleburne (AL), County of, Alabama 47. Cleveland (AL), Town of, Alabama 48. Coffee (AL), County of, Alabama 49. Colbert (AL), County of, Alabama 50. Conecuh (AL), County of, Alabama 51. Coosa (AL), County of, Alabama 52. Cordova (AL), City of, Alabama 53. Covington (AL), County of, Alabama 54. Crenshaw (AL), County of, Alabama 55. Cullman (AL), City of, Alabama 56. Cullman (AL), County of, Alabama 57. Cullman County Health Care Authority (AL), Alabama 58. Dadeville (AL), City of, Alabama 59. Dale (AL), County of, Alabama 60. Dale County Healthcare Authority (AL), Alabama 61. Daleville (AL), City of, Alabama 62. Dallas (AL), County of, Alabama ' For purposes of calculating the percentage of Litigating Subdivisions and Litigating Special Districts pursuant to Section V.E.5 and Exhibit H, an individual Litigating Subdivision or Litigating Special District shall not be included more than once in the numerator, and shall not be included more than once in the denominator, of the calculation regardless if it (or any of its officials) is named as multiple plaintiffs in the same lawsuit; provided, however, that for the avoidance of doubt, no Litigating Subdivision or Litigating Special District will be excluded from the numerator or denominator under this sentence unless a Litigating Subdivision or Litigating Special District otherwise counted in the denominator has the authority to release the Claims (consistent with Section IV) of the Litigating Subdivision or Litigating Special District to be excluded. DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 63. Daphne (AL), City of, Alabama 64. Dauphin Island (AL), Town of, Alabama 65. DCH Health Care Authority (AL), Alabama 66. Decatur (AL), City of, Alabama 67. DeKalb (AL), County of, Alabama 68. Demopolis (AL), City of, Alabama 69. Dora (AL), City of, Alabama 70. Dothan (AL), City of, Alabama 71. Double Springs (AL), Town of, Alabama 72. Douglas (AL), Town of, Alabama 73. Enterprise (AL), City of, Alabama 74. Escambia (AL), County of, Alabama 75. Etowah (AL), County of (Sheriff), Alabama 76. Etowah (AL), County of, Alabama 77. Eufaula (AL), City of, Alabama 78. Evergreen (AL), City of, Alabama 79. Fairfield (AL), City of, Alabama 80. Faunsdale (AL), Town of, Alabama 81. Fayette (AL), County of (Sheriff), Alabama 82. Fayette (AL), City of, Alabama 83. Fayette (AL), County of, Alabama 84. Florence (AL), City of, Alabama 85. Foley (AL), City of, Alabama 86. Fort Deposit (AL), Town of, Alabama 87. Fort Payne (AL), City of, Alabama 88. Franklin (AL), County of, Alabama 89. Fultondale (AL), City of, Alabama 90. Gadsden (AL), City of, Alabama 91. Geneva (AL), City of, Alabama 92. Geneva (AL), County of, Alabama 93. Geneva County Health Care Authority (AL), Alabama 94. Georgiana (AL), City of, Alabama 95. Geraldine (AL), Town of, Alabama 96. Gilbertown (AL), Town of, Alabama 97. Grant (AL), Town of, Alabama 98. Graysville (AL), City of, Alabama 99. Greene (AL), County of, Alabama 100. Greene County Hospital Board (AL), Alabama 101. Greensboro (AL), City of, Alabama 102. Greenville (AL), City of, Alabama 103. Guin (AL), City of, Alabama 104. Guntersville (AL), City of, Alabama 105. Gurley (AL), Town of, Alabama 106. Hale (AL), County of, Alabama 107. Haleyville (AL), City of, Alabama 108. Hamilton (AL), City of, Alabama 109. Hammondville (AL), Town of, Alabama 110. Hartselle (AL), City of, Alabama 111. Headland (AL), City of, Alabama 112. Healthcare Authority for Baptist Health (AL), Alabama 113. Health Care Authority of Clarke County (AL), Alabama 114. Health Care Authority of Morgan County - City of Decatur (AL), Alabama 115. Health Care Authority of the City of Huntsville d/b/a HH Health System, et al. (AL), Alabama 116. Health Care Authority of the City of Huntsville d/b/a Hunttville Hospital (AL), Alabama 117. Health Care Authority of the City of Huntsville d/b/a Huntsville Hospital for Women and Children (AL), Alabama 118. Health Care Authority of the City of Huntsville d/b/a Madison Hospital (AL), Alabama 119. Henagar (AL), City of, Alabama 120. Henry (AL), County of, Alabama 121. HH Health System - Athens Limestone, LLC d/b/a Athens Limestone Hospital (AL), Alabama 122. HH Health System - Morgan, LLC d/b/a Decatur Morgan Hospital - Decatur and Decatur Morgan Hospital - Parkway (AL), Alabama 123. HH Health System - Shoals, LLC d/b/a Helen Keller Hospital and Red Bay Hospital (AL), Alabama 124. Homewood (AL), City of, Alabama 125. Hoover (AL), City of, Alabama 126. Houston (AL), County of, Alabama 127. Hueytown (AL), City of, Alabama 128. Huntsville (AL), City of, Alabama 129. J. Paul Jones Hospital (AL), Alabama 130. Jackson (AL), County of, Alabama 131. Jackson County Health Care Authority (AL), Alabama 132. Jacksonville (AL), City of, Alabama 133. Jasper (AL), City of, Alabama 134. Jefferson (AL), County of (Sheriff), Alabama 135. Jefferson (AL), County of, Alabama 136. Killen (AL), City of, Alabama DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 137. Lamar (AL), County of (Sheriff), Alabama 138. Lamar (AL), County of, Alabama 139. Lanett (AL), City of, Alabama 140. Lauderdale (AL), County of, Alabama 141. Lawrence (AL), County of, Alabama 142. Leeds (AL), City of, Alabama 143. Leesburg (AL), City of, Alabama 144. Leighton (AL), Town of, Alabama 145. Level Plains (AL), City of, Alabama 146. Limestone (AL), County of, Alabama 147. Lincoln (AL), City of, Alabama 148. Linden (AL), City of, Alabama 149. Locust Fork (AL), Town of, Alabama 150. Louisville (AL), City of, Alabama 151. Lowndes (AL), County of, Alabama 152. Luverne (AL), City of, Alabama 153. Macon (AL), County of, Alabama 154. Madison (AL), City of, Alabama 155. Madison (AL), County of, Alabama 156. Marengo (AL), County of, Alabama 157. Marion (AL), City of, Alabama 158. Marion (AL), County of, Alabama 159. Marshall (AL), County of, Alabama 160. Marshall County Health Care Authority (AL), Alabama 161. McKenzie (AL), Town of, Alabama 162. Medical West Hospital Authority (AL), Alabama 163. Midfield (AL), City of, Alabama 164. Mobile (AL), City of, Alabama 165. Mobile (AL), County of, Alabama 166. Mobile County Board of Health and Family Oriented Primary Health Care Clinic (AL), Alabama 167. Mobile County Emergency Medical Services System Rescue Squad (AL), Alabama 168. Monroe (AL), County of, Alabama 169. Monroe County Health Care Authority (AL), Alabama 170. Monroeville (AL), City of, Alabama 171. Montgomery (AL), City of, Alabama 172. Montgomery (AL), County of, Alabama 173. Moody (AL), City of, Alabama 174. Morgan (AL), County of, Alabama 175. Moulton (AL), City of, Alabama 176. Mountain Brook (AL), City of, Alabama 177. Munford (AL), Town of, Alabama 178. Muscle Shoals (AL), City of, Alabama 179. Nauvoo (AL), City of, Alabama 180. New Hope (AL), City of, Alabama 181. Northport (AL), City of, Alabama 182. Oakman (AL), Town of, Alabama 183. Oneonta (AL), City of, Alabama 184. Opelika (AL), City of, Alabama 185. Opp (AL), City of, Alabama 186. Orange Beach (AL), City of, Alabama 187. Oxford (AL), City of, Alabama 188. Ozark (AL), City of, Alabama 189. Parrish (AL), City of, Alabama 190. Pell City (AL), City of, Alabama 191. Perry (AL), County of, Alabama 192. Phenix City (AL), City of, Alabama 193. Pickens (AL), County of, Alabama 194. Piedmont (AL), City of, Alabama 195. Pike (AL), County of, Alabama 196. Pleasant Grove (AL), City of, Alabama 197. Powell (AL), Town of, Alabama 198. Prattville (AL), City of, Alabama 199. Priceville (AL), Town of, Alabama 200. Prichard (AL), City of, Alabama 201. Ragland (AL), City of, Alabama 202. Rainbow City (AL), City of, Alabama 203. Rainsville (AL), City of, Alabama 204. Red Bay (AL), City of, Alabama 205. Robertsdale (AL), City of, Alabama 206. Rockford (AL), Town of, Alabama 207. Russell (AL), County of, Alabama 208. Russellville (AL), City of, Alabama 209. Satsuma (AL), City of, Alabama 210. Scottsboro (AL), City of, Alabama 211. Selma (AL), City of, Alabama 212. Sheffield (AL), City of, Alabama 213. Shelby (AL), County of, Alabama 214. Sipsey (AL), City of, Alabama 215. Slocomb (AL), City of, Alabama 216. Spanish Fort (AL), City of, Alabama 217. Springville (AL), City of, Alabama 218. St. Clair (AL), County of, Alabama 219. Sumiton (AL), City of, Alabama 220. Sumter (AL), County of, Alabama 221. Sweet Water (AL), Town of, Alabama 222. Sylacauga (AL), City of, Alabama 223. Sylacauga Health Care Authority (AL), Alabama DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 224. Talladega (AL), City of, Alabama 225. Talladega (AL), County of, Alabama 226. Tallapoosa (AL), County of, Alabama 227. Tarrant (AL), City of, Alabama 228. Thomasville (AL), City of, Alabama 229. Tombigmee Health Care Authority (AL), Alabama 230. Troy (AL), City of, Alabama 231. Trussville (AL), City of, Alabama 232. Tuscaloosa (AL), City of, Alabama 233. Tuscaloosa (AL), County of, Alabama 234. Tuscumbia (AL), City of, Alabama 235. Tuskegee (AL), City of, Alabama 236. Union Springs (AL), City of, Alabama 237. Uniontown (AL), City of, Alabama 238. Vance (AL), Town of, Alabama 239. Vernon (AL), City of, Alabama 240. Vestavia Hills (AL), City of, Alabama 241. Walker (AL), County of, Alabama 242. Washington (AL), County of, Alabama 243. Weaver (AL), City of, Alabama 244. West Blocton (AL), Town of, Alabama 245. Wilcox (AL), County of, Alabama 246. Winfield (AL), City of, Alabama 247. Woodville (AL), Town of, Alabama 248. Yellow Bluff (AL), Town of, Alabama 249. Grande Prairie (AB), City of, Alberta 250. Arizona Counties Insurance Pool (AZ), Arizona 251. Arizona Municipal Risk Retention Pool (AZ), Arizona 252. Arizona School Alliance for Workers' Compensation, Inc. (AZ), Arizona 253. Apache (AZ), County of, Arizona 254. Bullhead City (AZ), City of, Arizona 255. Cochise (AZ), County of, Arizona 256. Coconino (AZ), County of, Arizona 257. Gila (AZ), County of, Arizona 258. Glendale (AZ), City of, Arizona 259. Graham (AZ), County of, Arizona 260. Greenlee (AZ), County of, Arizona 261. Kingman (AZ), City of, Arizona 262. La Paz (AZ), County of, Arizona 263. Maricopa (AZ), County of, Arizona 264. Mohave (AZ), County of, Arizona 265. Navajo (AZ), County of, Arizona 266. Phoenix (AZ), City of, Arizona 267. Pima (AZ), County of, Arizona 268. Pinal (AZ), County of, Arizona 269. Prescott (AZ), City of, Arizona 270. Santa Cruz (AZ), County of, Arizona 271. Surprise (AZ), City of, Arizona 272. Tucson (AZ), City of, Arizona 273. Yavapai (AZ), County of, Arizona 274. Yuma (AZ), County of, Arizona 275. Adona (AR), City of, Arkansas 276. Alexander (AR), City of, Arkansas 277. Alicia (AR), City of, Arkansas 278. Allport (AR), City of, Arkansas 279. Alma (AR), City of, Arkansas 280. Almyra (AR), City of, Arkansas 281. Alpena (AR), City of, Arkansas 282. Altheimer (AR), City of, Arkansas 283. Altus (AR), City of, Arkansas 284. Amagon (AR), City of, Arkansas 285. Amity (AR), City of, Arkansas 286. Anthonyville (AR), City of, Arkansas 287. Antoine (AR), City of, Arkansas 288. Arkadelphia (AR), City of, Arkansas 289. Arkansas (AR), County of, Arkansas 290. Arkansas City (AR), City of, Arkansas 291. Ash Flat (AR), City of, Arkansas 292. Ashdown (AR), City of, Arkansas 293. Ashley (AR), County of, Arkansas 294. Association of Arkansas Counties (AR), Arkansas 295. Association of Arkansas Counties Risk Management Fund (AR), Arkansas 296. Association of Arkansas Counties Workers' Compensation Trust (AR), Arkansas 297. Atkins (AR), City of, Arkansas 298. Aubrey (AR), City of, Arkansas 299. Augusta (AR), City of, Arkansas 300. Austin (AR), City of, Arkansas 301. Avoca (AR), City of, Arkansas 302. Bald Knob (AR), City of, Arkansas 303. Banks (AR), City of, Arkansas 304. Burling (AR), City of, Arkansas 305. Bassett (AR), City of, Arkansas 306. Batesville (AR), City of, Arkansas 307. Bauxite (AR), City of, Arkansas 308. Baxter (AR), County of, Arkansas 309. Bay (AR), City of, Arkansas 310. Bearden (AR), City of, Arkansas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 311. Beaver (AR), City of, Arkansas 312. Beebe (AR), City of, Arkansas 313. Beedeville (AR), City of, Arkansas 314. Bella Vista (AR), City of, Arkansas 315. Bellefonte (AR), City of, Arkansas 316. Belleville (AR), City of, Arkansas 317. Ben Lomond (AR), City of, Arkansas 318. Benton (AR), County of, Arkansas 319. Benton (AR), City of, Arkansas 320. Bentonville (AR), City of, Arkansas 321. Bergman (AR), City of, Arkansas 322. Berryville (AR), City of, Arkansas 323. Bethel Heights (AR), City of, Arkansas 324. Big Flat (AR), City of, Arkansas 325. Bigelow (AR), City of, Arkansas 326. Biggers (AR), City of, Arkansas 327. Birdsong (AR), City of, Arkansas 328. Biscoe (AR), City of, Arkansas 329. Black Oak (AR), City of, Arkansas 330. Black Rock (AR), City of, Arkansas 331. Black Springs (AR), City of, Arkansas 332. Blevins (AR), City of, Arkansas 333, Blue Eye (AR), City of, Arkansas 334. Blue Mountain (AR), City of, Arkansas 335. Bluff City (AR), City of, Arkansas 336. Blytheville (AR), City of, Arkansas 337. Bodcaw (AR), City of, Arkansas 338. Bonanza (AR), City of, Arkansas 339. Bono (AR), City of, Arkansas 340. Boone (AR), County of, Arkansas 341. Booneville (AR), City of, Arkansas 342. Bradford (AR), City of, Arkansas 343. Bradley (AR), County of, Arkansas 344. Bradley (AR), City of, Arkansas 345. Branch (AR), City of, Arkansas 346. Briarcliff (AR), City of, Arkansas 347. Brinkley (AR), City of, Arkansas 348. Brookland (AR), City of, Arkansas 349. Bryant (AR), City of, Arkansas 350. Buckner (AR), City of, Arkansas 351. Bull Shoals (AR), City of, Arkansas 352. Burdette (AR), City of, Arkansas 353. Cabot (AR), City of, Arkansas 354. Caddo Valley (AR), City of, Arkansas 355. Caldwell (AR), City of, Arkansas 356. Cale (AR), City of, Arkansas 357. Calhoun (AR), County of, Arkansas 358. Calico Rock (AR), City of, Arkansas 359. Calion (AR), City of, Arkansas 360. Camden (AR), City of, Arkansas 361. Cammack Village (AR), City of, Arkansas 362. Campbell Station (AR), City of, Arkansas 363. Caraway (AR), City of, Arkansas 364. Carlisle (AR), City of, Arkansas 365. Carroll (AR), County of, Arkansas 366. Carthage (AR), City of, Arkansas 367. Casa (AR), City of, Arkansas 368. Cash (AR), City of, Arkansas 369. Caulksville (AR), City of, Arkansas 370. Cave City (AR), City of, Arkansas 371. Cave Springs (AR), City of, Arkansas 372. Cedarville (AR), City of, Arkansas 373. Centerton (AR), City of, Arkansas 374. Central City (AR), City of, Arkansas 375. Charleston (AR), City of, Arkansas 376. Cherokee Village (AR), City of, Arkansas 377. Cherry Valley (AR), City of, Arkansas 378. Chester (AR), City of, Arkansas 379. Chicot (AR), County of, Arkansas 380. Chidester (AR), City of, Arkansas 381. Clarendon (AR), City of, Arkansas 382. Clark (AR), County of, Arkansas 383. Clarksville (AR), City of, Arkansas 384. Clay (AR), County of, Arkansas 385. Cleburne (AR), County of, Arkansas 386. Cleveland (AR), County of, Arkansas 387. Clinton (AR), City of, Arkansas 388. Coal Hill (AR), City of, Arkansas 389. Colt (AR), City of, Arkansas 390. Columbia (AR), County of, Arkansas 391. Concord (AR), City of, Arkansas 392. Conway (AR), County of, Arkansas 393. Conway (AR), City of, Arkansas 394. Corning (AR), City of, Arkansas 395. Cotter (AR), City of, Arkansas 396. Cotton Plant (AR), City of, Arkansas 397. Cove (AR), City of, Arkansas 398. Coy (AR), City of, Arkansas 399. Craighead (AR), County of, Arkansas 400. Crawford (AR), County of, Arkansas 401. Crawfordsville (AR), City of, Arkansas 402. Crittenden (AR), County of, Arkansas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 403. Cross (AR), County of, Arkansas 404. Crossett (AR), City of, Arkansas 405. Cushman (AR), City of, Arkansas 406. Daisy (AR), City of, Arkansas 407. Dallas (AR), County of, Arkansas 408. Damascus (AR), City of, Arkansas 409. Danville (AR), City of, Arkansas 410. Dardanelle (AR), City of, Arkansas 411. Datto (AR), City of, Arkansas 412. De Queen (AR), City of, Arkansas 413. Decatur (AR), City of, Arkansas 414. Delaplaine (AR), City of, Arkansas 415. Delight (AR), City of, Arkansas 416. Dell (AR), City of, Arkansas 417. Denning (AR), City of, Arkansas 418. Dermott (AR), City of, Arkansas 419. Des Arc (AR), City of, Arkansas 420. Desha (AR), County of, Arkansas 421. DeValls Bluff (AR), City of, Arkansas 422. Dewitt (AR), City of, Arkansas 423. Diamond City (AR), City of, Arkansas 424. Diaz (AR), City of, Arkansas 425. Dierks (AR), City of, Arkansas 426. Donaldson (AR), City of, Arkansas 427. Dover (AR), City of, Arkansas 428. Drew (AR), County of, Arkansas 429. Dumas (AR), City of, Arkansas 430. Dyer (AR), City of, Arkansas 431. Dyess (AR), City of, Arkansas 432. Earle (AR), City of, Arkansas 433. East Camden (AR), City of, Arkansas 434. Edmondson (AR), City of, Arkansas 435. Egypt (AR), City of, Arkansas 436. El Dorado (AR), City of, Arkansas 437. Elaine (AR), City of, Arkansas 438. Elkins (AR), City of, Arkansas 439. Elm Springs (AR), City of, Arkansas 440. Emerson (AR), City of, Arkansas 441. Emmet (AR), City of, Arkansas 442. England (AR), City of, Arkansas 443. Enola (AR), City of, Arkansas 444. Etowah (AR), City of, Arkansas 445. Eudora (AR), City of, Arkansas 446. Eureka Springs (AR), City of, Arkansas 447. Evening Shade (AR), City of, Arkansas 448. Everton (AR), City of, Arkansas 449. Fairfield Bay (AR), City of, Arkansas 450. Fargo (AR), City of, Arkansas 451. Farmington (AR), City of, Arkansas 452. Faulkner (AR), County of, Arkansas 453. Felsenthal (AR), City of, Arkansas 454. Fifty -Six (AR), City of, Arkansas 455. Fisher (AR), City of, Arkansas 456. Flippin (AR), City of, Arkansas 457. Fordyce (AR), City of, Arkansas 458. Foreman (AR), City of, Arkansas 459. Forrest City (AR), City of, Arkansas 460. Fort Smith (AR), City of, Arkansas 461. Fouke (AR), City of, Arkansas 462. Fountain Hill (AR), City of, Arkansas 463. Fountain Lake (AR), City of, Arkansas 464. Fourche (AR), City of, Arkansas 465. Franklin (AR), County of, Arkansas 466. Franklin (AR), City of, Arkansas 467. Friendship (AR), City of, Arkansas 468. Fulton (AR), County of, Arkansas 469. Fulton (AR), City of, Arkansas 470. Garfield (AR), City of, Arkansas 471. Garland (AR), County of, Arkansas 472. Garland (AR), City of, Arkansas 473. Garner (AR), City of, Arkansas 474. Gassville (AR), City of, Arkansas 475. Gateway (AR), City of, Arkansas 476. Gentry (AR), City of, Arkansas 477. Georgetown (AR), City of, Arkansas 478. Gilbert (AR), City of, Arkansas 479. Gillett (AR), City of, Arkansas 480. Gillham (AR), City of, Arkansas 481. Gilmore (AR), City of, Arkansas 482. Glenwood (AR), City of, Arkansas 483. Goshen (AR), City of, Arkansas 484. Gosnell (AR), City of, Arkansas 485. Gould (AR), City of, Arkansas 486. Grady (AR), City of, Arkansas 487. Grannis (AR), City of, Arkansas 488. Grant (AR), County of, Arkansas 489. Gravette (AR), City of, Arkansas 490. Green Forest (AR), City of, Arkansas 491. Greenbrier (AR), City of, Arkansas 492. Greene (AR), County of, Arkansas 493. Greenland (AR), City of, Arkansas 494. Greenway (AR), City of, Arkansas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 495. Greenwood (AR), City of, Arkansas 496. Greers Ferry (AR), City of, Arkansas 497. Griffithville (AR), City of, Arkansas 498. Grubbs (AR), City of, Arkansas 499. Guion (AR), City of, Arkansas 500. Gum Springs (AR), City of, Arkansas 501. Gordon (AR), City of, Arkansas 502. Guy (AR), City of, Arkansas 503. Hackett (AR), City of, Arkansas 504. Hamburg (AR), City of, Arkansas 505. Hampton (AR), City of, Arkansas 506. Hardy (AR), City of, Arkansas 507. Harrell (AR), City of, Arkansas 508. Harrisburg (AR), City of, Arkansas 509. Harrison (AR), City of, Arkansas 510. Hartford (AR), City of, Arkansas 511. Hartman (AR), City of, Arkansas 512. Haskell (AR), City of, Arkansas 513. Hatfield (AR), City of, Arkansas 514. Havana (AR), City of, Arkansas 515. Haynes (AR), City of, Arkansas 516. Hazen (AR), City of, Arkansas 517. Heber Springs (AR), City of, Arkansas 518. Hector (AR), City of, Arkansas 519. Helena - West Helena (AR), City of, Arkansas 520. Hempstead (AR), County of, Arkansas 521. Hermitage (AR), City of, Arkansas 522. Hickory Ridge (AR), City of, Arkansas 523. Higden (AR), City of, Arkansas 524. Higginson (AR), City of, Arkansas 525. Highfill (AR), City of, Arkansas 526. Highland (AR), City of, Arkansas 527. Hidsville (AR), City of, Arkansas 528. Holland (AR), City of, Arkansas 529. Holly Grove (AR), City of, Arkansas 530. Hope (AR), City of, Arkansas 531. Horatio (AR), City of, Arkansas 532. Horseshoe Bend (AR), City of, Arkansas 533. Horseshoe Lake (AR), City of, Arkansas 534. Hot Spring (AR), County of, Arkansas 535. Hot Springs (AR), City of, Arkansas 536. Houston (AR), City of, Arkansas 537. Howard (AR), County of, Arkansas 538. Hoxie (AR), City of, Arkansas 539. Hughes (AR), City of, Arkansas 540. Humnoke (AR), City of, Arkansas 541. Humphrey (AR), City of, Arkansas 542. Hunter (AR), City of, Arkansas 543. Huntington (AR), City of, Arkansas 544. Huntsville (AR), City of, Arkansas 545. Huttig (AR), City of, Arkansas 546. Imboden (AR), City of, Arkansas 547. Independence (AR), County of, Arkansas 548. Izard (AR), County of, Arkansas 549. Jackson (AR), County of, Arkansas 550. Jacksonport (AR), City of, Arkansas 551. Jacksonville (AR), City of, Arkansas 552. Jasper (AR), City of, Arkansas 553. Jefferson (AR), County of, Arkansas 554. Jennette (AR), City of, Arkansas 555. Jericho (AR), City of, Arkansas 556. Jerome (AR), City of, Arkansas 557. Johnson (AR), County of, Arkansas 558. Johnson (AR), City of, Arkansas 559. Joiner (AR), City of, Arkansas 560. Jonesboro (AR), City of, Arkansas 561. Judsonia (AR), City of, Arkansas 562. Junction City (AR), City of, Arkansas 563. Keiser (AR), City of, Arkansas 564. Kensett (AR), City of, Arkansas 565. Ken (AR), City of, Arkansas 566. Kibler (AR), City of, Arkansas 567. Kingsland (AR), City of, Arkansas 568. Knobel (AR), City of, Arkansas 569. Knoxville (AR), City of, Arkansas 570. LaGrange (AR), City of, Arkansas 571. Lafayette (AR), County of, Arkansas 572. Lafe (AR), City of, Arkansas 573. Lake City (AR), City of, Arkansas 574. Lake View (AR), City of, Arkansas 575. Lake Village (AR), City of, Arkansas 576. Lakeview (AR), City of, Arkansas 577. Lamar (AR), City of, Arkansas 578. Lavaca (AR), City of, Arkansas 579. Lawrence (AR), County of, Arkansas 580. Leachville (AR), City of, Arkansas 581. Lead Hill (AR), City of, Arkansas 582. Lee (AR), County of, Arkansas 583. Leola (AR), City of, Arkansas 584. Lepanto (AR), City of, Arkansas 585. Leslie (AR), City of, Arkansas 586. Letona (AR), City of, Arkansas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 587. Lewisville (AR), City of, Arkansas 588. Lexa (AR), City of, Arkansas 589. Lincoln (AR), County of, Arkansas 590. Lincoln (AR), City of, Arkansas 591. Little Flock (AR), City of, Arkansas 592. Little River (AR), County of, Arkansas 593. Little Rock (AR), City of, Arkansas 594. Lockesburg (AR), City of, Arkansas 595. Logan (AR), County of, Arkansas 596. London (AR), City of, Arkansas 597. Lonoke (AR), County of, Arkansas 598. Lonoke (AR), City of, Arkansas 599. Lonsdale (AR), City of, Arkansas 600. Louann (AR), City of, Arkansas 601. Lowell (AR), City of, Arkansas 602. Luxora (AR), City of, Arkansas 603. Lynn (AR), City of, Arkansas 604. Madison (AR), County of, Arkansas 605. Madison (AR), City of, Arkansas 606. Magazine (AR), City of, Arkansas 607. Magness (AR), City of, Arkansas 608. Magnolia (AR), City of, Arkansas 609. Malvern (AR), City of, Arkansas 610. Mammoth Spring (AR), City of, Arkansas 611. Manila (AR), City of, Arkansas 612. Mansfield (AR), City of, Arkansas 613. Marianna (AR), City of, Arkansas 614. Marie (AR), City of, Arkansas 615. Marion (AR), County of, Arkansas 616. Marion (AR), City of, Arkansas 617. Marked Tree (AR), City of, Arkansas 618. Marmaduke (AR), City of, Arkansas 619. Marshall (AR), City of, Arkansas 620. Marvell (AR), City of, Arkansas 621. Maumelle (AR), City of, Arkansas 622. Mayflower (AR), City of, Arkansas 623. Maynard (AR), City of, Arkansas 624. McCaskill (AR), City of, Arkansas 625. McCrory (AR), City of, Arkansas 626. McDougal (AR), City of, Arkansas 627. McGehee (AR), City of, Arkansas 628. McNab (AR), City of, Arkansas 629. McNeil (AR), City of, Arkansas 630. McRae (AR), City of, Arkansas 631. Melbourne (AR), City of, Arkansas 632. Mena (AR), City of, Arkansas 633. Menifee (AR), City of, Arkansas 634. Midland (AR), City of, Arkansas 635. Miller (AR), County of, Arkansas 636. Mineral Springs (AR), City of, Arkansas 637. Mintum (AR), City of, Arkansas 638. Mississippi (AR), County of, Arkansas 639. Mitchellville (AR), City of, Arkansas 640. Monette (AR), City of, Arkansas 641. Monroe (AR), County of, Arkansas 642. Montgomery (AR), County of, Arkansas 643. Monticello (AR), City of, Arkansas 644. Montrose (AR), City of, Arkansas 645. Moorefield (AR), City of, Arkansas 646. Moro (AR), City of, Arkansas 647. Morrilton (AR), City of, Arkansas 648. Morrison Bluff (AR), City of, Arkansas 649. Mount Ida (AR), City of, Arkansas 650. Mount Pleasant (AR), City of, Arkansas 651. Mount Vernon (AR), City of, Arkansas 652. Mountain Home (AR), City of, Arkansas 653. Mountain Pine (AR), City of, Arkansas 654. Mountain View (AR), City of, Arkansas 655. Mountainburg (AR), City of, Arkansas 656. Mulberry (AR), City of, Arkansas 657. Murfreesboro (AR), City of, Arkansas 658. Nashville (AR), City of, Arkansas 659. Nevada (AR), County of, Arkansas 660. Newark (AR), City of, Arkansas 661. Newport (AR), City of, Arkansas 662. Newton (AR), County of, Arkansas 663. Nimmons (AR), City of, Arkansas 664. Norfork (AR), City of, Arkansas 665. Norman (AR), City of, Arkansas 666. Norphlet (AR), City of, Arkansas 667. North Little Rock (AR), City of, Arkansas 668. Oak Grove (AR), City of, Arkansas 669. Oak Grove Heights (AR), City of, Arkansas 670. Oakhaven (AR), City of, Arkansas 671. Oden (AR), City of, Arkansas 672. Ogden (AR), City of, Arkansas 673. Oil Trough (AR), City of, Arkansas 674. O'Kean (AR), City of, Arkansas 675. Okolona (AR), City of, Arkansas 676. Ola (AR), City of, Arkansas 677. Omaha (AR), City of, Arkansas 678. Oppelo (AR), City of, Arkansas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 679. Osceola (AR), City of, Arkansas 680. Ouachita (AR), County of, Arkansas 681. Oxford (AR), City of, Arkansas 682. Ozan (AR), City of, Arkansas 683. Ozark (AR), City of, Arkansas 684. Palestine (AR), City of, Arkansas 685. Pangburn (AR), City of, Arkansas 686. Paragould (AR), City of, Arkansas 687. Paris (AR), City of, Arkansas 688. Parkdale (AR), City of, Arkansas 689. Parkin (AR), City of, Arkansas 690. Patmos (AR), City of, Arkansas 691. Patterson (AR), City of, Arkansas 692. Pea Ridge (AR), City of, Arkansas 693. Peach Orchard (AR), City of, Arkansas 694. Perla (AR), City of, Arkansas 695. Perry (AR), County of, Arkansas 696. Perry (AR), City of, Arkansas 697. Perrytown (AR), City of, Arkansas 698. Perryville (AR), City of, Arkansas 699. Phillips (AR), County of, Arkansas 700. Piggott (AR), City of, Arkansas 701. Pike (AR), County of, Arkansas 702. Pindall (AR), City of, Arkansas 703. Pine Bluff (AR), City of, Arkansas 704. Pineville (AR), City of, Arkansas 705. Plainview (AR), City of, Arkansas 706. Pleasant Plains (AR), City of, Arkansas 707. Plumerville (AR), City of, Arkansas 708. Pocahontas (AR), City of, Arkansas 709. Poinsett (AR), County of, Arkansas 710. Polk (AR), County of, Arkansas 711. Pollard (AR), City of, Arkansas 712. Pope (AR), County of, Arkansas 713. Portia (AR), City of, Arkansas 714. Portland (AR), City of, Arkansas 715. Pottsville (AR), City of, Arkansas 716. Powhatan (AR), City of, Arkansas 717. Poyen (AR), City of, Arkansas 718. Prairie (AR), County of, Arkansas 719. Prairie Grove (AR), City of, Arkansas 720. Prttsville (AR), City of, Arkansas 721. Prescott (AR), City of, Arkansas 722. Pulaski (AR), County of, Arkansas 723. Pyatt (AR), City of, Arkansas 724. Quitman (AR), City of, Arkansas 725. Randolph (AR), County of, Arkansas 726. Ratcliff (AR), City of, Arkansas 727. Ravenden (AR), City of, Arkansas 728. Ravenden Springs (AR), City of, Arkansas 729. Rector (AR), City of, Arkansas 730. Redfield (AR), City of, Arkansas 731. Reed (AR), City of, Arkansas 732. Reyno (AR), City of, Arkansas 733. Risen (AR), City of, Arkansas 734. Rockport (AR), City of, Arkansas 735. Roe (AR), City of, Arkansas 736. Rogers (AR), City of, Arkansas 737. Rondo (AR), City of, Arkansas 738. Rose Bud (AR), City of, Arkansas 739. Rosston (AR), City of, Arkansas 740. Rudy (AR), City of, Arkansas 741. Russell (AR), City of, Arkansas 742. Russellville (AR), City of, Arkansas 743. Salem (AR), City of, Arkansas 744. Salesville (AR), City of, Arkansas 745. Saline (AR), County of, Arkansas 746. Scott (AR), County of, Arkansas 747. Scranton (AR), City of, Arkansas 748. Searcy (AR), County of, Arkansas 749. Searcy (AR), City of, Arkansas 750. Sebastian (AR), County of, Arkansas 751. Sedgwick (AR), City of, Arkansas 752. Sevier (AR), County of, Arkansas 753. Shannon Hills (AR), City of, Arkansas 754. Sharp (AR), County of, Arkansas 755. Sheridan (AR), City of, Arkansas 756. Sherrill (AR), City of, Arkansas 757. Sherwood (AR), City of, Arkansas 758. Shirley (AR), City of, Arkansas 759. Sidney (AR), City of, Arkansas 760. Siloam Springs (AR), City of, Arkansas 761. Smackover (AR), City of, Arkansas 762. Smithville (AR), City of, Arkansas 763. South Lead Hill (AR), City of, Arkansas 764. Sparkman (AR), City of, Arkansas 765. Springdale (AR), City of, Arkansas 766. Spring -town (AR), City of, Arkansas 767. St. Charles (AR), City of, Arkansas 768. St. Francis (AR), County of, Arkansas 769. St. Francis (AR), City of, Arkansas 770. St. Joe (AR), City of, Arkansas DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 771. St. Paul (AR), City of, Arkansas 817. Washington (AR), County of, Arkansas 772. Stamps (AR), City of, Arkansas 818. Washington (AR), City of, Arkansas 773. Star City (AR), City of, Arkansas 819. Watson (AR), City of, Arkansas 774. Stephens (AR), City of, Arkansas 820. Weiner (AR), City of, Arkansas 775. Stone (AR), County of, Arkansas 821. Weldon (AR), City of, Arkansas 776. Strawberry (AR), City of, Arkansas 822. West Fork (AR), City of, Arkansas 777. Strong (AR), City of, Arkansas 823. West Memphis (AR), City of, Arkansas 778. Stuttgart (AR), City of, Arkansas 824. West Point (AR), City of, Arkansas 779. Subiaco (AR), City of, Arkansas 825. Western Grove (AR), City of, Arkansas 780. Success (AR), City of, Arkansas 826. Wheatley (AR), City of, Arkansas 781. Sulphur Rock (AR), City of, Arkansas 827. Whelen Springs (AR), City of, Arkansas 782. Sulphur Springs (AR), City of, Arkansas 828. White (AR), County of, Arkansas 783. Summit (AR), City of, Arkansas 829. White Hall (AR), City of, Arkansas 784. Sunset (AR), City of, Arkansas 830. Wickes (AR), City of, Arkansas 785. Swifton (AR), City of, Arkansas 831. Widener (AR), City of, Arkansas 786. Taylor (AR), City of, Arkansas 832. Wiederkehr Village (AR), City of, 787. Texarkana (AR), City of, Arkansas Arkansas 788. Thornton (AR), City of, Arkansas 833. Williford (AR), City of, Arkansas 789. Tillar (AR), City of, Arkansas 834. W illisville (AR), City of, Arkansas 790. Tinsman (AR), City of, Arkansas 835. Wilmar (AR), City of, Arkansas 791. Tollette (AR), City of, Arkansas 836. Wilmot (AR), City of, Arkansas 792. Tontitown (AR), City of, Arkansas 837. Wilson (AR), City of, Arkansas 793. Traskwood (AR), City of, Arkansas 838. Wilton (AR), City of, Arkansas 794. Trumann (AR), City of, Arkansas 839. Winchester (AR), City of, Arkansas 795. Tuckerman (AR), City of, Arkansas 840. Winslow (AR), City of, Arkansas 796. Tull (AR), City of, Arkansas 841. Winthrop (AR), City of, Arkansas 797. Tupelo (AR), City of, Arkansas 842. Woodruff (AR), County of, Arkansas 798. Tunell (AR), City of, Arkansas 843. Wooster (AR), City of, Arkansas 799. Twin Groves (AR), City of, Arkansas 844. Wrightsville (AR), City of, Arkansas 800. Tyronza (AR), City of, Arkansas 845. Wynne (AR), City of, Arkansas 801. Ulm (AR), City of, Arkansas 846. Yell (AR), County of, Arkansas 802. Union (AR), County of, Arkansas 847. Yellville (AR), City of, Arkansas 803. Valley Springs (AR), City of, Arkansas 848. Zinc (AR), City of, Arkansas 804. Van Buren (AR), County of, Arkansas 849. Alameda (CA), County of, California 805. Van Buren (AR), City of, Arkansas 850. Amador (CA), County of, California 806. Vandervoort (AR), City of, Arkansas 851. Anaheim (CA), City of, California 807. Victoria (AR), City of, Arkansas 852. Butte (CA), County of, California 808. Vilonia (AR), City of, Arkansas 853. Calaveras (CA), County of, California 809. Viola (AR), City of, Arkansas 854. Central California Alliance for Health 810. Wabbaseka (AR), City of, Arkansas (CA), California 811. Waldenburg (AR), City of, Arkansas 855. Chico (CA), City of, California 812. Waldo (AR), City of, Arkansas 856. Chula Vista (CA), City of, California 813. Waldron (AR), City of, Arkansas 857. Clearlake (CA), City of, California 814. Walnut Ridge (AR), City of, Arkansas 858. Commission On Medical Care d/b/a 815. Ward (AR), City of, Arkansas Partnership HealthPlan of California (CA), 816. Warren (AR), City of, Arkansas California 859. Contra Costa (CA), County of, California DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 860. Costa Mesa (CA), City of, California 861. Del Norte (CA), County of, California 862. Downey Unified School District (CA), California 863. Dublin. (CA), City of, California 864. El Dorado (CA), County of, California 865. El Monte (CA), City of, California 866. Elk Grove Unified School District (CA), California 867. Encinitas (CA), City of, California 868. Eureka (CA), City of, California 869. Fresno (CA), County of, California 870. Fullerton (CA), City of, California 871. Glenn (CA), County of, California 872. Health Plan of San Joaquin (CA), California 873. Humboldt (CA), County of, California 874. Huntington Beach (CA), City of, California 875. Imperial (CA), County of, California 876. Inland Empire Health Plan (CA), California 877. Inyo (CA), County of, California 878. Irvine (CA), City of, California 879. Kern (CA), County of, California 880. Kern High School District (CA), California 881. La Habra (CA), City of, California 882. La Mesa (CA), City of, California 883. Laguna Beach (CA), City of, California 884. Lakeport (CA), City of, California 885. Lassen (CA), County of, California 886. Local Initiative Health Authority For Los Angeles County (CA), California 887. Los Angeles (CA), City of, California 888. Los Angeles (CA), County of, California 889. Madera (CA), County of, California 890. Marin (CA), County of, California 891. Mariposa (CA), County of, California 892. Mendocino (CA), County of, California 893. Merced (CA), County of, California 894. Modoc (CA), County of, California 895. Mono (CA), County of, California 896. Monterey (CA), County of, California 897. Montezuma Fire Protection District (CA), California 898. Murrieta (CA), City of, California 899. Napa (CA), County of, California 900. Nevada (CA), County of, California 901. Oakland (CA), City of, California 902. Orange (CA), County of, California 903. Oxnard (CA), City of, California 904. Placentia (CA), City of, California 905. Placer (CA), County of, California 906. Plumas (CA), County of, California 907. Riverside (CA), County of, California 908. Sacramento (CA), City of, California 909. Sacramento (CA), County of, California 910. San Benito (CA), County of, California 911. San Bernardino (CA), County of, California 912. San Clemente (CA), City of, California 913. San Diego (CA), City of, California 914. San Diego (CA), County of, California 915. San Francisco (CA), County of, California 916. San Joaquin (CA), County of, California 917. San Jose (CA), City of, California 918. San Luis Obispo (CA), County of, California 919. San Mateo (CA), County of, California 920. Santa Ana (CA), City of, California 921. Santa Barbara (CA), County of, California 922. Santa Barbara San Luis Obispo Regional Health Authority (CA), California 923. Santa Clara (CA), County of, California 924. Santa Cruz (CA), County of, California 925. Shasta (CA), County of, California 926. Siskiyou (CA), County of, California 927. Sonoma (CA), County of, California 928. Stockton (CA), City of, California 929. Sutter (CA), County of, California 930. Tehama (CA), County of, California 931. Trinity (CA), County of, California 932. Tulare (CA), County of, California 933. Tuolumne (CA), County of, California 934. Ventura (CA), County of, California 935. Ventura County Medi-Cal Managed Care Commission d/b/a Gold Coast Health Plan (CA), California 936. Westminster (CA), City of, California 937. Yolo (CA), County of, California 938. Yuba (CA), County of, California 939. Adams (CO), County of, Colorado 940. Alamosa (CO), City of, Colorado DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 941. Alamosa (CO), County of, Colorado 942. Arapahoe (CO), County of, Colorado 943. Aurora (CO), City of, Colorado 944. Black Hawk (CO), City of, Colorado 945. Boulder (CO), County of, Colorado 946. Brighton (CO), City of, Colorado 947. Broomfield (CO), County of, Colorado 948. Chaffee (CO), County of, Colorado 949. Commerce City (CO), City of, Colorado 950. Conejos (CO), County of, Colorado 951. Crowley (CO), County of, Colorado 952. Denver (CO), County of, Colorado 953. Federal Heights (CO), City of, Colorado 954. Fremont (CO), County of, Colorado 955. Greeley (CO), City of, Colorado 956. Hudson (CO), Town of, Colorado 957. Huerfano (CO), County of, Colorado 958. Jefferson (CO), County of, Colorado 959. Lakewood (CO), City of, Colorado 960. Latimer (CO), County of, Colorado 961. Las Animas (CO), County of, Colorado 962. Mesa (CO), County of, Colorado 963. Mesa County Valley School District 51 (CO), Colorado 964. Northglenn (CO), City of, Colorado 965. Otero (CO), County of, Colorado 966. Pueblo (CO), County of, Colorado 967. Sheridan (CO), City of, Colorado 968. Teller (CO), County of, Colorado 969. Thornton (CO), City of, Colorado 970. Tri-County Health Department (CO), Colorado 971. Westminster (CO), City of, Colorado 972. Wheat Ridge (CO), City of, Colorado 973. Ansonia (CT), City of, Connecticut 974. Beacon Falls (CT), Town of, Connecticut 975. Berlin (CT), Town of, Connecticut 976. Bethlehem (CT), Town of, Connecticut 977. Bridgeport (CT), City of, Connecticut 978. Bristol (CT), City of, Connecticut 979. Coventry (CT), Town of, Connecticut 980. Danbury (CT), City of, Connecticut 981. Derby (CT), City of, Connecticut 982. East Hartford (CT), Town of, Connecticut 983. Enfield (CT), Town of, Connecticut 984. Fairfield (CT), Town of, Connecticut 985. Middlebury (CT), Town of, Connecticut 986. Middletown (CT), City of, Connecticut 987. Milford (CT), City of, Connecticut 988. Monroe (CT), Town of, Connecticut 989. Naugatuck (CT), Borough of, Connecticut 990. New Britain (CT), City of, Connecticut 991. New Haven (CT), City of, Connecticut 992. New London (CT), City of, Connecticut 993. New Milford (CT), Town of, Connecticut 994. Newtown (CT), Town of, Connecticut 995. North Haven (CT), Town of, Connecticut 996. Norwalk (CT), City of, Connecticut 997. Norwich (CT), City of, Connecticut 998. Oxford (CT), Town of, Connecticut 999. Prospect (CT), Town of, Connecticut 1000. Roxbury (CT), Town of, Connecticut 1001. Seymour (CT), Town of, Connecticut 1002. Shelton (CT), City of, Connecticut 1003. Southbury (CT), Town of, Connecticut 1004. Southington (CT), Town of, Connecticut 1005. Stratford (CT), Town of, Connecticut 1006. Thomaston (CT), Town of, Connecticut 1007. Tolland (CT), Town of, Connecticut 1008. Torrington (CT), City of, Connecticut 1009. Wallingford (CT), Town of, Connecticut 1010. Waterbury (CT), City of, Connecticut 1011. West Haven (CT), City of, Connecticut 1012. Wethersfield (CT), Town of, Connecticut 1013. Windham (CT), Town of, Connecticut 1014. Wolcott (CT), Town of, Connecticut 1015. Woodbury (CT), Town of, Connecticut 1016. Dover (DE), City of, Delaware 1017. Kent (DE), County of, Delaware 1018. Seaford (DE), City of, Delaware 1019. Sussex (DE), County of, Delaware 1020. Alachua (FL), County of, Florida 1021. Apopka (FL), City of, Florida 1022. Bay (FL), County of, Florida 1023. Bradenton (FL), City of, Florida 1024. Bradford (FL), County of, Florida 1025. Brevard (FL), County of, Florida 1026. Broward (FL), County of, Florida 1027. Calhoun (FL), County of, Florida 1028. Clay (FL), County of, Florida 1029. Clearwater (FL), City of, Florida 1030. Coconut Creek (FL), City of, Florida 1031. Coral Gables (FL), City of, Florida DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1032. Coral Springs (FL), City of, Florida 1033. Daytona Beach (FL), City of, Florida 1034. Daytona Beach Shores (FL), City of, Florida 1035. Deerfield Beach (FL), City of, Florida 1036. Delray Beach (FL), City of, Florida 1037. Deltona (FL), City of, Florida 1038. Dixie (FL), County of, Florida 1039. Eatonville (FL), Town of, Florida 1040. Escambia (FL), County of, Florida 1041. Florida City (FL), City of, Florida 1042. Fort Lauderdale (FL), City of, Florida 1043. Fort Pierce (FL), City of, Florida 1044. Gilchrist (FL), County of, Florida 1045. Gulf (FL), County of, Florida 1046. Halifax Hospital Medical Center (FL), Florida 1047. Hallandale Beach (FL), City of, Florida 1048. Hamilton (FL), County of, Florida 1049. Hernando (FL), County of, Florida 1050. Hillsborough (FL), County of, Florida 1051. Holmes (FL), County of, Florida 1052. Homestead (FL), City of, Florida 1053. Jackson (FL), County of, Florida 1054. Jacksonville (FL), City of, Florida 1055. Lake (FL), County of, Florida 1056. Lauderhill (FL), City of, Florida 1057. Lee (FL), County of, Florida 1058. Lee Memorial Health System d/b/a Lee Health (FL), Florida 1059. Leon (FL), County of, Florida 1060. Levy (FL), County of, Florida 1061. Lynn Haven (FL), City of, Florida 1062. Manatee (FL), County of, Florida 1063. Marion (FL), County of, Florida 1064. Miami (FL), City of, Florida 1065. Miami Gardens (FL), City of, Florida 1066. Miami -Dade (FL), County of, Florida 1067. Miami -Dade County School Board (FL), Florida 1068. Miramar (FL), City of, Florida 1069. Monroe (FL), County of, Florida 1070. New Port Richey (FL), City of, Florida 1071. Niceville (FL), City of, Florida 1072. North Broward Hospital District (FL), Florida 1073. North Miami (FL), City of, Florida 1074. Ocala (FL), City of, Florida 1075. Ocoee (FL), City of, Florida 1076. Okaloosa (FL), County of, Florida 1077. Orange (FL), County of, Florida 1078. Orlando (FL), City of, Florida 1079. Ormond Beach (FL), City of, Florida 1080. Osceola (FL), County of, Florida 1081. Oviedo (FL), City of, Florida 1082. Palatka (FL), City of, Florida 1083. Palm Bay (FL), City of, Florida 1084. Palm Beach (FL), County of, Florida 1085. Palmetto (FL), City of, Florida 1086. Panama City (FL), City of, Florida 1087. Pasco (FL), County of, Florida 1088. Pembroke Pines (FL), City of, Florida 1089. Pensacola (FL), City of, Florida 1090. Pinellas (FL), County of, Florida 1091. Pinellas Park (FL), City of, Florida 1092. Polk (FL), County of, Florida 1093. Pompano Beach (FL), City of, Florida 1094. Port St. Lucie (FL), City of, Florida 1095. Putnam (FL), County of, Florida 1096. Sanford (FL), City of, Florida 1097. Santa Rosa (FL), County of, Florida 1098. Sarasota (FL), City of, Florida 1099. Sarasota (FL), County of, Florida 1100. Sarasota County Public Hospital District (FL), Florida 1101. Seminole (FL), County of, Florida 1102. South Florida Behavioral Health Network (FL), Florida 1103. St. Augustine (FL), City of, Florida 1104. St. Johns (FL), County of, Florida 1105. St. Lucie (FL), County of, Florida 1106. St. Petersburg (FL), City of, Florida 1107. Stuart (FL), City of, Florida 1108. Suwannee (FL), County of, Florida 1109. Sweetwater (FL), City of, Florida 1110. Tallahassee (FL), City of, Florida 1111. Tampa (FL), City of, Florida 1112. Taylor (FL), County of, Florida 1113. Union (FL), County of, Florida 1114. Volusia (FL), County of, Florida 1115. Walton (FL), County of, Florida 1116. Washington (FL), County of, Florida 1117. West Volusia Hospital Authority (FL), Florida DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1118. Adel (GA), City of, Georgia 1159. Clinch (GA), County of, Georgia 1119. Albany (GA), City of, Georgia 1160. Clinch County Hospital Authority (GA), 1120. Alma (GA), City of, Georgia Georgia 1121. Appling (GA), County of (Sheriff), 1161. Cobb (GA), County of, Georgia Georgia 1162. Coffee (GA), County of (Sheriff), 1122. Appling (GA), County of, Georgia Georgia 1123. Arlington (GA), City of, Georgia 1163. Columbia (GA), County of, Georgia 1124. Athens -Clarke (GA), County of, Georgia 1164. Columbus (GA), City of, Georgia 1125. Atkinson (GA), County of, Georgia 1165. Cook (GA), County of, Georgia 1126. Atlanta (GA), City of, Georgia 1166. Crawford (GA), County of (Sheriff), 1127. Augusta (GA), City of, Georgia Georgia 1128. Bacon (GA), County of, Georgia 1167. Crisp (GA), County of (Sheriff), Georgia 1129. Bacon County Hospital Foundation 1168. Crisp (GA), County of, Georgia (GA), Georgia 1169. Dade (GA), County of, Georgia 1130. Bainbridge (GA), City of, Georgia 1170. Damascus (GA), City of, Georgia 1131. Baldwin (GA), County,of (Sheriff), 1171. Dawson (GA), City of, Georgia Georgia 1172. Dawson (GA), County of, Georgia 1132. Banks (GA), County of, Georgia 1173. Decatur (GA), County of, Georgia 1133. Bartow (GA), County of, Georgia 1174. DeKalb (GA), County of, Georgia 1134. Ben Hill (GA), County of, Georgia 1175. Demorest (GA), City of, Georgia 1135. Berrien (GA), County of, Georgia 1176. Dodge County Hospital Authority (GA), 1136. Bibb (GA), County of (Sheriff), Georgia Georgia 1137. Bibb County School District (GA), 1177. Dooly (GA), County of, Georgia Georgia 1178. Doraville (GA), City of, Georgia 1138. Blackshear (GA), City of, Georgia 1179. Dougherty (GA), County of, Georgia 1139. Blakely (GA), City of, Georgia 1180. Douglas (GA), County of, Georgia 1140. Brantley (GA), County of, Georgia 1181. Dunwoody (GA), City of, Georgia 1141. Brooks (GA), County of, Georgia 1182. Early (GA), County of, Georgia 1142. Brunswick (GA), City of, Georgia 1183. Echols (GA), County of, Georgia 1143. Bulloch (GA), County of, Georgia 1184. Effingham (GA), County of, Georgia 1144. Burke (GA), County of, Georgia 1185. Elbert (GA), County of, Georgia 1145. Butts (GA), County of, Georgia 1186. Emanuel (GA), County of, Georgia 1146. Camden (GA), County of, Georgia 1187. Evans (GA), County of, Georgia 1147. Candler (GA), County of, Georgia 1188. Evans Memorial Hospital, Inc. (GA), 1148. Candler County Hospital Authority Georgia (GA), Georgia 1189. Fannin (GA), County of, Georgia 1149. Carroll (GA), County of, Georgia 1190. Fayette (GA), County of, Georgia 1150. Cartersville (GA), City of, Georgia 1191. Fitzgerald (GA), City of, Georgia 1151. Catoosa (GA), County of, Georgia 1192. Floyd (GA), County of, Georgia 1152. Charlton (GA), County of, Georgia 1193. Forsyth (GA), County of, Georgia 1153. Chatham (GA), County of, Georgia 1194. Fulton (GA), County of, Georgia 1154. Chatham County Hospital Authority 1195. Gainesville (GA), City of, Georgia (GA), Georgia 1196. Glascock (GA), County of, Georgia 1155. Chattooga (GA), County of, Georgia 1197. Glynn (GA), County of (Sheriff), 1156. Cherokee (GA), County of, Georgia Georgia 1157. Clay (GA), County of, Georgia 1198. Glynn (GA), County of, Georgia 1158. Clayton (GA), County of, Georgia 1199. Grady (GA), County of, Georgia DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1200. Greene (GA), County of, Georgia 1201. Gwinnett (GA), County of, Georgia 1202. Habersham (GA), County of, Georgia 1203. Habersham County Medical Center (GA), Georgia 1204. Hall (GA), County of, Georgia 1205. Hancock (GA), County of, Georgia 1206. Harris (GA), County of (Sheriff), Georgia 1207. Heard (GA), County of, Georgia 1208. Henry (GA), County of, Georgia 1209. Hospital Authority of Bainbridge and Decatur County (GA), Georgia 1210. Hospital Authority of Baxley and Appling County (GA), Georgia 1211. Hospital Authority of Bleckley County (GA), Georgia 1212. Hospital Authority of Valdosta and Lowndes County (GA), Georgia 1213. Hospital Authority of Wayne County (GA), Georgia 1214. Houston (GA), County of (Sheriff), Georgia 1215. Houston (GA), County of, Georgia 1216. Irwin (GA), County of, Georgia 1217. Jackson (GA), County of, Georgia 1218. Jasper (GA), County of, Georgia 1219. Jeff Davis (GA), County of (Sheriff), Georgia 1220. Jeff Davis (GA), County of, Georgia 1221. Jefferson (GA), County of, Georgia 1222. Johnson (GA), County of, Georgia 1223. Jones (GA), County of (Sheriff), Georgia 1224. Jones (GA), County of, Georgia 1225. Lakeland (GA), City of, Georgia 1226. Lanier (GA), County of, Georgia 1227. Laurens (GA), County of (Sheriff), Georgia 1228. Laurens (GA), County of, Georgia 1229. Lee (GA), County of, Georgia 1230. Liberty (GA), County of, Georgia 1231 . Lincoln (GA), County of, Georgia 1232. Long (GA), County of, Georgia 1233. Lowndes (GA), County of, Georgia 1234. Lumpkin (GA), County of, Georgia 1235. Macon (GA), County of, Georgia 1236. Macon -Bibb (GA), County of, Georgia 1237. Madison (GA), County of, Georgia 1238. McDuffie (GA), County of, Georgia 1239. McIntosh (GA), County of, Georgia 1240. Meriwether (GA), County of (Sheriff), Georgia 1241. Meriwether (GA), County of, Georgia 1242. Milledgeville (GA), City of, Georgia 1243. Monroe (GA), County of, Georgia 1244. Montgomery (GA), County of, Georgia 1245. Murray (GA), County of (Sheriff), Georgia 1246. Nashville (GA), City of, Georgia 1247. Newton (GA), County of, Georgia 1248. Oconee (GA), County of (Sheriff), Georgia 1249. Oconee (GA), County of, Georgia 1250. Oglethorpe (GA), County of, Georgia 1251. Peach (GA), County of (Sheriff), Georgia 1252. Peach (GA), County of, Georgia 1253. Pierce (GA), County of (Sheriff), Georgia 1254. Pierce (GA), County of, Georgia 1255. Pike (GA), County of, Georgia 1256. Polk (GA), County of, Georgia 1257. Pouter (GA), City of, Georgia 1258. Pulaski (GA), County of, Georgia 1259. Rabun (GA), County of, Georgia 1260. Randolph (GA), County of, Georgia 1261. Richmond Hill (GA), City of, Georgia 1262. Rockdale (GA), County of, Georgia 1263. Rome (GA), City of, Georgia 1264. Sandy Springs (GA), City of, Georgia 1265. Savannah (GA), City of, Georgia 1266. Schley (GA), County of, Georgia 1267. Screven (GA), County of (Sheriff), Georgia 1268. Screven (GA), County of, Georgia 1269. Seminole (GA), County of, Georgia 1270. Spalding (GA), County of, Georgia 1271. Springfield (GA), City of, Georgia 1272. Stephens (GA), County of, Georgia 1273. Sumter (GA), County of, Georgia 1274. Taliaferro (GA), County of, Georgia 1275. Tattnall (GA), County of, Georgia 1276. Telfair (GA), County of (Sheriff), Georgia DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1277. Tift (GA), County of (Sheriff), Georgia 1323. Alexander (IL), County of, Illinois 1278. Tifton (GA), City of, Georgia 1324. Algonquin (IL), Village of, Illinois 1279. Toombs (GA), County of, Georgia 1325. Algonquin - Lake in the Hills Fire 1280. Towns (GA), County of, Georgia Protection District (IL), Illinois 1281. Troup (GA), County of, Georgia 1326. Anna (IL), City of, Illinois 1282. Twiggs (GA), County of, Georgia 1327. Arlington Heights (IL), Village of, 1283. Union (GA), County of, Georgia Illinois 1284. Walton (GA), County of, Georgia 1328. Barrington (IL), Village of, Illinois 1285. Ware (GA), County of (Sheriff), Georgia 1329. Bartlett (IL), Village of, Illinois 1286. Warren (GA), County of, Georgia 1330. Bartlett Fire Protection District (IL), 1287. Warwick (GA), City of, Georgia Illinois 1288. Washington (GA), County of, Georgia 1331. Batavia (IL), City of, Illinois 1289. Wayne (GA), County of (Sheriff), 1332. Beach Park (IL), Village of, Illinois Georgia 1333. Bedford Park (IL), Village of, Illinois 1290. Wayne (GA), County of, Georgia 1334. Beecher (IL), Village of, Illinois 1291. Whitfield (GA), County of, Georgia 1335. Bellwood (IL), Village of, Illinois 1292. Wilcox (GA), County of, Georgia 1336. Bensenville (IL), Village of, Illinois 1293. Wilkes (GA), County of, Georgia 1337. Benton (IL), City of, Illinois 1294. Wilkinson (GA), County of, Georgia 1338. Berkeley (IL), Village of, Illinois 1295. Woodbury (GA), City of, Georgia 1339. Berwyn (IL), City of, Illinois 1296. Worth (GA), County of, Georgia 1340. Bloomingdale (IL), Village of, Illinois 1297. Hawai'i (HI), County of, Hawai'i 1341. Bloomington (IL), Village of, Illinois 1298. Kaua'i (HI), County of, Hawai'i 1342. Board of Education of East Aurora, 1299. Ada (ID), County of, Idaho School District 131 (IL), Illinois 1300. Adams (ID), County of, Idaho 1343. Board of Education of Joliet Township 1301. Bannock (ID), County of, Idaho High School, District 204 (IL), Illinois 1302. Bingham (ID), County of, Idaho 1344. Board of Education of Thornton 1303. Blaine (ID), County of, Idaho Fractional Township High Schools, District 215 1304. Boise (ID), City of, Idaho (IL), Illinois 1345. Board of Education of Thornton 1305. Boise (ID), County of, Idaho Township High Schools, District 205 (IL), 1306. Bonneville (ID), County of, Idaho Illinois 1307. Camas (ID), County of, Idaho 1346. Bolingbrook (IL), Village of, Illinois 1308. Canyon (ID), County of, Idaho 1347. Bond (IL), County of, Illinois 1309. Caribou (ID), County of, Idaho 1348. Boone (IL), County of, Illinois 1310. Cassia (ID), County of, Idaho 1349. Bridgeview (IL), Village of, Illinois 1311. Chubbuck (ID), City of, Idaho 1350. Broadview (IL), Village of, Illinois 1312. Elmore (ID), County of, Idaho 1351. Brookfield (IL), Village of, Illinois 1313. Gooding (ID), County of, Idaho 1352. Buffalo Grove (IL), Village of, Illinois 1314. Latah (ID), County of, Idaho 1353. Burbank (IL), City of, Illinois 1315. Minidoka (ID), County of, Idaho 1354. Bureau (IL), County of, Illinois 1316. Owyhee (ID), County of, Idaho 1355. Burr Ridge (IL), Village of, Illinois 1317. Payette (ID), County of, Idaho 1356. Calhoun (IL), County of, Illinois 1318. Pocatello (ID), City of, Idaho 1357. Campton Hills (IL), Village of, Illinois 1319. Preston (ID), City of, Idaho 1358. Carbondale (IL), City of, Illinois 1320. Twin Falls (ID), City of, Idaho 1359. Carol Stream (IL), Village of, Illinois 1321. Twin Falls (ID), County of, Idaho 1322. Addison (IL), Village of, Illinois DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1360. Carol Stream Fire Protection District (IL), Illinois 1361. Bloomingdale (IL), Village of, Illinois 1362. Cary (IL), Village of, Illinois 1363. Cary Area Public Library (IL), Illinois 1364. Champaign (IL), County of, Illinois 1365. Channabon (IL), Village of, Illinois 1366. Chicago (IL), City of, Illinois 1367. Chicago Board of Education District No. 299 (IL), Illinois 1368. Chicago Heights (IL), City of, Illinois 1369. Chicago Ridge (IL), Village of, Illinois 1370. Christian (IL), County of, Illinois 1371. Clarendon Hills (IL), Village of, Illinois 1372. Coal City (IL), Village of, Illinois 1373. Collinsville (IL), City of, Illinois 1374. Coles (IL), County of, Illinois 1375. Colona (IL), City of, Illinois 1376. Cook (IL), County of, Illinois 1377. Countryside (IL), City of, Illinois 1378. Crest Hill (IL), City of, Illinois 1379. Crete (IL), Village of, Illinois 1380. Crete Township (IL), Township of, Illinois 1381. Crystal Lake (IL), City of, Illinois 1382. Darien (IL), City of, Illinois 1383. Deerfield (IL), Village of, Illinois 1384. DeKalb (IL), City of, Illinois 1385. DeKalb (IL), County of, Illinois 1386. Des Plaines (IL), City of, Illinois 1387. Dolton (IL), Village of, Illinois 1388. DuPage (IL), County of, Illinois 1389. DuPage Public Safety Communications (DU-COMM) (IL), Illinois 1390. East Hazel Crest (IL), Village of, Illinois 1391. East Moline (IL), City of, Illinois 1392. Edwards (IL), County of, Illinois 1393. Effingham (IL), City of, Illinois 1394. Effingham (IL), County of, Illinois 1395. Elk Grove Village (IL), Village of, Illinois 1396. Evanston (IL), City of, Illinois 1397. Evergreen Park (IL), Village of, Illinois 1398. Flossmoor (IL), Village of, Illinois 1399. Forest Park (IL), Village of, Illinois 1400. Forest Preserve District of DuPage County (IL), Illinois 1401. Forest Preserve District of Kane County (IL), Illinois 1402. Forest Preserve District of Winnebago County (IL), Illinois 1403. Franklin (IL), County of, Illinois 1404. Franklin Park (IL), Village of, Illinois 1405. Freeport (IL), City of, Illinois 1406. Gallatin (IL), County of, Illinois 1407. Gilberts (IL), Village of, Illinois 1408. Glen Carbon (IL), Village of, Illinois 1409. Glen Ellyn (IL), Village of, Illinois 1410. Glencoe (IL), Village of, Illinois 1411. Glenview (IL), Village of, Illinois 1412. Glenview Park District (IL), Illinois 1413. Granite City (IL), City of, Illinois 1414. Hamilton (IL), County of, Illinois 1415. Hanover Park (IL), Village of, Illinois 1416. Hardin (IL), County of, Illinois 1417. Harrisburg (IL), City of, Illinois 1418. Harvey. (IL), City of, Illinois 1419. Harwood Heights (IL), Village of, Illinois 1420. Hazel Crest (IL), Village of, Illinois 1421. Henry (IL), County of, Illinois 1422. Herrin (IL), City of, Illinois 1423. Highland Park (IL), City of, Illinois 1424. Highwood (IL), City of, Illinois 1425. Hillside (IL), Village of, Illinois 1426. Hinsdale (IL), Village of, Illinois 1427. Hodgkins (IL), Village of, Illinois 1428. Hoffman Estates (IL), Village of, Illinois 1429. Homer Glen (IL), Village of, Illinois 1430. Homewood (IL), Village of, Illinois 1431. Homewood Public Library (IL), Illinois 1432. Huntley (IL), Village of, Illinois 1433. Indian Head Park (IL), Village of, Illinois 1434. Intergovernmental Personnel Benefit Cooperative (IL), Illinois 1435. Intergovernmental Risk Management Agency (IL), Illinois 1436. Itasca (IL), Village of, Illinois 1437. Jasper (IL), County of, Illinois 1438. Jefferson (IL), County of, Illinois 1439. Jersey (IL), County of, Illinois 1440. Johnson (IL), County of, Illinois 1441. Joint Action Water Agency (IL), Illinois DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1442. Justice (IL), Village of, Illinois 1443. Kane (IL), County of, Illinois 1444. Kankakee (IL), City of, Illinois 1445. Kankakee (IL), County of, Illinois 1446. Kendall (IL), County of, Illinois 1447. Kenilworth (IL), Village of, Illinois 1448. LaGrange (IL), Village of, Illinois 1449. La Grange Park (IL), Village of, Illinois 1450. Lake (IL), County of (Sheriff), Illinois 1451. Lake (IL), County of, Illinois 1452. Lake Bluff (IL), Village of, Illinois 1453. Lake Forest (IL), City of, Illinois 1454. Lake in the Hills (IL), Village of, Illinois 1455. Lake Zurich (IL), Village of, Illinois 1456. LaSalle (IL), County of, Illinois 1457. Lawrence (IL), County of, Illinois 1458. Lee (IL), County of, Illinois 1459. Lemont (IL), Village of, Illinois 1460. Libertyville (IL), Village of, Illinois 1461. Lincolnville (IL), Village of, Illinois 1462. Lisle (IL), Village of, Illinois 1463. Lisle Park District (IL), Illinois 1464. Lisle Woodridge Fire Protection District (IL), Illinois 1465. Livingston (IL), County of, Illinois 1466. Lockport (IL), City of, Illinois 1467. Lombard (IL), Village of, Illinois 1468. Lyons (IL), Township of, Illinois 1469. Lyons (IL), Village of, Illinois 1470. Lyons Township Area Community Center (IL), Illinois 1471. Macon (IL), County of, Illinois 1472. Macoupin (IL), County of, Illinois 1473. Marion (IL), City of, Illinois 1474. Marion (IL), County of, Illinois 1475. Massac (IL), County of, Illinois 1476. Maywood (IL), Village of, Illinois 1477. McCook (IL), Village of, Illinois 1478. McHenry (IL), City of, Illinois 1479. McHenry (IL), County of, Illinois 1480. McLean (IL), County of, Illinois 1481. Melrose Park (IL), Village of, Illinois 1482. Merrionette Park (IL), Village of, Illinois 1483. Metropolis (IL), City of, Illinois 1484. Metropolitan Pier and Exposition Authority (IL), Illinois 1485. Mokena (IL), Village of, Illinois 1486. Monee (IL), Village of, Illinois 1487. Monroe (IL), County of, Illinois 1488. Montgomery (IL), Village of, Illinois 1489. Morton Grove (IL), Village of, Illinois 1490. Mount Prospect (IL), Village of, Illinois 1491. Mundelein (IL), Village of, Illinois 1492. Municipal Consolidated Dispatch (IL), Illinois 1493. Naperville Park District (IL), Illinois 1494. New Baden (IL), Village of, Illinois 1495. North Aurora (IL), Village of, Illinois 1496. North East Multi -Regional Training Center (IL), Illinois 1497. North Riverside (IL), Village of, Illinois 1498. Northbrook (IL), Village of, Illinois 1499. Northbrook Public Library (IL), Illinois 1500. Northeastern Illinois Public Safety Training Academy (IL), Illinois 1501. Northwest Central Dispatch System (IL), Illinois 1502. Northfield (IL), Village of, Illinois 1503. Northlake (IL), City of, Illinois 1504. Oak Brook (IL), Village of, Illinois 1505. Oak Lawn (IL), Village of, Illinois 1506. Oak Park (IL), Township of, Illinois 1507. Oak Park (IL), Village of, Illinois 1508. Oak Park Public Library (IL), Illinois 1509. Olympia Fields (IL), Village of, Illinois 1510. Orland Fire Protection District (IL), Illinois 1511. Orland Park (IL), Village of, Illinois 1512. Oswego (IL), Village of, Illinois 1513. Oswegoland Park District (IL), Illinois 1514. Palatine (IL), Village of, Illinois 1515. Palatine Police Department (IL), Illinois 1516. Palos Heights (IL), City of, Illinois 1517. Palos Hills (IL), City of, Illinois 1518. Palos Park (IL), Village of, Illinois 1519. Park Forest (IL), Village of, Illinois 1520. Park Ridge (IL), City of, Illinois 1521. Pekin (IL), City of, Illinois 1522. Peoria (IL), City of, Illinois 1523. Peotone (IL), Village of, Illinois 1524. Piatt (IL), County of, Illinois 1525. Plainfield (IL), Village of, Illinois 1526. Posen (IL), Village of, Illinois 1527. Princeton (IL), City of, Illinois DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1528. Pulaski (IL), County of, Illinois 1529. Richton Park (IL), Village of, Illinois 1530. River Forest (IL), Village of, Illinois 1531. River Grove (IL), Village of, Illinois 1532. Riverside (IL), Village of, Illinois 1533. Rochelle (IL), City of, Illinois 1534. Rock Falls (IL), City of, Illinois 1535. Rockford (IL), City of, Illinois 1536. Rolling Meadows (IL), City of, Illinois 1537. Roscoe (IL), Village of, Illinois 1538. Roselle (IL), Village of, Illinois 1539. Saline (IL), County of, Illinois 1540. Sangamon (IL), County of, Illinois 1541. Schaumburg (IL), Village of, Illinois 1542. Schiller Park (IL), Village of, Illinois 1543. Schuyler (IL), County of, Illinois 1544. Sesser (IL), City of, Illinois 1545. Shelby (IL), County of, Illinois 1546. South Chicago Heights (IL), Village of, Illinois 1547. South Holland (IL), Village of, Illinois 1548. Southeast Emergency Communications (SEECOM) (IL), Illinois 1549. Spring Grove (IL), Village of, Illinois 1550. St. Clair (IL), County of, Illinois 1551. Steger (IL), Village of, Illinois 1552. Stickney (IL), Village of, Illinois 1553. Stone Park (IL), Village of, Illinois 1554. Streamwood (IL), Village of, Illinois 1555. Streator (IL), City of, Illinois 1556. Sugar Grove (IL), Village of, Illinois 1557. Summit (IL), Village of, Illinois 1558. Swansea (IL), Village of, Illinois 1559. Tinley Park (IL), Village of, Illinois 1560. Trenton (IL), City of, Illinois 1561. Union (IL), County of, Illinois 1562. Villa Park (IL), Village of, Illinois 1563. Wabash (IL), County of, Illinois 1564. Warrenville (IL), City of, Illinois 1565. Washington (IL), City of, Illinois 1566. Washington (IL), County of, Illinois 1567. Wauconda (IL), Village of, Illinois 1568. Waukegan Community Unit School District (IL), Illinois 1569. West Central Consolidated Communications (IL), Illinois 1570. West Chicago (IL), City of, Illinois 1571. West Chicago Fire Protection District (IL), Illinois 1572. West Dundee (IL), Village of, Illinois 1573. West Frankfort (IL), City of, Illinois 1574. West Franklin (IL), County of (Central Dispatch), Illinois 1575. West Suburban Consolidated Dispatch Center (IL), Illinois 1576. Westchester (IL), Village of, Illinois 1577. Western Springs (IL), Village of, Illinois 1578. Westmont (IL), Village of, Illinois 1579. Westmont Police Department (IL), Illinois 1580. Wheaton (IL), City of, Illinois 1581. Wheeling (IL), Village of, Illinois 1582. White (IL), County of, Illinois 1583. Will (IL), County of, Illinois 1584. Williamson (IL), County of, Illinois 1585. Willowbrook (IL), Village of, Illinois 1586. Wilmette (IL), Village of, Illinois 1587. Winfield (IL), Village of, Illinois 1588. Winfield Fire Protection District (IL), Illinois 1589. Winnebago (IL), County of, Illinois 1590. Winnetka (IL), Village of, Illinois 1591. Wood Dale (IL), City of, Illinois 1592. Wood River (IL), City of, Illinois 1593. Woodridge (IL), Village of, Illinois 1594. Woodridge Public Library (IL), Illinois 1595. Alexandria (IN), City of, Indiana 1596. Allen (IN), County of, Indiana 1597. Austin (IN), City of, Indiana 1598. Beech Grove (IN), City of, Indiana 1599. Benton (IN), County of, Indiana 1600. Blackford (IN), County of, Indiana 1601. Bloomington (IN), City of, Indiana 1602. Brownstown (IN), Town of, Indiana 1603. Chandler (IN), Town of, Indiana 1604. Connersville (IN), City of, Indiana 1605. Danville (IN), Town of, Indiana 1606. Delaware (IN), County of, Indiana 1607. Elwood (IN), City of, Indiana 1608. Evansville (IN), City of, Indiana 1609. Fayette (IN), County of, Indiana 1610. Fishers (IN), City of, Indiana 1611. Fort Wayne Community Schools (IN), Indiana DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1612. Franklin (IN), City of, Indiana 1613. Franklin (IN), County of, Indiana 1614. Gary (IN), City of, Indiana 1615. Greenwood (IN), City of, Indiana 1616. Hammond (IN), City of, Indiana 1617. Hartford City (IN), City of, Indiana 1618. Howard (IN), County of, Indiana 1619. Huntington (IN), City of, Indiana 1620. Indianapolis (IN), City of, Indiana 1621. Jackson (IN), County of, Indiana 1622. Jasper (IN), City of, Indiana 1623. Jay (IN), County of, Indiana 1624. Jeffersonville (IN), City of, Indiana 1625. Jennings (IN), County of, Indiana 1626. Kokomo (IN), City of, Indiana 1627. Lafayette (IN), City of, Indiana 1628. Lake (IN), County of, Indiana 1629. LaPorte (IN), County of, Indiana 1630. Lawrence (IN), City of, Indiana 1631. Lawrence (IN), County of, Indiana 1632. Logansport (IN), City of, Indiana 1633. Madison (IN), City of, Indiana 1634. Madison (IN), County of, Indiana 1635. Marion (IN), County of, Indiana 1636. Marshall (IN), County of, Indiana 1637. Martinsville (IN), City of, Indiana 1638. Mishawaka (IN), City of, Indiana 1639. Mishawaka (IN), City of, Indiana 1640. Monroe (IN), County of, Indiana 1641. Montpelier (IN), City of, Indiana 1642. Mooresville (IN), Town of, Indiana 1643. Morgan (IN), County of, Indiana 1644. New Albany (IN), City of, Indiana 1645. New Castle (IN), City of, Indiana 1646. Noblesville (IN), City of, Indiana 1647. Orange (IN), County of, Indiana 1648. Pendleton (IN), Town of, Indiana 1649. Penn -Harris -Madison School Corporation (IN), Indiana 1650. Peru (IN), City of, Indiana 1651. Plainfield (IN), Town of, Indiana 1652. Porter (IN), County of, Indiana 1653. Portland (IN), City of, Indiana 1654. Pulaski (IN), County of, Indiana 1655. Richmond (IN), City of, Indiana 1656. Ripley (IN), County of, Indiana 1657. School City of Mishawaka (IN), Indiana 1658. Scott (IN), County of, Indiana 1659. Seymour (IN), City of, Indiana 1660. Shelbyville (IN), City of, Indiana 1661. Sheridan (IN), Town of, Indiana 1662. Smith -Green Community Schools (IN), Indiana 1663. South Bend (IN), City of, Indiana 1664. South Bend Community School Corporation (IN), Indiana 1665. St. Joseph (IN), County of, Indiana 1666. Starke (IN), County of, Indiana 1667. Tippecanoe (IN), County of, Indiana 1668. Upland (IN), Town of, Indiana 1669. Vanderburgh (IN), County of, Indiana 1670. Vigo (IN), County of, Indiana 1671. West Lafayette (IN), City of, Indiana 1672. Westfield (IN), City of, Indiana 1673. Zionsville (IN), Town of, Indiana 1674. Adair (IA), County of, Iowa 1675. Adams (IA), County of, Iowa 1676. Allamakee (IA), County of, Iowa 1677. Appanoose (IA), County of, Iowa 1678. Audubon (IA), County of, Iowa 1679. Benton (IA), County of, Iowa 1680. Black Hawk (IA), County of, Iowa 1681. Bremer (IA), County of, Iowa 1682. Buchanan (IA), County of, Iowa 1683. Buena Vista (IA), County of, Iowa 1684. Calhoun (IA), County of, Iowa 1685. Carroll (IA), County of, Iowa 1686. Cedar (IA), County of, Iowa 1687. Cerro Gordo (IA), County of, Iowa 1688. Cherokee (IA), County of, Iowa 1689. Chickasaw (IA), County of, Iowa 1690. Clay (IA), County of, Iowa 1691. Clayton (IA), County of, Iowa 1692. Clinton (IA), County of, Iowa 1693. Dallas (IA), County of, Iowa 1694. Delaware (IA), County of, Iowa 1695. Des Moines (IA), County of, Iowa 1696. Emmet (IA), County of, Iowa 1697. Fayette (IA), County of, Iowa 1698. Fremont (IA), County of, Iowa 1699. Hamilton (IA), County of, Iowa 1700. Hancock (IA), County of, Iowa 1701. Hardin (IA), County of, Iowa 1702. Harrison (IA), County of, Iowa DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1703. Henry (IA), County of, Iowa 1704. Howard (IA), County of, Iowa 1705. Humboldt (IA), County of, Iowa 1706. Ida (IA), County of, Iowa 1707. Jasper (IA), County of, Iowa 1708. Johnson (IA), County of, Iowa 1709. Jones (IA), County of, Iowa 1710. Keokuk (IA), County of, Iowa 1711. Lee (IA), County of, Iowa 1712. Lyon (IA), County of, Iowa 1713. Madison (IA), County of, Iowa 1714. Mahaska (IA), County of, Iowa 1715. Marion (IA), County of, Iowa 1716. Mills (IA), County of, Iowa 1717. Mitchell (IA), County of, Iowa 1718. Monroe (IA), County of, Iowa 1719. Montgomery (IA), County of, Iowa 1720. Muscatine (IA), County of, Iowa 1721. O'Brien (IA), County of, Iowa 1722. Osceola (IA), County of, Iowa 1723. Plymouth (IA), County of, Iowa 1724. Pocahontas (IA), County of, Iowa 1725. Polk (IA), County of, Iowa 1726. Pottawattamie (IA), County of, Iowa 1727. Poweshiek (IA), County of, Iowa 1728. Sac (IA), County of, Iowa 1729. Scott (IA), County of, Iowa 1730. Shelby (IA), County of, Iowa 1731. Sioux (IA), County of, Iowa 1732. Tama (IA), County of, Iowa 1733. Taylor (IA), County of, Iowa 1734. Union (IA), County of, Iowa 1735. Webster (IA), County of, Iowa 1736. Winnebago (IA), County of, Iowa 1737. Winneshiek (IA), County of, Iowa 1738. Worth (IA), County of, Iowa 1739. Wright (IA), County of, Iowa 1740. Allen (KS), County of, Kansas 1741. Barber (KS), County of, Kansas 1742. Bourbon (KS), County of, Kansas 1743. Cherokee (KS), County of, Kansas 1744. Cowley (KS), County of, Kansas 1745. Crawford (KS), County of, Kansas 1746. Dickinson (KS), County of, Kansas 1747. Elk (KS), County of, Kansas 1748. Elkhardt (KS), City of, Kansas 1749. Finney (KS), County of, Kansas 1750. Ford (KS), County of, Kansas 1751. Grant (KS), County of, Kansas 1752. Greenwood (KS), County of, Kansas 1753. Harvey (KS), County of, Kansas 1754. Johnson (KS), County of, Kansas 1755. Leavenworth (KS), County of, Kansas 1756. Manter (KS), City of, Kansas 1757. Meade (KS), County of, Kansas 1758. Montgomery (KS), County of, Kansas 1759. Morton (KS), County of, Kansas 1760. Neosho (KS), County of, Kansas 1761. Overland Park (KS), City of, Kansas 1762. Pratt (KS), County of, Kansas 1763. Reno (KS), County of, Kansas 1764. Sedgwick (KS), County of, Kansas 1765. Seward (KS), County of, Kansas 1766. Shawnee (KS), County of, Kansas 1767. Stanton (KS), County of, Kansas 1768. Ulysses (KS), City of, Kansas 1769. Wabaunsee (KS), County of, Kansas 1770. Wichita (KS), City of, Kansas 1771. Wyandotte County/Kansas City (KS), Unified Government of, Kansas 1772. Adair (KY), County of (Fiscal Court), Kentucky 1773. Allen (KY), County of, Kentucky 1774. Anderson (KY), County of (Fiscal Court), Kentucky 1775. Ballard (KY), County of, Kentucky 1776. Bath (KY), County of (Fiscal Court), Kentucky 1777. Bell (KY), County of (Fiscal Court), Kentucky 1778. Bellefonte (KY), City of, Kentucky 1779. Benham (KY), City of, Kentucky 1780. Board of Education of Breathitt County Public Schools (KY), Kentucky 1781. Board of Education of Bullitt County Public Schools (KY), Kentucky 1782. Board of Education of Estill County Public Schools (KY), Kentucky 1783. Board of Education of Fayette County Public Schools (KY), Kentucky 1784. Board of Education of Harrison County Public Schools (KY), Kentucky DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1785. Board of Education of Hart County Public Schools (KY), Kentucky 1786. Board of Education of Jefferson County Public Schools (KY), Kentucky 1787. Board of Education of Johnson County Public School District (KY), Kentucky 1788. Board of Education of LaRue County Public Schools (KY), Kentucky 1789. Board of Education of Lawrence County Public Schools (KY), Kentucky 1790. Board of Education of Martin County Public Schools (KY), Kentucky 1791. Board of Education of Menifee County Public Schools (KY), Kentucky 1792. Board of Education of Owsley County Public Schools (KY), Kentucky 1793. Board of Education of Wolfe County Public Schools (KY), Kentucky 1794. Boone (KY), County of (Fiscal Court), Kentucky 1795. Bourbon (KY), County of (Fiscal Court), Kentucky 1796. Boyd (KY), County of (Fiscal Court), Kentucky 1797. Boyle (KY), County of (Fiscal Court), Kentucky 1798. Bracken (KY), County of (Fiscal Court), Kentucky 1799. Breathitt (KY), County of (Fiscal Court), Kentucky 1800. Breckinridge (KY), County of, Kentucky 1801. Buckhorn (KY), City of, Kentucky 1802. Bullitt (KY), County of (Fiscal Court), Kentucky 1803. Caldwell (KY), County of (Fiscal Court), Kentucky 1804. Calloway (KY), County of (Fiscal Court), Kentucky 1805. Campbell (KY), County of (Fiscal Court), Kentucky 1806. Campbellsville (KY), City of, Kentucky 1807. Carlisle (KY), County of (Fiscal Court), Kentucky 1808. Carter (KY), County of (Fiscal Court), Kentucky 1809. Casey (KY), County of (Fiscal Court), Kentucky 1810. Christian (KY), County of (Fiscal Court), Kentucky 1811. Clark (KY), County of (Fiscal Court), Kentucky 1812. Clay (KY), County of (Fiscal Court), Kentucky 1813. Clinton (KY), County of (Fiscal Court), Kentucky 1814. Columbia (KY), City of, Kentucky 1815. Covington (KY), City of, Kentucky 1816. Cumberland (KY), County of (Fiscal Court), Kentucky 1817. Daviess (KY), County of (Fiscal Court), Kentucky 1818. Edmonson (KY), County of (Fiscal Court), Kentucky 1819. Elliott (KY), County of (Fiscal Court), Kentucky 1820. Estill (KY), County of (Fiscal Court), Kentucky 1821. Estill County Emergency Medical Services (KY), Kentucky 1822. Fleming (KY), County of (Fiscal Court), Kentucky 1823. Florence (KY), City of, Kentucky 1824. Floyd (KY), County of, Kentucky 1825. Franklin (KY), County of (Fiscal Court), Kentucky 1826. Fulton (KY), County of (Fiscal Court), Kentucky 1827. Gallatin (KY), County of (Fiscal Court), Kentucky 1828. Garrard (KY), County of (Fiscal Court), Kentucky 1829. Grant (KY), County of (Fiscal Court), Kentucky 1830. Grayson (KY), City of, Kentucky 1831. Green (KY), County of (Fiscal Court), Kentucky 1832. Greenup (KY), County of (Fiscal Court), Kentucky 1833. Greenup (KY), City of, Kentucky 1834. Hancock (KY), County of (Fiscal Court), Kentucky 1835. Hardin (KY), County of (Fiscal Court), Kentucky 1836. Harlan (KY), County of (Fiscal Court), Kentucky DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1837. Harlan (KY), City of, Kentucky 1838. Harrison (KY), County of (Fiscal Court), Kentucky 1839. Hart (KY), County of (Fiscal Court), Kentucky 1840. Henderson (KY), County of (Fiscal Court), Kentucky 1841. Henderson (KY), City of, Kentucky 1842. Henry (KY), County of (Fiscal Court), Kentucky 1843. Hickman (KY), County of (Fiscal Court), Kentucky 1844. Hillview (KY), City of, Kentucky 1845. Hopkins (KY), County of (Fiscal Court), Kentucky 1846. Hyden (KY), City of, Kentucky 1847. Inez (KY), City of, Kentucky 1848. Jamestown (KY), City of, Kentucky 1849. Jenkins (KY), City of, Kentucky 1850. Jessamine (KY), County of (Fiscal Court), Kentucky 1851. Kenton (KY), County of (Fiscal Court), Kentucky 1852. Kentucky River District Health Department (KY), Kentucky 1853. Knott (KY), County of, Kentucky 1854. Knox (KY), County of (Fiscal Court), Kentucky 1855. Larne (KY), County of (Fiscal Court), Kentucky 1856. Laurel (KY), County of (Fiscal Court), Kentucky 1857. Lawrence (KY), County of, Kentucky 1858. Lee (KY), County of (Fiscal Court), Kentucky 1859. Leslie (KY), County of (Fiscal Court), Kentucky 1860. Letcher (KY), County of (Fiscal Court), Kentucky 1861. Lewis (KY), County of (Fiscal Court), Kentucky 1862. Lexington -Fayette Urban (KY), County of, Kentucky 1863. Lincoln (KY), County of (Fiscal Court), Kentucky 1864. Logan (KY), County of (Fiscal Court), Kentucky 1865. London (KY), City of, Kentucky 1866. Louisville -Jefferson (KY), County of, Kentucky 1867. Loyall (KY), City of, Kentucky 1868. Lynch (KY), City of, Kentucky 1869. Madison (KY), County of (Fiscal Court), Kentucky 1870. Manchester (KY), City of, Kentucky 1871. Marshall (KY), County of (Fiscal Court), Kentucky 1872. Martin (KY), County of (Fiscal Court), Kentucky 1873. Mason (KY), County of (Fiscal Court), Kentucky 1874. McCracken (KY), County of, Kentucky 1875. McLean (KY), County of (Fiscal Court), Kentucky 1876. Meade (KY), County of (Fiscal Court), Kentucky 1877. Mercer (KY), County of (Fiscal Court), Kentucky 1878. Monroe (KY), County of (Fiscal Court), Kentucky 1879. Montgomery (KY), County of (Fiscal Court), Kentucky 1880. Morehead (KY), City of, Kentucky 1881. Morgan (KY), County of (Fiscal Court), Kentucky 1882. Morganfield (KY), City of, Kentucky 1883. Mt. Washington (KY), City of, Kentucky 1884. Muhlenberg (KY), County of (Fiscal Court), Kentucky 1885. Murray (KY), City of, Kentucky 1886. Nicholas (KY), County of (Fiscal Court), Kentucky 1887. Ohio (KY), County of (Fiscal Court), Kentucky 1888. Oldham (KY), County of (Fiscal Court), Kentucky 1889. Owen (KY), County of (Fiscal Court), Kentucky 1890. Owensboro (KY), City of, Kentucky 1891. Owsley (KY), County of (Fiscal Court), Kentucky 1892. Paducah (KY), City of, Kentucky 1893. Paintsville (KY), City of, Kentucky 1894. Pendleton (KY), County of (Fiscal Court), Kentucky DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1895. Perry (KY), County of (Fiscal Court), Kentucky 1896. Pike (KY), County of, Kentucky 1897. Pineville (KY), City of, Kentucky 1898. Pippa Passes (KY), City of, Kentucky 1899. Powell (KY), County of (Fiscal Court), Kentucky 1900. Prestonsburg (KY), City of, Kentucky 1901. Pulaski (KY), County of (Fiscal Court), Kentucky 1902. Rowan (KY), County of (Fiscal Court), Kentucky 1903. Russell (KY), County of (Fiscal Court), Kentucky 1904. Russell (KY), City of, Kentucky 1905. Russell Springs (KY), City of, Kentucky 1906. Scott (KY), County of (Fiscal Court), Kentucky 1907. Shelby (KY), County of (Fiscal Court), Kentucky 1908. Shepherdsville (KY), City of, Kentucky 1909. South Shore (KY), City of, Kentucky 1910. Spencer (KY), County of (Fiscal Court), Kentucky 1911. Taylor (KY), County of (Fiscal Court), Kentucky 1912. Taylor County Hospital District Health Facilities Corporation (KY), Kentucky 1913. Todd (KY), County of (Fiscal Court), Kentucky 1914. Union (KY), County of (Fiscal Court), Kentucky 1915. Vanceburg (KY), City of, Kentucky 1916. Warfield (KY), City of, Kentucky 1917. Warren (KY), County of, Kentucky 1918. Wayne (KY), County of (Fiscal Court), Kentucky 1919. Webster (KY), County of (Fiscal Court), Kentucky 1920. West Liberty (KY), City of, Kentucky 1921. Whitesburg (KY), City of, Kentucky 1922. Whitley (KY), County of (Fiscal Court), Kentucky 1923. Winchester (KY), City of, Kentucky 1924. Wolfe (KY), County of (Fiscal Court), Kentucky 1925. Woodford (KY), County of (Fiscal Court), Kentucky 1926. Worthington (KY), City of, Kentucky 1927. Abita Springs (LA), Town of, Louisiana 1928. Acadia -St. Landry Hospital Service District (LA), Louisiana 1929. Alexandria (LA), City of, Louisiana 1930. Allen (LA), Parish of (Sheriff), Louisiana 1931. Ascension (LA), Parish of (Sheriff), Louisiana 1932. Ascension (LA), Parish of, Louisiana 1933. Ascension Parish School Board (LA), Louisiana 1934. Assumption (LA), Parish of (Sheriff), Louisiana 1935. Assumption (LA), Parish of, Louisiana 1936. Avoyelles (LA), Parish of (Sheriff), Louisiana 1937. Avoyelles (LA), Parish of, Louisiana 1938. Baldwin (LA), Town of, Louisiana 1939. Bastrop (LA), City of, Louisiana 1940. Baton Rouge (LA), City of, Louisiana 1941. Beauregard (LA), Parish of, Louisiana 1942. Benton Fire Protection District No. 4 (LA), Louisiana 1943. Berwick (LA), Town of, Louisiana 1944. Bienville (LA), Parish of (Sheriff), Louisiana 1945. Bogalusa (LA), City of, Louisiana 1946. Bossier (LA), Parish of, Louisiana 1947. Bossier City (LA), City of, Louisiana 1948. Bossier Parish Emergency Medical Services Ambulance District (LA), Louisiana 1949. Caddo (LA), Parish of, Louisiana 1950. Caddo Fire Protection District No. 1 (LA), Louisiana 1951. Calcasieu (LA), Parish of (Sheriff), Louisiana 1952. Calcasieu (LA), Parish of, Louisiana 1953. Caldwell (LA), Parish of, Louisiana 1954. Cameron (LA), Parish of, Louisiana 1955. Catahoula (LA), Parish of (Sheriff), Louisiana 1956. Catahoula (LA), Parish of, Louisiana 1957. Claiborne (LA), Parish of, Louisiana 1958. Concordia (LA), Parish of (Sheriff), Louisiana 1959. Concordia (LA), Parish of, Louisiana 1960. Covington (LA), City of, Louisiana DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 1961. Delhi (LA), Town of, Louisiana 1962. Desoto (LA), Parish of, Louisiana 1963. Desoto Fire Protection District No. 8 (LA), Louisiana 1964. Donaldsonville (LA), City of, Louisiana 1965. East Baton Rouge (LA), Parish of (Sheriff), Louisiana 1966. East Baton Rouge (LA), Parish of, Louisiana 1967. East Carroll (LA), Parish of (Sheriff), Louisiana 1968. East Carroll (LA), Parish of, Louisiana 1969. Eunice (LA), City of, Louisiana 1970. Evangeline (LA), Parish of (Sheriff), Louisiana 1971. Evangeline (LA), Parish of, Louisiana 1972. Ferriday (LA), Town of, Louisiana 1973. Franklin (LA), Parish of, Louisiana 1974. Franklin (LA), City of, Louisiana 1975. Gramercy (LA), Town of, Louisiana 1976. Grant (LA), Parish of (Sheriff), Louisiana 1977. Grant (LA), Parish of, Louisiana 1978. Gretna (LA), City of, Louisiana 1979. Hospital Service District No. 1 of the Parish of Avoyelles (LA), Louisiana 1980. Hospital Service District No. I of the Parish of LaSalle (LA), Louisiana 1981. Iberia (LA), Parish of (Sheriff), Louisiana 1982. Iberia (LA), Parish of, Louisiana 1983. Iberia Parish School Board (LA), Louisiana 1984. Iberville (LA), Parish of, Louisiana 1985. Jackson (LA), Parish of (Sheriff), Louisiana 1986. Jackson (LA), Parish of, Louisiana 1987. Jean Lafiitte (LA), Town of, Louisiana 1988. Jefferson (LA), Parish of (Sheriff), Louisiana 1989. Jefferson (LA), Parish of, Louisiana 1990. Jefferson Davis (LA), Parish of (Sheriff), Louisiana 1991. Jefferson Davis (LA), Parish of, Louisiana 1992. Jefferson Parish Coroner's Office (LA), Louisiana 1993. Jefferson Parish Hospital Service District No. 1 (LA), Louisiana 1994. Jefferson Parish Hospital Service District No. 2 (LA), Louisiana 1995. Kenner (LA), City of, Louisiana 1996. Lafayette (LA), Parish of (Sheriff), Louisiana 1997. Lafourche (LA), Parish of, Louisiana 1998. Lafourche Parish School Board (LA), Louisiana 1999. Lake Charles (LA), City of, Louisiana 2000. Lake Providence (LA), Town of, Louisiana 2001. LaSalle (LA), Parish of, Louisiana 2002. Lincoln (LA), Parish of (Sheriff), Louisiana 2003. Livingston (LA), Parish of (Sheriff), Louisiana 2004. Livingston (LA), Parish of, Louisiana 2005. Lutcher (LA), Town of, Louisiana 2006. Madisonville (LA), Town of, Louisiana 2007. Mandeville (LA), City of, Louisiana 2008. Monroe (LA), City of, Louisiana 2009. Morehouse (LA), Parish of (Sheriff), Louisiana 2010. Morehouse (LA), Parish of, Louisiana 2011. Morgan City (LA), City of, Louisiana 2012. Natchitoches (LA), City of, Louisiana 2013. Natchitoches (LA), Parish of (Parish Council), Louisiana 2014. New Iberia (LA), City of, Louisiana 2015. New Orleans (LA), City of, Louisiana 2016. New Roads (LA), City of, Louisiana 2017. North Caddo Hospital Service District (LA), Louisiana 2018.Opelousas (LA), City of, Louisiana 2019. Opelousas General Hospital Authority (LA), Louisiana 2020. Orleans (LA), Parish of (DA), Louisiana 2021. Orleans (LA), Parish of (Sheriff), Louisiana 2022. Orleans Parish Hospital Service Dist. - District A (LA), Louisiana 2023. Ouachita (LA), Parish of (Sheriff), Louisiana 2024. Ouachita (LA), Parish of, Louisiana 2025. Patterson (LA), City of, Louisiana 2026. Pearl River (LA), Town of, Louisiana DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2027. Pineville (LA), City of, Louisiana 2028. Pointe Coupee (LA), Parish of, Louisiana 2029. Pointe Coupee Parish Health Services District Number 1 (LA), Louisiana 2030. Rapides (LA), Parish of (Sheriff), Louisiana 2031. Rapides (LA), Parish of (DA), Louisiana 2032. Rapides (LA), Parish of, Louisiana 2033. Red River (LA), Parish of, Louisiana 2034. Red River Fire Protection District (LA), Louisiana 2035. Richland (LA), Parish of (Sheriff), Louisiana 2036. Richland (LA), Parish of, Louisiana 2037. Richwood (LA), Town of, Louisiana 2038. Sabine (LA), Parish of (Sheriff), Louisiana 2039. Sabine (LA), Parish of, Louisiana 2040. Saint Martinville (LA), City of, Louisiana 2041. Shreveport (LA), City of, Louisiana 2042. Slidell (LA), City of, Louisiana 2043. St. Bernard (LA), Parish of (Sheriff), Louisiana 2044. St. Bernard (LA), Parish of, Louisiana 2045. St. Bernard Parish Coroner's Office (LA), Louisiana 2046. St. Bernard Parish School Board (LA), Louisiana 2047. St. Charles (LA), Parish of (Sheriff), Louisiana 2048. St. Charles (LA), Parish of, Louisiana 2049. St. James (LA), Parish of, Louisiana 2050. St. James Parish School Board (LA), Louisiana 2051. St. John the Baptist (LA), Parish of, Louisiana 2052. St. Landry (LA), Parish of (Sheriff), Louisiana 2053. St. Landry (LA), Parish of, Louisiana 2054. St. Martin (LA), Parish of, Louisiana 2055. St. Mary (LA), Parish of (Sheriff), Louisiana 2056. St. Mary (LA), Parish of, Louisiana 2057. St. Mary Parish School Board (LA), Louisiana 2058. St. Tammany (LA), Parish of (Sheriff), Louisiana 2059. St. Tammany (LA), Parish of, Louisiana 2060. St. Tammany (LA), Parish of (DA), Louisiana 2061. St. Tammany Fire Protection District No. I (LA), Louisiana 2062. St. Tammany Fire Protection District No. 12 (LA), Louisiana 2063. St. Tammany Fire Protection District No. 13 (LA), Louisiana 2064. St. Tammany Fire Protection District No. 2 (LA), Louisiana 2065. St. Tammany Fire Protection District No. 3 (LA), Louisiana 2066. St. Tammany Fire Protection District No. 4 (LA), Louisiana 2067. St. Tammany Fire Protection District No. 5 (LA), Louisiana 2068. St. Tammany Parish Coroner's Office (LA), Louisiana 2069. Tensas (LA), Parish of (Sheriff), Louisiana 2070. Terrebonne (LA), Parish of (Sheriff), Louisiana 2071. Terrebonne (LA), Parish of, Louisiana 2072. Union (LA), Parish of (Sheriff), Louisiana 2073. Union (LA), Parish of, Louisiana 2074. Vermilion (LA), Parish of, Louisiana 2075. Vernon (LA), Parish of (Sheriff), Louisiana 2076. Vernon (LA), Parish of, Louisiana 2077. Washington (LA), Parish of (Sheriff), Louisiana 2078. Washington (LA), Parish of, Louisiana 2079. Washington (LA), Parish of (DA), Louisiana 2080. Webster (LA), Parish of, Louisiana 2081. West Ascension Parish Hospital Service District (LA), Louisiana 2082. West Baton Rouge (LA), Parish of, Louisiana 2083. West Baton Rouge Fire Protection District No. I (LA), Louisiana 2084. West Carroll (LA), Parish of (Sheriff), Louisiana 2085. West Carroll (LA), Parish of, Louisiana 2086. West Monroe (LA), City of, Louisiana 2087. Westwego (LA), City of, Louisiana DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2088. Winn -(LA), Parish of (DA), Louisiana 2089. Winn (LA), Parish of, Louisiana 2090. Androscoggin (ME), County of, Maine 2091. Aroostook (ME), County of, Maine 2092. Auburn (ME), City of, Maine 2093. Augusta (ME), City of, Maine 2094. Bangor (ME), City of, Maine 2095. Biddeford (ME), City of, Maine 2096. Board of Education of Bangor School Department (ME), Maine 2097. Board of Education of Cape Elizabeth School Department (ME), Maine 2098. Board of Education of Ellsworth School Department (ME), Maine 2099. Board of Education of Maine Regional School Unit ("RSU") 9 (ME), Maine 2100. Board of Education of Maine RSU 10 (ME), Maine 2101. Board of Education of Maine RSU 13 (ME), Maine 2102. Board of Education of Maine RSU 25 (ME), Maine 2103. Board of Education of Maine RSU 26 (ME), Maine 2104. Board of Education of Maine RSU 29 (ME), Maine 2105. Board of Education of Maine RSU 34 (ME), Maine 2106. Board of Education of Maine RSU 40 (ME), Maine 2107. Board of Education of Maine RSU 50 (ME), Maine 2108. Board of Education of Maine RSU 57 (ME), Maine 2109. Board of Education of Maine RSU 60 (ME), Maine 2110. Board of Education of Maine RSU 71 (ME), Maine 2111. Board of Education of Maine School Administrative District ("SAD") 6 (ME), Maine 2112. Board of Education of Maine SAD 11 (ME), Maine 2113. Board of Education of Maine SAD 15 (ME), Maine 2114. Board of Education of Maine SAD 28/Five Town Central School District (ME), Maine 2115. Board of Education of Maine SAD 35 (ME), Maine 2116. Board of Education of Maine SAD 44 (ME), Maine 2117. Board of Education of Maine SAD 53 (ME), Maine 2118. Board of Education of Maine SAD 55 (ME), Maine 2119. Board of Education of Maine SAD 61 (ME), Maine 2120. Board of Education of Maine SAD 72 (ME), Maine 2121. Board of Education of Portland School Department (ME), Maine 2122. Board of Education of Scarborough School Department (ME), Maine 2123. Board of Education of South Portland School Department (ME), Maine 2124. Board of Education of St George Municipal School District (ME), Maine 2125. Board of Education of Waterville School Department (ME), Maine 2126. Calais (ME), City of, Maine 2127. Cumberland (ME), County of, Maine 2128. Kennebec (ME), County of, Maine 2129. Knox (ME), County of, Maine 2130. Lewiston (ME), City of, Maine 2131. Lincoln (ME), County of, Maine 2132. Penobscot (ME), County of, Maine 2133. Portland (ME), City of, Maine 2134. Rockland (ME), City of, Maine 2135. Saco (ME), City of, Maine 2136. Sagadahoc (ME), County of, Maine 2137. Sanford (ME), City of, Maine 2138. Somerset (ME), County of, Maine 2139. Waldo (ME), County of, Maine 2140. Washington (ME), County of, Maine 2141. Waterville (ME), City of, Maine 2142. York (ME), County of, Maine 2143. Aberdeen (MD), City of, Maryland 2144. Allegany (MD), County of, Maryland 2145. Annapolis (MD), City of, Maryland 2146. Anne Arundel (MD), County of, Maryland 2147. Baltimore (MD), City of, Maryland 2148. Baltimore (MD), County of, Maryland 2149. Baltimore City Board of School Commissioners (MD), Maryland DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2150. Bel Air (MD), City of, Maryland 2151. Berlin (MD), City of, Maryland 2152. Bowie (MD), City of, Maryland 2153. Calvert (MD), County of, Maryland 2154. Cambridge (MD), City of, Maryland 2155. Caroline (MD), County of, Maryland 2156. Carroll (MD), County of, Maryland 2157. Cecil (MD), County of, Maryland 2158. Charles (MD), County of, Maryland 2159. Charlestown (MD), City of, Maryland 2160. Cottage City (MD), Town of, Maryland 2161. Cumberland (MD), City of, Maryland 2162. Dorchester (MD), County of, Maryland 2163. Forest Heights (MD), Town of, Maryland 2164. Frederick (MD), City of, Maryland 2165. Frederick (MD), County of, Maryland 2166. Frostburg (MD), City of, Maryland 2167. Garrett (MD), County of, Maryland 2168. Grantsville (MD), City of, Maryland 2169. Hagerstown (MD), City of, Maryland 2170. Harford (MD), County of, Maryland 2171. Havre De Grace (MD), City of, Maryland 2172. Howard (MD), County of, Maryland 2173. Laurel (MD), City of, Maryland 2174. Montgomery (MD), County of, Maryland 2175. Mountain Lake Park (MD), City of, Maryland 2176. North Brentwood (MD), Town of, Maryland 2177. North East (MD), City of, Maryland 2178. Oakland (MD), City of, Maryland 2179. Perryville (MD), City of, Maryland 2180. Prince George's (MD), County of, Maryland 2181. Rockville (MD), City of (Mayor and Common Council), Maryland 2182. Seat Pleasant (MD), City of, Maryland 2183. Somerset (MD), County of, Maryland 2184. St. Mary's (MD), County of, Maryland 2185. Talbot (MD), County of, Maryland 2186. Upper Marlboro (MD), Town of, Maryland 2187. Vienna (MD), City of, Maryland 2188. Washington (MD), County of, Maryland 2189. Westminster (MD), City of (Mayor and Common Council), Maryland 2190. Wicomico (MD), County of, Maryland 2191. Acushnet (MA), Town of, Massachusetts 2192. Agawam (MA), Town of, Massachusetts 2193. Amesbury (MA), City of, Massachusetts 2194. Andover (MA), Town of, Massachusetts 2195. Aquinnah (MA), Town of, Massachusetts 2196. Athol (MA), Town of, Massachusetts 2197. Auburn (MA), Town of, Massachusetts 2198. Ayer (MA), Town of, Massachusetts 2199. Barnstable (MA), Town of, Massachusetts 2200. Belchertown (MA), Town of, Massachusetts 2201. Beverly (MA), City of, Massachusetts 2202. Billerica (MA), Town of, Massachusetts 2203. Boston (MA), City of, Massachusetts 2204. Boston Housing Authority (MA), Massachusetts 2205. Boston Public Health Commission (MA), Massachusetts 2206. Braintree (MA), Town of, Massachusetts 2207. Brewster (MA), Town of, Massachusetts 2208. Bridgewater (MA), Town of, Massachusetts 2209. Brockton (MA), City of, Massachusetts 2210. Brockton Area Transit (MA), Massachusetts 2211. Brookline (MA), Town of, Massachusetts 2212. Cambridge (MA), City of, Massachusetts 2213. Canton (MA), Town of, Massachusetts 2214. Carver (MA), Town of, Massachusetts 2215. Carver Marion Wareham Regional Refuse Disposal District (MA), Massachusetts 2216. Charlton (MA), Town of, Massachusetts 2217. Chelmsford (MA), Town of, Massachusetts 2218. Chelsea (MA), City of, Massachusetts 2219. Chicopee (MA), City of, Massachusetts 2220. Clarksburg (MA), Town of, Massachusetts 2221. Clinton (MA), Town of, Massachusetts 2222. Danvers (MA), Town of, Massachusetts 2223. Dartmouth Fire District No. 3 (MA), Massachusetts DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2224. Dedham (MA), Town of, Massachusetts 2225. Dennis (MA), Town of, Massachusetts 2226. Douglas (MA), Town of, Massachusetts 2227. Dudley (MA), Town of, Massachusetts 2228. East Bridgewater (MA), Town of, Massachusetts 2229. Eastham (MA), Town of, Massachusetts 2230. Easthampton (MA), City of, Massachusetts 2231. Easton (MA), Town of, Massachusetts 2232. Everett (MA), City of, Massachusetts 2233. Fairhaven (MA), Town of, Massachusetts 2234. Fall River (MA), City of, Massachusetts 2235. Falmouth (MA), Town of, Massachusetts 2236. Fitchburg (MA), City of, Massachusetts 2237. Framingham (MA), City of, Massachusetts 2238. Freetown (MA), Town of, Massachusetts 2239. Georgetown (MA), Town of, Massachusetts 2240. Gloucester (MA), City of, Massachusetts 2241. Grafton (MA), Town of, Massachusetts2242. Greater Attleboro Taunton Regional Authority (MA), Massachusetts 2243. Greater New Bedford Regional Refuse Management District (MA), Massachusetts 2244. Greenfield (MA), City of, Massachusetts 2245. Halifax (MA), Town of, Massachusetts 2246. Hanson (MA), Town of, Massachusetts 2247. Haverhill (MA), City of, Massachusetts 2248. Holliston (MA), Town of, Massachusetts 2249. Holyoke (MA), City of, Massachusetts 2250. Hopedale (MA), Town of, Massachusetts 2251. Hull (MA), Town of, Massachusetts 2252. Kingston (MA), Town of, Massachusetts 2253. Lakeville (MA), Town of, Massachusetts 2254. Leicester (MA), Town of, Massachusetts 2255. Leominster (MA), City of, Massachusetts 2256. Leverett (MA), Town of, Massachusetts 2257. Longmeadow (MA), Town of, Massachusetts 2258. Lowell (MA), City of, Massachusetts 2259. Ludlow (MA), Town of, Massachusetts 2260. Lunenberg (MA), Town of, Massachusetts 2261. Lynn (MA), City of, Massachusetts 2262. Lynnfield (MA), Town of, Massachusetts 2263. Malden (MA), City of, Massachusetts 2264. Marblehead (MA), Town of, Massachusetts 2265. Marshfield (MA), Town of, Massachusetts 2266. Mashpee (MA), Town of, Massachusetts 2267. Mattapoisett (MA), Town of, Massachusetts 2268. Medford (MA), City of, Massachusetts 2269. Melrose (MA), City of, Massachusetts 2270. Methuen (MA), City of, Massachusetts 2271. Middleborough (MA), Town of, Massachusetts 2272. Milford (MA), Town of, Massachusetts 2273. Millbury (MA), Town of, Massachusetts 2274. Millis (MA), Town of, Massachusetts 2275. Nantucket (MA), Town of, Massachusetts 2276. Natick (MA), Town of, Massachusetts 2277. New Bedford (MA), City of, Massachusetts 2278. Newburyport (MA), City of, Massachusetts 2279. Norfolk (MA), County of, Massachusetts 2280. North Adams (MA), City of, Massachusetts 2281. North Andover (MA), Town of, Massachusetts 2282. North Attleborough (MA), Town of, Massachusetts 2283. North Reading (MA), Town of, Massachusetts 2284. North River Collaborative School (MA), Massachusetts 2285. Northampton (MA), City of, Massachusetts 2286. Northbridge (MA), Town of, Massachusetts 2287. Norton (MA), Town of, Massachusetts 2288. Norwell (MA), Town of, Massachusetts 2289. Norwood (MA), Town of, Massachusetts 2290. Onset Fire District (MA), Massachusetts 2291. Orange (MA), Town of, Massachusetts 2292. Oxford (MA), Town of, Massachusetts 2293. Palmer (MA), Town of, Massachusetts DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2294. Peabody (MA), City of, Massachusetts 2295. Pembroke (MA), Town of, Massachusetts 2296. Pittsfield (MA), City of, Massachusetts 2297. Plainville (MA), Town of, Massachusetts 2298. Plymouth (MA), County of, Massachusetts 2299. Plymouth (MA), Town of, Massachusetts 2300. Plymouth County Retirement Association (MA), Massachusetts 2301. Plympton (MA), Town of, Massachusetts 2302. Provincetown (MA), Town of, Massachusetts 2303. Quincy (MA), City of, Massachusetts 2304. Randolph (MA), Town of, Massachusetts 2305. Rehoboth (MA), Town of, Massachusetts 2306. Revere (MA), City of, Massachusetts 2307. Rochester (MA), Town of, Massachusetts 2308. Rockland (MA), Town of, Massachusetts 2309. Salem (MA), City of, Massachusetts 2310. Salisbury (MA), Town of, Massachusetts 2311. Sandwich (MA), Town of, Massachusetts 2312. Scituate (MA), Town of, Massachusetts 2313. Seekonk (MA), Town of, Massachusetts 2314. Sheffield (MA), Town of, Massachusetts 2315. Shirley (MA), Town of, Massachusetts 2316. Silver Lake Regional School District (MA), Massachusetts 2317. Somerset (MA), Town of, Massachusetts 2318. Somerville (MA), City of, Massachusetts 2319. South Hadley (MA), Town of, Massachusetts 2320. South Shore Educational Collaborative (MA), Massachusetts 2321. South Shore Regional Emergency Communication Center (MA), Massachusetts 2322. South Shore Vocational School District (MA), Massachusetts 2323. Southbridge (MA), Town of, Massachusetts 2324. Southeastern Regional Transit Authority (MA), Massachusetts 2325. Southfield Redevelopment Authority (MA), Massachusetts 2326. Spencer (MA), Town of, Massachusetts 2327. Springfield (MA), City of, Massachusetts 2328. Stoneham (MA), Town of, Massachusetts 2329. Stoughton (MA), Town of, Massachusetts 2330. Sturbridge (MA), Town of, Massachusetts 2331. Sudbury (MA), Town of, Massachusetts 2332. Sutton (MA), Town of, Massachusetts 2333. Swampscott (MA), Town of, Massachusetts 2334. Templeton (MA), Town of, Massachusetts 2335. Tewksbury (MA), Town of, Massachusetts 2336. Truro (MA), Town of, Massachusetts 2337. Tyngsborough (MA), Town of, Massachusetts 2338. Upton (MA), Town of, Massachusetts 2339. Wakefield (MA), Town of, Massachusetts 2340. Walpole (MA), Town of, Massachusetts 2341. Ware (MA), Town of, Massachusetts 2342. Wareham (MA), Town of, Massachusetts2343. Wareham Fire District (MA), Massachusetts 2344. Warren (MA), Town of, Massachusetts 2345. Watertown (MA), Town of, Massachusetts 2346. Wellfleet (MA), Town of, Massachusetts 2347. West Boylston (MA), Town of, Massachusetts 2348. West Bridgewater (MA), Town of, Massachusetts 2349. West Springfield (MA), Town of, Massachusetts 2350. West Tisbury, (MA), Town of, Massachusetts 2351. Westborough (MA), Town of, Massachusetts 2352. Westford (MA), Town of, Massachusetts 2353. Weymouth (MA), Town of, Massachusetts 2354. Whitman (MA), Town of, Massachusetts 2355. Whitman -Hanson Regional School District (MA), Massachusetts 2356. Williamsburg (MA), Town of, Massachusetts DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2357. Wilmington (MA), Town of, Massachusetts 2358. Winchendon (MA), Town of, Massachusetts 2359. Winthrop (MA), Town of, Massachusetts 2360. Woburn (MA), City of, Massachusetts 2361. Worcester (MA), City of, Massachusetts 2362. Alcona (MI), County of, Michigan 2363. Alger (MI), County of, Michigan 2364. Alpena (MI), County of, Michigan 2365. Antrim (MI), County of, Michigan 2366. Arenac (MI), County of, Michigan 2367. Baraga (MI), County of, Michigan 2368. Bay (MI), County of, Michigan 2369. Benzie (MI), County of, Michigan 2370. Berrien (MI), County of, Michigan 2371. Branch (MI), County of, Michigan 2372. Calhoun (MI), County of, Michigan 2373. Canton (MI), Charter Township of, Michigan 2374. Cass (MI), County of, Michigan 2375. Charlevoix (MI), County of, Michigan 2376. Cheboygan (MI), County of, Michigan 2377. Chippewa (MI), County of, Michigan 2378. Clinton (MI), County of, Michigan 2379. Clinton (MI), Charter Township of, Michigan 2380. Crawford (MI), County of, Michigan 2381. Delta (MI), County of, Michigan 2382. Detroit (MI), City of, Michigan 2383. Detroit Wayne Mental Health Authority (MI), Michigan 2384. Dickinson (MI), County of, Michigan 2385. East Lansing (MI), City of, Michigan 2386. Eaton (MI), County of, Michigan 2387. Escanaba (MI), City of, Michigan 2388. Flint (MI), City of, Michigan 2389. Genesee (MI), County of, Michigan 2390. Grand Rapids (MI), City of, Michigan 2391. Grand Traverse (MI), County of, Michigan 2392. Gratiot (MI), County of, Michigan 2393. Harrison (MI), Charter Township of, Michigan 2394. Hillsdale (MI), County of, Michigan 2395. Houghton (MI), County of, Michigan 2396. Huron (MI), Charter Township of, Michigan 2397. Ingham (MI), County of, Michigan 2398. Ionia (MI), County of, Michigan 2399. Iosco (MI), County of, Michigan 2400. Iron (MI), County of, Michigan 2401. Iron Mountain (MI), City of, Michigan 2402. Isabella (MI), County of, Michigan 2403. Jackson (MI), City of, Michigan 2404. Kalamazoo (MI), County of, Michigan 2405. Kent (MI), County of, Michigan 2406. Lake (MI), County of, Michigan 2407. Lansing (MI), City of, Michigan 2408. Leelanau (MI), County of, Michigan 2409. Lenawee (MI), County of, Michigan 2410. Livingston (MI), County of, Michigan 2411. Livonia (MI), City of, Michigan 2412. Luce (MI), County of, Michigan 2413. Macomb (MI), County of, Michigan 2414. Manistee (MI), County of, Michigan 2415. Marquette (MI), County of, Michigan 2416. Mason (MI), County of, Michigan 2417. Monroe (MI), County of, Michigan 2418. Montcalm (MI), County of, Michigan 2419. Montmorency (MI), County of, Michigan 2420. Muskegon (MI), County of, Michigan 2421. Newaygo (MI), County of, Michigan 2422. Northville (MI), Charter Township of, Michigan 2423. Oakland (MI), County of, Michigan 2424. Oceana (MI), County of, Michigan 2425. Ogemaw (MI), County of, Michigan 2426. Ontonagon (MI), County of, Michigan 2427. Osceola (MI), County of, Michigan 2428. Otsego (MI), County of, Michigan 2429. Pittsfield (MI), Charter Township of, Michigan 2430. Pontiac (MI), City of, Michigan 2431. Presque Isle (MI), County of, Michigan 2432. Romulus (MI), City of, Michigan 2433. Roscommon (MI), County of, Michigan 2434. Saginaw (MI), County of, Michigan 2435. Sanilac (MI), County of, Michigan 2436. Sault Ste. Marie (MI), City of, Michigan 2437. Shiawassee (MI), County of, Michigan 2438. St. Clair (MI), County of, Michigan DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2439. Sterling Heights (MI), City of, Michigan 2440. Traverse City (MI), City of, Michigan 2441. Tuscola (MI), County of, Michigan 2442. Van Buren (MI), Charter Township of, Michigan 2443. Warren (MI), City of, Michigan 2444. Washtenaw (MI), County of, Michigan 2445. Wayne (MI), City of, Michigan 2446. Wayne (MI), County of, Michigan 2447. Westland (MI), City of, Michigan 2448. Wexford (MI), County of, Michigan 2449. Anoka (MN), County of, Minnesota 2450. Beltrami (MN), County of, Minnesota 2451. Big Stone (MN), County of, Minnesota 2452. Board of Education of Minnetonka School District No. 276 (MN), Minnesota 2453. Carlton (MN), County of, Minnesota 2454. Carver (MN), County of, Minnesota 2455. Coon Rapids (MN), City of, Minnesota 2456. Dakota (MN), County of, Minnesota 2457. Douglas (MN), County of, Minnesota 2458. Duluth (MN), City of, Minnesota 2459. Freeborn (MN), County of, Minnesota 2460. Hennepin (MN), County of, Minnesota 2461. Itasca (MN), County of, Minnesota 2462. McLeod (MN), County of, Minnesota 2463. Meeker (MN), County of, Minnesota 2464. Minneapolis (MN), City of, Minnesota 2465. Minnesota Prairie Health Alliance (MN), Minnesota 2466. Morrison (MN), County of, Minnesota 2467. Mower (MN), County of, Minnesota 2468. North St. Paul (MN), City of, Minnesota 2469. Olmsted (MN), County of, Minnesota 2470. Pine (MN), County of, Minnesota 2471. Proctor (MN), City of, Minnesota 2472. Ramsey (MN), County of, Minnesota 2473. Rochester (MN), City of, Minnesota 2474. Roseau (MN), County of, Minnesota 2475. Saint Paul (MN), City of, Minnesota 2476. Sibley (MN), County of, Minnesota 2477. St. Louis (MN), County of, Minnesota 2478. Steele (MN), County of, Minnesota 2479. Waseca (MN), County of, Minnesota 2480. Washington (MN), County of, Minnesota 2481. Winona (MN), County of, Minnesota 2482. Wright (MN), County of, Minnesota 2483. Yellow Medicine (MN), County of, Minnesota 2484. Adams (MS), County of, Mississippi 2485. Amite (MS), County of, Mississippi 2486. Amory (MS), City of, Mississippi 2487. Arcola (MS), Town of, Mississippi 2488. Attala (MS), County of, Mississippi 2489. Benton (MS), County of, Mississippi 2490. Bolivar (MS), County of, Mississippi 2491. Brookhaven (MS), City of, Mississippi 2492. Caledonia (MS), Town of, Mississippi 2493. Carroll (MS), County of, Mississippi 2494. Charleston (MS), City of, Mississippi 2495. Chickasaw (MS), County of, Mississippi 2496. Claiborne (MS), County of, Mississippi 2497. Clarke (MS), County of, Mississippi 2498. Clarksdale (MS), City of, Mississippi 2499. Cleveland (MS), City of, Mississippi 2500. Columbia (MS), City of, Mississippi 2501. Columbus (MS), City of, Mississippi 2502. Copiah (MS), County of, Mississippi 2503. Covington (MS), County of, Mississippi 2504. Desoto (MS), County of, Mississippi 2505. Diamondhead (MS), City of, Mississippi 2506. Forrest (MS), County of, Mississippi 2507. Franklin (MS), County of, Mississippi 2508. Gautier (MS), City of, Mississippi 2509. George (MS), County of, Mississippi 2510. Greene (MS), County of, Mississippi 2511. Greenwood (MS), City of, Mississippi 2512. Grenada (MS), City of, Mississippi 2513. Grenada (MS), County of, Mississippi 2514. Gulfport (MS), City of, Mississippi 2515. Hancock (MS), County of, Mississippi 2516. Harrison (MS), County of, Mississippi 2517. Hattiesburg (MS), City of, Mississippi 2518. Hinds (MS), County of, Mississippi 2519. Holly Springs (MS), City of, Mississippi 2520. Holmes (MS), County of, Mississippi 2521. Humphreys (MS), County of, Mississippi 2522. Indianola (MS), City of, Mississippi 2523. Issaquena (MS), County of, Mississippi 2524. Itawamba (MS), County of, Mississippi 2525. Iuka (MS), City of, Mississippi 2526. Jackson (MS), City of, Mississippi 2527. Jackson (MS), County of, Mississippi 2528. Jefferson (MS), County of, Mississippi DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2529. Jefferson Davis (MS), County of, Mississippi 2530. Jones (MS), County of, Mississippi 2531. Jonestown (MS), City of, Mississippi 2532. Kemper (MS), County of, Mississippi 2533. Kosciusko (MS), City of, Mississippi 2534. Lafayette (MS), County of, Mississippi 2535. Lauderdale (MS), County of, Mississippi 2536. Laurel (MS), City of, Mississippi 2537. Lawrence (MS), County of, Mississippi 2538. Leakesville (MS), Town of, Mississippi 2539. Lee (MS), County of, Mississippi 2540. Leflore (MS), County of, Mississippi 2541. Lincoln (MS), County of, Mississippi 2542. Long Beach (MS), City of, Mississippi 2543. Lumberton (MS), City of, Mississippi 2544. Madison (MS), County of, Mississippi 2545. Marion (MS), County of, Mississippi 2546. Marshall (MS), County of, Mississippi 2547. McLain (MS), Town of, Mississippi 2548. Memorial Hospital at Gulfport (MS), Mississippi 2549. Meridian (MS), City of, Mississippi 2550. Monroe (MS), County of, Mississippi 2551. Morton (MS), City of, Mississippi 2552. Moss Point (MS), City of, Mississippi 2553. Mound Bayou (MS), City of, Mississippi 2554. Neshoba (MS), County of, Mississippi 2555. Nettleton (MS), City of, Mississippi 2556. New Albany (MS), City of, Mississippi 2557. Ocean Springs (MS), City of, Mississippi 2558. Panola (MS), County of, Mississippi 2559. Pascagoula (MS), City of, Mississippi 2560. Pearl River (MS), County of, Mississippi 2561. Pearl River County Hospital (MS), Mississippi 2562. Perry (MS), County of, Mississippi 2563. Philadelphia (MS), City of, Mississippi 2564. Prentiss (MS), County of, Mississippi 2565. Quitman (MS), City of, Mississippi 2566. Scott (MS), County of, Mississippi 2567. Shannon (MS), City of, Mississippi 2568. Sharkey-Issaquena Community Hospital (MS), Mississippi 2569. Shubuta (MS), Town of, Mississippi 2570. South Central Regional Medical Center (MS), Mississippi 2571. Southwest Mississippi Regional Medical Center (MS), Mississippi 2572. Starkville (MS), City of, Mississippi 2573. Stone (MS), County of, Mississippi 2574. Summit (MS), Town of, Mississippi 2575. Sunflower (MS), County of, Mississippi 2576. Tallahatchie (MS), County of, Mississippi 2577. Tate (MS), County of, Mississippi 2578. Tippah (MS), County of, Mississippi 2579. Tishomingo (MS), County of, Mississippi 2580. Tunica (MS), County of, Mississippi 2581. Tupelo (MS), City of, Mississippi 2582. Union (MS), County of, Mississippi 2583. Verona (MS), City of, Mississippi 2584. Vicksburg (MS), City of, Mississippi 2585. Walthall (MS), County of, Mississippi 2586. Washington (MS), County of, Mississippi 2587. Wayne (MS), County of, Mississippi 2588. Waynesboro (MS), City of, Mississippi 2589. Webb (MS), City of, Mississippi 2590. Wiggins (MS), City of, Mississippi 2591. Yalobusha (MS), County of, Mississippi 2592. Adair (MO), County of, Missouri 2593. Andrew (MO), County of, Missouri 2594. Atchison (MO), County of, Missouri 2595. Audrain (MO), County of, Missouri 2596. Barry (MO), County of, Missouri 2597. Barton (MO), County of, Missouri 2598. Boone (MO), County of, Missouri 2599. Buchanan (MO), County of, Missouri 2600. Butler (MO), County of, Missouri 2601. Callaway (MO), County of, Missouri 2602. Camden (MO), County of, Missouri 2603. Cape Girardeau (MO), County of, Missouri 2604. Cass (MO), County of, Missouri 2605. Chariton (MO), County of, Missouri 2606. Christian (MO), County of, Missouri 2607. Clinton (MO), County of, Missouri 2608. Cole (MO), County of, Missouri 2609. Crawford (MO), County of, Missouri 2610. Dade (MO), County of, Missouri 2611. DeKalb (MO), County of, Missouri 2612. Dent (MO), County of, Missouri DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2613. Douglas (MO), County of, Missouri 2614. Dunklin (MO), County of, Missouri 2615. Franklin (MO), County of, Missouri 2616. Gasconade (MO), County of, Missouri 2617. Greene (MO), County of, Missouri 2618. Grundy (MO), County of, Missouri 2619. Harrisonville (MO), City of, Missouri 2620. Henry (MO), County of, Missouri 2621. Hickory (MO), County of, Missouri 2622. Howell (MO), County of, Missouri 2623. Independence (MO), City of, Missouri 2624. Iron (MO), County of, Missouri 2625. Jackson (MO), County of, Missouri 2626. Jasper (MO), County of, Missouri 2627. Jefferson (MO), County of, Missouri 2628. Johnson (MO), County of, Missouri 2629. Joplin (MO), City of, Missouri 2630. Kansas City (MO), City of, Missouri 2631. Kinloch Fire Protection District of St. Louis County (MO), Missouri 2632. Knox (MO), County of, Missouri 2633. Lafayette (MO), County of, Missouri 2634. Lawrence (MO), County of, Missouri 2635. Lewis (MO), County of, Missouri 2636. Lincoln (MO), County of, Missouri 2637. Livingston (MO), County of, Missouri 2638. Madison (MO), County of, Missouri 2639. Maries (MO), County of, Missouri 2640. McDonald (MO), County of, Missouri 2641. Miller (MO), County of, Missouri 2642. Moniteau (MO), County of, Missouri 2643. Montgomery (MO), County of, Missouri 2644. Morgan (MO), County of, Missouri 2645. New Madrid (MO), County of, Missouri 2646. Nodaway (MO), County of, Missouri 2647. Northeast Ambulance and Fire Protection District of St. Louis County (MO), Missouri 2648. Osage (MO), County of, Missouri 2649. Ozark (MO), County of, Missouri 2650. Pemiscot (MO), County of, Missouri 2651. Perry (MO), County of, Missouri 2652. Pettis (MO), County of, Missouri 2653. Phelps (MO), County of, Missouri 2654. Pike (MO), County of, Missouri 2655. Polk (MO), County of, Missouri 2656. Pulaski (MO), County of, Missouri 2657. Rails (MO), County of, Missouri 2658. Randolph (MO), County of, Missouri 2659. Ray (MO), County of, Missouri 2660. Reynolds (MO), County of, Missouri 2661. Ripley (MO), County of, Missouri 2662. Saint Joseph (MO), City of, Missouri 2663. Schuyler (MO), County of, Missouri 2664. Scott (MO), County of, Missouri 2665. Sedalia (MO), City of, Missouri 2666. Shannon (MO), County of, Missouri 2667. Shelby (MO), County of, Missouri 2668. Springfield (MO), City of, Missouri 2669. St. Charles (MO), County of, Missouri 2670. St. Clair (MO), County of, Missouri 2671. St. Francois (MO), County of, Missouri 2672. St. Louis (MO), City of, Missouri 2673. St. Louis (MO), County of, Missouri 2674. Ste. Genevieve (MO), County of, Missouri 2675. Stone (MO), County of, Missouri 2676. Taney (MO), County of, Missouri 2677. Texas (MO), County of, Missouri 2678. Vernon (MO), County of, Missouri 2679. Warren (MO), County of, Missouri 2680. Washington (MO), County of, Missouri 2681. Webster (MO), County of, Missouri 2682. Worth (MO), County of, Missouri 2683. Wright (MO), County of, Missouri 2684. Anaconda -Deer Lodge (MT), County of, Montana 2685. Cascade (MT), County of, Montana 2686. Gallatin (MT), County of, Montana 2687. Great Falls (MT), City of, Montana 2688. Lake (MT), County of, Montana 2689. Missoula (MT), City of, Montana 2690. Missoula (MT), County of, Montana 2691. Douglas (NE), County of, Nebraska 2692. Keith (NE), County of, Nebraska 2693. Knox (NE), County of, Nebraska 2694. Lincoln (NE), County of, Nebraska 2695. Sarpy (NE), County of, Nebraska 2696. South Sioux City (NE), City of, Nebraska 2697. Boulder City (NV), City of, Nevada 2698. Carson City (NV), City of, Nevada 2699. Central Lyon County Fire Protection District (NV), Nevada DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2700. Churchill (NV), County of, Nevada 2701. Douglas (NV), County of, Nevada 2702. Ely (NV), City of, Nevada 2703. Fernley (NV), City of, Nevada 2704. Henderson (NV), City of, Nevada 2705. Humboldt (NV), County of, Nevada 2706. Las Vegas (NV), City of, Nevada 2707. Lincoln (NV), County of, Nevada 2708. Lyon (NV), County of, Nevada 2709. Mesquite (NV), City of, Nevada 2710. North Las Vegas (NV), City of, Nevada 2711. North Lyon County Fire Protection District (NV), Nevada 2712. Nye (NV), County of, Nevada 2713. Reno (NV), City of, Nevada 2714. Sparks (NV), City of, Nevada 2715. Washoe (NV), County of, Nevada 2716. West Wendover (NV), City of, Nevada 2717. White Pine (NV), County of, Nevada 2718. Belknap (NH), County of, New Hampshire 2719. Belmont (NH), City of, New Hampshire 2720. Berlin (NH), City of, New Hampshire 2721. Board of Education of Goshen School District (NH), New Hampshire 2722. Board of Education of Kearsarge RSU- School Administrative Unit 65 (NH), New Hampshire 2723. Board of Education of Lebanon School District (NH), New Hampshire 2724. Board of Education of Pittsfield School District (NH), New Hampshire 2725. Board of Education of Tamworth School District (NH), New Hampshire 2726. Carroll (NH), County of, New Hampshire 2727. Cheshire (NH), County of, New Hampshire 2728. Claremont (NH), City of, New Hampshire 2729. Concord (NH), City of, New Hampshire 2730. Coos (NH), County of, New Hampshire 2731. Deny (NH), Town of, New Hampshire 2732. Dover (NH), City of, New Hampshire 2733. Franklin (NH), City of, New Hampshire 2734. Grafton (NH), County of, New Hampshire 2735. Hillsborough (NH), County of, New Hampshire 2736. Keene (NH), City of, New Hampshire 2737. Laconia (NH), City of, New Hampshire 2738. Londonderry (NH), Town of, New Hampshire 2739. Manchester (NH), City of, New Hampshire 2740. Merrimack (NH), County of, New Hampshire 2741. Nashua (NH), City of, New Hampshire 2742. Rochester (NH), City of, New Hampshire 2743. Rockingham (NH), County of, New Hampshire 2744. Strafford (NH), County of, New Hampshire 2745. Sullivan (NH), County of, New Hampshire 2746. Atlantic (NJ), County of, New Jersey 2747. Barnegat (NJ), Township of, New Jersey 2748. Bayonne (NJ), City of, New Jersey 2749. Bergen (NJ), County of, New Jersey 2750. Bloomfield (NJ), Township of, New Jersey 2751. Brick (NJ), Township of, New Jersey 2752. Burlington (NJ), County of, New Jersey 2753. Camden (NJ), County of, New Jersey 2754. Cape May (NJ), County of, New Jersey 2755. Clifton (NJ), City of, New Jersey 2756. Clinton (NJ), Town of, New Jersey 2757. Cumberland (NJ), County of, New Jersey 2758. Elizabeth (NJ), City of, New Jersey 2759. Essex (NJ), County of, New Jersey 2760. Hudson (NJ), County of, New Jersey 2761. Irvington (NJ), Township of, New Jersey 2762. Jersey City (NJ), City of, New Jersey 2763. Monmouth (NJ), County of, New Jersey 2764. Newark (NJ), City of, New Jersey 2765. Ocean (NJ), County of, New Jersey 2766. Paramus (NJ), Borough of, New Jersey 2767. Passaic (NJ), County of, New Jersey 2768. Paterson (NJ), City of, New Jersey 2769. Ridgefield (NJ), Borough of, New Jersey 2770. Saddle Brook (NJ), Township of, New Jersey 2771. Sussex (NJ), County of, New Jersey DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2772. Trenton (NJ), City of, New Jersey 2773. Union (NJ), County of, New Jersey 2774. Alamogordo (NM), City of, New Mexico 2775. Albuquerque (NM), City of, New Mexico 2776. Bernalillo (NM), County of, New Mexico 2777. Catron (NM), County of, New Mexico 2778. Cibola (NM), County of, New Mexico 2779. Colfax (NM), County of, New Mexico 2780. Curry (NM), County of, New Mexico 2781. Dona Ana (NM), County of, New Mexico 2782. Espanola (NM), City of, New Mexico 2783. Grant (NM), County of, New Mexico 2784. Hidalgo (NM), County of, New Mexico 2785. Hobbs (NM), City of, New Mexico 2786. Las Cruces (NM), City of, New Mexico 2787. Lea (NM), County of, New Mexico 2788. Lincoln (NM), County of, New Mexico 2789. Luna (NM), County of, New Mexico 2790. McKinley (NM), County of, New Mexico 2791. Mora (NM), County of, New Mexico 2792. Otero (NM), County of, New Mexico 2793. Rio Arriba (NM), County of, New Mexico 2794. Roosevelt (NM), County of, New Mexico 2795. San Juan (NM), County of, New Mexico 2796. San Miguel (NM), County of, New Mexico 2797. Sandoval (NM), County of, New Mexico 2798. Santa Fe (NM), City of, New Mexico 2799. Santa Fe (NM), County of, New Mexico 2800. Sierra (NM), County of, New Mexico 2801. Socorro (NM), County of, New Mexico 2802. Taos (NM), County of, New Mexico 2803. Union (NM), County of, New Mexico 2804. Valencia (NM), County of, New Mexico 2805. Albany (NY), City of, New York 2806. Albany (NY), County of, New York 2807. Allegany (NY), County of, New York 2808. Amherst (NY), Town of, New York 2809. Amityville (NY), Village of, New York 2810. Amsterdam (NY), City of, New York 2811. Auburn (NY), City of, New York 2812. Babylon (NY), Incorporated Village of, New York 2813. Babylon (NY), Village of, New York 2814. Babylon (NY), Town of, New York 2815. Bellmore Fire District (NY), New York 2816. Bellport (NY), Village of, New York 2817. Board of Education of Rochester City School District (NY), New York 2818. Brookhaven (NY), Town of, New York 2819. Broome (NY), County of, New York 2820. Buffalo (NY), City of, New York 2821. Cattaraugus (NY), County of, New York 2822. Cayuga (NY), County of, New York 2823. Centereach Fire District (NY), New York 2824. Centerport Fire District (NY), New York 2825. Chautauqua (NY), County of, New York 2826. Cheektowaga (NY), Town of, New York 2827. Chemung (NY), County of, New York 2828. Chenango (NY), County of, New York 2829. Clarkstown (NY), Town of, New York 2830. Clinton (NY), County of, New York 2831. Columbia (NY), County of, New York 2832. Cortland (NY), County of, New York 2833. Dutchess (NY), County of, New York 2834. East Hampton (NY), Village of, New York 2835. East Rockaway (NY), Incorporated Village of, New York 2836. Erie (NY), County of, New York 2837. Essex (NY), County of, New York 2838. Farmingdale (NY), Incorporated Village of, New York 2839. Floral Park (NY), Incorporated Village of, New York 2840. Franklin (NY), County of, New York 2841. Fulton (NY), County of, New York 2842. Garden City (NY), Incorporated Village of, New York 2843. Genesee (NY), County of, New York 2844. Geneva (NY), City of, New York 2845. Great Neck (NY), Village of, New York 2846. Greene (NY), County of, New York 2847. Greenport (NY), Village of, New York 2848. Hamilton (NY), County of, New York 2849. Hauppauge Fire District (NY), New York DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2850. Haverstraw (NY), Town of, New York 2851. Hempstead (NY), Incorporated Village of, New York 2852. Hempstead (NY), Village of, New York 2853. Hempstead (NY), Town of, New York 2854. Herkimer (NY), Village of, New York 2855. Herkimer (NY), County of, New York 2856. Hicksville Water District (NY), New York 2857. Huntington (NY), Town of, New York 2858. Island Park (NY), Incorporated Village of, New York 2859. Islandia (NY), Incorporated Village of, New York 2860. Islip (NY), Town of, New York 2861. Islip Terrace Fire District (NY), New York 2862. Ithaca (NY), City of, New York 2863. Jefferson (NY), County of, New York 2864. Kingston (NY), City of, New York 2865. Lackawanna (NY), City of, New York 2866. Lake Grove (NY), Incorporated Village of, New York 2867. Lancaster (NY), Town of, New York 2868. Lawrence (NY), Incorporated Village of, New York 2869. Levittown Fire District (NY), New York 2870. Lewis (NY), County of, New York 2871. Lindenhurst (NY), Incorporated Village of, New York 2872. Livingston (NY), County of, New York 2873. Lloyd Harbor (NY), Incorporated Village of, New York 2874. Long Beach (NY), City of, New York 2875. Lynbrook (NY), Incorporated Village of, New York 2876. Madison (NY), County of, New York 2877. Massapequa Park (NY), Incorporated Village of, New York 2878. Melville Fire District (NY), New York 2879. Merrick Library (NY), New York 2880. Mill Neck (NY), Incorporated Village of, New York 2881. Miller Place Fire District (NY), New York 2882. Millerton (NY), Village of, New York 2883. Monroe (NY), County of, New York 2884. Montgomery (NY), County of, New York 2885. Mount Sinai Fire District (NY), New York 2886. Mount Vernon (NY), City of, New York 2887. Nassau (NY), County of, New York 2888. Nassau University Medical Center (NY), New York 2889. Nesconset Fire District (NY), New York 2890. New Hyde Park (NY), Incorporated Village of, New York 2891. New York (NY), City of, New York 2892. Niagara (NY), County of, New York 2893. Nissequogue (NY), Incorporated Village of, New York 2894. North Hempstead (NY), Town of, New York 2895. North Merrick Fire District (NY), New York 2896. North Patchogue Fire District (NY), New York 2897. Northport (NY), Incorporated Village of, New York 2898. Ogdensburg (NY), City of, New York 2899.Old Westbury (NY), Incorporated Village of, New York 2900. Oneida (NY), County of, New York 2901. Onondaga (NY), County of, New York 2902. Ontario (NY), County of, New York 2903. Orange (NY), County of, New York 2904. Orangetown (NY), Town of, New York 2905. Orleans (NY), County of, New York 2906. Oswego (NY), County of, New York 2907. Otsego (NY), County of, New York 2908. Oyster Bay (NY), Town of, New York 2909. Patchogue (NY), Incorporated Village of, New York 2910. Plainview - Old Bethpage Public Library (NY), New York 2911. Plattsburgh (NY), City of, New York 2912. Poquott (NY), Incorporated Village of, New York 2913. Port Washington North (NY), Village of, New York 2914. Port Washington Water District (NY), New York 2915. Poughkeepsie (NY), City of, New York 2916. Poughkeepsie (NY), Town of, New York DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2917. Putnam (NY), County of, New York 2918. Ramapo (NY), Town of, New York 2919. Rensselaer (NY), County of, New York 2920. Ridge Fire District (NY), New York 2921. Riverhead (NY), Town of, New York 2922. Rochester (NY), City of, New York 2923. Rockland (NY), County of, New York 2924. Rockville Centre Public Library (NY), New York 2925. Rome (NY), City of, New York 2926. Rosalyn Water District (NY), New York 2927. Saltaire (NY), Village of, New York 2928. Saratoga (NY), County of, New York 2929. Saratoga Springs (NY), City of, New York 2930. Schenectady (NY), City of, New York 2931. Schenectady (NY), County of, New York 2932. Schoharie (NY), County of, New York 2933. Schuyler (NY), County of, New York 2934. Seneca (NY), County of, New York 2935. Smithtown (NY), Town of, New York 2936. Smithtown Fire District (NY), New York 2937. South Farmingdale Fire District (NY), New York 2938. Southampton (NY), Town of, New York 2939. Southold (NY), Town of, New York 2940. St. James Fire District (NY), New York 2941. St. Lawrence (NY), County of, New York 2942. Steuben (NY), County of, New York 2943. Stewart Manor (NY), Village of, New York 2944. Stony Brook Fire District (NY), New York 2945. Stony Point (NY), Town of, New York 2946. Suffern (NY), Village of, New York 2947. Suffolk (NY), County of, New York 2948. Sullivan (NY), County of, New York 2949. Syracuse (NY), City of, New York 2950. The Branch (NY), Village of, New York 2951. Tioga (NY), County of, New York 2952. Tompkins (NY), County of, New York 2953. Tonawanda (NY), Town of, New York 2954. Troy (NY), City of, New York 2955. Ulster (NY), County of, New York 2956. Uniondale Fire District (NY), New York 2957. Utica (NY), City of, New York 2958. Valley Stream (NY), Incorporated Village of, New York 2959. Wappinger (NY), Town of, New York 2960. Wappingers Falls (NY), Village of, New York 2961. Wappingers Falls (NY), City of, New York 2962. Wappingers Falls (NY), Town of, New York 2963. Warren (NY), County of, New York 2964. Washington (NY), County of, New York 2965. West Hampton Dunes (NY), Incorporated Village of, New York 2966. West Haverstraw (NY), Village of, New York 2967. West Hempstead Public Library (NY), New York 2968. Westbury (NY), Incorporated Village of, New York 2969. Westchester (NY), County of, New York 2970. Wyoming (NY), County of, New York 2971. Yates (NY), County of, New York 2972. Yonkers (NY), City of, New York 2973. Alamance (NC), County of, North Carolina 2974. Alexander (NC), County of, North Carolina 2975. Alleghany (NC), County of, North Carolina 2976. Anson (NC), County of, North Carolina 2977. Ashe (NC), County of, North Carolina 2978. Beaufort (NC), County of, North Carolina 2979. Bertie (NC), County of, North Carolina 2980. Bladen (NC), County of, North Carolina 2981. Brunswick (NC), County of, North Carolina 2982. Buncombe (NC), County of, North Carolina 2983. Burke (NC), County of, North Carolina 2984. Cabarrus (NC), County of, North Carolina 2985. Caldwell (NC), County of, North Carolina 2986. Camden (NC), County of, North Carolina 2987. Canton (NC), City of, North Carolina 2988. Carteret (NC), County of, North Carolina DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 2989. Caswell (NC), County of, North Carolina 2990. Catawba (NC), County of, North Carolina 2991. Chatham (NC), County of, North Carolina 2992. Cherokee (NC), County of, North Carolina 2993. Chowan (NC), County of, North Carolina 2994. Cleveland (NC), County of, North Carolina 2995. Columbus (NC), County of, North Carolina 2996. Craven (NC), County of, North Carolina 2997. Cumberland (NC), County of, North Carolina 2998. Currituck (NC), County of, North Carolina 2999. Dare (NC), County of, North Carolina 3000. Davidson (NC), County of, North Carolina 3001. Davie (NC), County of, North Carolina 3002. Duplin (NC), County of, North Carolina 3003. Durham (NC), County of, North Carolina 3004. Fayetteville (NC), City of, North Carolina 3005. Forsyth (NC), County of, North Carolina 3006. Franklin (NC), County of, North Carolina 3007. Gaston (NC), County of, North Carolina 3008. Granville (NC), County of, North Carolina 3009. Greene (NC), County of, North Carolina 3010. Greensboro (NC), City of, North Carolina 3011. Guilford (NC), County of, North Carolina 3012. Halifax (NC), County of, North Carolina 3013. Haywood (NC), County of, North Carolina 3014. Henderson (NC), City of, North Carolina 3015. Hickory (NC), City of, North Carolina 3016. Iredell (NC), County of, North Carolina 3017. Jacksonville (NC), City of, North Carolina 3018. Jones (NC), County of, North Carolina 3019. Lee (NC), County of, North Carolina 3020. Lenoir (NC), County of, North Carolina 3021. Lincoln (NC), County of, North Carolina 3022. Madison (NC), County of, North Carolina 3023. Martin (NC), County of, North Carolina 3024. McDowell (NC), County of, North Carolina 3025. Mecklenburg (NC), County of, North Carolina 3026. Mitchell (NC), County of, North Carolina 3027. Moore (NC), County of, North Carolina 3028. New Hanover (NC), County of, North Carolina 3029. Onslow (NC), County of, North Carolina 3030. Orange (NC), County of, North Carolina 3031. Pamlico (NC), County of, North Carolina 3032. Pasquotank (NC), County of, North Carolina 3033. Person (NC), County of, North Carolina 3034. Pitt (NC), County of, North Carolina 3035. Polk (NC), County of, North Carolina 3036. Randolph (NC), County of, North Carolina 3037. Richmond (NC), County of, North Carolina 3038. Robeson (NC), County of, North Carolina 3039. Rockingham (NC), County of, North Carolina 3040. Rowan (NC), County of, North Carolina 3041. Rutherford (NC), County of, North Carolina 3042. Sampson (NC), County of, North Carolina 3043. Scotland (NC), County of, North Carolina 3044. Stokes (NC), County of, North Carolina 3045. Surry (NC), County of, North Carolina 3046. Tyrrell (NC), County of, North Carolina 3047. Vance (NC), County of, North Carolina 3048. Warren (NC), County of, North Carolina 3049. Washington (NC), County of, North Carolina 3050. Watauga (NC), County of, North Carolina 3051. Wayne (NC), County of, North Carolina 3052. Wilkes (NC), County of, North Carolina DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3053. Wilmington (NC), City of, North Carolina 3054. Winston-Salem (NC), City of, North Carolina 3055. Yadkin (NC), County of, North Carolina 3056. Yancey (NC), County of, North Carolina 3057. Barnes (ND), County of, North Dakota 3058. Benson (ND), County of, North Dakota 3059. Bismarck (ND), City of, North Dakota 3060. Burleigh (ND), County of, North Dakota 3061. Cass (ND), County of, North Dakota 3062. Devils Lake (ND), City of, North Dakota 3063. Dickey (ND), County of, North Dakota 3064. Dunn (ND), County of, North Dakota 3065. Eddy (ND), County of, North Dakota 3066. Fargo (ND), City of, North Dakota 3067. Foster (ND), County of, North Dakota 3068. Grand Forks (ND), City of, North Dakota 3069. Grand Forks (ND), County of, North Dakota 3070. Lamoure (ND), County of, North Dakota 3071. Lisbon (ND), City of, North Dakota 3072. McKenzie (ND), County of, North Dakota 3073. McLean (ND), County of, North Dakota 3074. Mercer (ND), County of, North Dakota 3075. Mountrail (ND), County of, North Dakota 3076. Pembina (ND), County of, North Dakota 3077. Pierce (ND), County of, North Dakota 3078. Ramsey (ND), County of, North Dakota 3079. Ransom (ND), County of, North Dakota 3080. Richland (ND), County of, North Dakota 3081. Rolette (ND), County of, North Dakota 3082. Sargent (ND), County of, North Dakota 3083. Stark (ND), County of, North Dakota 3084. Towner (ND), County of, North Dakota 3085. Walsh (ND), County of, North Dakota 3086. Ward (ND), County of, North Dakota 3087. Wells (ND), County of, North Dakota 3088. Williams (ND), County of, North Dakota 3089. Adams (OH), County of, Ohio 3090. Akron, (OH), City of, Ohio 3091. Allen (OH), County of, Ohio 3092. Ashland (OH), City of, Ohio 3093. Ashland (OH), County of, Ohio 3094. Ashtabula (OH), County of, Ohio 3095. Athens (OH), County of, Ohio 3096. Auglaize (OH), County of, Ohio 3097. Aurora (OH), City of, Ohio 3098. Barberton (OH), City of, Ohio 3099. Belmont (OH), County of, Ohio 3100. Boston (OH), Township of, Ohio 3101. Boston Heights (OH), Village of, Ohio 3102. Broadview Heights (OH), City of, Ohio 3103. Brooklyn Heights (OH), Village of, Ohio 3104. Brown (OH), County of, Ohio 3105. Brunswick (OH), City of, Ohio 3106. Butler (OH), County of, Ohio 3107. Carroll (OH), County of, Ohio 3108. Champaign (OH), County of, Ohio 3109. Cincinnati (OH), City of, Ohio 3110. Clermont (OH), County of, Ohio 3111. Cleveland (OH), City of, Ohio 3112. Clinton (OH), Village of, Ohio 3113. Clinton (OH), County of, Ohio 3114. Columbiana (OH), County of, Ohio 3115. Columbus (OH), City of, Ohio 3116. Copley (OH), Township of, Ohio 3117. Coshocton (OH), County of, Ohio 3118. Coventry (OH), Township of, Ohio 3119. Crawford (OH), County of, Ohio 3120. Cuyahoga Falls (OH), City of, Ohio 3121. Darke (OH), County of, Ohio 3122. Dayton (OH), City of, Ohio 3123. Delaware (OH), County of, Ohio 3124. East Cleveland (OH), City of, Ohio 3125. Elyria (OH), City of, Ohio 3126. Erie (OH), County of, Ohio 3127. Euclid (OH), City of, Ohio 3128. Fairfield (OH), City of, Ohio 3129. Fairfield (OH), County of, Ohio 3130. Fairlawn (OH), City of, Ohio 3131. Fayette (OH), County of, Ohio 3132. Findlay (OH), City of, Ohio 3133. Fostoria (OH), City of, Ohio 3134. Four County Board of Alcohol, Drug Addiction and Mental Health Services (OH), Ohio 3135. Franklin (OH), County of, Ohio 3136. Fulton (OH), County of, Ohio 3137. Gallia (OH), County of, Ohio 3138. Garfield Heights (OH), City of, Ohio DRAFT- SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3139. Geauga (OH), County of, Ohio 3140. Green (OH), City of, Ohio 3141. Guernsey (OH), County of, Ohio 3142. Hamilton (OH), City of, Ohio 3143. Hamilton (OH), County of, Ohio 3144. Hancock (OH), County of, Ohio 3145. Harrison (OH), County of, Ohio 3146. Hocking (OH), County of, Ohio 3147. Huron (OH), City of, Ohio 3148. Huron (OH), County of, Ohio 3149. Ironton (OH), City of, Ohio 3150. Jackson (OH), County of, Ohio 3151. Jefferson (OH), County of, Ohio 3152. Kent (OH), City of, Ohio 3153. Knox (OH), County of, Ohio 3154. Lake (OH), County of, Ohio 3155. Lakemore (OH), Village of, Ohio 3156. Lakewood (OH), City of, Ohio 3157. Lawrence (OH), County of, Ohio 3158. Lebanon (OH), City of, Ohio 3159. Licking (OH), County of, Ohio 3160. Lima (OH), City of, Ohio 3161. Logan (OH), County of, Ohio 3162. Lorain (OH), City of, Ohio 3163. Lorain (OH), County of, Ohio 3164. Lucas (OH), County of, Ohio 3165. Lucas County Children Services Board of Trustees (OH), Ohio 3166. Lyndhurst (OH), City of, Ohio 3167. Macedonia (OH), City of, Ohio 3168. Mansfield (OH), City of, Ohio 3169. Marietta (OH), City of, Ohio 3170. Marion (OH), County of, Ohio 3171. Mayfield Heights (OH), City of, Ohio 3172. Medina (OH), County of, Ohio 3173. Meigs (OH), County of, Ohio 3174. Mental Health & Recovery Services Board of Allen, Auglaize, and Hardin Counties (OH), Ohio 3175. Mental Health & Recovery Services Board of Lucas County (OH), Ohio 3176. Mercer (OH), County of, Ohio 3177. Miami (OH), County of, Ohio 3178. Middletown (OH), City of, Ohio 3179. Mogadore (OH), Village of, Ohio 3180. Monroe (OH), County of, Ohio 3181. Montgomery (OH), County of, Ohio 3182. Morrow (OH), County of, Ohio 3183. Munroe Falls (OH), City of, Ohio 3184. Muskingum (OH), County of, Ohio 3185. New Franklin (OH), City of, Ohio 3186. Newburgh Heights (OH), Village of, Ohio 3187. Noble (OH), County of, Ohio 3188. North Olmsted (OH), City of, Ohio 3189. North Ridgeville (OH), City of, Ohio 3190. North Royalton (OH), City of, Ohio 3191. Norton (OH), City of, Ohio 3192. Norwalk (OH), City of, Ohio 3193. Olmsted Falls (OH), City of, Ohio 3194. Ottawa (OH), County of, Ohio 3195. Painesville (OH), Township of, Ohio 3196. Parma (OH), City of, Ohio 3197. Parma Heights (OH), City of, Ohio 3198. Peninsula (OH), Village of, Ohio 3199. Perry (OH), County of, Ohio 3200. Pike (OH), County of, Ohio 3201. Portage (OH), County of, Ohio 3202. Portsmouth (OH), City of, Ohio 3203. Ravenna (OH), City of, Ohio 3204. Richfield (OH), Village of, Ohio 3205. Richland County Children's Services (OH), Ohio 3206. Ross (OH), County of, Ohio 3207. Sandusky (OH), City of, Ohio 3208. Sandusky (OH), County of, Ohio 3209. Scioto (OH), County of, Ohio 3210. Seneca (OH), County of, Ohio 3211. Seven Hills (OH), City of, Ohio 3212. Shelby (OH), County of, Ohio 3213. Silver Lake (OH), Village of, Ohio 3214. Springfield (OH), Township of, Ohio 3215. St. Marys (OH), City of, Ohio 3216. Stark (OH), County of, Ohio 3217. Stow (OH), City of, Ohio 3218. Strongsville (OH), City of, Ohio 3219. Tallmadge (OH), City of, Ohio 3220. Toledo (OH), City of, Ohio 3221. Trumbull (OH), County of, Ohio 3222. Tuscarawas (OH), County of, Ohio 3223. Valley Fire District (OH), Ohio 3224. Van Wert (OH), City of, Ohio 3225. Van Wert (OH), County of, Ohio 3226. Vinton (OH), County of, Ohio DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3227. Warren (OH), City of, Ohio 3228. Warrensville Heights (OH), City of, Ohio 3229. Washington (OH), County of, Ohio 3230. Wayne (OH), County of, Ohio 3231. Wickliffe (OH), City of, Ohio 3232. Williams (OH), County of, Ohio 3233. Wyandot (OH), County of, Ohio 3234. Youngstown (OH), City of, Ohio 3235. Ada (OK), City of, Oklahoma 3236. Altus (OK), City of, Oklahoma 3237. Anadarko (OK), City of, Oklahoma 3238. Atoka (OK), County of, Oklahoma 3239. Beckham (OK), County of, Oklahoma 3240. Bethany (OK), City of, Oklahoma 3241. Broken Arrow (OK), City of, Oklahoma 3242. Burns Flat (OK), City of, Oklahoma 3243. Caddo (OK), County of, Oklahoma 3244. Choctaw (OK), County of, Oklahoma 3245. Cimarron (OK), County of, Oklahoma 3246. Cleveland (OK), County of, Oklahoma 3247. Coal (OK), County of, Oklahoma 3248. Comanche (OK), County of, Oklahoma 3249. Craig (OK), County of, Oklahoma 3250. Creek (OK), County of, Oklahoma 3251. Custer (OK), County of, Oklahoma 3252. Delaware (OK), County of, Oklahoma 3253. Dewey (OK), County of, Oklahoma 3254. Edmond (OK), City of, Oklahoma 3255. El Reno (OK), City of, Oklahoma 3256. Elk City (OK), City of, Oklahoma 3257. Enid (OK), City of, Oklahoma 3258. Fort Cobb (OK), City of, Oklahoma 3259. Garvin (OK), County of, Oklahoma 3260. Grady (OK), County of, Oklahoma 3261. Greer (OK), County of, Oklahoma 3262. Guthrie (OK), City of, Oklahoma 3263. Harmon (OK), County of, Oklahoma 3264. Harper (OK), County of, Oklahoma 3265. Haskell (OK), County of, Oklahoma 3266. Hughes (OK), County of, Oklahoma 3267. Jackson (OK), County of, Oklahoma 3268. Jefferson (OK), County of, Oklahoma 3269. Jenks (OK), City of, Oklahoma 3270. Johnston (OK), County of, Oklahoma 3271. Kay (OK), County of, Oklahoma 3272. Kiowa (OK), County of, Oklahoma 3273. Latimer (OK), County of, Oklahoma 3274. Lawton (OK), City of, Oklahoma 3275. Le Flore (OK), County of, Oklahoma 3276. Lincoln (OK), County of, Oklahoma 3277. Logan (OK), County of, Oklahoma 3278. Love (OK), County of, Oklahoma 3279. Major (OK), County of, Oklahoma 3280. Mayes (OK), County of, Oklahoma 3281. McClain (OK), County of, Oklahoma 3282. McCurtain (OK), County of, Oklahoma 3283. Midwest City (OK), City of, Oklahoma 3284. Muskogee (OK), City of, Oklahoma 3285. Muskogee (OK), County of, Oklahoma 3286. Mustang (OK), City of, Oklahoma 3287. Noble (OK), County of, Oklahoma 3288. Nowata (OK), County of, Oklahoma 3289. Okfuskee (OK), County of, Oklahoma 3290. Oklahoma (OK), County of, Oklahoma 3291. Oklahoma City (OK), City of, Oklahoma 3292. Okmulgee (OK), County of, Oklahoma 3293. Osage (OK), County of, Oklahoma 3294. Ottawa (OK), County of, Oklahoma 3295. Owasso (OK), City of, Oklahoma 3296. Pawnee (OK), County of, Oklahoma 3297. Payne (OK), County of, Oklahoma 3298. Pittsburg (OK), County of, Oklahoma 3299. Ponca City (OK), City of, Oklahoma 3300. Pottawatomie (OK), County of, Oklahoma 3301. Roger Mills (OK), County of, Oklahoma 3302. Rogers (OK), County of, Oklahoma 3303. Seminole (OK), City of, Oklahoma 3304. Seminole (OK), County of, Oklahoma 3305. Shawnee (OK), City of, Oklahoma 3306. Stephens (OK), County of, Oklahoma 3307. Stillwater (OK), City of, Oklahoma 3308. Texas (OK), County of, Oklahoma 3309. Tillman (OK), County of, Oklahoma 3310. Tulsa (OK), City of, Oklahoma 3311. Tulsa (OK), County of, Oklahoma 3312. Washington (OK), County of, Oklahoma 3313. Woods (OK), County of, Oklahoma 3314. Woodward (OK), County of, Oklahoma 3315. Yukon (OK), City of, Oklahoma 3316. Clackamas (OR), County of, Oregon 3317. Clatsop (OR), County of, Oregon 3318. Columbia (OR), County of, Oregon DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3319. Coos (OR), County of, Oregon 3320. Curry (OR), County of, Oregon 3321. Jackson (OR), County of, Oregon 3322. Josephine (OR), County of, Oregon 3323. Lane (OR), County of, Oregon 3324. Multnomah (OR), County of, Oregon 3325. Portland (OR), City of, Oregon 3326. Washington (OR), County of, Oregon 3327. Yamhill (OR), County of, Oregon 3328. Adams (PA), County of, Pennsylvania 3329. Aliquippa (PA), City of, Pennsylvania 3330. Allegheny (PA), County of, Pennsylvania 3331. Armstrong (PA), County of, Pennsylvania 3332. Beaver (PA), County of, Pennsylvania 3333. Bedford (PA), County of, Pennsylvania 3334. Bensalem (PA), Township of, Pennsylvania 3335. Berks (PA), County of (DA), Pennsylvania 3336. Bradford (PA), County of, Pennsylvania 3337. Bristol (PA), Township of, Pennsylvania 3338. Bucks (PA), County of, Pennsylvania 3339. Cambria (PA), County of, Pennsylvania 3340. Carbon (PA), County of, Pennsylvania 3341. Chester (PA), County of, Pennsylvania 3342. Clarion (PA), County of, Pennsylvania 3343. Clearfield (PA), County of, Pennsylvania 3344. Clinton (PA), County of, Pennsylvania 3345. Coatesville (PA), City of, Pennsylvania 3346. Columbia (PA), County of, Pennsylvania 3347. Cumberland (PA), County of, Pennsylvania 3348. Dauphin (PA), County of, Pennsylvania 3349. Delaware (PA), County of, Pennsylvania 3350. Edwardsville (PA), Borough of, Pennsylvania 3351. Erie (PA), County of, Pennsylvania 3352. Exeter (PA), Borough of, Pennsylvania 3353. Fairview (PA), Township of, Pennsylvania 3354. Fayette (PA), County of, Pennsylvania 3355. Forty Fort (PA), Borough of, Pennsylvania 3356. Franklin (PA), County of, Pennsylvania 3357. Greene (PA), County of, Pennsylvania 3358. Hanover (PA), Township of, Pennsylvania 3359. Hazleton (PA), City of, Pennsylvania 3360. Huntingdon (PA), County of, Pennsylvania 3361. Indiana (PA), County of, Pennsylvania 3362. Kingston (PA), Borough of, Pennsylvania 3363. Lackawanna (PA), County of, Pennsylvania 3364. Lawrence (PA), County of, Pennsylvania 3365. Lehigh (PA), County of (DA), Pennsylvania 3366. Lock Haven (PA), City of, Pennsylvania 3367. Lower Makefield (PA), Township of, Pennsylvania 3368. Lower Southampton (PA), Township of, Pennsylvania 3369. Luzerne (PA), County of, Pennsylvania 3370. Lycoming (PA), County of, Pennsylvania 3371. Mahoning (PA), Township of, Pennsylvania 3372. Mercer (PA), County of, Pennsylvania 3373. Middletown (PA), Township of, Pennsylvania 3374. Monroe (PA), County of, Pennsylvania 3375. Morrisville (PA), Borough of, Pennsylvania 3376. Nanticoke (PA), City of, Pennsylvania 3377. New Castle (PA), City of, Pennsylvania 3378. Newtown (PA), Township of, Pennsylvania 3379. Norristown (PA), Municipality of, Pennsylvania 3380. Northampton (PA), County of, Pennsylvania 3381. Northumberland (PA), County of, Pennsylvania 3382. Philadelphia (PA), City of, Pennsylvania 3383. Pike (PA), County of, Pennsylvania 3384. Pittsburgh (PA), City of, Pennsylvania 3385. Plains (PA), Township of, Pennsylvania 3386. Schuylkill (PA), County of, Pennsylvania 3387. Sugar Notch (PA), Borough of, Pennsylvania 3388. Tioga (PA), County of, Pennsylvania DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3389. Union (PA), Township of, Pennsylvania 3390. Wampum (PA), Borough of, Pennsylvania 3391. Warminster (PA), Township of, Pennsylvania 3392. Warrington (PA), Township of, Pennsylvania 3393. Washington (PA), County of, Pennsylvania 3394. West Norriton (PA), Township of, Pennsylvania 3395. West Pittston (PA), Borough of, Pennsylvania 3396. Westmoreland (PA), County of, Pennsylvania 3397. Wilkes-Barre (PA), Township of, Pennsylvania 3398. Wilkes-Barre (PA), City of, Pennsylvania 3399. Wright (PA), Township of, Pennsylvania 3400. Wyoming (PA), Borough of, Pennsylvania 3401. Wyoming (PA), County of, Pennsylvania 3402. York (PA), County of, Pennsylvania 3403. Adjuntas (PR), Municipality of, Puerto Rico 3404. Arroyo (PR), Municipality of, Puerto Rico 3405. Barceloneta (PR), Municipality of, Puerto Rico 3406. Bayamon (PR), Municipality of, Puerto Rico 3407. Caguas (PR), Municipality of, Puerto Rico 3408. Can6vanas (PR), Municipality of, Puerto Rico 3409. Catano (PR), Municipality of, Puerto Rico 3410. Cayey (PR), Municipality of, Puerto Rico 3411. Ceiba (PR), Municipality of, Puerto Rico 3412. Cidra (PR), Municipality of, Puerto Rico 3413. Coamo (PR), Municipality of, Puerto Rico 3414. Guayanilla (PR), Municipality of, Puerto Rico 3415. Isla De Vieques (PR), Municipality of, Puerto Rico 3416. Juncos (PR), Municipality of, Puerto Rico 3417. Loiza (PR), Municipality of, Puerto Rico 3418. Rio Grande (PR), Municipality of, Puerto Rico 3419. Sabana Grande (PR), Municipality of, Puerto Rico 3420. San Juan (PR), Municipality of, Puerto Rico 3421. Vega Alta (PR), Municipality of, Puerto Rico 3422. Villalba (PR), Municipality of, Puerto Rico 3423. Yabucoa (PR), Municipality of, Puerto Rico 3424. Barrington (RI), Town of, Rhode Island 3425. Bristol (RI), Town of, Rhode Island 3426. Burrillville (RI), Town of, Rhode Island 3427. Central Falls (RI), City of, Rhode Island 3428. Charlestown (RI), Town of, Rhode Island 3429. Coventry (RI), Town of, Rhode Island 3430. Cranston (RI), City of, Rhode Island 3431. Cumberland (RI), Town of, Rhode Island 3432. East Greenwich (RI), Town of, Rhode Island 3433. East Providence (RI), City of, Rhode Island 3434. Foster (RI), Town of, Rhode Island 3435. Glocester (RI), Town of, Rhode Island 3436. Hopkinton (RI), Town of, Rhode Island 3437. Jamestown (RI), Town of, Rhode Island 3438. Johnston (RI), Town of, Rhode Island 3439. Middletown (RI), Town of, Rhode Island 3440. Narragansett (RI), Town of, Rhode Island 3441. Newport (RI), City of, Rhode Island 3442. North Kingstown (RI), Town of, Rhode Island 3443. North Providence (RI), Town of, Rhode Island 3444. Pawtucket (RI), City of, Rhode Island 3445. Portsmouth (RI), Town of, Rhode Island 3446. Providence (RI), City of, Rhode Island 3447. Richmond (RI), Town of, Rhode Island 3448. Scituate (RI), Town of, Rhode Island 3449. Smithfield (RI), Town of, Rhode Island DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3450. South Kingstown (RI), Town of, Rhode Island 3451. Warren (RI), Town of, Rhode Island 3452. Warwick (RI), City of, Rhode Island 3453. West Greenwich (RI), Town of, Rhode Island 3454. West Warwick (RI), Town of, Rhode Island 3455. Westerly (RI), Town of, Rhode Island 3456. Woonsocket (RI), City of, Rhode Island 3457. Abbeville (SC), County of, South Carolina 3458. Aiken (SC), County of, South Carolina 3459. Allendale (SC), County of, South Carolina 3460. Anderson (SC), County of, South Carolina 3461. Bamberg (SC), County of, South Carolina 3462. Barnwell (SC), County of, South Carolina 3463. Beaufort (SC), County of, South Carolina 3464. Berkeley (SC), County of, South Carolina 3465. Calhoun (SC), County of, South Carolina 3466. Charleston (SC), City of, South Carolina 3467. Charleston (SC), County of, South Carolina 3468. Cherokee (SC), County of, South Carolina 3469. Chester (SC), City of, South Carolina 3470. Chester (SC), County of, South Carolina 3471. Chesterfield (SC), County of, South Carolina 3472. Clarendon (SC), County of, South Carolina 3473. Colleton (SC), County of, South Carolina 3474. Columbia (SC), City of, South Carolina 3475. Dillon (SC), County of, South Carolina 3476. Dorchester (SC), County of, South Carolina 3477. Edgefield (SC), County of, South Carolina 3478. Fairfield (SC), County of, South Carolina 3479. Florence (SC), County of, South Carolina 3480. Georgetown (SC), County of, South Carolina 3481. Georgetown City (SC), City of, South Carolina 3482. Greenville (SC), County of, South Carolina 3483. Greenwood (SC), County of, South Carolina 3484. Hampton (SC), County of, South Carolina 3485. Horry (SC), County of, South Carolina 3486. Jasper (SC), County of, South Carolina 3487. Kershaw (SC), County of, South Carolina 3488. Kershaw County Hospital Board (SC), South Carolina 3489. Lancaster (SC), County of, South Carolina 3490. Laurens (SC), County of, South Carolina 3491. Lee (SC), County of, South Carolina 3492. Lexington (SC), County of, South Carolina 3493. Marion (SC), County of, South Carolina 3494. Marlboro (SC), County of, South Carolina 3495. McCormick (SC), County of, South Carolina 3496. Mount Pleasant (SC), Town of, South Carolina 3497. Myrtle Beach (SC), City of, South Carolina 3498. Newberry (SC), County of, South Carolina 3499. North Charleston (SC), City of, South Carolina 3500. Oconee (SC), County of, South Carolina 3501. Orangeburg (SC), City of, South Carolina 3502. Orangeburg (SC), County of, South Carolina 3503. Pickens (SC), County of, South Carolina 3504. Richland (SC), County of, South Carolina 3505. Saluda (SC), County of, South Carolina 3506. Spartanburg (SC), County of, South Carolina 3507. Summerville (SC), Town of, South Carolina DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3508. Sumter (SC), County of, South Carolina 3509. Union (SC), County of, South Carolina 3510. Williamsburg (SC), County of, South Carolina 3511. York (SC), County of, South Carolina 3512. Pennington (SD), County of, South Dakota 3513. Arlington (TN), Town of, Tennessee 3514. Blount (TN), County of, Tennessee 3515. Campbell (TN), County of, Tennessee 3516. Cannon (TN), County of, Tennessee 3517. Centerville (TN), Town of, Tennessee 3518. Claiborne (TN), County of, Tennessee 3519. Clarksville (TN), City of, Tennessee 3520. Crockett (TN), County of, Tennessee 3521. Dandridge (TN), Town of, Tennessee 3522. Decatur (TN), County of, Tennessee 3523. Decatur (TN), Town of, Tennessee 3524. Fentress (TN), County of, Tennessee 3525. Gatlinburg (TN), City of, Tennessee 3526. Germantown (TN), City of, Tennessee 3527. Greene (TN), County of, Tennessee 3528. Hamilton (TN), County of, Tennessee 3529. Hancock (TN), County of, Tennessee 3530. Hawkins (TN), County of, Tennessee 3531. Haywood (TN), County of, Tennessee 3532. Henderson (TN), County of, Tennessee 3533. Jefferson (TN), County of, Tennessee 3534. Johnson (TN), County of, Tennessee 3535. Lauderdale (TN), County of, Tennessee 3536. Lexington (TN), City of, Tennessee 3537. Madison (TN), County of, Tennessee 3538. Maryville (TN), City of, Tennessee 3539. Memphis (TN), City of, Tennessee 3540. Millington (TN), City of, Tennessee 3541. Montgomery (TN), County of, Tennessee 3542. Morgan (TN), County of, Tennessee 3543. Nashville & Davidson (TN), City of/County of, Tennessee 3544. Obion (TN), County of, Tennessee 3545. Overton (TN), County of, Tennessee 3546. Pickett (TN), County of, Tennessee 3547. Pigeon Forge (TN), City of, Tennessee 3548. Ripley (TN), City of, Tennessee 3549. Rutherford (TN), County of, Tennessee 3550. Scott (TN), County of, Tennessee 3551. Shelby (TN), County of, Tennessee 3552. Smith (TN), County of, Tennessee 3553. Sumner (TN), County of, Tennessee 3554. Washington (TN), County of, Tennessee 3555. Williamson (TN), County of, Tennessee 3556. Angelina (TX), County of, Texas 3557. Bailey (TX), County of, Texas 3558. Bastrop (TX), County of, Texas 3559. Bee (TX), County of, Texas 3560. Bexar (TX), County of, Texas 3561. Bexar County Hospital District (TX), Texas 3562. Blanco (TX), County of, Texas 3563. Bowie (TX), County of, Texas 3564. Brazos (TX), County of, Texas 3565. Brooks (TX), County of, Texas 3566. Burleson (TX), County of, Texas 3567. Burnet (TX), County of, Texas 3568. Caldwell (TX), County of, Texas 3569. Calhoun (TX), County of, Texas 3570. Cameron (TX), County of, Texas 3571. Camp (TX), County of, Texas 3572. Cass (TX), County of, Texas 3573. Castro (TX), County of, Texas 3574. Cherokee (TX), County of, Texas 3575. Childress (TX), County of, Texas 3576. Clay (TX), County of, Texas 3577. Colorado (TX), County of, Texas 3578. Cooke (TX), County of, Texas 3579. Coryell (TX), County of, Texas 3580. Dallas (TX), County of, Texas 3581. Dallas County Hospital District (TX), Texas 3582. Delta (TX), County of, Texas 3583. Dimmit (TX), County of, Texas 3584. Duval (TX), County of, Texas 3585. Eagle Pass (TX), City of, Texas 3586. Ector (TX), County of, Texas 3587. El Paso (TX), County of, Texas 3588. Ellis (TX), County of, Texas 3589. Falls (TX), County of, Texas 3590. Fannin (TX), County of, Texas 3591. Fort Bend (TX), County of, Texas 3592. Franklin (TX), County of, Texas 3593. Freestone (TX), County of, Texas 3594. Galveston (TX), County of, Texas 3595. Grayson (TX), County of, Texas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3596. Guadalupe (TX), County of, Texas 3597. Guadulupe Valley Hospital (TX), Texas 3598. Hardin (TX), County of, Texas 3599. Harris (TX), County of, Texas 3600. Harris County Hospital District (TX), Texas 3601. Harrison (TX), County of, Texas 3602. Haskell (TX), County of, Texas 3603. Hays (TX), County of, Texas 3604. Henderson (TX), County of, Texas 3605. Hidalgo (TX), County of, Texas 3606. Hopkins (TX), County of, Texas 3607. Houston (TX), City of, Texas 3608. Houston (TX), County of, Texas 3609. Irving Independent School District (TX), Texas 3610. Jasper (TX), County of, Texas 3611. Jefferson (TX), County of, Texas 3612. Jim Hogg (TX), County of, Texas 3613. Jim Wells (TX), County of, Texas 3614. Johnson (TX), County of, Texas 3615. Jones (TX), County of, Texas 3616. Kaufman (TX), County of, Texas 3617. Kendall (TX), County of, Texas 3618. Kerr (TX), County of, Texas 3619. Kinney (TX), County of, Texas 3620. Kleberg (TX), County of, Texas 3621. Lamar (TX), County of, Texas 3622. Laredo (TX), City of, Texas 3623. LaSalle (TX), County of, Texas 3624. Leon (TX), County of, Texas 3625. Leon Valley (TX), City of, Texas 3626. Liberty (TX), County of, Texas 3627. Limestone (TX), County of, Texas 3628. Lubbock (TX), County of, Texas 3629. Madison (TX), County of, Texas 3630. Marion (TX), County of, Texas 3631. Maverick (TX), County of, Texas 3632. McLennan (TX), County of, Texas 3633. McMullen (TX), County of, Texas 3634. Milam (TX), County of, Texas 3635. Mitchell (TX), County of, Texas 3636. Montgomery (TX), County of, Texas 3637. Morris (TX), County of, Texas 3638. Nacogdoches (TX), County of, Texas 3639. Newton (TX), County of, Texas 3640. Nolan (TX), County of, Texas 3641. Nueces (TX), County of, Texas 3642. Nueces County Hospital District (TX), Texas 3643. Ochiltree County Hospital District (TX), Texas 3644. Orange (TX), County of, Texas 3645. Palo Pinto County Hospital District (TX), Texas 3646. Panola (TX), County of, Texas 3647. Parker (TX), County of, Texas 3648. Polk (TX), County of, Texas 3649. Potter (TX), County of, Texas 3650. Red River (TX), County of, Texas 3651. Roberts (TX), County of, Texas 3652. Robertson (TX), County of, Texas 3653. Rockwall (TX), County of, Texas 3654. Rusk (TX), County of, Texas 3655. San Antonio (TX), City of, Texas 3656. San Patricio (TX), County of, Texas 3657. San Saba (TX), County of, Texas 3658. Shackelford (TX), County of, Texas 3659. Shelby (TX), County of, Texas 3660. Smith (TX), County of, Texas 3661. Socorro Independent School District (TX), Texas 3662. Stephens (TX), County of, Texas 3663. Tarrant (TX), County of, Texas 3664. Tarrant County Hospital District (TX), Texas 3665. Terrell (TX), County of, Texas 3666. Texarkana Independent School District (TX),'Texas 3667. Throckmorton (TX), County of, Texas 3668. Titus (TX), County of, Texas 3669. Travis (TX), County of, Texas 3670. Trinity (TX), County of, Texas 3671. Upshur (TX), County of, Texas 3672. Uvalde (TX), County of, Texas 3673. Van Zandt (TX), County of, Texas 3674. Walker (TX), County of, Texas 3675. Waller (TX), County of, Texas 3676. Webb (TX), County of, Texas 3677. West Wharton County Hospital District (TX), Texas 3678. Wichita (TX), County of, Texas 3679. Williamson (TX), County of, Texas 3680. Wilson (TX), County of, Texas DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3681. Wilson County Memorial Hospital District (TX), Texas 3682. Wood (TX), County of, Texas 3683. Zavala (TX), County of, Texas 3684. Beaver (UT), County of, Utah 3685. Cache (UT), County of, Utah 3686. Carbon (UT), County of, Utah 3687. Daggett (UT), County of, Utah 3688. Davis (UT), County of, Utah 3689. Duchesne (UT), County of, Utah 3690. Emery (UT), County of, Utah 3691. Garfield (UT), County of, Utah 3692. Grand (UT), County of, Utah 3693. Iron (UT), County of, Utah 3694. Juab (UT), County of, Utah 3695. Kane (UT), County of, Utah 3696. Millard (UT), County of, Utah 3697. Pluto (UT), County of, Utah 3698. Rich (UT), County of, Utah 3699. Salt Lake (UT), County of, Utah 3700. San Juan (UT), County of, Utah 3701. Sanpete (UT), County of, Utah 3702. Sevier (UT), County of, Utah 3703. Summit (UT), County of, Utah 3704. Tooele (UT), County of, Utah 3705. Tri-County Health Department (UT), Utah 3706. Uintah (UT), County of, Utah 3707. Utah (UT), County of, Utah 3708. Wasatch (UT), County of, Utah 3709. Washington (UT), County of, Utah 3710. Wayne (UT), County of, Utah 3711. Weber (UT), County of, Utah 3712. Bennington (VT), Town of, Vermont 3713. Brattleboro (VT), Town of, Vermont 3714. Sharon (VT), Town of, Vermont 3715. St. Albans (VT), City of, Vermont 3716. Accomack (VA), County of, Virginia 3717. Alexandria (VA), City of, Virginia 3718. Alleghany (VA), County of, Virginia 3719. Amherst (VA), County of, Virginia 3720. Arlington (VA), County of, Virginia 3721. Bland (VA), County of, Virginia 3722. Botetourt (VA), County of, Virginia 3723. Bristol (VA), City of, Virginia 3724. Buchanan (VA), County of, Virginia 3725. Buena Vista (VA), City of, Virginia 3726. Carroll (VA), County of, Virginia 3727. Charlotte (VA), County of, Virginia 3728. Chesapeake (VA), City of, Virginia 3729. Chesterfield (VA), County of, Virginia 3730. Covington (VA), City of, Virginia 3731. Culpeper (VA), County of, Virginia 3732. Cumberland (VA), County of, Virginia 3733. Danville (VA), City of, Virginia 3734. Dickenson (VA), County of, Virginia 3735. Dinwiddie (VA), County of, Virginia 3736. Emporia (VA), City of, Virginia 3737. Fairfax (VA), City of, Virginia 3738. Fairfax (VA), County of, Virginia 3739. Fauquier (VA), County of, Virginia 3740. Floyd (VA), County of, Virginia 3741. Franklin (VA), County of, Virginia 3742. Frederick (VA), County of, Virginia 3743. Fredericksburg (VA), City of, Virginia 3744. Galax (VA), City of, Virginia 3745. Giles (VA), County of, Virginia 3746. Goochland (VA), County of, Virginia 3747. Grayson (VA), County of, Virginia 3748. Greenville (VA), County of, Virginia 3749. Halifax (VA), County of, Virginia 3750. Henrico (VA), County of, Virginia 3751. Henry (VA), County of, Virginia 3752. Hopewell (VA), City of, Virginia 3753. Isle of Wight (VA), County of, Virginia 3754. King and Queen (VA), County of, Virginia 3755. Lee (VA), County of, Virginia 3756. Lexington (VA), City of, Virginia 3757. Loudoun (VA), County of, Virginia 3758. Louisa (VA), County of, Virginia 3759. Madison (VA), County of, Virginia 3760. Martinsville (VA), City of, Virginia 3761. Mecklenburg (VA), County of, Virginia 3762. Montgomery (VA), County of, Virginia 3763. Norfolk (VA), City of, Virginia 3764. Northampton (VA), County of, Virginia 3765. Northumberland (VA), County of, Virginia 3766. Norton (VA), City of, Virginia 3767. Page (VA), County of, Virginia 3768. Patrick (VA), County of, Virginia 3769. Pittsylvania (VA), County of, Virginia 3770. Portsmouth (VA), City of, Virginia DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3771. Prince George (VA), County of, Virginia 3772. Prince William (VA), County of, Virginia 3773. Pulaski (VA), County of, Virginia 3774. Radford (VA), City of, Virginia 3775. Richlands (VA), Town of, Virginia 3776. Richmond (VA), City of, Virginia 3777. Richmond (VA), County of, Virginia 3778. Roanoke (VA), City of, Virginia 3779. Roanoke (VA), County of, Virginia 3780. Rockbridge (VA), County of, Virginia 3781. Russell (VA), County of, Virginia 3782. Salem (VA), City of, Virginia 3783. Scott (VA), County of, Virginia 3784. Shenandoah (VA), County of, Virginia 3785. Smyth (VA), County of, Virginia 3786. Stafford (VA), County of, Virginia 3787. Tazewell (VA), County of, Virginia 3788. Virginia Beach (VA), City of (Sheriff), Virginia 3789. Virginia Beach (VA), City of, Virginia 3790. Warren (VA), County of, Virginia 3791. Washington (VA), County of, Virginia 3792. Waynesboro (VA), City of, Virginia 3793. Westmoreland (VA), County of, Virginia 3794. Winchester (VA), City of, Virginia 3795. Wise (VA), County of, Virginia 3796. Wythe (VA), County of, Virginia 3797. Anacortes (WA), City of, Washington 3798. Bainbridge Island (WA), City of, Washington 3799. Burlington (WA), City of, Washington 3800. Chelan (WA), County of, Washington 3801. Clallam (WA), County of, Washington 3802. Clark (WA), County of, Washington 3803. Everett (WA), City of, Washington 3804. Franklin (WA), County of, Washington 3805. Island (WA), County of, Washington 3806. Jefferson (WA), County of, Washington 3807. Kent (WA), City of, Washington 3808. King (WA), County of, Washington 3809. Kirkland (WA), City of, Washington 3810. Kitsap (WA), County of, Washington 3811. Kittitas (WA), County of, Washington 3812. La Conner School District (WA), Washington 3813. Lakewood (WA), City of, Washington 3814. Lewis (WA), County of, Washington 3815. Lincoln (WA), County of, Washington 3816. Mount Vernon (WA), City of, Washington 3817. Mount Vernon School District (WA), Washington 3818. Olympia (WA), City of, Washington 3819. Pierce (WA), County of, Washington 3820. San Juan (WA), County of, Washington 3821. Seattle (WA), City of, Washington 3822. Sedro-Woolley (WA), City of, Washington 3823. Sedro-Woolley School District (WA), Washington 3824. Skagit (WA), County of, Washington 3825. Snohomish (WA), County of, Washington 3826. Spokane (WA), City of, Washington 3827. Spokane (WA), County of, Washington 3828. Tacoma (WA), City of, Washington 3829. Thurston (WA), County of, Washington 3830. Vancouver (WA), City of, Washington 3831. Walla Walla (WA), County of, Washington 3832. Whatcom (WA), County of, Washington 3833. Whitman (WA), County of, Washington 3834. Addison (a/k/a) Webster Springs (WV), Town of, West Virginia 3835. Barbour (WV), County of, West Virginia 3836. Barboursville (WV), Village of, West Virginia 3837. Beckley (WV), City of, West Virginia 3838. Belington (WV), City of, West Virginia 3839. Belle (WV), Town of, West Virginia 3840. Berkeley (WV), County of, West Virginia 3841. Bluefield (WV), City of, West Virginia 3842. Board of Education of Mason County Public Schools (WV), West Virginia 3843. Boone (WV), County of, West Virginia 3844. Braxton (WV), County of, West Virginia 3845. Brooke (WV), County of, West Virginia 3846. Buckhannon (WV), City of, West Virginia 3847. Cabell (WV), County of, West Virginia 3848. Calhoun (WV), County of, West Virginia 3849. Ceredo (WV), Town of, West Virginia DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3850. Charles Town (WV), City of, West Virginia 3851. Chesapeake (WV), Town of, West Virginia 3852. Clarksburg (WV), City of, West Virginia 3853. Clay (WV), County of, West Virginia 3854. Clendenin (WV), Town of, West Virginia 3855. Delbarton (WV), Town of, West Virginia 3856. Doddridge (WV), County of, West Virginia 3857. Dunbar (WV), City of, West Virginia 3858. Eleanor (WV), Town of, West Virginia 3859. Elizabeth (WV), Town of, West Virginia 3860. Fairmont (WV), City of, West Virginia 3861. Fayette (WV), County of, West Virginia 3862. Fort Gay (WV), Town of, West Virginia 3863. Gauley Bridge (WV), Town of, West Virginia 3864. Gilmer (WV), County of, West Virginia 3865. Glenville (WV), Town of, West Virginia 3866. Grafton (WV), City of, West Virginia 3867. Grant (WV), County of, West Virginia 3868. Granville (WV), Town of, West Virginia 3869. Greenbrier (WV), County of, West Virginia 3870. Hamlin (WV), Town of, West Virginia 3871. Hancock (WV), County of, West Virginia 3872. Hardy (WV), County of, West Virginia 3873. Harrison (WV), County of, West Virginia 3874. Harrisville (WV), Town of, West Virginia 3875. Huntington (WV), City of, West Virginia 3876. Hurricane (WV), City of, West Virginia 3877. Jackson (WV), County of, West Virginia 3878. Jefferson (WV), County of, West Virginia 3879. Junior (WV), Town of, West Virginia 3880. Kanawha (WV), County of, West Virginia 3881. Kenova (WV), City of, West Virginia 3882. Lewis (WV), County of, West Virginia 3883. Logan (WV), City of, West Virginia 3884. Logan (WV), County of, West Virginia 3885. Madison (WV), Town of, West Virginia 3886. Man (WV), Town of, West Virginia 3887. Marion (WV), County of, West Virginia 3888. Marshall (WV), County of, West Virginia 3889. Mason (WV), County of, West Virginia 3890. Matewan (WV), Town of, West Virginia 3891. McDowell (WV), County of, West Virginia 3892. Milton (WV), City of, West Virginia 3893. Mineral (WV), County of, West Virginia 3894. Mingo (WV), County of, West Virginia 3895. Monongalia (WV), County of, West Virginia 3896. Monroe (WV), County of, West Virginia 3897. Montgomery (WV), City of, West Virginia 3898. Morgan (WV), County of, West Virginia 3899. Moundsville (WV), City of, West Virginia 3900. Mullens (WV), City of, West Virginia 3901. Nicholas (WV), County of, West Virginia 3902. Nitro (WV), City of, West Virginia 3903. Oceana (WV), Town of, West Virginia 3904. Ohio (WV), County of, West Virginia 3905. Parkersburg (WV), City of, West Virginia 3906. Pendleton (WV), County of, West Virginia 3907. Philippi (WV), City of, West Virginia 3908. Pleasants (WV), County of, West Virginia 3909. Pocahontas (WV), County of, West Virginia 3910. Point Pleasant (WV), City of, West Virginia 3911. Preston (WV), County of, West Virginia 3912. Princeton (WV), City of, West Virginia 3913. Putnam (WV), County of, West Virginia 3914. Quinwood (WV), Town of, West Virginia 3915. Rainelle (WV), Town of, West Virginia 3916. Randolph (WV), County of, West Virginia 3917. Ravenswood (WV), Town of, West Virginia 3918. Richwood (WV), City of, West Virginia 3919. Ripley (WV), City of, West Virginia DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 3920. Ritchie (WV), County of, West Virginia 3921. Roane (WV), County of, West Virginia 3922. Romney (WV), Town of, West Virginia 3923. Rupert (WV), Town of, West Virginia 3924. Saint Albans (WV), City of, West Virginia 3925. Smithers (WV), City of, West Virginia 3926. Sophia (WV), Town of, West Virginia 3927. South Charleston (WV), City of, West Virginia 3928. Spencer (WV), City of, West Virginia 3929. St. Marys (WV), City of, West Virginia 3930. Star City (WV), Town of, West Virginia 3931. Summers (WV), County of, West Virginia 3932. Summersville (WV), City of, West Virginia 3933. Sutton (WV), Town of, West Virginia 3934. Taylor (WV), County of, West Virginia 3935. Tucker (WV), County of, West Virginia 3936. Tyler (WV), County of, West Virginia 3937. Upshur (WV), County of, West Virginia 3938. Vienna (WV), City of, West Virginia 3939. Wayne (WV), County of, West Virginia 3940. Webster (WV), County of, West Virginia 3941. Weirton (WV), City of, West Virginia 3942, West Hamlin (WV), Town of, West Virginia 3943. Wetzel (WV), County of, West Virginia 3944. White Sulphur Springs (WV), City of, West Virginia 3945. Whitesville (WV), Town of, West Virginia 3946. Williamstown (WV), City of, West Virginia 3947. Winfield (WV), City of, West Virginia 3948. Wirt (WV), County of, West Virginia 3949. Wood (WV), County of, West Virginia 3950. Adams (WI), County of, Wisconsin 3951. Ashland (WI), County of, Wisconsin 3952. Barron (WI), County of, Wisconsin 3953. Bayfield (WI), County of, Wisconsin 3954. Brown (WI), County of, Wisconsin 3955. Buffalo (WI), County of, Wisconsin 3956. Burnett (WI), County of, Wisconsin 3957. Calumet (WI), County of, Wisconsin 3958. Chippewa (WI), County of, Wisconsin 3959. Clark (WI), County of, Wisconsin 3960. Columbia (WI), County of, Wisconsin 3961. Crawford (WI), County of, Wisconsin 3962. Cudahy (WI), City of, Wisconsin 3963. Dane (WI), County of, Wisconsin 3964. Dodge (WI), County of, Wisconsin 3965. Door (WI), County of, Wisconsin 3966. Douglas (WI), County of, Wisconsin 3967. Dunn (WI), County of, Wisconsin 3968. Eau Claire (WI), County of, Wisconsin 3969. Florence (WI), County of, Wisconsin 3970. Fond du Lac (WI), County of, Wisconsin 3971. Forest (WI), County of, Wisconsin 3972. Franklin (WI), City of, Wisconsin 3973. Grant (WI), County of, Wisconsin 3974. Green (WI), County of, Wisconsin 3975. Green Lake (WI), County of, Wisconsin 3976. Greenfield (WI), City of, Wisconsin 3977. Iowa (WI), County of, Wisconsin 3978. Iron (WI), County of, Wisconsin 3979. Jackson (WI), County of, Wisconsin 3980. Janesville (WI), City of, Wisconsin 3981. Jefferson (WI), County of, Wisconsin 3982. Juneau (WI), County of, Wisconsin 3983. Kenosha (WI), City of, Wisconsin 3984. Kenosha (WI), County of, Wisconsin 3985. Kewaunee (WI), County of, Wisconsin 3986. LaCrosse (WI), County of, Wisconsin 3987. Lafayette (WI), County of, Wisconsin 3988. Langlade (WI), County of, Wisconsin 3989. Lincoln (WI), County of, Wisconsin 3990. Manitowoc (WI), County of, Wisconsin 3991. Marathon (WI), County of, Wisconsin 3992. Marinette (WI), City of, Wisconsin 3993. Marinette (WI), County of, Wisconsin 3994. Marquette (WI), County of, Wisconsin 3995. Menominee (WI), County of, Wisconsin 3996. Milwaukee (WI), City of, Wisconsin 3997. Milwaukee (WI), County of, Wisconsin 3998. Monroe (WI), County of, Wisconsin 3999. Mount Pleasant (WI), Village of, Wisconsin 4000. Oak Creek (WI), City of, Wisconsin 4001. Oconto (WI), County of, Wisconsin 4002. Oneida (WI), County of, Wisconsin 4003. Outagamie (WI), County of, Wisconsin 4004. Ozaukee (WI), County of, Wisconsin DRAFT - SUBJECT TO CHANGE FOR QUALITY CONTROL PURPOSES 4005. Pepin (WI), County of, Wisconsin 4006. Pierce (WI), County of, Wisconsin 4007. Pleasant Prairie (WI), Village of, Wisconsin 4008. Portage (WI), County of, Wisconsin 4009. Price (WI), County of, Wisconsin 4010. Racine (WI), County of, Wisconsin 4011. Richland (WI), County of, Wisconsin 4012. Rock (WI), County of, Wisconsin 4013. Rusk (WI), County of, Wisconsin 4014. Sauk (WI), County of, Wisconsin 4015. Sawyer (WI), County of, Wisconsin 4016. Shawano (WI), County of, Wisconsin 4017. Sheboygan (WI), County of, Wisconsin 4018. South Milwaukee (WI), City of, Wisconsin 4019. St. Croix (WI), County of, Wisconsin 4020. Sturtevant (WI), Village of, Wisconsin 4021. Superior (WI), City of, Wisconsin 4022. Taylor (WI), County of, Wisconsin 4023. Trempealeau (WI), County of, Wisconsin 4024. Union Grove (WI), Village of, Wisconsin 4025. Vernon (WI), County of, Wisconsin 4026. Vilas (WI), County of, Wisconsin 4027. Walworth (WI), County of, Wisconsin 4028. Washburn (WI), County of, Wisconsin 4029. Washington (WI), County of, Wisconsin 4030. Waukesha (WI), County of, Wisconsin 4031. Waupaca (WI), County of, Wisconsin 4032. Waushara (WI), County of, Wisconsin 4033. Wauwatosa (WI), City of, Wisconsin 4034. West Allis (WI), City of, Wisconsin 4035. Winnebago (WI), County of, Wisconsin 4036. Wood (WI), County of, Wisconsin 4037. Yorkville (WI), Village of, Wisconsin 4038. Carbon (WY), County of, Wyoming 4039. Casper (WY), City of, Wyoming 4040. Cheyenne (WY), City of, Wyoming 4041. Green River (WY), City of, Wyoming 4042. Riverton (WY), City of, Wyoming 4043. Rock Springs (WY), City of, Wyoming 4044. Sweetwater (WY), County of, Wyoming EXHIBIT D [Intentionally Omitted] 62 revised July30, 2021 EXHIBIT E List of Opioid Remediation Uses Schedule A Core Strategies States and Qualifying Block Grantees shall choose from among the abatement strategies listed in Schedule B. However, priority shall be given to the following core abatement strategies ("Core Strategies"). 1 A. NALOXONE OR OTHER FDA -APPROVED DRUG TO Expand training for first responders, schools, community support groups and families; and 2. Increase distribution to individuals who are uninsured or whose insurance does not cover the needed service. B. MEDICATION -ASSISTED TREATMENT ("MAT') DISTRIBUTION AND OTHER OPIOID-RELATED TREATMENT Increase distribution of MAT to individuals who are uninsured or whose insurance does not cover the needed service; 2. Provide education to school -based and youth -focused programs that discourage or prevent misuse; Provide MAT education and awareness training to healthcare providers, EMTs, law enforcement, and other first responders; and 4. Provide treatment and recovery support services such as residential and inpatient treatment, intensive outpatient treatment, outpatient therapy or counseling, and recovery housing that allow or integrate medication and with other support services. As used in this Schedule A, words like "expand," "fund," "provide" or the like shall not indicate a preference for new or existing programs. 63 revised July 30, 2021 C. PREGNANT & POSTPARTUM WOMEN Expand Screening, Brief Intervention, and Referral to Treatment ("SBIRT') services to non -Medicaid eligible or uninsured pregnant women; 2. Expand comprehensive evidence -based treatment and recovery services, including MAT, for women with co- occurring Opioid Use Disorder ("OUD") and other Substance Use Disorder ("SUD")/Mental Health disorders for uninsured individuals for up to 12 months postpartum; and 3. Provide comprehensive wrap -around services to individuals with OUD, including housing, transportation, job placement/training, and childcare. D. EXPANDING TREATMENT FOR NEONATAL ABSTINENCE SYNDROME ("NAS") Expand comprehensive evidence -based and recovery support for NAS babies; Expand services for better continuum of care with infant - need dyad; and 3. Expand long-term treatment and services for medical monitoring of NAS babies and their families. E. EXPANSION OF WARM HAND-OFF PROGRAMS AND RECOVERY SERVICES Expand services such as navigators and on -call teams to begin MAT in hospital emergency departments; 2. Expand warm hand-off services to transition to recovery services; Broaden scope of recovery services to include co-occurring SUD or mental health conditions; 4. Provide comprehensive wrap -around services to individuals in recovery, including housing, transportation, job placement/training, and childcare; and 5. Hire additional social workers or other behavioral health workers to facilitate expansions above. ul revised July 30, 2021 F. TREATMENT FOR INCARCERATED POPULATION Provide evidence -based treatment and recovery support, including MAT for persons with OUD and co-occurring SUD/MH disorders within and transitioning out of the criminal justice system; and 2. Increase funding for jails to provide treatment to inmates with OUD. G. PREVENTION PROGRAMS Funding for media campaigns to prevent opioid use (similar to the FDA's "Real Cost" campaign to prevent youth from misusing tobacco); 2. Funding for evidence -based prevention programs in schools; 3. Funding for medical provider education and outreach regarding best prescribing practices for opioids consistent with the 2016 CDC guidelines, including providers at hospitals (academic detailing); 4. Funding for community drug disposal programs; and 5. Funding and training for first responders to participate in pre - arrest diversion programs, post -overdose response teams, or similar strategies that connect at -risk individuals to behavioral health services and supports. H. EXPANDING SYRINGE SERVICE PROGRAMS 1. Provide comprehensive syringe services programs with more wrap -around services, including linkage to OUD treatment, access to sterile syringes and linkage to care and treatment of infectious diseases. I. EVIDENCE -BASED DATA COLLECTION AND RESEARCH ANALYZING THE EFFECTIVENESS OF THE ABATEMENT STRATEGIES WITHIN THE STATE 65 revised July 30, 2021 Schedule B Approved Uses Support treatment of Opioid Use Disorder (OUD) and any co-occurring Substance Use Disorder or Mental Health (SUD/MH) conditions through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, the following: PART ONE: TREATMENT A. TREAT OPIOID USE DISORDER (OUD) Support treatment of Opioid Use Disorder ("OUD") and any co-occurring Substance Use Disorder or Mental Health ("SUDIMFP') conditions through evidence -based or evidence - informed programs or strategies that may include, but are not limited to, those that? 1. Expand availability of treatment for OUD and any co-occurring SUD/MH conditions, including all forms of Medication -Assisted Treatment ("MAT') approved by the U.S. Food and Drug Administration. 2. Support and reimburse evidence -based services that adhere to the American Society of Addiction Medicine ("ASAM') continuum of care for OUD and any co-occurring SUD/MH conditions. 3. Expand telehealth to increase access to treatment for OUD and any co-occurring SUD/MH conditions, including MAT, as well as counseling, psychiatric support, and other treatment and recovery support services. 4. Improve oversight of Opioid Treatment Programs ("OTPs") to assure evidence -based or evidence -informed practices such as adequate methadone dosing and low threshold approaches to treatment. Support mobile intervention, treatment, and recovery services, offered by qualified professionals and service providers, such as peer recovery coaches, for persons with OUD and any co-occurring SUD/MH conditions and for persons who have experienced an opioid overdose. 6. Provide treatment of trauma for individuals with OUD (e.g., violence, sexual assault, human trafficking, or adverse childhood experiences) and family members (e.g., surviving family members after an overdose or overdose fatality), and training of health care personnel to identify and address such trauma. 7. Support evidence -based withdrawal management services for people with OUD and any co-occurring mental health conditions. 2 As used in this Schedule B, words like "expand," "fund," "provide" or the like shall not indicate a preference for new or existing programs. revised July 30, 2021 8. Provide training on MAT for health care providers, first responders, students, or other supporting professionals, such as peer recovery coaches or recovery outreach specialists, including telementoring to assist community -based providers in rural or underserved areas. 9. Support workforce development for addiction professionals who work with persons with OUD and any co-occurring SUD/MIl conditions. 10. Offer fellowships for addiction medicine specialists for direct patient care, instructors, and clinical research for treatments. 11. Offer scholarships and supports for behavioral health practitioners or workers involved in addressing OUD and any co-occurring SUD/MH or mental health conditions, including, but not limited to, training, scholarships, fellowships, loan repayment programs, or other incentives for providers to work in rural or underserved areas. 12. Provide funding and training for clinicians to obtain a waiver under the federal Drug Addiction Treatment Act of 2000 ("DATA 2000") to prescribe MAT for OUD, and provide technical assistance and professional support to clinicians who have obtained a DATA 2000 waiver. 13. Disseminate web -based training curricula, such as the American Academy of Addiction Psychiatry's Provider Clinical Support Service—Opioids web -based training curriculum and motivational interviewing. 14. Develop and disseminate new curricula, such as the American Academy of Addiction Psychiatry's Provider Clinical Support Service for Medication —Assisted Treatment. B. SUPPORT PEOPLE IN TREATMENT AND RECOVERY Support people in recovery from OUD and any co-occurring SUD/MH conditions through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, the programs or strategies that: 1. Provide comprehensive wrap -around services to individuals with OUD and any co- occurring SUD/MH conditions, including housing, transportation, education, job placement, job training, or childcare. 2. Provide the full continuum of care of treatment and recovery services for OUD and any co-occurring SUD/MH conditions, including supportive housing, peer support services and counseling, community navigators, case management, and connections to community -based services. 3. Provide counseling, peer -support, recovery case management and residential treatment with access to medications for those who need it to persons with OUD and any co-occurring SUD/MH conditions. 67 revised July 30, 2021 4. Provide access to housing for people with OUD and any co-occurring SUD/MH conditions, including supportive housing, recovery housing, housing assistance programs, training for housing providers, or recovery housing programs that allow or integrate FDA -approved mediation with other support services. 5. Provide community support services, including social and legal services, to assist in deinstitutionalizing persons with OUD and any co-occurring SUD/MH conditions. 6. Support or expand peer -recovery centers, which may include support groups, social events, computer access, or other services for persons with OUD and any co- occurring SUD/MH conditions. 7. Provide or support transportation to treatment or recovery programs or services for persons with OUD and any co-occurring SUD/MH conditions. 8. Provide employment training or educational services for persons in treatment for or recovery from OUD and any co-occurring SUD/MH conditions. 9. Identify successful recovery programs such as physician, pilot, and college recovery programs, and provide support and technical assistance to increase the number and capacity of high -quality programs to help those in recovery. 10. Engage non -profits, faith -based communities, and community coalitions to support people in treatment and recovery and to support family members in their efforts to support the person with OUT) in the family. 11. Provide training and development of procedures for government staff to appropriately interact and provide social and other services to individuals with or in recovery from OUD, including reducing stigma. 12. Support stigma reduction efforts regarding treatment and support for persons with OUD, including reducing the stigma on effective treatment. 13. Create or support culturally appropriate services and programs for persons with OUD and any co-occurring SUD/MH conditions, including new Americans. 14. Create and/or support recovery high schools. 15. Hire or train behavioral health workers to provide or expand any of the services or supports listed above. C. CONNECT PEOPLE WHO NEED HELP TO THE HELP THEY NEED (CONNECTIONS TO CARE) Provide connections to care for people who have —or are at risk of developing—OUD and any co-occurring SUD/MH conditions through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, those that: W revised July30, 2021 1. Ensure that health care providers are screening for OUD and other risk factors and know how to appropriately counsel and treat (or refer if necessary) a patient for OUD treatment. 2. Fund SBIRT programs to reduce the transition from use to disorders, including SBIRT services to pregnant women who are uninsured or not eligible for Medicaid. 3. Provide training and long-term implementation of SBIRT in key systems (health, schools, colleges, criminal justice, and probation), with a focus on youth and young adults when transition from misuse to opioid disorder is common. 4. Purchase automated versions of SBIRT and support ongoing costs of the technology. 5. Expand services such as navigators and on -call teams to begin MAT in hospital emergency departments. 6. Provide training for emergency room personnel treating opioid overdose patients on post -discharge planning, including community referrals for MAT, recovery case management or support services. 7. Support hospital programs that transition persons with OUD and any co-occurring SUD/MH conditions, or persons who have experienced an opioid overdose, into clinically appropriate follow-up care through a bridge clinic or similar approach. 8. Support crisis stabilization centers that serve as an alternative to hospital emergency departments for persons with OUD and any co-occurring SUD/MH conditions or persons that have experienced an opioid overdose. 9. Support the work of Emergency Medical Systems, including peer support specialists, to connect individuals to treatment or other appropriate services following an opioid overdose or other opioid-related adverse event. 10. Provide funding for peer support specialists or recovery coaches in emergency departments, detox facilities, recovery centers, recovery housing, or similar settings; offer services, supports, or connections to care to persons with OUD and any co- occurring SUD/MH conditions or to persons who have experienced an opioid overdose. 11. Expand warm hand-off services to transition to recovery services. 12. Create or support school -based contacts that parents can engage with to seek immediate treatment services for their child; and support prevention, intervention, treatment, and recovery programs focused on young people. 13. Develop and support best practices on addressing OUD in the workplace. 14. Support assistance programs for health care providers with OUD. :' revised July 30, 2021 15. Engage non -profits and the faith community as a system to support outreach for treatment. 16. Support centralized call centers that provide information and connections to appropriate services and supports for persons with OUD and any co-occurring SUD/MH conditions. D. ADDRESS THE NEEDS OF CRIMINAL JUSTICE -INVOLVED PERSONS Address the needs of persons with OUD and any co-occurring SUD/MH conditions who are involved in, are at risk of becoming involved in, or are transitioning out of the criminal justice system through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, those that: Support pre -arrest or pre -arraignment diversion and deflection strategies for persons with OUD and any co-occurring SUD/MH conditions, including established strategies such as: 1. Self -referral strategies such as the Angel Programs or the Police Assisted Addiction Recovery Initiative ("PAARP'); 2. Active outreach strategies such as the Drug Abuse Response Team ("DART') model; 3. "Naloxone Plus" strategies, which work to ensure that individuals who have received naloxone to reverse the effects of an overdose are then linked to treatment programs or other appropriate services; 4. Officer prevention strategies, such as the Law Enforcement Assisted Diversion ("LEAD") model; 5. Officer intervention strategies such as the Leon County, Florida Adult Civil Citation Network or the Chicago Westside Narcotics Diversion to Treatment Initiative; or 6. Co -responder and/or alternative responder models to address OUD-related 911 calls with greater SUD expertise. 2. Support pre-trial services that connect individuals with OUD and any co-occurring SUD/MH conditions to evidence -informed treatment, including MAT, and related services. 3. Support treatment and recovery courts that provide evidence -based options for persons with OUD and any co-occurring SUD/MH conditions. 4. Provide evidence -informed treatment, including MAT, recovery support, harm reduction, or other appropriate services to individuals with OUD and any co- occurring SUD/MH conditions who are incarcerated in jail or prison. %ll; revised July 30, 2021 Provide evidence -informed treatment, including MAT, recovery support, harm reduction, or other appropriate services to individuals with OUD and any co- occurring SUD/MH conditions who are leaving jail or prison or have recently left jail or prison, are on probation or parole, are under community corrections supervision, or are in re-entry programs or facilities. 6. Support critical time interventions ("CTT'), particularly for individuals living with dual -diagnosis OUD/serious mental illness, and services for individuals who face immediate risks and service needs and risks upon release from correctional settings. 7. Provide training on best practices for addressing the needs of criminal justice - involved persons with OLD and any co-occurring SUD/MH conditions to law enforcement, correctional, or judicial personnel or to providers of treatment, recovery, harm reduction, case management, or other services offered in connection with any of the strategies described in this section. E. ADDRESS THE NEEDS OF PREGNANT OR PARENTING WOMEN AND THEIR FAMILIES, INCLUDING BABIES WITH NEONATAL ABSTINENCE Address the needs of pregnant or parenting women with OUD and any co-occurring SUD/MH conditions, and the needs of their families, including babies with neonatal abstinence syndrome ("NAS"), through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, those that: 1. Support evidence -based or evidence -informed treatment, including MAT, recovery services and supports, and prevention services for pregnant women —or women who could become pregnant —who have OUD and any co-occurring SUD/MH conditions, and other measures to educate and provide support to families affected by Neonatal Abstinence Syndrome. 2. Expand comprehensive evidence -based treatment and recovery services, including MAT, for uninsured women with OUD and any co-occurring SUD/MH conditions for up to 12 months postpartum. 3. Provide training for obstetricians or other healthcare personnel who work with pregnant women and their families regarding treatment of OUD and any co-occurring SLD/MH conditions. 4. Expand comprehensive evidence -based treatment and recovery support for NAS babies; expand services for better continuum of care with infant -need dyad; and expand long-term treatment and services for medical monitoring of NAS babies and their families. 5. Provide training to health care providers who work with pregnant or parenting women on best practices for compliance with federal requirements that children born with NAS get referred to appropriate services and receive a plan of safe care. 71 revised July 30, 2021 6. Provide child and family supports for parenting women with OUD and any co- occurring SUD/MH conditions. 7. Provide enhanced family support and child care services for parents with OUD and any co-occurring SUD/MH conditions. 8. Provide enhanced support for children and family members suffering trauma as a result of addiction in the family; and offer trauma -informed behavioral health treatment for adverse childhood events. 9. Offer home -based wrap -around services to persons with, OUD and any co-occurring SUD/MH conditions, including, but not limited to, parent skills training. 10. Provide support for Children's Services —Fund additional positions and services, including supportive housing and other residential services, relating to children being removed from the home and/or placed in foster care due to custodial opioid use. PART TWO: PREVENTION F. PREVENT OVER -PRESCRIBING AND ENSURE APPROPRIATE PRESCRIBING AND DISPENSING OF OPIOIDS Support efforts to prevent over -prescribing and ensure appropriate prescribing and dispensing of opioids through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, the following: 1. Funding medical provider education and outreach regarding best prescribing practices for opioids consistent with the Guidelines for Prescribing Opioids for Chronic Pain from the U.S. Centers for Disease Control and Prevention, including providers at hospitals (academic detailing). 2. Training for health care providers regarding safe and responsible opioid prescribing, dosing, and tapering patients off opioids. 3. Continuing Medical Education (CME) on appropriate prescribing of opioids. 4. Providing Support for non-opioid pain treatment alternatives, including training providers to offer or refer to multi -modal, evidence -informed treatment of pain. 5. Supporting enhancements or improvements to Prescription Drug Monitoring Programs ("PDMPs"), including, but not limited to, improvements that: 1. Increase the number of prescribers using PDMPs; 2. Improve point -of -care decision -making by increasing the quantity, quality, or format of data available to prescribers using PDMPs, by improving the interface that prescribers use to access PDMP data, or both; or 72 revised July30, 2021 " 3. Enable states to use PDMP data in support of surveillance or intervention strategies, including MAT referrals and follow-up for individuals identified within PDMP data as likely to experience OUD in a manner that complies with all relevant privacy and security laws and rules. 6. Ensuring PDMPs incorporate available overdose/naloxone deployment data, including the United States Department of Transportation's Emergency Medical Technician overdose database in a manner that complies with all relevant privacy and security laws and rules. 7. Increasing electronic prescribing to prevent diversion or forgery. 8. Educating dispensers on appropriate opioid dispensing. Support efforts to discourage or prevent misuse of opioids through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, the following: 1. Funding media campaigns to prevent opioid misuse. 2. Corrective advertising or affirmative public education campaigns based on evidence. 3. Public education relating to drug disposal. 4. Drug take -back disposal or destruction programs. 5. Funding community anti -drug coalitions that engage in drug prevention efforts. 6. Supporting community coalitions in implementing evidence -informed prevention, such as reduced social access and physical access, stigma reduction —including staffing, educational campaigns, support for people in treatment or recovery, or training of coalitions in evidence -informed implementation, including the Strategic Prevention Framework developed by the U.S. Substance Abuse and Mental Health Services Administration ("SAMHSA"). 7. Engaging non -profits and faith -based communities as systems to support prevention. 8. Funding evidence -based prevention programs in schools or evidence -informed school and community education programs and campaigns for students, families, school employees, school athletic programs, parent -teacher and student associations, and others. 9. School -based or youth -focused programs or strategies that have demonstrated effectiveness in preventing drug misuse and seem likely to be effective in preventing the uptake and use of opioids. 73 revised July 30, 2021 10. Create or support community -based education or intervention services for families, youth, and adolescents at risk for OUD and any co-occurring SUD/NM conditions. 11. Support evidence -informed programs or curricula to address mental health needs of young people who may be at risk of misusing opioids or other drugs, including emotional modulation and resilience skills. 12. Support greater access to mental health services and supports for young people, including services and supports provided by school nurses, behavioral health workers or other school staff, to address mental health needs in young people that (when not properly addressed) increase the risk of opioid or another drug misuse. H. PREVENT OVERDOSE DEATHS AND OTHER HARMS (HARM REDUCTION) Support efforts to prevent or reduce overdose deaths or other opioid-related harms through evidence -based or evidence -informed programs or strategies that may include, but are not limited to, the following: 1. Increased availability and distribution of naloxone and other drugs that treat overdoses for first responders, overdose patients, individuals with OUD and their friends and family members, schools, community navigators and outreach workers, persons being released from jail or prison, or other members of the general public. 2. Public health entities providing free naloxone to anyone in the community. 3. Training and education regarding naloxone and other drugs that treat overdoses for first responders, overdose patients, patients taking opioids, families, schools, community support groups, and other members of the general public. 4. Enabling school nurses and other school staff to respond to opioid overdoses, and provide them with naloxone, training, and support. 5. Expanding, improving, or developing data tracking software and applications for overdoses/naloxone revivals. 6. Public education relating to emergency responses to overdoses. 7. Public education relating to immunity and Good Samaritan laws. 8. Educating first responders regarding the existence and operation of immunity and Good Samaritan laws. 9. Syringe service programs and other evidence -informed programs to reduce harms associated with intravenous drug use, including supplies, staffing, space, peer support services, referrals to treatment, fentanyl checking, connections to care, and the full range of harm reduction and treatment services provided by these programs. 74 revised July 30, 2021 10. Expanding access to testing and treatment for infectious diseases such as HIV and Hepatitis C resulting from intravenous opioid use. 11. Supporting mobile units that offer or provide referrals to harm reduction services, treatment, recovery supports, health care, or other appropriate services to persons that use opioids or persons with OUD and any co-occurring SUD/MH conditions. 12. Providing training in harm reduction strategies to health care providers, students, peer recovery coaches, recovery outreach specialists, or other professionals that provide care to persons who use opioids or persons with OUD and any co-occurring SUD/MH conditions. 13. Supporting screening for fentanyl in routine clinical toxicology testing. PART THREE: OTHER STRATEGIES I. In addition to items in section C, D and H relating to first responders, support the following: 1. Education of law enforcement or other first responders regarding appropriate practices and precautions when dealing with fentanyl or other drugs. 2. Provision of wellness and support services for first responders and others who experience secondary trauma associated with opioid-related emergency events. J. LEADERSHIP, PLANNING AND COORDINATION Support efforts to provide leadership, planning, coordination, facilitation, training and technical assistance to abate the opioid epidemic through activities, programs, or strategies that may include, but are not limited to, the following: 1. Statewide, regional, local or community regional planning to identify root causes of addiction and overdose, goals for reducing harms related to the opioid epidemic, and areas and populations with the greatest needs for treatment intervention services, and to support training and technical assistance and other strategies to abate the opioid epidemic described in this opioid abatement strategy list. 2. A dashboard to (a) share reports, recommendations, or plans to spend opioid settlement funds; (b) to show how opioid settlement funds have been spent; (c) to report program or strategy outcomes; or (d) to track, share or visualize key opioid- or health -related indicators and supports as identified through collaborative statewide, regional, local or community processes. 3. Invest in infrastructure or staffing at government or not -for -profit agencies to support collaborative, cross -system coordination with the purpose of preventing 75 revised July 30, 2021 overprescribing, opioid misuse, or opioid overdoses, treating those with OUD and any co-occurring SUD/MH conditions, supporting them in treatment or recovery, connecting them to care, or implementing other strategies to abate the opioid epidemic described in this opioid abatement strategy list. 4. Provide resources to staff government oversight and management of opioid abatement programs. K. TRAINING In addition to the training referred to throughout this document, support training to abate the opioid epidemic through activities, programs, or strategies that may include, but are not limited to, those that: 1. Provide funding for staff training or networking programs and services to improve the capability of government, community, and not -for -profit entities to abate the opioid crisis. 2. Support infrastructure and staffing for collaborative cross -system coordination to prevent opioid misuse, prevent overdoses, and treat those with OUD and any co- occurring SUD/MH conditions, or implement other strategies to abate the opioid epidemic described in this opioid abatement strategy list (e.g., health care, primary care, pharmacies, PDMPs, etc.). L. RESEARCH Support opioid abatement research that may include, but is not limited to, the following: 1. Monitoring, surveillance, data collection and evaluation of programs and strategies described in this opioid abatement strategy list. 2. Research non-opioid treatment of chronic pain. Research on improved service delivery for modalities such as SBIRT that demonstrate promising but mixed results in populations vulnerable to opioid use disorders. 4. Research on novel harm reduction and prevention efforts such as the provision of fentanyl test strips. 5. Research on innovative supply-side enforcement efforts such as improved detection of mail -based delivery of synthetic opioids. 6. Expanded research on swift/certain/fair models to reduce and deter opioid misuse within criminal justice populations that build upon promising approaches used to address other substances (e.g., Hawaii HOPE and Dakota 24/7). 76 revised July 30, 2021 7. Epidemiological surveillance of OUD-related behaviors in critical populations, including individuals entering the criminal justice system, including, but not limited to approaches modeled on the Arrestee Drug Abuse Monitoring ("ADAM') system. 8. Qualitative and quantitative research regarding public health risks and harm reduction opportunities within illicit drug markets, including surveys of market participants who sell or distribute illicit opioids. 9. Geospatial analysis of access barriers to MAT and their association with treatment engagement and treatment outcomes. 77 revised July 30, 2021 EXHIBIT F List of States and Overall Allocation Percentages Alabama 1.6491291250% Alaska 0.2619596435% American Samoa 0.0174609943% Arizona 2.3755949882% Arkansas 0.9713856799% California 9.9213830698% Colorado 1.6616291219% Connecticut 1.3399918096% Delaware 0.4951498892% District of Columbia 0.2078293111% Florida 7.0259134409% Georgia 2.7882080114% Guam 0.0513089852% Hawaii 0.3443244815% Idaho 0.5297889112% Illinois 3.3263363702% Indiana 2.2168933059% Iowa 0.7611448951% Kansas 0.8077259480% Kentucky 2.1047890943% Louisiana 1.5229786769% Maine 0.5651006743% Maryland 2.1106090494% Massachusetts 2.3035761083% Michigan 3.4020234989% Minnesota 1.2972597706% Mississippi 0.8942157086% Missouri 2.0056475170% Montana 0.3457758645% N. Mariana Islands 0.0188110001% Nebraska 0.4313919963% Nevada 1.2547155559% New Hampshire 0.6311550689% New Jersey 2.7551354545% New Mexico 0.8623532836% New York 5.3903813405% 78 revised July 30, 2021 North Carolina 3.2502525994% North Dakota 0.1878951417% Ohio 4.3567051408% Oklahoma 0.3053135060% Oregon 1.4309172888% Pennsylvania 4.5882419559% Puerto Rico 0.7295764154% Rhode Island 0.4942737092% South Carolina 1.5905629933% South Dakota 0.2193860923% Tennessee 2.6881474977% Texas 6.2932157196% Utah 1.1945774957% Vermont 0.2876050633% Virgin Islands 0.0343504215% Virginia 2.2801150757% Washington 2.3189040182% West Vir inia 1.1438786260% Wisconsin 1.7582560561% Wyoming 0.1987475390% 79 revised July30, 2021 EXHIBIT G Subdivisions Eligible to become Participating Subdivisions and Default Subdivision Fund Allocation Percentages The Subdivisions set forth on this Exhibit G are eligible to become Participating Subdivisions. By default, the Subdivisions set forth on this Exhibit G shall include: (1) all Litigating Subdivisions; (2) all counties and parishes in States with functional counties or parishes; (3) all Subdivisions that are the highest level of general purpose government in States without functional counties or parishes; and (4) all other Subdivisions with a population of 10,000 or greater. A State may elect to add any additional Subdivisions to this Exhibit G at any time prior to the Initial Participation Date. Immediately upon the effectiveness of any State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VI.D.3 (or upon the effectiveness of an amendment to any State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VI.D.3) that addresses allocation from the Subdivision Fund, whether before or after the Initial Participation Date, this Exhibit G will automatically be amended to reflect the allocation from the Subdivision Fund pursuant to the State -Subdivision Agreement, Allocation Statute, Statutory Trust, or voluntary redistribution allowed by subsection VI.D.3. For the avoidance of doubt, inclusion on this Exhibit G shall not create any claim for any amount of the Settlement Fund, and no such amounts shall be allocated or distributed to any Subdivision included herein if such Subdivision does not otherwise meet all requirements to receive any such funds pursuant to the Agreement. The Parties recognize the benefits of remediation funds reaching all communities, including through direct payments from the Subdivision Fund. However, to promote efficiency in the use of such funds and avoid administratively -burdensome disbursements that would be too small to add a meaningful abatement response, certain Subdivisions do not receive a direct allocation from the Subdivision Fund. However, such Subdivisions will benefit from Opioid Remediation in their community, and are eligible to receive direct benefits from the Abatement Accounts Fund in their State. All settlement funds, whether allocated to a Settling State, an Abatement Accounts Fund or a Subdivision listed on this Exhibit G can be used for Opioid Remediation in communities not listed herein. As provided by subsection VI.D.4.c, the Allocation Percentages shown below apply to distribution of each Settling State's Subdivision Fund in the absence of a State -Subdivision Agreement, Allocation Statute, or Statutory Trust. The allocation that would have otherwise gone to Subdivisions not listed below as receiving a direct allocation shall be (1) directed to the county or parish in which such Subdivision is located in Settling States with functional counties or parishes if the relevant county or parish is a Participating Subdivision or (2) to the highest - level general purpose government in which such Subdivision is located in Settling States without functional counties or parishes if the relevant highest -level general purpose government is a Participating Subdivision. Where the relevant county, parish or highest -level General Purpose Government is not a Participating Subdivision, allocations of General Purpose Subdivisions not revised July 30, 2021 listed below as eligible to become Participating Subdivisions shall be allocated pursuant to subsection VII L The redirecting of funds described in this paragraph is intended to promote the efficient use of Opioid Remediation funds while keeping, where possible, local control of the distribution of those funds. This Exhibit G will be updated with Subdivisions eligible to become Participating Subdivisions pursuant to subsection I.77. 81 revised July 30, 2021 EXHIBIT H Participation Tier Determination* Participation Settling States as Percentage of Litigating Percentage of Non - Tier of the Payment Subdivisions that Are Litigating Subdivisions Date (beginning Participating with Populations over in Payment Year Subdivisions and/or 10,000 that Are 1) Subdivisions Subject to Participating Subdivisions a Bar, Case -Specific and/or Subdivisions Resolution, or Subject to a Bar, Case - Settlement Class Specific Resolution, or Resolution in effect as of Settlement Class the Payment Date resolution in effect as of (beginning in Payment the Payment Date Year 1) (beginning in Payment Year 1 1 44 95% 90% 2 45 96% 96% 3 46 97% 97% 4 48 98% 97% * The following conditions apply to the determination of Participation Tiers: 1. For the sole purpose of the Participation Tier determination under this Exhibit, the States used to calculate each criterion (including the percentages of Litigating and Non - Litigating Subdivisions in Settling States that are Participating Subdivisions) will include each of the 50 states in the United States, excluding the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. 2. Assessment of Subdivision participation percentage will be national in scope. 3. For purposes of determining Participation Tiers, "Litigating Subdivisions" includes Special Districts that have brought any Released Claims against any Released Entities. Special Districts shall have their population measured as set forth in subsection XIII.C. 4. The percentage of Litigating Subdivisions and percentage of Non -Litigating Subdivisions with populations over 10,000 will be calculated as follows: Each Litigating Subdivision and each Non -Litigating Subdivision with a population over 10,000 in the States used to calculate the Participation Tier will be assigned a metric reflecting both population and severity (the "Population -Severity Metric"). The Population -Severity Metric shall be the Subdivision's population plus the Subdivision's population multiplied by the severity factor for the State of the Subdivision (the severity factors for each State are attached as Exhibit T hereto) and then divided in two, thus giving 50% weight to each of population and population multiplied by the severity factor. The denominator for each percentage shall be the sum total of the Population -Severity Metric for all the Subdivisions in the 82 revised July 30, 2021 relevant category (Litigating Subdivisions or Non -Litigating Subdivisions with populations over 10,000) in the Settling States, notwithstanding that persons may be included within the population (and therefore the Population -Severity Metric) of more than one Subdivision. The numerator will be the sum total of the Population -Severity Metrics of all Subdivisions in the relevant category of Subdivision (i.e., Litigating Subdivisions or Non -Litigating Subdivisions with populations over 10,000) in the Settling States that are either Participating Subdivisions or are subject to a Bar, Case - Specific Resolution, or Settlement Class Resolution, notwithstanding that persons may be included within the population of more than one Subdivision. For the avoidance of doubt, Subdivisions in Non -Settling States are excluded from both the denominator and numerator of the calculations for the percentage of Litigating Subdivisions and percentage of Non -Litigating Subdivisions with populations over 10,000. 5. When the Participation Tier is redetermined annually, Later Participating Subdivisions described in Section VII.E.3 or Section VILE. shall not be included as Participating Subdivisions, and for Subdivisions subject to a Bar, Case -Specific Resolution, or Settlement Class Resolution to be included, the Bar, Case -Specific Resolution, or Settlement Class Resolution must have been in effect both as of the relevant Payment Date and for the entire period since the prior Payment Date. 6. Subdivisions with populations over 10,000 are listed on Exhibit I. 83 revised July 30, 2021 EXHIBIT I Primary Subdivisions and Subdivisions over 10,000 [Distributor Agreement Exhibit I to be inserted] 84 revised July 30, 2021 EXHIBIT J Janssen Predecessors and Former Affiliates The following includes a non-exclusive list of Janssen's predecessors and former affiliates: 1. Janssen Pharmaceutica, Inc. 2. Janssen Pharmaceutica N.V. 3. Janssen-Cilag Manufacturing, LLC 4. Janssen Global Services, LLC 5. Janssen Ortho LLC 6. Janssen Products, LP 7. Janssen Research & Development, LLC 8. Janssen Supply Group, LLC 9. Janssen Scientific Affairs, LLC 10. JOM Pharmaceutical Services, Inc. 11. OMJ Pharmaceuticals, Inc. 12. Ortho-McNeil Finance Co. 13. Ortho-McNeil Pharmaceutical 14. Ortho-McNeil-Janssen Pharmaceuticals 15. Ortho-McNeil Pharmaceutical Services Division 16. Ortho-McNeil Neurologic 17. Patriot Pharmaceuticals, LLC 18. Pricara, Ortho-McNeil-Janssen Pharmaceuticals 19. Alza Corp. 20. Alza Development Corp. 21.Janssen Supply Chain, Alza Corp. 22. Noramco, Inc. 23. Tasmanian Alkaloids PTY LTD. 85 revised July 30, 2021 EXHIBIT K Settlement Participation Form Governmental Entity: State: Authorized Official: Address 1: Address 2: City, State, Zip: Phone: Email: The governmental entity identified above ("Governmental Entity"), in order to obtain and in consideration for the ben s rovided to the Governmental Entity pursuant to the Settlement Agreement dated JuleQE ("Janssen Settlement"), and acting through the undersigned authorized official, his o participate in the Janssen Settlement, release all Released Claims against all Rand agrees as follows. 1. The Governmental Entity Ma f and has reviewed the Janssen Settlement, understands that all terms i E ion and Release have the meanings defined therein, and agrees that by this El on, Go ernmental Entity elects to participate in the Janssen Settlement and beco a P icip 'ng Subdivision as provided therein. 2. The Governmental Entity shall, w 4 d o the Reference Date and prior to the filing of the Consent Judgment, dismiss dice any Released Claims that it has filed. 3. The Governmental Entity agrees to the terms N t a e ettlement pertaining to Subdivisions as defined therein. 4. By agreeing to the terms of the Janssen Settlement and%ecIffi a R leasor, the Governmental Entity is entitled to the benefits provided t re' i ding, if applicable, monetary payments beginning after the Effective Date. 5. The Governmental Entity agrees to use any monies it receives through the Janssen Settlement solely for the purposes provided therein. 6. The Governmental Entity submits to the jurisdiction of the court in the Governmental Entity's state where the Consent Judgment is filed for purposes limited to that court's role as provided in, and for resolving disputes to the extent provided in, the Janssen Settlement. 7. The Governmental Entity has the right to enforce the Janssen Settlement as provided therein. 86 revised July 30, 2021 The Governmental Entity, as a Participating Subdivision, hereby becomes a Releasor for all purposes in the Janssen Settlement, including but not limited to all provisions of Section IV (Release), and along with all departments, agencies, divisions, boards, commissions, districts, instrumentalities of any kind and attorneys, and any person in their official capacity elected or appointed to serve any of the foregoing and any agency, person, or other entity claiming by or through any of the foregoing, and any other entity identified in the definition of Releasor, provides for a release to the fullest extent of its authority. As a Releasor, the Governmental Entity hereby absolutely, unconditionally, and irrevocably covenants not to bring, file, or claim, or to cause, assist or permit to be brought, filed, or claimed, or to otherwise seek to establish liability for any Released Claims against any Released Entity in any forum whatsoever. The releases provided for in the Janssen Settlement are intended by the Parties to be broad and shall be interpreted so as to give the Released Entities the broadest possible bar against any liability relating in any way to Rel ed Claims and extend to the full extent of the power of the Governmental E ity release claims. The Janssen Settlement shall be a complete bar to any Releasedlai 9. In connection with eas provided for in the Janssen Settlement, each Governmental Entity expr ves, releases, and forever discharges any and all provisions, rights, and ben:;i.ctio' � on ed by any law of any state or territory of the United States or other juri or 'nciple of common law, which is similar, comparable, or equivalent to 154 t fCalifornia Civil Code, which reads: General Release; extent. A g rel a oes not extend to claims that the creditor or releasing party does n o suspect to exist in his or her favor at the time of executing th re - s at, known by him or her, would have materially affected his or h r 'th the debtor or released party. A Releasor may hereafter discover facts other than diffbent in those which it knows, believes, or assumes to be true with respect to : R a d C aims, but each Governmental Entity hereby expressly waives and fully, f 1 all a aorever settles, releases and discharges, upon the Effective Date, any and all sed Claims that may exist as of such date but which Releasors do not know or suspe t to exist, whether through ignorance, oversight, error, negligence or through no fault whatsoever, and which, if known, would materially affect the Governmental Entities' decision to participate in the Janssen Settlement. 10. Nothing herein is intended to modify in any way the terms of the Janssen Settlement, to which Governmental Entity hereby agrees. To the extent this Election and Release is interpreted differently from the Janssen Settlement in any respect, the Janssen Settlement controls. m revised July 30, 2021 I have all necessary power and authorization to execute this Election and Release on behalf of the Governmental Entity. Signature: Name: Title: Date: W 88 revised July 30, 2021 EXHIBIT L Settlement Fund Administrator This Exhibit L will be appended to the Agreement prior to the Initial Participation Date pursuant to subsection I.66. revised July 30, 2021 EXHIBIT M Settlement Payment Schedule Suspension Ally Fee, Payment Costs & Incentives Incentive D # /Year Additional Base A, B & C (Lookback Credit Total Applies to: Restitution (maximum) Payment) Amount Payment 1 ED+90 None $103,244,576 $282,175,271 $14,580,153 $400,000,000 days Payment 2 None --- $658,320,615 --- $658,320,615 July 2022 Payment 3 Bonus $93,629,192 --- $526,905,161 --- $71,145,032 $691,679,385 July 2023 Payment 4 Bonus $93,629,191 $259,273,971 $549,768,597 --- $47,328,241 $950,000,000 July 2024 Payment 5 Bonus $43,720,414 $262,463,219 $634,274,384 --- $59,541,983 $1,000,000,000 July 2025 Payment 6 Bonus $43,720,414 $105,720,216 $54,325,273 --- $12,900,764 $216,666,667 July 2026 Payment Bonus & 7 lookback $43,720,414 $63,074,061 $54,325,273 $42,646,154 $12,900,765 $216,666,667 July 2027 Payment Bonus & 8 lookback $43,720,414 $63,074,060 $54,325,272 $42,646,154 $12,900,766 $216,666,666 July 2028 Payment Bonus & 9 lookback --- $82,748,246 $78,371,501 $42,646,154 $12,900,766 $216,666,667 July 2029 Payment Base, bonus 10 &lookback --- $82,748,248 $78,371,500 $42,646,154 $12,900,765 $216,666,667 July 2030 Payment Base, bonus 11 &lookback --- $82,748,248 $78,371,500 $42,646,153 $12,900,765 $216,666,666 July 2031 Total $465,384,615 $1,942,346,155 F $2,109,038,461 1 $213,230,769 $270,000,000 $5,000,000,000 iN V'1'LS: 1. Any adjustments to attorneys' fees and costs will be addressed in the separate attorneys' fees and costs agreement. revised July 30, 2021 2. The attorneys' fees and costs included in the schedule include the Additional Restitution Amount, which will be paid in lieu of attorneys' fees to Settling States listed on Exhibit N. 3. Any offsets under Section V would also be deducted from the base, Incentive B & C maximum, and Incentive D lookback payments and applied proportionately to all payments. 4. Accelerated payments for Incentive A would adjust figures for base and Incentive B & C payments. The dates of payments shown on the schedule are approximate, and will be determined by subsection V.B.1. 91 revised July 30, 2021 EXHIBIT N Additional Restitution Amount Allocation Alabama 2.1169269268% Alaska 0.3443798454% American Samoa 0.0219613287% Arizona 2.9452135100% California 13.1510781360% Colorado 2.1897380150% Connecticut 1.7275419499% Delaware 0.6508743856% District of Columbia 0.2811929384% Georgia 3.7040606512% Guam 0.0665280480% Hawaii 0.4710748102% Illinois 4.3924998997% Indiana 2.7750263890% Iowa 1.0610119129% Kansas 1.0960862986% Louisiana 2.0857625133% Maine 0.7470015721% Maryland 2.6658205590% Massachusetts 2.9180077435% Michigan 4.3144215263% Minnesota 1.7616910858% Missouri 2.5748706956% Montana 0.4612247807% N. Mariana Islands 0.0240110183% Nebraska 0.5931074216% New York 8.4314865530% North Carolina 4.1880762974% North Dakota 0.2646479540% Oregon 1.8098698760% Pennsylvania 5.6817646992% Rhode Island 0.6444665757% South Carolina 2.0610356358% Tennessee 3.3570652958% Texas 10.8573789344% Utah 1.5481963920% 92 revised July 30, 2021 Vermont 0.3893298238% Virgin Islands 0.0453295506% Virginia 3.0182689455% Wisconsin 2.2927931680% Wyoming 0.2691763371% 93 revised July 30, 2021 EXHIBIT O Adoption of a State -Subdivision Agreement A State -Subdivision Agreement shall be applied if it meets the requirements of Section VI and is approved by the State and by the State's Subdivisions as follows: 1. Requirements for Approval. A State -Subdivision Agreement shall be deemed as agreed to when it has been approved by the State and either (a) Subdivisions whose aggregate "Population Percentages," determined as set forth below, total more than sixty percent (60%), or (b) Subdivisions whose aggregate Population Percentages total more than fifty percent (50%) provided that these Participating Subdivisions also represent fifteen percent (15%) or more of the State's counties or parishes (or, in the case of Settling States whose counties and parishes do not function as local governments, 15% of or more of the Settling State's non -county Subdivisions), by number. 2. Approval Authority. Approval by the State shall be by the Attorney General. Approval by a Subdivision shall be by the appropriate official or legislative body pursuant to the required procedures for that Subdivision to agree to a legally binding settlement. 3. Population Percentage Calculation. For purposes of this Exhibit O only, Population Percentages shall be determined as follows: For States with functional counties or parishes3, the Population Percentage of each county or parish shall be deemed to be equal to (a) (1) 200% of the population of such county or parish, minus (2) the aggregate population of all Primary Incorporated Municipalities located in such county or parish, divided by (b) 200% of the State's population. A "Primary Incorporated Municipality" means a city, town, village or other municipality incorporated under applicable state law with a population of at least 25,000 that is not located within another incorporated municipality. The Population Percentage of each Primary Incorporated Municipality shall be equal to its population (including the population of any incorporated or unincorporated municipality located therein) divided by 200% of the State's population; provided that the Population Percentage of a Primary Incorporated Municipality that is not located within a county shall be equal to 200% of its population (including the population of any incorporated or unincorporated municipality located therein) divided by 200% of the State's population. For all States that do not have functional counties or parishes, the Population Percentage of each non -county Subdivision (including any incorporated or unincorporated municipality located therein), shall be equal to its population divided by the State's population. 4. Preexisting Agreements and Statutory Provisions. A State may include with the notice to its Subdivisions an existing agreement, a proposed agreement, or statutory provisions regarding the distribution and use of settlement funds and have the acceptance of such an agreement or statutory provision be part of the requirements to be an Initial Participating Subdivision. 3 Certain states do not have counties or parishes that have functional governments, including: Alaska, Connecticut, Massachusetts, Rhode Island, and Vermont. 94 revised July 30, 2021 5. Revised Agreements. A State -Subdivision Agreement that has been revised, supplemented, or refined shall be applied if it meets the requirements of Section VI and is approved by the State and by the State's Subdivisions pursuant to the terms above. 95 revised July 30, 2021 EXHIBIT P Iniunctive Relief A. Definitions Specific to this Exhibit 1. "Cancer -Related Pain Care" means care that provides relief from pain resulting from a patient's active cancer or cancer treatment as distinguished from treatment provided during remission. 2. "Janssen" means Johnson & Johnson, Janssen Pharmaceuticals, Inc., Ortho- McNeil-Janssen Pharmaceuticals, Inc., and Janssen Pharmaceutica, Inc. (collectively, "Janssen"), including all of their subsidiaries, predecessors, successors, current officers, directors, employees, representatives, agents, affiliates, parents, and assigns acting on behalf of Janssen in the United States. 3. "End -of -Life Care" means care for persons with a terminal illness or at high risk for dying in the near future in hospice care, hospitals, long-term care settings, or at home. 4. "Health Care Provider" means any U.S.-based physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical products and any medical facility, practice, hospital, clinic, or pharmacy. 5. "In -Kind Support" means payment or assistance in the form of goods, commodities, services, or anything else of value. 6. "Lobby" and "Lobbying" shall have the same meaning as "lobbying activities" and "lobbying contacts" under the federal lobbying disclosure act, 2 U.S.C. § 1602 et seq., and any analogous state or local provisions governing the person or entity being lobbied. As used in this document, "Lobby" and "Lobbying" include Lobbying directly or indirectly, through grantees or Third Parties. "Opioid(s)" means all naturally occurring, synthetic, or semisynthetic substances that interact with opioid receptors and act like opium. For the avoidance of doubt, the term "Opioid(s)" does not include Imodium. 8. "Opioid Product(s)" means all current and future medications containing Opioids approved by the U.S. Food & Drug Administration (FDA) and listed by the DEA as Schedule II, III, or IV drugs pursuant to the federal Controlled Substances Act (including but not limited to buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, tapentadol, and tramadol). The term "Opioid Products(s)" shall not include (i) methadone and other substances when used exclusively to treat opioid abuse, addiction, or overdose; or (ii) raw materials, immediate precursors, and/or active pharmaceutical ingredients (APIs) used in the manufacture or study of Opioids or Opioid Products, but only when such materials, immediate precursors, and/or 96 revised July 30, 2021 APIs are sold or marketed exclusively to DEA-licensed manufacturers or DEA- licensed researchers. 9. "OUD" means opioid use disorder defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM—S), as updated or amended. 10. "Product(s) for the Treatment of Opioid-Induced Side Effects" means any over- the-counter or prescription remedy used to treat those side effects identified on the FDA label for any Opioid Product, except that, for purposes of the Agreement, Product(s) for the Treatment of Opioid-Induced Side Effects shall not include products that treat OUD or respiratory depression. 11. "Promote," "Promoting," "Promotion," and "Promotional' means dissemination of information or other practices intended or reasonably anticipated to increase sales, prescriptions, or that attempts to influence prescribing practices in the United States. These terms shall not include the provision of scientific information or data in response to unsolicited requests from Health Care Providers or payors as allowed in subsection C.2.e-h. 12. "Third Party(ies)" means any person or entity other than Janssen or a government entity. 13. "Treatment of Pain" means the provision of therapeutic modalities to alleviate or reduce pain. 14. "Unbranded Information" means any information that does not identify a specific branded or generic product. B. Ban on Selling and Manufacturing Opioids Janssen shall not manufacture or sell any Opioids or Opioid Products for distribution in the United States. Janssen represents that prior to the Effective Date, it de -listed all of its Opioid Products and no longer ships any of them to or within the United States. Janssen shall provide notice to the Settling States when the last of the inventory Janssen has shipped has expired. 2. Notwithstanding subsection B.1, above, Janssen may continue to manufacture Nucynta and Nucynta ER (collectively "Nucynta") in accordance with the terms of its April 2, 2015 contract with Depomed, Inc., rights to which were assigned to Collegium Pharmaceutical, Inc. ("Collegium") on February 13, 2020, so long as Janssen is not Promoting Nucynta, or selling Nucynta. to anyone other than Collegium. Janssen shall not extend, amend, or otherwise alter the terms of its April 2, 2015 contract or enter into any similar agreement related to Nucynta or any other Opioid or Opioid Product. For the term of its April 2, 2015 contract, or until the expiration of subsection B.1, whichever is shorter, Janssen shall make an annual report to the Settling States showing the amount of Nucynta manufactured in accordance with the April 2, 2015 contract. 97 revised July 30, 2021 C. Ban on Promotion Janssen shall not engage in Promotion of Opioids or Opioid Products including but not limited to, by: a. Employing or contracting with sales representatives or other persons to Promote Opioids or Opioid Products to Health Care Providers or patients, or to persons involved in determining the Opioid Products included in formularies; b. Using speakers, key opinion leaders, thought leaders, lecturers, and/or speaking events for Promotion of Opioids or Opioid Products; C. Sponsoring, or otherwise providing financial support or In -Kind Support to medical education programs for Promotion of Opioids or Opioid Products; d. Creating, sponsoring, operating, controlling, or otherwise providing financial support or In -Kind Support to any website, network, and/or social or other media account for the Promotion of Opioids or Opioid Products; e. Creating, sponsoring, distributing, or otherwise providing financial support or In -Kind Support for materials Promoting Opioids or Opioid Products, including but not limited to brochures, newsletters, pamphlets, journals, books, and guides; Creating, sponsoring, or otherwise providing financial support or In -Kind Support for advertisements that Promote Opioids or Opioid Products, including but not limited to internet advertisements or similar content, and providing hyperlinks or otherwise directing internet traffic to advertisements; and g. Engaging in internet search engine optimization or other techniques designed to Promote Opioids or Opioid Products by improving rankings or making content appear among the top results in an internet search or otherwise be more visible or more accessible to the public on the intemet. 2. Notwithstanding subsection C.1 directly above, Janssen may: a. Maintain a corporate website; b. Maintain a website for any Opioid Product that contains principally the following content: the FDA -approved package insert, medication guide, and labeling, and a statement directing patients or caregivers to speak with a licensed Health Care Provider; revised July 30, 2021 C. Provide information or support the provision of information as expressly required by law or any state or federal government agency with jurisdiction in [State]; d. Provide the following by mail, electronic mail, on or through Janssen's corporate or product websites or through other electronic or digital methods: FDA -approved package insert, medication guide, approved labeling for Opioid Products, or other prescribing information for Opioid Products that are published by a state or federal government agency with jurisdiction in [State]; e. Provide scientific and/or medical information in response to an unsolicited request by a Health Care Provider consistent with the standards set forth in the FDA's Draft Guidance for Industry, Responding to Unsolicited Requests for Off -Label Information About Prescription Drugs and Medical Devices (Dec. 2011) as updated or amended by the FDA, and Guidance for Industry, Good Reprint Practices for the Distribution of Medical Journal Articles and Medical or Scientific Reference Publications on Unapproved New Uses of Approved Drugs and Approved or Cleared Medical Devices (Jan. 2009) as updated or amended by the FDA; f. Provide a response to any unsolicited question or request from a patient or caregiver, directing the patient or caregiver to the FDA -approved labeling or to speak with a licensed Health Care Provider without describing the safety or effectiveness of Opioids or any Opioid Product or naming any specific provider or healthcare institution; or directing the patient or caregiver to speak with their insurance carrier regarding coverage of an Opioid Product; g. Provide Health Care Economic Information, as defined at 21 U.S.C. § 352(a), to a payor, formulary committee, or other similar entity with knowledge and expertise in the area of health care economic analysis consistent with standards set forth in the FDA's Draft Questions and Answers Guidance for Industry and Review Staff, Drug and Device Manufacturer Communications With Payors, Formulary Committees, and Similar Entities (Jan. 2018), as updated or amended by the FDA; h. Provide information relating solely to the pricing of any Opioid Product; i. Sponsor or provide financial support or In -Kind Support for an accredited or approved continuing medical education program required by either an FDA -approved Risk Evaluation and Mitigation Strategy (REMS) program or other federal or state law or regulation applicable in [State] through an independent Third Party, which shall be responsible for the program's content without the participation of Janssen; and M revised July 30, 2021 j Provide information in connection with patient support information on co - pay assistance and managing pain in End -of -Life Care and/or Cancer - Related Pain Care relating to the use of Opioids for managing such pain, as long as the information identifies Janssen as the source of the information. 3. Janssen shall not engage in the Promotion of Products for the Treatment of Opioid-Induced Side Effects, including but not limited to: a. Employing or contracting with sales representatives or other persons to Promote Products for the Treatment of Opioid-Induced Side Effects to Health Care Providers or patients; b. Using speakers, key opinion leaders, thought leaders, lecturers, and/or speaking events to Promote Products for the Treatment of Opioid-Induced Side Effects; C. Sponsoring, or otherwise providing financial support or In -Kind Support to medical education programs that Promote Products for the Treatment of Opioid-Induced Side Effects; d. Creating, sponsoring, or otherwise providing financial support or In -Kind Support for advertisements that Promote Products for the Treatment of Opioid-Induced Side Effects, including but not limited to internet advertisements or similar content, and providing hyperlinks or otherwise directing internet traffic to advertisements. 4. Notwithstanding subsection C.3 directly above, Janssen may Promote Products for the Treatment of Opioid-Induced Side Effects so long as such Promotion does not associate the product with Opioids or Opioid Products. Treatment of Pain a. Janssen shall not, either through Janssen or through Third Parties, engage in any conduct that Promotes the Treatment of Pain, except that Janssen may continue to Promote the Treatment of Pain with branded non- Opioids, including Tylenol and Motrin. b. Janssen shall not, either through Janssen or through Third Parties, engage in any conduct that Promotes the concept that pain is undertreated, except in connection with Promoting the use of branded non-Opioids, including Tylenol and Motrin, for the Treatment of Pain. C. Janssen shall not disseminate Unbranded Information, including Unbranded Information about a medical condition or disease state, that contains links to branded information about Opioid Products or that otherwise Promotes Opioids or Opioid Products. 100 revised July 30, 2021 6. Notwithstanding subsection C.5 above: a. Janssen may Promote or provide educational information about the Treatment of Pain with non-Opioids or therapies such as acetaminophen or non -steroidal anti-inflammatory drugs (NSAIDs), including Promoting or providing educational information about such non-Opioids or therapies as alternatives to Opioid use, or as part of multimodal therapy which may include Opioid use, so long as such non-Opioid Promotional or educational information does not Promote Opioids or Opioid Products. b. Janssen may provide educational information about the Treatment of Pain related to medical procedures involving devices manufactured or sold by Janssen, including educational information about Opioids or Opioid Products, so long as such information does not Promote Opioids or Opioid Products. The Promotional conduct prohibited in subsection C is not prohibited insofar as it relates to the Promotion of Opioids or Opioid Products for Cancer -Related Pain Care or End -of -Life Care only, and so long as Janssen is identified as the sponsor or source of such Promotional conduct. D. No Financial Reward or Discipline Based on Volume of Opioid Sales 1. Janssen shall not provide financial incentives to its sales and marketing employees or discipline its sales and marketing employees based upon sales volume or sales quotas for Opioid Products; 2. Janssen shall not offer or pay any remuneration (including any kickback, bribe, or rebate) directly or indirectly, to any person in return for the prescribing, sale, use, or distribution of an Opioid Product; and 3. Janssen's compensation policies and procedures shall ensure compliance with the Agreement. E. Ban on Funding/Grants to Third Parties Janssen shall not directly or indirectly provide financial support or In -Kind Support to any Third Party that primarily engages in conduct that Promotes Opioids, Opioid Products, or Products for the Treatment of Opioid-Induced Side Effects (subject to subsections C.2, CA, and C.6), including educational programs or websites that Promote Opioids, Opioid Products, or Products for the Treatment of Opioid-Induced Side Effects, excluding financial support otherwise required by the Agreement, a court order, or by a federal or state agency. 2. Janssen shall not create, sponsor, provide financial support or In -Kind Support to, or otherwise operate or control any medical society or patient advocacy group that primarily engages in conduct that Promotes Opioids, Opioid Products, or Products for the Treatment of Opioid-Induced Side Effects. 101 revised July 30, 2021 3. Janssen shall not provide links to any Third Party website or materials or otherwise distribute materials created by a Third Party for the purpose of Promoting Opioids, Opioid Products, or Products for the Treatment of Opioid- Induced Side Effects (subject to subsections C.2, CA, and C.6). 4. Janssen shall not use, assist, or employ any Third Party to engage in any activity that Janssen itself would be prohibited from engaging in pursuant to the Agreement. To the extent Janssen supports trade groups engaged in Lobbying, Janssen shall stipulate that such support not be used for any purpose prohibited by the Agreement. 5. Janssen shall not enter into any contract or agreement with any person or entity or otherwise attempt to influence any person or entity in such a manner that has the purpose or foreseeable effect of limiting the dissemination of information regarding the risks and side effects of using Opioids. 6. Janssen shall not compensate or support Health Care Providers or organizations to advocate for formulary access or treatment guideline changes for the purpose of increasing access to any Opioid Product through third -party payors, i.e., any entity, other than an individual, that pays or reimburses for the dispensing of prescription medicines, including but not limited to managed care organizations and pharmacy benefit managers. 7. No officer or management -level employee of Janssen may concurrently serve as a director, board member, employee, agent, or officer of any entity that primarily engages in conduct that Promotes Opioids, Opioid Products, or Products for the Treatment of Opioid-Induced Side Effects. For the avoidance of doubt, nothing in this provision shall preclude an officer or management -level employee of Janssen from concurrently serving on the board of a hospital. 8. Janssen shall play no role in appointing persons to the board, or hiring persons to the staff, of any entity that primarily engages in conduct that Promotes Opioids, Opioid Products, or Products for the Treatment of Opioid-Induced Side Effects. For the avoidance of doubt, nothing in this paragraph shall prohibit Janssen from fully and accurately responding to unsolicited requests or inquiries about a person's fitness to serve as an employee or Board member at any such entity. F. Lobbying Restrictions Janssen shall not Lobby for the enactment of any federal, state, or local legislative or regulatory provision that: a. Encourages or requires Health Care Providers to prescribe Opioids or sanctions Health Care Providers for failing to prescribe Opioids or failing to treat pain with Opioids; b. Has the effect of limiting access to any non-Opioid alternative pain treatments; or 102 revised July 30, 2021 C. Pertains to the classification of any Opioid or Opioid Product as a scheduled drug under the Controlled Substances Act. 2. Janssen shall not Lobby against the enactment of any federal, state or local legislative or regulatory provision that supports: a. The use of non-pharmacologic therapy and/or non-Opioid pharmacologic therapy to treat chronic pain over or instead of Opioid use, including but not limited to third party payment or reimbursement for such therapies; b. The use and/or prescription of immediate release Opioids instead of extended release Opioids when Opioid use is initiated, including but not limited to third party reimbursement or payment for such prescriptions; C. The prescribing of the lowest effective dose of an Opioid, including but not limited to third party reimbursement or payment for such prescription; d. The limitation of initial prescriptions of Opioids to treat acute pain; e. The prescribing and other means of distribution of naloxone to minimize the risk of overdose, including but not limited to third party reimbursement or payment for naloxone; f. The use of urine testing before starting Opioid use and annual urine testing when Opioids are prescribed, including but not limited to third party reimbursement or payment for such testing; g. Evidence -based treatment (such as using medication -assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for OUD, including but not limited to third party reimbursement or payment for such treatment; or h. The implementation or use of Opioid drug disposal systems. 3. Janssen shall not Lobby against the enactment of any federal, state or local legislative or regulatory provision expanding the operation or use of PDMPs, including but not limited to provisions requiring Health Care Providers to review PDMPs when Opioid use is initiated and with every prescription thereafter. 4. Notwithstanding the foregoing restrictions in subsections F.1-3, the following conduct is not restricted: a. Challenging the enforcement of or suing for declaratory or injunctive relief with respect to legislation, rules, or regulations referred to in subsection F.1; b. Communications made by Janssen in response to a statute, rule, regulation, or order requiring such communication; 103 revised July 30, 2021 C. Communications by a Janssen representative appearing before a federal or state legislative or administrative body, committee, or subcommittee as a result of a mandatory order or subpoena commanding that person to testify; d. Responding, in a manner consistent with the Agreement, to an unsolicited request for input on the passage of legislation or the promulgation of any rule or regulation when such request is submitted in writing specifically to Janssen from a government entity directly involved in the passage of that legislation or promulgation of that rule or regulation; or e. Lobbying for or against provisions of legislation or regulation that address other subjects in addition to those identified in subsections F.1-3, so long as the company does not support specific portions of such legislation or regulation covered by subsection F.1 or oppose specific portions of such legislation or regulation covered by subsections F.2-3. Janssen shall provide notice of the prohibitions in subsection F to all employees engaged in Lobbying; shall incorporate the prohibitions in subsection F into trainings provided to Janssen employees engaged in Lobbying; and shall certify to the Settling States that it has provided such notice and trainings to Janssen employees engaged in Lobbying. G. Ban on Prescription Savings Programs Janssen shall not directly or indirectly offer any discounts, coupons, rebates, or other methods which have the effect of reducing or eliminating a patient's co - payments or the cost of prescriptions (e.g., free trial prescriptions) for any Opioid Product. 2. Janssen shall not directly or indirectly provide financial support to any Third Party for discounts, coupons, rebates, or other methods which have the effect of reducing or eliminating a patient's co -payments or the cost of prescriptions (e.g., free trial prescriptions) for any Opioid Product. 3. Janssen shall not directly or indirectly assist patients, Health Care Providers, or pharmacies with the claims and/or prior authorization process required for third - party payors to approve payment for any Opioid Product. H. General Terms Janssen shall not make any written or oral statement about Opioids or any Opioid Product that is unfair, false, misleading, or deceptive as defined under the law of [State]. For purposes of this paragraph, "Opioid Product" shall also include methadone and other substances when used exclusively to treat opioid abuse, addiction, or overdose. 104 revised July 30, 2021 2. Janssen shall not represent that Opioids or any Opioid Product(s) have approvals, characteristics, uses, benefits, or qualities that they do not have. For purposes of this paragraph, "Opioid Product" shall also include methadone and other substances when used exclusively to treat opioid abuse, addiction, or overdose. 3. For the avoidance of doubt, the Agreement shall not be construed or used as a waiver or limitation of any defense otherwise available to Janssen in any action, and nothing in the Agreement is intended to or shall be construed to prohibit Janssen in any way whatsoever from taking legal or factual positions with regard to any Opioid Product(s) in defense of litigation or other legal proceedings. 4. Upon the request of the [State] Attorney General, Janssen shall provide the [State] Attorney General with copies of the following, within thirty (30) calendar days of the request: a. Any litigation or civil or criminal law enforcement subpoenas or Civil Investigative Demands relating to Janssen's Opioid Product(s); and b. Warning or untitled letters issued by the FDA regarding Janssen's Opioid Product(s) and all correspondence between Janssen and the FDA related to such letters. 5. The Agreement applies to conduct that results in the Promotion of Opioids or Opioid Products, or the Treatment of Pain inside the United States. 6. Janssen will enter into the Agreement solely for the purpose of settlement, and nothing contained therein may be taken as or construed to be an admission or concession of any violation of law, rule, or regulation, or of any other matter of fact or law, or of any liability or wrongdoing, all of which Janssen expressly denies. No part of the Agreement, including its statements and commitments, shall constitute evidence of any liability, fault, or wrongdoing by Janssen. The Agreement is not intended for use by any third party for any purpose, including submission to any court for any purpose. 7. Nothing in the Agreement shall be construed to limit or impair Janssen's ability to: a. Communicate its positions and respond to media inquiries concerning litigation, investigations, reports or other documents or proceedings relating to Janssen or its Opioid Products. b. Maintain a website explaining its litigation positions and responding to allegations concerning its Opioid Products, including the website, www.factsaboutourprescriptionopioids.com. 105 revised July 30, 2021 Compliance with All State Laws and Regulations Relating to the Sale, Promotion, and Distribution of Any Opioid Product Janssen shall comply with all applicable state laws and regulations that relate to the sale, promotion, distribution, and disposal of Opioids or Opioid Products, including conduct permitted by subsection B.2, provided that nothing in this paragraph requires Janssen to violate federal law or regulations, including but not limited to: a. [State] Controlled Substances Act, including all guidance issued by the applicable state regulator(s); b. [State] Consumer Protection Laws; C. [State] laws, regulations, and guidelines related to opioid prescribing, distribution, and disposal; and d. [State Specific Laws]. Clinical Data Transparency 1. Janssen agrees to continue sharing clinical trial data under the Yale University Open Data Access (YODA) Project to allow researchers qualified under the program to access the company's proprietary data under the terms of the project. 2. In the event Yale University discontinues or withdraws from the YODA Project agreement with Janssen, Janssen shall make its clinical research data regarding Opioids and Opioid Products, and any additional clinical research data that Janssen sponsors and controls regarding Opioids and Opioid Products, available to an independent entity that is the functional equivalent of the YODA Project under functionally equivalent terms. K. Enforcement t. For the purposes of resolving disputes with respect to compliance with this Exhibit, should any of the Settling States have a reasonable basis to believe that Janssen has engaged in a practice that violates a provision of this Exhibit subsequent to the Effective Date, such Settling State shall notify Janssen in writing of the specific objection, identify with particularity the provision of the Agreement that the practice appears to violate, and give Janssen thirty (30) days to respond in writing to the notification; provided, however, that a Settling State may take any action if the Settling State believes that, because of the specific practice, a threat to health or safety of the public requires immediate action. 2. Upon receipt of written notice, Janssen shall provide a good faith written response to the Settling State's notification, containing either a statement explaining why Janssen believes it is in compliance with this Exhibit of the Agreement, or a detailed explanation of how the alleged violation occurred and a statement 106 revised July 30, 2021 explaining how Janssen intends to remedy the alleged breach. Nothing in this section shall be interpreted to limit the [State's] civil investigative demand ("CID") or investigative subpoena authority, to the extent such authority exists under applicable law, and Janssen reserves all of its rights in responding to a CID or investigative subpoena issued pursuant to such authority. If Janssen notifies the Settling States in writing that two or more Settling States have notified Janssen of alleged violations, the Settling States that provided notice of alleged violations shall work in good faith to collectively resolve the alleged violation with Janssen before taking any enforcement action(s). 3. The Settling States may agree, in writing, to provide Janssen with additional time beyond thirty (30) days to respond to a notice provided under subsection K.1, above, without Court approval. 4. Upon giving Janssen thirty (30) days to respond to the notification described above, the Settling State shall also be permitted reasonable access to inspect and copy relevant, non -privileged, non -work product records and documents in possession, custody, or control of Janssen that relate to Janssen's compliance with each provision of the Agreement pursuant to that Settling State's CID or investigative subpoena authority. 5. The Settling State may assert any claim that Janssen has violated the Agreement in a separate civil action to enforce compliance with the Agreement, or may seek any other relief afforded by law for violations of the Agreement, but only after providing Janssen an opportunity to respond to the notification described in subsection K.1, above; provided, however, the Settling State may take any action if the Settling State believes that, because of the specific practice, a threat to the health or safety of the public requires immediate action. 6. In the event of a conflict between the requirements of the Agreement and any other law, regulation, or requirement such that Janssen cannot comply with the law without violating the terms of the Agreement or being subject to adverse action, including fines and penalties, Janssen shall document such conflicts and notify the Settling State of the extent to which it will comply with the Agreement in order to eliminate the conflict within thirty (30) days of Janssen's discovery of the conflict. Janssen shall comply with the terms of the Agreement to the fullest extent possible without violating the law. Janssen or any Settling State may request that Janssen and any Settling State meet and confer regarding the resolution of an actual or potential conflict between the Agreement and any other law, or between interpretations of the Agreement by different courts. Nothing herein is intended to modify or extend the jurisdiction of any single judicial authority as provided by law. L. Compliance Duration Subsections B-J shall be effective for 10 years from the Effective Date. 107 revised July 30, 2021 2. Nothing in this Agreement shall relieve Janssen of its independent obligation to fully comply with the laws of [State] after expiration of the 10-year period specified in this subsection. M. Compliance Deadlines Janssen must be in full compliance with the provisions included this Agreement by the Effective Date. Nothing herein shall be construed as permitting Janssen to avoid existing legal obligations. 108 revised July 30, 2021 EXHIBIT O Non -Released Entities The following includes a non-exclusive list of non -Released Entities: 1. Actavis LLC 2. Actavis Pharma, Inc. 3. Allergan PLC 4. Allergan Finance, LLC 5. AmerisourceBergen Corporation 6. AmerisourceBergen Drug Corporation 7. Anda, Inc. 8. Cardinal Health, Inc. 9. Cephalon, Inc. 10. Collegium Pharmaceuticals 11. CVS Health Corp. 12. CVS Pharmacy, Inc. 13. Endo Pharmaceuticals Inc. 14. Endo Health Solutions Inc. 15. Mallinckrodt LLC 16. McKesson Corporation 17. McKinsey & Company Inc. 18. Par Pharmaceutical, Inc. 19. Par Pharmaceutical Companies, Inc. 20. Purdue Pharma L.P. 21. Purdue Pharma Inc. 22. SpecGx LLC 23. Teva Pharmaceuticals USA, Inc. 24. The Purdue Frederick Company 25. Walgreen Co. 26. Walgreens Boots Alliance, Inc. 27. Walmart Inc. 28. Watson Laboratories, Inc. 109 revised July 30, 2021 EXHIBIT R Agreement on Attorneys' Fees, Costs, and Expenses This Agreement on Attorneys' Fees, Expenses and Costs ("Fee Agreement"), is entered between Janssen and the Plaintiffs' Executive Committee appointed in the multidistrict litigation in the Northern District of Ohio, In re National Prescription Opiate Litigation, No. 1:17-MD- 2804 ("MDL PEC"), in connection with the Janssen Master Settlement Agreement ("Janssen Agreement"). This Fee Agreement becomes effective on the Effective Date of the Janssen Agreement or the date that the Consent Judgments anticipated under the Janssen Agreement become final in 25 Settling States (whichever is later). However, the costs specified in paragraphs II.I.1 and II.I.4 of this Fee Agreement that are to be funded pre -Effective Date by Janssen are effective upon agreement in writing with Janssen. L Definitions A. This Fee Agreement incorporates all defined terms in the Janssen Agreement, unless otherwise defined herein, and shall be interpreted in a manner consistent with the Janssen Agreement. B. "Attorney." Any of the following retained through a legal contract: a solo practitioner, multi -attorney law firm, or other legal representative of a Participating Subdivision. C. `Attorney Fee Fund." An account consisting of funds allocated to pay attorneys' fees approved pursuant to Section II of this Fee Agreement established by Order of and under the ongoing jurisdiction of the MDL Court, as provided below. D. "Common Benefit Fund." The sub fund of the Attorney Fee Fund described in Section II.C. E. "Contingency Fee Fund." The sub fund of the Attorney Fee Fund described in Section II.D. F. "Cost and Expense Fund Administrator." The administrator appointed by the MDL Court to administer the MDL Expense Fund and Litigating Subdivision Cost Fund as provided in the Fee Agreement. G. "Cost Funds." Collectively, the MDL Expense Fund and Litigating Subdivision Cost Fund. H. "Fee Entitlement." Any right, entitlement or expectation, including but not limited to a fee contract, contingent fee contract, agreement, referral arrangement, co -counsel arrangement, State Back -Stop agreement, or any other arrangement by which counsel could receive compensation or other consideration. For the avoidance of doubt, the scope of Fee Entitlement under paragraph II.G.3.a does not include any Attorneys' fees associated with representation of a State. 110 revised July 30, 2021 I. "Fee Panel." The three -person panel appointed by the MDL Court to administer the Attorney Fee Fund and its sub funds as provided in the Fee Agreement. "Litigating Subdivision Cost Fund." The cost fund described in Section II.E herein. K. "MDL Court." United States District Court for the Northern District of Ohio Eastern Division, Case No. 1:17-and-2804, Judge Dan Aaron Polster. L. "MDL Expense Fund." The cost fund described in Section II.F below. M. "MDL PEC." The Plaintiffs' Executive Committee appointed by the MDL Court. N. "Non -Participating Litigating Subdivision." A Litigating Subdivision that is not a Participating Subdivision. O. "Participating Litigating Subdivision." A Litigating Subdivision that is also a Participating Subdivision. P. "Participation Agreement." An agreement executed by an Attorney that acknowledges the obligation to pay an appropriate MDL Common Benefit Assessment. Q. "Qualifying Representation." Legal services provided for representation of a Participating Litigating Subdivision regarding Released Claims against Released Entities. R. "State Back -Stop Agreement." Any agreement by a Settling State and private counsel for Participating Subdivisions in that State (or legislation enacted in that State) to provide, adjust, or guarantee attorneys' fees and costs, whether from the Attorney Fee Fund or any other source recognized in the agreement or legislation. II. Fees and Costs A. Total Attorneys' Fees and Costs. 1. Total attorneys' fees and costs to be paid by Janssen to Attorneys in each of the relevant Payment Years under this Agreement shall be up to the following amounts, subject to the provisions set forth below, including with respect to the division of the Attorney Fee Fund into its sub funds: 111 revised July 30, 2021 Attorney Fee Fund (Contingency MDL Expense Litigating Fee Fund and Fund Subdivision Cost Common Fund Benefit Fund Payment $32,391,518.74 $9,615,384.61 $10,000,000.00 Year 1 Payment $35,936,883.63 $10,000,000.00 Year 2 Payment $64,482,248.52 $10,000,000.00 Year 3 Payment $g3,720,414.21 Year 4 Payment $43,720,414.21 Year 5 Payment $43,720,414.21 Year 6 Payment $43,720,414.21 Year 7 2. The sub funds within the Attorney Fee Fund shall include the Common Benefit Fund and the Contingency Fee Fund. The Cost Funds shall include the MDL Expense Fund, and the Litigating Subdivision Cost Fund. The State Counsel Fee Fund and the State Cost Fund shall be separate funds under the control of the Settling States. 3. The Contingency Fee Fund and the Common Benefit Fund shall be administered by a Fee Panel to be appointed by the MDL Court that will be governed by the provisions of this Fee Agreement and shall design the process and procedures for the allocation of fees pursuant to this Fee Agreement and the MDL Court's Order. The Cost Funds shall be administered by the Cost and Expense Fund Administrator to be appointed by the MDL Court who will be governed by the provisions of this Fee Agreement and shall design the process and procedures for the allocation of costs pursuant to this Agreement and the MDL Court's Order. 4. The fees and costs to be paid under this Fee Agreement are available for Attorneys engaged in Qualifying Representations only. Fees and costs to be paid under this Fee Agreement are not available prior to the Effective Date of the Janssen Agreement or if the Janssen Agreement does not proceed past Janssen's determination in Section VIII.A of the Janssen Agreement. Fees and costs to be paid under this Fee Agreement are not available for representation of Non -Participating Subdivisions or Non -Litigating Subdivisions and are not available for representation of private hospitals, third -party payors, NAS claimants, personal injury/wrongful death claimants, or any entity other than Participating Litigating Subdivisions. In addition, fees and costs under this Fee Agreement are not available for representation of 112 revised July 30, 2021 any individual or entity in matters other than those claims against Released Entities, but may include a reasonable share of representations that involve development of facts for pursuit of opioid-related claims against multiple defendants in the pharmacy, manufacturing, and distribution chain. B. Attorney Fee Fund and Sub Funds 1. There shall be a split of the Attorney Fee Fund into the Contingency Fee Fund and the Common Benefit Fund. The split shall be 40% to the Contingency Fee Fund and 60% to the Common Benefit Fund. 2. In no event shall Janssen be required to pay more into the Attorney Fee Fund in any Payment Year than the maximum amount specified for that Payment Year in paragraph II.A.1, which amounts are reflected in Exhibit M to the Janssen Agreement. The amounts allocated to the Contingency Fee Fund and the Common Benefit Fund set by the Fee Panel shall be subject to the reductions and offsets set forth below. 3. Awards of fees from the Contingency Fee Fund shall be available to Attorneys with Qualifying Representations of Participating Litigating Subdivisions eligible to receive an allocation under the Janssen Agreement, as set forth in Exhibit G to the Janssen Agreement, and shall be made applying the Mathematical Model attached as Exhibit "A" to this Fee Agreement. The collection of the data and calculations for the Mathematical Model has been a cooperative effort among private counsel for a large number of Litigating Subdivisions. The analysis has been spearheaded by Joseph Tann and Andrew Arnold. The Fee Panel is encouraged to continue working with those counsel in application of the Model. The Fee Panel shall oversee the application of the Model and resolve any questions or disputes concerning the eligibility of a Counsel to participate as required in Section II.G. The Panel is empowered to hear disputes concerning and ensure the accuracy of the mathematical calculation. 4. As to awards from the Contingency Fee Fund, there shall be no right of appeal. 5. Any appeal of an award of the Fee Panel from the Common Benefit Fund will be made to the MDL Court and be reviewed under an abuse of discretion standard. C. Common Benefit Fund (60% of the Attorney Fee Fund.) 1. Funds in the Attorney Fee Fund shall be allocated to the Common Benefit Fund according to the schedule set forth below, subject to the adjustments described in paragraph II.C.5. The payments are to be made on the following yearly schedule, subject to the adjustments set forth below: 113 revised July 30, 2021 Payment Year 1 $19,434,911.24 Payment Year 2 $21,562,130.18 Payment Year 3 $38,689,349.11 Payment Year 4 $26,232,248.53 Payment Year 5 $26,232,248.53 Payment Year 6 $26,232,248.53 Payment Year 7 $26,232,248.53 Total: $184,615,384.64 2. The Common Benefit Fund shall be available to compensate Attorneys engaged in Qualifying Representations of Participating Litigating Subdivisions who: a. have performed work for the common benefit of all subdivisions pursuant to the guidelines established by Judge Polster set forth in MDL 2804 and the Order dated June 19, 2018, under docket number 636, which is included herein by reference; and b. satisfy the eligibility criteria set forth in Section II.G. For purposes of Common Benefit Fund distribution, notwithstanding paragraph II.A.4, Attorneys representing Tribal Nations litigating against Janssen that have reached a settlement for Released Claims with Janssen and/or Released Entities and meet the eligibility criteria in Section ILG shall be eligible. The Common Benefit Fund shall be overseen by the Fee Panel, which shall determine the allocation of funds to eligible Attorneys consistent with this Fee Agreement and the June 19, 2018 Order; 4. In assessing the benefits that an Attorney has conferred to Participating Subdivisions (including non -Litigating Subdivisions) and/or Tribes for purposes of any compensation decision, the Fee Panel shall give significant weight to the extent to which (i) the Attorney and his or her clients have contributed to increasing (or reducing) the Initial Participation Tier achieved through participation in the Janssen Agreement, (ii) the Attorney and his or her clients have contributed to increasing (or reducing) the amounts achieved under Incentive Payments A-D through participation in the Janssen Agreement, and (iii) the Attorney and his or her clients have contributed to the potential triggering of any suspension, reduction, or offset of Settlement payment amounts under the Janssen Agreement. The panel may also consider additional fee recoveries the Attorney may potentially obtain, including, but not limited to, from State Back -Stop Agreements, representations of States or Tribal Nations, representations of other clients in opioids-related matters, or through the representation of Subdivision clients, 114 revised July30, 2021 whether they participated in the Janssen Agreement or not. It is the intent of this provision to recognize that the goal of the Janssen Agreement is to provide for maximum participation by the Subdivisions, maximum abatement funding for all Subdivisions nationally, and the maximum peace for Released Entities. Therefore, representing a Non -Participating Subdivision does not further the goal of the Janssen Agreement, and should not be considered Common Benefit because it does not increase funds available to Participating Subdivisions' abatement programs. Representing Later Litigating Subdivisions is antithetical to the Janssen Settlement, detracts from Common Benefit, and is addressed by the ethics opinion discussed in paragraph II.I.4. The Fee Panel shall consider this concept of "common detriment" set forth in this paragraph in all of its decision making with respect to the allocation of the Attorney Fee Fund among Attorneys, as well as, in its discretion, any offsets provided to Janssen as set forth in paragraph II.C.6 and Section II.H. The Fee Panel shall consider the totality of the Attorney's Participating Litigating Subdivisions as compared to the Attorney's Non -Participating Litigating Subdivisions; the Parties recognize that, although the goal is for 100% participation, Attorneys with a higher number of clients have a higher probability of having one or more non -Participating Litigating Subdivision. As used in this paragraph II.C.4, "client" or "representing" a Subdivision shall include any Litigating Subdivision as to which the Attorney has a Fee Entitlement. 5. As set forth in paragraph II.C.6 and Section II.H, the Fee Panel must consider the factors described in paragraph II.C.4 to determine how and whether to reduce the amounts to be paid by Janssen under this Fee Agreement and to determine how to allocate funds among Attorneys. They may also, at their discretion, consider other factors. Any reduction in payment obligation or credit to be given Janssen in this Fee Agreement shall be applied against Payment Year 7 and working backwards. Any reduction to an Attorney not credited to Janssen shall be allocated to attorneys whose Litigating Subdivision clients participated in the settlement by the Initial Participation Date. 6. The amounts to be provided as a credit or offset to Janssen from the Common Benefit Fund shall depend on the relevant Participation Tier achieved, set forth in Exhibit H of the Janssen Agreement, as follows: a. At Participation Tier 1 or below, the Common Benefit Fund payments to be paid by Janssen shall be reduced as follows: i. With respect to any Attorney seeking payment from the Common Benefit Fund, the Fee Panel shall compare the aggregate allocation that Participating Litigating Subdivisions with which the Attorney has a Fee Entitlement would receive using the negotiating class allocation metrics with the aggregate amount that all Litigating Subdivisions (Participating and Non -Participating) with which the Attorney has a 115 revised July 30, 2021 Fee Entitlement would receive using the negotiating class allocation metrics, provided that only Litigating Subdivisions in Settling States shall be considered for this ratio. The Fee Panel will multiply the amount to be paid to that Attorney from the Common Benefit Fund by that ratio, reduce the Attorney's award by a maximum reduction of 15%, and the dollar amount of such reduction shall be deducted, dollar -for -dollar, from the amount owed by Janssen to the Common Benefit Fund of the Attorney Fee Fund. ii. In the event that any Non -Participating Subdivision that is (a) under the jurisdiction of the MDL Court or (b) represented by an Attorney that is obligated to pay into the MDL Common Benefit Fund pursuant to a Participation Agreement, an order of the MDL Court, or any other arrangement settles with or wins a judgment against a Released Entity separate from the Janssen Agreement, and such settlement or judgment results in a common benefit fee assessment or fee payment into the MDL Common Benefit Fund during the time of Janssen's obligation to pay fees under this Fee Agreement, Janssen's obligation to pay into the Common Benefit Fund shall be reduced dollar -for -dollar for any amount of such fee assessments or payments (in the aggregate based on all reductions in this subparagraph II.C.6.a.ii) that exceed the reductions in subparagraph II.C.6.a.i. iii. For the avoidance of doubt, in Tier I for each settlement or judgment with Janssen that results in an assessment or payment to the MDL Common Benefit Fund, that payment shall result in an offset for Janssen, unless the assessment or payment occurs after the Payment Date for Year 7. b. At Participation Tier 2, the Common Benefit Fund payments to be made by Janssen shall be reduced only as follows: i. Reduction by the Fee Panel. With respect to all Attorneys making an application that seeks payment from the Common Benefit Fund, the Fee Panel shall, following a determination that an Attorney is eligible under Section II.G, apply the criteria specified in paragraph II.CA in determining whether the lack of participation by Subdivisions with which an Attorney has a Fee Entitlement has resulted in a reduction in the Participation Tier achieved, reduction in benefit to Participating Subdivisions as a result of reductions in Incentives A-D, and/or potential triggering of a suspension, reduction, or offset under the Janssen Agreement. If the Fee Panel concludes that such a reduction has occurred, it must consider (1) the relative size of the Non - Participating Subdivision, as adjusted by the severity measures reflected in Exhibit H (governing the Participation Tiers) of the Janssen Agreement, and the impact of its non -participation on the 116 revised July 30, 2021 Janssen Agreement as a whole (including amounts of Incentive Payments and triggering of suspensions, reductions, or offsets); (2) whether and by how much the payment to the Attorney from the Common Benefit Fund should be reduced as a result of the impact of such non -participation on Participating Subdivisions; and (3) whether some or all of said reduction should revert to Janssen due to the reduction in peace obtained from the Janssen Agreement. Consideration of the factors discussed in this subparagraph and paragraph II.C.4 is mandatory. The decision whether to (and by how much) to reduce payments by Janssen or to reduce the payment to any Attorney based on the factors in paragraph II.C.4 shall be in the sole discretion of the Fee Panel. ii. Offsets. (1) In the event that any Non -Participating Subdivision that is (a) under the jurisdiction of the MDL Court or (b) represented by an Attorney that is obligated to pay into the MDL Common Benefit Fund pursuant to a Participation Agreement, an order of the MDL Court, or any other arrangement settles with or wins a judgment against a Released Entity separate from the Janssen Agreement, and such settlement or judgment results in a common benefit fee assessment or fee payment into the MDL Common Benefit Fund during the time of Janssen's obligation to pay Common Benefit Fees under this Fee Agreement, Janssen's obligation to pay into the Common Benefit Fund shall be reduced dollar -for -dollar up to the amount of the fee assessment or payment, except that such amount shall be capped at 7.5% of the amount of the settlement or judgment. Such reduction shall be taken first from Payment Year 7 of Janssen's payments to the Common Benefit Fund of the Attorney Fee Fund up to the full amount of Janssen's payment obligation in Payment Year 7, then from Payment Year 6, and so on. (2) For the avoidance of doubt, for each settlement or judgment with Janssen that results in an assessment or payment to the MDL Common Benefit Fund, that payment shall result in an offset for Janssen, unless the assessment or payment occurs after the Payment Date for Payment Year 7. c. At Participation Tier 3, the reductions to the Attorney Fee Fund shall be the same as set forth in subparagraph II.C.6.b, except that the cap on each offset shall be 5% of the amount of such settlement or judgment. d. At Participation Tier 4, there shall be no reductions to Janssen's obligations to make payment into the Common Benefit Fund, but the principles set forth in paragraph II.C.4 shall continue to apply. 117 revised July 30, 2021 D. Contingency Fee Fund. (40% of the Attorney Fee Fund.) Funds from the Attorney Fee Fund shall be allocated to the Contingency Fee Fund on the following yearly schedule, subject to the adjustments set forth below: Payment Year 1 $12,956,607.50 Payment Year 2 $14,374,753.45 Payment Year 3 $25,792,899.41 Payment Year 4 $17,488,165.68 Payment Year 5 $17,488,165.68 Payment Year 6 $17,488,165.68 Payment Year 7 $17,488,165.68 Total: $123,076,923.09 2. The Contingency Fee Fund shall be available to compensate Attorneys engaged in Qualifying Representations of Participating Litigating Subdivisions that meet the criteria set forth in Section II.G. 3. The Contingency Fee Fund shall be available to Attorneys who a. represent Litigating Subdivisions that are Participating Subdivisions, whether their actions are filed in state or federal court, and b. meet the eligibility criteria of Section II.G. c. Participation in the Contingency Fee Fund by counsel that have a case that is not subject to the jurisdiction of the MDL Court shall not create, provide, or waive jurisdiction of the MDL Court over that Litigating Subdivision, that case or Attorneys, other than to oversee the fairness of the distribution process, and enforcement of this Fee Agreement. 4. The amounts owed by Janssen to the Contingency Fee Fund shall depend on the relevant Participation Tier set forth in Exhibit H of the Janssen Agreement as follows: a. At Participation Tiers 1, 2 and 3, the Contingency Fee Fund payments shall be reduced as follows: For Non -Settling States, the Contingency Fee Fund payments shall first be reduced by the amounts identified by the Fee Panel, pursuant to paragraph II.H.6, that would have been owed to counsel for Litigating Subdivisions in Non -Settling States, had those States and those Litigating Subdivisions been Settling States and Participating Subdivisions. 118 revised July 30, 2021 ii. Following the calculation in subparagraph II.DA.a.i, the Contingency Fee Fund payments shall be reduced to reflect the non joinder of Litigating Subdivisions in Settling States by subtracting the amounts identified by the Fee Panel, pursuant to paragraph II.H.6, that would have been owed to counsel for Non -Participating Litigating Subdivisions in Settling States had such Litigating Subdivisions been Participating Subdivisions. b. At Participation Tier 4, there shall be no reductions in the Contingency Fee Fund. c. In the event that Janssen, prior to the Effective Date of the Janssen Agreement, settles with any Litigating Subdivision and, under such settlement agreement pays attorneys' fees, the Fee Panel shall treat those Litigating Subdivisions as Participating Litigating Subdivisions and, applying the same criteria applicable to all Attorneys for Participating Litigating Subdivisions, determine what amount they would have been paid from the Contingency Fee Fund if they had become Participating Subdivisions under the Janssen Agreement without such prior settlement. That sum, rather than being paid to the Attorney for the previously settling Litigating Subdivision, shall be credited and/or returned to Janssen as if determined under (a)(ii) above, except that such credit shall not be greater than the amount to the Attorneys paid under the Litigating Subdivision's prior settlement agreement. E. Litigating Subdivision Cost Fund. 1. Janssen shall pay $30,000,000.00 into the Litigating Subdivision Cost Fund, according to the schedule set forth below: Payment Year 1 $10,000,000.00 Payment Year 2 $10,000,000.00 Payment Year 3 $10,000,000.00 Total $30,000,000.00 2. The Litigating Subdivision Cost Fund shall be available to compensate Attorneys for costs and expenses arising out of representation of Participating Litigating Subdivisions or to compensate Participating Litigating Subdivisions for direct in-house costs for expenditures related to their litigation against Janssen including the cost of in-house employees. No funds in the Litigating Subdivision Cost Fund may be used to compensate the costs incurred by Non - Participating Subdivisions or Non -Litigating Subdivisions or costs and expenses arising out of representation of any such Subdivision. In allocating the Litigating Subdivision Cost Fund, the Administrator shall not allocate any funds for costs incurred after July 21, 2021. 119 revised July 30, 2021 During the period between July 21, 2021, and the Effective Date, the MDL PEC, as well as Litigating Subdivisions eligible to claim costs from the Litigating Subdivision Cost Fund, shall make best efforts to cease litigation activity against Janssen, including by jointly seeking stays or severance of claims against Janssen, where feasible, or postponements if a motion to stay or sever is not feasible or is denied, so long as such actions are not otherwise detrimental to the Litigating Subdivision. 4. In the event that Janssen, prior to the Effective Date of the Janssen Agreement, settles with any Litigating Subdivision and, under such settlement agreement pay costs to the Litigating Subdivision or its Attorney, the MDL Cost and Expense Fund Administrator shall treat those Litigating Subdivisions as Participating Litigating Subdivisions and, using the same criteria applicable to all applicants to the Litigating Subdivision Cost Fund, determine what amount in costs the Litigating Subdivision or its Attorney would have been paid from the Subdivision Cost Fund if they had settled under the Janssen Agreement. That sum, rather than being paid to the Attorney or the previously settling Litigating Subdivision, shall be credited and/or returned to Janssen, except that such sum shall not be greater than the amount paid under the previously settled Litigating Subdivision's settlement agreement. 5. The MDL Court shall appoint a Cost and Expense Fund Administrator, who shall develop a process and criteria, with input from participating counsel, by which to a) determine the distribution of amounts from the MDL Expense Fund in pursuit of the claims against Janssen; and b) receive and evaluate applications from Participating Litigating Subdivisions, whether filed in Federal Court or State Court, to seek reimbursement from the Litigating Subdivision Cost Fund for eligible costs under Section II.E.2 in pursuit of the claims against Janssen. The Cost and Expense Fund Administrator shall require transparency from all applicants as to any other sources for compensating Attorneys for Litigating Subdivisions for costs incurred. The Cost and Expense Fund Administrator shall be compensated from the Fund. 6. In the event that the total amount of reimbursements from the Litigating Subdivision Cost Fund approved as reasonable by the Cost and Expense Administrator is less than the $30,000,000.00, any remaining funds shall revert to Janssen. MDL Expense Fund. 1. In Payment Year 1 of the Janssen Settlement, Janssen shall pay the following amount into the MDL Expense Fund: MDL Expense Fund $9,615,384.61 120 revised July 30, 2021 Page 3 of 18 109298572 1/ 11/15/2009/1512010110/20 1,366.33 0.00 0.00 1,366.33 SUPPLIES 109298378 f 11/15/20 09/15/20 10/10120 1,288.45 0.00 0.00 1,286.45 r/l LEASE 109333229 ✓ 11/15/2010/01/2010/26/20 446.46 0.00 0.00 446.46 SUPPLIES 109340220 ✓ 11/15/20 10/04/20 10/29/20 645.73 0.00 0.00 645.73 SUPPLIES 109375002 f 11/15/20, 10/04/2010/29/20 269.02 0.00 0.00 269.02 SUPPLIES 109338008 4✓ 11115/2010104/2010/29120. 4,396.83 0.00 0.00 4,396.83 „✓ SSUPPLIES 109362988 ,f 11/15/2010/15/2011/09120 1,288,45 0.00 0.00 1,288.45 y✓ LEASE 109159456 ,/ 11/16/20 07/02/20 07/27/20. 239.94 0.00 0.00 239.94 SUPPLIES 109298946 ✓ 11/16/20. 09/15/2010/10120, 53.75 0100 0.00 53.75 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 81220 BECKMAN COULTER INC 58,202.84 0.00 0.00 58,202.84 Vendor# Vendor Name Class Pay Code 31800 BRIGGS HEALTHCARE M Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net B373043 v✓ 11/12/2011101/2012/0t/20 9720 0.00 0.00 97.20 rf SUPPLIES Vendor Totals Number Name Grass Discount No -Pay Net 81800 BRIGGS HEALTHCARE 97.20 0.00 0.00 97.20 Vendor# Vendor Name Class Pay Code 11224 CABLES AND SENSORS f Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net 5615 f 06/30/20.06/11/2012101/20 -182.00 0.00 0.00 -182.00 y CREDIT INVOICE 112806 , 120539 y 10/31/20.10/26/2011/25/20. 15.90 0.00 0.00 15.00 SUPPLIES 120683 f 11/01/2010/28/2011/27/20 252.00 0.00 0.00 262.00 �.✓ SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11224 CABLES AND SENSORS 85.90 0.00 0.00 85.90 Vendor# Vendor Name Class Pay Code C1325 CARDINAL HEALTH 414, INC. ✓ W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 800267699E f 11/10/20 10/31/20 11/26/20 485.64 0.00 0.00 485.64 ,f SUPPLIES Vendor Totals Number Name dross Discount No -Pay Net 01325 CARDINAL HEALTH 414, INC. 485.64 0.00 0.00 485.64 Vendor# Vendor Name Class Pay Cade 13992 CARIANT HEALTH PARTNERS Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 129340 f 11/0912011/03/2011/26/20. 2,900.00 0.00 0.00 2,900.00 TRAVEL NURSE STAFFING / 129341 ✓ 11/09/20 11/03/20 11/26/20 3,802.50 0.00 0.00 3,802.50 i„✓ file:///C:/Users/eheiman/cpsi/memmed.cpsinet.comlu98547/data_5/tmp cw5report8582-.. 11/18/2021 Page 4 of 18 TRAVEL NURSE STAFFING 129560 11/15/20 11/10/20 11/10/20 2,880.00 0.00 0.00 2,880.00 TRAVEL NURSE STAFFING ' Vendor Totals Number Name Gross Discount No -Pay Net 13992 CARIANT HEALTH PARTNERS 9,582.50 0.00 0Ao 9,582.50 Vendor# Vendor Name Class Pay Code C1992 CDW GOVERNMENT, INC. ✓/ M Invoice# Comment Tram Dt Inv Dt Due Dt Check D• Pay Gross Discount No -Pay Net L997693 11JI212010/1112011/25/20 195.05 0.00 0.00 195.05 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net C1992 CDW GOVERNMENT, INC. 195.05 0.00 0.00 I95.05 Vendor# Vendor Name Class Pay Code 13760 CIGNA „/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D-Pay Gross Discount No -Pay Net 162948 ✓ 11/15/20, 11/03/20 11/03/20 104.82 0.00 0.00 104.82 REFUND Vendor Totals Number Name Gross Discount No -Pay Net 13760 CIGNA 104.82 0.00 0.00 104.82 Vendor# Vendor Name Class Pay Cade C1166 COASTAL OFFICE SOLUTONS ✓ W Invoice# Comment Tran Dt Inv Dt. Due Dt Check D Pay Gross Discount No -Pay Net OE313481tdflEDIT 0812612E 04/13/2012/01120. -231.42 0.00 0.00 -231.42 CREDIT INVOICE OE313481 OEOT186071 ✓ 11/15/2011/05l2011/15/20 7,616.55 0.00. 0.00 7,616.55 1% SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 01166 COASTAL OFFICE SOLUTONS 7,385.13 0.00 0100 7.385.13 Vendor# Vendor Name Class Pay Code 13336 COCA COLA SOUTHWEST BEVERAGES Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net / 24165200140 11/17/2010/06/2011/30/20 -250.00 0.00 0.00 -250.00,% CREDIT 24165200288 ,/ 11/17/2011/17/2011/17/20, 487.61 0.00 0.00 487.61 SUPPLIES 24165200289 J 11/17/20AI/17/2011/17/20. -125.00 0.00 0.00 -125.00 v% CREDIT Vendor Totals Number Name Gross Discount No -Pay Net 13336 COCA COLA SOUTHWEST BEVERAGES 112.61 0.00 0.00 112.61 Vendor#Vendor Name Class Pay Code l C1970 CONMED CORPORATION �,/ M Invoice# Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net ,Comment 703490 11A 6/2011101/2011/16/20 555.52 0.00 0.00 555.52 SUPPLIES Vendor Totale Number Name Gross Discount No -Pay Net C1970 CONMED CORPORATION 555.52 0.00 0.00 555.52 Vendor# Vendor Name Class Pay Code 10368 DEWITT POTH & SON �/ Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Gross Discount ND -Pay Net 6613000 „% 11/05/2011/0112011/26/20 21.23 0.00 0.00 21.23 ✓ SUPPLIES file:!//C:lUsersleheimanlcpsi/memmed.cpsinet.coralu985471data_5/tmp_cw5report8582... 11 / 18/2021 Page 5 of 18 6612950 ✓ 11105120.11/0112011/26/20 211.12 0.00 0100 211.12 r/ SUPPLIES 6612970 11/05/201110112011126/20 70.99 0.00 0.00 70.99 SUPPLIES 6527601 �✓ 11/08/20. 11/04/2011129/20 97.90 0.00 0.00 97.90 SUPPLIES 6597801 �' 11/08/20. 11/04/2011/29120 97.90 0.00 0.00 97.90 .✓ SUPPLIES 6616050 �'� 11/08/2011/0412011/29/20 77.14 0.00 0.00 77.14 ./ /SUPPLIES 6619660 �/ 11110/20. 11105/2011130/20 78.00 0.00 0.00 78,00 SUPPLIES 6604770 y,/ 11/16/20. 10/2212011/16120 234.56 0.00 0.00 234.56 ✓ SUPPLIES 661029 ✓ 11/16/20 10/27/20 11/21/20, 395.09 0100 0.00 395.09 SUPPLIES Vendor Total: Number Name Gross Discount No -Pay Net 10368 DEWITT POTH & SON 1,283.93 0.00 0.00 1,283.93 Vendor# Vendor Name Class Pay Cade 11011 DIAMOND HEALTHCARE CORP ✓/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross Discount No -Pay Net IN20054997 ✓ 11109120. 11/01/2011/26120 19,166.67 0= 0.00 1%166.67 ✓ OCT/CPR IN20054996 11/16120 11101/20 11126120. 31,144.58 0.00 0.00 31,144.58 N/ BEHAVIOR HEALTH - IN20055008 ✓ 11/16/20 11/01/20 11/26/20 2,500,00 0.00 0.00 2,500.00 V/ INPATIENT ASSESSMENT Vendor TatelE Number Name Gross Discount No -Pay, Net 11011 DIAMOND HEALTHCARE CORP 52,811.25 0.00 0.00 52,811.25 Vendor# Vendor Name Class Pay Cade 12044 DRIESSEN WATER INC.(CULLIGAN) f Invoice# Comment Tran Dt Inv Dt Due Dt Check 0, Pay Gross Discount No -Pay Not -227690.1 / 11/11/20 10/31/20 11/25120 31.50 0.00 0.00 31.50 I'#3Ua-103-(031��-1 WATER . Vendor Totals Number Name Gross Discount No -Pay Nei 120" DRIESSEN WATER INC. (CULLIGAN) 31.50 0.00 0.00 31.50 Vendor# Vendor Name Class Pay Code 11046 E-MDS, INC I/' Invoice# ; Comment Tran Ot Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 471814 11/05/2011/03/2012/01120. 63,933.23 0.00 0:00 63,933.23 HOSTING SUBSCRIPTION QR- IN nw0l- VendorTotal:Number Name Gross Discount No -Pay Net 11046 E-MDS, INC 63,933.23 0.00 0.00 63,933,23 Vendor# Vendor Name Class Pay Code W1167 ELITECH GROUP INC.(WESCOR) ✓f W Invoice# Comment Tran Ot. Inv Dt Due Dt Check D.Pay Gross Discount No -Pay Net 762887 ✓'f 11/11/20. 10/26/2011/25/20 592.60 0.00 0.00 592.60 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net W1167 ELITECH GROUP INC (WESCOR) 592.60 0.00 0.00 592.60 Vendor# Vendor Name Class Pay Code file.///C:/Users/eheiman/cpsilmemmed.cpsinet.com/u98547/data_5/tmp cw5report8582... 11/18/2021 Page 6 of 18 11284 EMERGENCY STAFFING SOLUTIONS ✓ Invoice# Tran Dt Inv Dt Due Dt Check D pay Gross Discount No -Pay Net /Comment 411/11/20. tt/15/2011/25/20 0726 ✓ 40,062.50 0.00 0.00 40,062.50 ED PHYSICIAN STAFFING L 1'16'tM) Vendor Totals Number Name Gross Discount No -Pay Net 11284 EMERGENCY STAFFING SOLUTIONS 40,062.50 0.00 0.00 40,062.50 Vendor# Vendor Name Class Pay Code 13804 EVERGREEN MEDICAL SERVICES / Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Gross Discount No -Pay Net EMSIN0004280 11/17/20 10/22/20 11/30/20 1,500,00 0.00 0.00 1,500.00 EVALUATION Vendor Totals Number Name Gross Discount No -Pay Not 13804 EVERGREEN MEDICAL SERVICES 1,500.00 0.00 0.00 1,500.00 Vendor# Vendor Name Class Pay Cade C2510 EVIDENT ✓ M Invoice# Comment Tran Ot Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net A2111031378 11/15/20. 11/03/2011128120 17,414.00 0.00 0.00 17,414.00 L,/ SUPPORT Vendor TotalENumber Name Gross Discount No -Pay Net C2510 EVIDENT 17,414.00 0.00 0.00 17,414.00 Vendor# Vendor Name Class Pay Code R1185 FARAHJANAK V; Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 111221 11115/2011/12/2011/30/20 122.08 0.00 0.00 122.08 t.' TRAVEL Ctt4114)vvl.0"dt-4 IIA1AIL,l@ W41w' luj,,uU 3 td Uuy- it ��'1-17_6 Vendor Totals Number Name k� Gross Discount No -Pay Net R1185 FARAH JANAK 122.08 0.00 0.00 122.08 Vendor# Vendor Name Class Pay Code F1100 FEDERAL EXPRESS CORP.,/ w Invoice# Comment: Tran Dt Inv Ot Due Dt Check D Pay Gross Discount No -Pay Net 755491162 ✓!11/05120,1110412011129/20. 59.15 0.00 0.00 59.15 �..' FREIGHT Vendor Totals Number Name Grass Discount No -Pay Net F1100 FEDERAL EXPRESS CORP. 59.15 0.00 0.00 59.15 Vendor# Vendor Name Class Pay Code F1400 FISHER HEALTHCARE 4/ M Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Nat 3327708 s,/ 11/09/2011101/2011/26/20 52.76 0.00 0.00 52.76 SUPPLIES 3813342 ✓ 11/09/20 11/02/20 11/28/20 428.61 0.00 0.00 426,61 SUPPLIES '9813350 11/1012011/03/2011/28120 82.82 0.00 0.00 82.82 y% SUPPLIES 3013347 ✓/11/10/2011/03/2011/28/20 1,117.07 0.00 0.00 1,117'A7 LEASE 3843349 V,,% 11/10120 11/03/20 11/28/20 78.49 0.00 0.00 78.49 SUPPLIES 2008336 11/1112010/2212011/25/20 181.98 0.00 0.00 181.98 „!' f. SUPPLIES f 3577649 ,/ 11/11/20, 11/11/20 11/25/20 78.36 0.00 0.00 78.38 ✓.- SUPPLIES file:/l/C:/Users/eheimanlcpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582... 11/18/2021 2. The MDL Expense Fund shall be released following the Effective Date of this Fee Agreement without any delay to reimburse the MDL Counsel for an agreed -to portion of the expenses incurred, as approved by the Cost and Expense Fund Administrator. The MDL Expense Fund will be paid directly to the MDL Cost Account, set up by MDL Order and will be administered under the ongoing jurisdiction of the MDL Court, as provided below. No funds may be used to compensate the costs incurred by Non -Participating Subdivisions or to compensate any Attorney for costs incurred in representing one or more Non -Participating Subdivisions. 3. In allocating the MDL Expense Fund, the Administrator shall not allocate any funds for costs incurred after July 21, 2021, unless the Administrator determines that there are sufficient funds to cover all subdivision costs incurred prior to July 21, 2021 and that special circumstances exist to justify costs incurred following the public announcement of the Janssen Agreement. G. Eligibility. It is the intention of all parties participating in the Fee Panel process that there should be total transparency to the Fee Panel and to all fund participants. In connection with the process to be developed by the Fee Panel, any and all monies in attorney's fees, including referral fees, expenses paid, promises for payment, or any other Fee Entitlement, to any applicant in any opioid litigation shall be disclosed to the Fee Panel as a condition of participating in the Attorney Fee Fund and prior to an award from the Fee Panel. Any payment, expectation of payment or perceived entitlement to participate in a State Back -Stop Agreement or any other agreement reached with a Settling State or any Subdivision or any other source regarding payment of fees must be disclosed to the Fee Panel. Similarly, any right to payment from any other fund, for example a fund for payment to lawyers representing Settling States or Tribal Nations or Subdivisions shall be disclosed to the Fee Panel. Because it is anticipated that there will be multiple firms listed on contingent fee agreements with Litigating Subdivisions, the Fee Panel shall establish procedures, with input from Attorneys for Participating Litigating Subdivisions, for who should petition for fees from such groups and to whom the fee shall be paid and thereafter distributed to co -counsel in accordance with applicable agreements. For the avoidance of doubt, all Attorneys that are part of such groups must meet the eligibility criteria in paragraph II.G.3, must be subject to the criteria set forth in paragraph II.CA, and must be disclosed to the Fee Panel. 2. An Attorney may apply for and recover attorneys' fees from the Common Benefit Fund, the Contingency Fee Fund, and the Litigating Subdivision Cost Fund and any fund created by a past or future State Back -Stop Agreement, provided the Attorney satisfies the requirements relevant to each such fund and requirements for disclosure to the Fee Panel. 121 revised July 30, 2021 3. An Attorney may not receive any payment from the Attorney Fee Fund (which includes both the Contingency Fee Fund and the Common Benefit Fund) unless the following eligibility criteria are met and annually certified by the Attorney: a. The Attorney must expressly waive the enforcement against the Litigating Subdivision client of all Fee Entitlements (other than under State Back - Stop Agreements) arising out of or related to any or all Qualifying Representations of any Participating Litigating Subdivision prior to applying for attorneys' fees from the Attorney Fee Fund or costs from the Cost Funds. All applications for attorneys' fees or costs under this Fee Agreement shall include an affirmation by the Attorney of such waiver and notice to the client(s) of such waiver. Such waiver shall not preclude the Attorney from submitting such Fee Entitlements to the Fee Panel as a factor for consideration in allocating payments from the Attorney Fee Fund or in connection with a State Back -Stop Agreement. For the avoidance of doubt, no Attorney may recover fees or costs under this Fee Agreement unless the Attorney expressly agrees not to enforce Fee Entitlements as to each and every Participating Litigating Subdivision represented by that Attorney, but such Attorneys may participate in and receive funds from a State Back -Stop Agreement. b. The Attorney must represent that s/he has no present intent to represent or participate in the representation of any Later Litigating Subdivision or any Releasor with respect to Released Claims against Released Entities. c. The Attorney must represent that s/he has not and will not engage in any advertising or solicitation related to Released Claims against Released Entities where such advertising or solicitation relates to a representation that the Attorney could not undertake consistent with the ethics opinion referenced in paragraph II.I.4. d. The Attorney must represent s/he will not charge or accept any referral fees for any Released Claims brought against Released Entities by Later Litigating Subdivisions. For the avoidance of doubt, this representation shall not prohibit Attorneys from receiving allocated shares of any future common benefit assessments arising out of settlements or judgments with Later Litigating Subdivisions represented by other Attorneys that are the result of the MDL Court's Common Benefit order. e. The Attorney may not have and must represent that s/he does not have a Fee Entitlement related to a Later Litigating Subdivision. 122 revised July30, 2021 f. The Attorney must certify that s/he has reviewed the ethics opinion referenced in paragraph II.I.4 and will act in conformity with such opinion. g. The Attorney must fully disclose the participation, or the anticipation of participation, in any agreement with a Settling State or Participating Subdivision concerning fees arising out of or related to the Janssen Agreement, including any fees paid or anticipated to be paid or any State Back -Stop Agreement. h. The Attorney must identify for the Fee Panel whether s/he utilized state litigation work product or MDL work product, including but not limited to ARCOS data, document repositories, experts developed in the MDL, and deposition transcripts. The Attorney must identify whether s/he signed the MDL Participation Agreement, and for which case(s) it was signed. Any Attorney who applies for fees from one or both Funds must represent that, having exercised his/her independent judgment, s/he believes the Janssen Agreement to be fair and will make or has made best efforts to recommend the Janssen Agreement to his or her Subdivision clients in Settling States. For avoidance of doubt, each Attorney is expected to exercise his or her independent judgment in the best interest of each client individually before determining whether to recommend joining the settlement. All applications for attorneys' fees or costs under this section shall include an affirmation by the Attorney in compliance with this Subsection. 4. No Attorney receiving fees under this Fee Agreement may apply for or recover from the Attorney Fee Fund fees arising from representing a Non - Settling State or a Non -Participating Subdivision. All applications for attorneys' fees under this Section shall include an affirmation by the Attorney of compliance with this Section. 5. An Attorney who has filed an application under this section and received an award of attorneys' fees shall provide a certification of compliance with the Sections of this Fee Agreement annually during the years upon which they are still entitled to receive attorneys' fee payments. 6. If, at any time, the Attorney is unable to make the representations set forth in this Section, such representations become untrue, or the Attorney falsely represents compliance with the eligibility criteria, the Attorney shall cease to be eligible to receive funds from the Attorney Fee Fund until further review by the Fee Panel of the Attorney's eligibility under and compliance with this Section II. 123 revised July 30, 2021 If an Attorney has a Fee Entitlement with a Later Litigating Subdivision or otherwise becomes unable to reaffirm compliance with the eligibility criteria set forth above, the Attorney shall notify Janssen and the Fee Panel. For the avoidance of doubt, any Attorney who undertakes any new representation of, or has a Fee Entitlement with, a Later Litigating Subdivision shall be prohibited from receiving any future funds from the Attorney Fee Fund. If an Attorney fails to notify Janssen and the Fee Panel of such Fee Entitlement with a Later Litigating Subdivision, the Attorney shall be required to refund amounts previously paid. 8. In the event that an Attorney is deemed ineligible by the Fee Panel (whether based on its initial application or subsequent recertification), the Fee Panel shall provide notice to the Attorney and give the Attorney 30 days to provide additional information such that the Fee Panel could re -consider the Attorney's eligibility. 9. To the extent that an Attorney has a Fee Entitlement with a Participating Subdivision and is authorized to bring Released Claims against Released Entities, but such authorization is, in scope, less broad than the category of Released Claims set forth in the Janssen Agreement, such Attorney may participate fully in both the Contingency Fee Fund and the Common Benefit Fund, without any reduction imposed by the Fee Panel due to the scope of the authorization, so long as the Participating Subdivision fully releases all Released Claims against Released Entities. 10. Attorneys applying to the Attorney Fee Fund knowingly and expressly agree to be bound by the decisions of the Fee Panel, subject to the limited appeal rights set forth in this Fee Agreement, and waive the ability to assert the lack of enforceability of the allocation reached through the arbitration procedures outlined herein. H. Calculation of Amounts Due. The Fee Panel shall be solely responsible for determining the amount of fees to be paid to each Attorney and each Participating Subdivision that applies under this Section. None of the Released Entities shall have any responsibility, obligation, or liability of any kind whatsoever with respect to how attorneys' fees are calculated under this Section, except that the Fee Panel may receive information from Janssen as to (a) the identity of Participating, Non -Participating, Litigating, Later Litigating, and Non - Litigating Subdivisions; (b) the impact of non -participation by a Litigating Subdivision as is relevant to the Fee Panel's determination in paragraph II.C.4; and (c) such other information as Janssen may voluntarily elect to provide. 124 revised July30, 2021 2. The Fee Panel shall establish procedures for the arbitration process consistent with this Fee Agreement and orders of the MDL Court. Such procedures may include submission of documentary and/or other evidence, interviews with applicants and/or other counsel (including counsel for Janssen) that the Fee Panel deems appropriate, and/or other means of creating a record upon which fee awards will be based. 3. In making determinations under this Fee Agreement, the Fee Panel must apply the eligibility criteria set forth in Section ILG of this Fee Agreement and the criteria set forth in Section II. In addition, the Fee Panel will give consideration in regard to Common Benefit awards to the Johnson factors, as well as the following factors (which factors may be applied and given relative weight in the Fee Panel's discretion): a. The Attorney's contemporaneously recorded time and labor dedicated to Qualifying Representations along with the Attorney's financial commitment to such Qualifying Representations. Claimed "time" will not be automatically accepted by the Fee Panel but will be critically reviewed and given substantially more weight and consideration if such time was subject to the audit process described in any Pretrial Order(s) governing the collection of common benefit time; b. The novelty, time, and complexity of the Qualifying Representations; c. The skill requisite to perform legal services properly and undesirability of the case; d. The preclusion of other employment by the Attorney due to time dedicated to Qualifying Representations; e. The "common benefit," if any, alleged to have been conferred by the Attorney and whether such common benefit work product by that Attorney was used by others in parallel litigations against Released Entities whether within or outside the MDL, provided that any Attorney claiming that s/he substantially benefited cases other than those in which s/he entered an appearance as counsel must substantiate such claims by proffering factual support, such as proper supporting affidavits or other documents as determined by the Fee Panel with input from Attorneys for Participating Litigating Subdivisions; f. Any "common detriment," as set forth in paragraph II.CA. g. Any contingent fee agreement or other Fee Entitlement with Participating Subdivisions, enforcement of which, except for State Back -Stop Agreements, are waived in conjunction with the application, the nature and extent of any work for those Participating Subdivisions, whether such 125 revised July 30, 2021 Participating Subdivisions actively litigated and, if so, the nature and procedural history of such case(s); h. The experience, reputation, and ability of the Attorney; i. Whether the Attorney's clients brought Released Claims against Released Entities; j. The status of discovery in cases primarily handled by the Attorney; k. The nature of any work by the Attorney on "bellwether" cases or cases that were similarly active in litigation; 1. Any pressure points successfully asserted by the Attorney in cases against Janssen or any risk for Janssen created by the Attorney in cases against them; in. Any risk for defendants created by applicants in cases against Janssen; n. Successful and unsuccessful motion practice in cases worked on by the Attorney; o. The date of filing of any cases filed by the Attorney; p. Obtaining consolidation of the litigation in the Attorney's jurisdiction; q. The number and population of entities represented by the Attorney and the fees that would have been awarded under extinguished contingent fee arrangements; r. Whether the Attorney's clients brought claims against Janssen; s. Whether the Attorney has had a leadership role in the litigation, whether in state or federal court; t. Whether the Attorney has had a leadership role in any negotiations aimed at resolving the litigation; u. Whether the Attorney's cases have survived motions to dismiss; v. The extent to which the Attorney contributed to the work product used for the common benefit of opioids litigants, including, without limitation, work on ARCOS data, Prescription Data Monitoring Programs, IQVIA data, depositions, document production and analysis experts, motions, briefs and pleadings, trial preparations, and trials; 126 revised July 30, 2021 w. The extent to which litigation was done prior to and contributed to completion of settlement negotiations, as distinct from litigation that was done litigating after the announcement of the Janssen Agreement, such latter litigation both being of less value and potentially resulting a common detriment to the settlement process; and x. Any other factors that the Fee Panel finds to be appropriate to consider after input from applicants to the Attorney Fee Fund. 4. The Fee Panel shall develop procedures for receiving a single application, which may be updated or amended based on new information (such as participation by additional Litigating Subdivisions) from each Attorney seeking compensation from the Attorney Fee Fund pursuant to processes and procedures developed by the Fee Panel, which shall not be inconsistent with this Fee Agreement. Any request for attorneys' fees not included on the single application or through the updating/amendment process designed by the Fee Panel shall be deemed waived. For purposes of transparency and to permit the Fee Panel to conduct its work, the application from each Attorney shall, at a minimum, require each Attorney to a. Identify all Litigating Subdivisions for which s/he is seeking payment from the Attorney Fee Fund; b. Identify all Subdivisions in both Settling and Non -Settling States (and, where applicable, Tribal Nations) with respect to which s/he has a Fee Entitlement with respect to Relevant Claims against Released Entities, and identify all co -counsel in such cases; c. Identify which of those Subdivisions are Participating Subdivisions and which are not (with similar information for Tribal Nations, where applicable); d. Specify the specific fund or funds within the Attorney Fee Fund from which the Attorney is seeking compensation; e. Demonstrate his or her eligibility for compensation from the relevant sub funds within the Attorney Fee Fund pursuant to the criteria set forth for the relevant sub fund; f. Identify any and all Fee Entitlements from representations of States, Tribal Nations, or other plaintiffs related to Released Claims against Released Entities or in opioids-related matters; g. Notwithstanding "a-f' above, the Panel may consider a supplemental application if the Attorney shows good cause why circumstances exist that will lead to consideration for additional Common Benefit award. 127 revised July 30, 2021 Examples would include, but are not limited to, an Attorney having Non - Participating Litigating Subdivision clients that subsequently become Participating Subdivisions, a Bar Date passes that increases participation or the Participation Tier, or an Allocation Agreement is reached. 5. With respect to the Common Benefit Fund, the Fee Panel shall (subject to any applicable MDL Court Order): a. Review the applications of all Attorneys seeking compensation from the Common Benefit Fund, including determining eligibility for each Attorney as set forth in Section II.G. b. Reduce, on an annual basis, Janssen's payment obligations, as set forth in paragraph ILC.5. The Panel shall inform Janssen and the MDL PEC of all such amounts and adjust Janssen's payment obligations accordingly. c. Using criteria set forth in Sections II.0 and II.I, allocate amounts from the Common Benefit Fund to eligible Attorneys, including payment amounts for each Payment Year. In making such allocations (regardless of the Participation Tier achieved), the Panel shall apply the principles set forth in paragraph II.CA and shall allocate any reduction in the payments of Janssen specified in paragraph II.C.5 to the amounts paid to Attorneys with a Fee Entitlement to Litigating Subdivisions that are not Participating Subdivisions. 6. With respect to the Contingency Fee Fund, the Fee Panel shall: a. Review the applications of all Attorneys seeking compensation from the Litigating Subdivision Fee Fund, including determining eligibility for each Attorney as set forth in Section II.G. b. Apply the Mathematical Model in Exhibit A. c. Use such allocations to reduce payments, on an annual basis, the payment obligations of Janssen to the Attorney Fee Fund as set forth in paragraph ILDA, and distributions therefrom, and inform Janssen and the MDL PEC of all such adjustments. To the extent that there is a dispute about the calculations of the Fee Panel related to the amounts that Janssen is required to pay (including application of any reductions or offsets under this Fee Agreement), such disputes shall be presented to the Fee Panel and any disputed funds be paid into/held in escrow. The Fee Panel shall resolve such disputes expeditiously, with either Party having the right to seek review from the MDL Court. 128 revised July 30, 2021 8. For purposes of determination of fee or cost awards, allocations, reductions, and possible reversions under this Fee Agreement, unless specified otherwise a Subdivision will be considered a Non -Participating Subdivision if it is not a Participating Subdivision as of the deadline for the application for the fee or cost award at issue (or, if the determination does not involve a specific application, the date on which the record for such determination closes). 9. In the event that the Fee Panel, through the use of the Mathematical Model set forth in Exhibit A, allocates funds from the Contingency Fee Fund for an Attorney based on a Qualifying Representation of a Participating Litigating Subdivision or allocates cost to such Participating Litigating Subdivision and that Subdivision is in a Settling State in which the Consent Judgment has not been approved, such funds shall be placed into escrow until the Consent Judgment is approved, after which time they shall be released. Miscellaneous. The costs associated with the Fee Panel prior to the Effective Date of the Attorney Fee Agreement shall be funded by Janssen. The Fee Panel shall charge an hourly rate that previously has been approved by a federal or state court and shall provide a budget and a cap for such work prior to the Effective Date, which shall be approved by Janssen and such approval shall not be unreasonably withheld. Janssen shall receive a refund for any such payment of pre -Effective Date costs from interest that accrues on the monies in the Attorney Fee Fund (including interest that accrues during such time as the Attorney Fee Fund monies are in escrow prior to the Effective Date of the Janssen Agreement), up to the amount of such costs. Post -Effective Date, the cost of the Fee Panel shall be charged against the applicable Fee Fund based on allocation by the Fee Panel and shall not be otherwise funded by Janssen. The costs associated with the Cost and Expense Fund Administrator shall be paid from funds in the MDL Expense Fund and the Litigating Subdivision Cost Fund and shall not be otherwise funded by Janssen. 2. The MDL PEC will seek, and the Attorneys General for Settling States and Janssen will not oppose, a Common Benefit Fee Order requiring an assessment of 7.5% on the gross recovery (by judgment or settlement) of any Non -Participating Subdivision that is subject to the federal court jurisdiction, represented by a MDL PEC firm, represented by any Attorney receiving fees from the Common Benefit Fund, represented by any Attorney that signed a Participation Agreement or paid in a case otherwise under the jurisdiction of the MDL Court. 3. The MDL PEC shall provide to Janssen information they have that identifies Attorneys who represent Litigating Subdivisions who are not Participating Subdivisions and who have an obligation to pay a common benefit assessment, either due to the MDL Court's orders or having signed a Participation Agreement. 129 revised July 30, 2021 4. The MDL PEC shall retain ethics counsel of its choice to provide an opinion that addresses the compliance of its ethical obligations, as it relates to the Janssen Agreement. Such opinion shall address the issue of the potential conflict of interest for an Attorney that had represented a Participating Subdivision also representing a Later Litigating Subdivision as defined in the Janssen Agreement. This Subsection shall be enforceable to the extent permitted by the equivalent to Rules 1.16 and 5.6 of the ABA Model Rules of Professional Conduct in the relevant jurisdictions. The opinion shall be provided to Janssen as soon as it is completed and, in any event, prior to July 31, 2021 and shall be disseminated to counsel eligible to apply to the Attorney Fee Fund within 30 days of the announcement of the Janssen Agreement. The MDL PEC represents that it will comply with this opinion until the Reference Date and thereafter if the Janssen Agreement proceeds. 5. Participating Subdivisions agree to instruct their counsel to treat information, work product and expert materials as secret under Rule 1.6 of the ABA Model Rules of Professional Conduct. Accordingly, an Attorney shall not share information or work product with, or experts or materials to, non -participants (other than the Attorney's own current clients or their lawyers, consultants, experts or other representatives or agents). However, nothing herein shall prevent MDL Leadership or PEC Counsel from fulfilling their obligations in any MDL and the MDL Court Order. III. Miscellaneous A. Termination. If the Janssen Agreement does not proceed past the Reference Date, whether because Janssen does not determine to proceed or for any other reason, this Fee Agreement shall be null and void, Janssen shall have no obligation to make any payments under this Fee Agreement, and Janssen and the PEC shall take such steps as are necessary to restore the status quo ante. B. MDL Court Consideration. This Fee Agreement shall be attached as an exhibit to the Janssen Agreement. This Fee Agreement shall also be submitted by Janssen and the MDL PEC to the MDL Court for approval pursuant to the motion and order that shall be attached, prior to the Preliminary Agreement Date of the Janssen Agreement, as Exhibit B. In the event that the MDL Court, through an order, makes any change to the amounts potentially to be paid by Janssen under this Fee Agreement, makes any change to the Fee Panel's consideration of the factors set forth in paragraph II.C.4, or any other material change to the draft Order attached as part of Exhibit B or the terms of this Fee Agreement, Janssen and the MDL PEC shall meet and confer concerning such changes. 2. If Janssen and the MDL PEC are unable to reach agreement and revisions to this Fee Agreement in the event discussed in paragraph III.B.1, this Fee 130 revised July 30, 2021 Agreement shall be null and void, Janssen shall have no obligation to make any payments under this Fee Agreement, and Janssen and the MDL PEC shall take such steps as are necessary to restore the status quo ante. C. Amendment. Once the MDL Court has entered an order implementing this Fee Agreement, this Fee Agreement can only be amended by (1) written agreement of Janssen and the MDL PEC and (2) approval by the MDL Court. D. Jurisdiction and Enforcement. The MDL Court shall have exclusive and ongoing jurisdiction over the enforcement and implementation of this Fee Agreement as set forth herein. The MDL PEC shall be the Authorized Party to enforce this Fee Agreement, as to the payment obligations of Janssen as set forth in this section, and as to Attorneys making application to the Funds under this Fee Agreement. Solely for purposes of assessing or allocating common benefit fees, the MDL Court will continue to have jurisdiction over the work product developed in the MDL Court by and under the direction of the MDL PEC with respect to claims against Janssen, including data and documents, depositions, expert reports, briefs and pleadings; and the MDL Court's protective orders, management orders, and other decisions regarding such discovery and other work product, including but not limited to, conditions on its use, will continue in full force and effect. Nothing in this paragraph authorizes the MDL Court to act contrary to this Agreement or to share any of the work product, or provides the MDL Court with jurisdiction over the Janssen Agreement. 131 revised July 30, 2021 EXHIBIT S Agreement on the State Cost Fund Administration 1. Creation of a State Cost Fund. Janssen and the Settling States agree to the creation of a state cost fund to pay litigation costs and expenses associated with litigation and investigation related to the opioid litigation (hereinafter the "State Cost Fund"). This agreement is a material part of the Settlement Agreement. The State Cost Fund shall be administered separately from the Common Benefit Fund, the Contingency Fee Fund, the State Counsel Fee Fund, Subdivision Costs Fund, and the MDL Expense Fund. No funds may be released from the State Cost Fund to Non -Settling States. 2. State Cost Fund Amount. In Payment 1 of the Settlement, Janssen shall pay into the State Cost Fund $13,461,539 (the "State Cost Fund Amount"). Janssen's State Cost Fund payment shall be a component of its Global Settlement Attorney Fee Amount payable to the Attorney Fee Fund, for Payment 1. 3. State Cost Fund Committee. A committee of Attorneys General from Settling States or their designated representatives (hereinafter the "State Cost Fund Committee") shall oversee the State Cost Fund. The committee shall initially consist of the following states: (a) Delaware; (b) Florida; (c) Georgia; (d) New York; (e) North Carolina; (f) Ohio; (g) Tennessee; and (h) Texas. The Settling State Attorneys General may by majority vote add or change the composition of the State Cost Fund Committee, including replacing any above State, if that State is not a Settling State. 4. State Cost Fund Administrator. The State Cost Fund Committee shall select an administrator (the "State Cost Fund Administrator"). The State Cost Fund Administrator may be different from the Settlement Administrator under the Settlement Agreement. The State Cost Fund Administrator shall be responsible for administering the State Cost Fund and making payments to Settling States. 5. State Cost Fund Guidelines. Monies in the State Cost Fund shall be released without any delay to reimburse Settling States for documented opioid litigation and investigation costs incurred or paid. In allocating the State Cost Fund, no funds shall be allocated for costs incurred after July 21, 2021. The State Cost Fund Committee shall establish guidelines for the submission and approval of expenses eligible for reimbursement from the State Cost Fund. The State Cost Fund Administrator shall, in accordance with such guidelines, receive from Settling States records sufficient to demonstrate the incurrence and/or payment of each expense attributable to investigation or litigation related to the opioid litigation, including any outstanding National Association of Attorneys General grant. 6. State Cost Fund Payment Priorities and Residual. To the extent that that the aggregate eligible submissions of costs and expenses from Settling States exceed the State Cost Fund Amount, payments to Settling States shall be paid in the following order until the State 132 revised July 30, 2021 Cost Fund is exhausted. If the State Cost Fund is unable to fully pay costs at any of the following levels, then Settling States with costs at that level shall be paid on a proportional basis. All expenses with a lesser priority from the level where the State Cost Fund is exhausted will not be reimbursed from the State Cost Fund. Costs shall be paid in the following order: (a) the reasonable costs of the State Cost Fund Administrator, if any; (b) repayment of the National Association of Attorneys General grants connected to opioid litigation; (c) costs incurred or paid by outside counsel for a Settling State litigating against Janssen apart from any fee owed; (d) litigation -related costs attributable to the Janssen case incurred or paid by a Settling State litigating against Janssen; (e) pre -suit investigation -related costs attributable to a Janssen investigation incurred or paid by either a Settling State outside counsel (not including any amount of fees or any costs which have already been reimbursed pursuant to clause (c), above) or a Settling State investigating Janssen; (f) costs incurred or paid by a Settling State or outside counsel litigating against another opioid defendant other than a cost share entered into by a Settling State, which costs have not yet been paid under a preceding clause of this paragraph; (g) the amounts paid by a Settling State as part of cost share related to the filing of a proof of claim in the Purdue Pharma, L.P. bankruptcy; and (h) the amounts paid by a Settling State as part of any other cost share, including, but not limited to the cost share entered into by the Non - Consenting States in the Purdue Pharma, L.P. bankruptcy. If the State Cost Fund has additional monies after payment of the State Cost Fund Administrator's and all Settling States' submitted costs, then the remaining funds will be provided to the National Association of Attorneys General to be placed in the Financial Services Fund for the purpose of funding grants for consumer protection or healthcare -related enforcement or training activities. In determining what costs are attributable to Janssen, the State Fund Committee shall develop a guideline that ensures that all Settling States are treated equitably. 133 revised July 30, 2021 EXHIBIT T Severity Factors State Severity Factor Alabama 108.5243% Alaska 107.8614% American Samoa 102.7639% Arizona 107.7129% Arkansas 103.2818% California 82.8688% Colorado 95.2263% Connecticut 121.0971% Delaware 155.5946% District of Columbia 88.3270% Florida 107.9604% Georgia 86.6675% Guam 96.8019% Hawaii 77.1051% Idaho 93.0570% Illinois 86.6318% Indiana 108.6768% Iowa 78.2056% Kansas 89.6374% Kentucky 150.0126% Louisiana 105.2878% Maine 132.7534% Maryland 115.2160% Massachusetts 110.3001 % Michigan 112.4239% Minnesota 75.9148% Mississippi 96.7243% Missouri 107.8496% Montana 99.7815% N. Mariana Islands 100.2421% Nebraska 71.9045% Nevada 130.5519% New Hampshire 144.4997% New Jersey 102.3701% New Mexico 128.9295% New York 91.4472% 134 revised July 30, 2021 North Carolina 102.2754% North Dakota 76.0864% Ohio 123.0063% Oklahoma 129.3047% Oregon 108.9094% Pennsylvania 118.2821 % Puerto Rico 73.9803% Rhode Island 143.8802% South Carolina 99.6801% South Dakota 76.4482% Tennessee 129.9078% Texas 71.6286% Utah 119.5878% Vermont 140.2239% Virgin Islands 100.4396% Virginia 88.1611% Washington 100.5007% Wisconsin 99.6616% Wyoming 100.9659% 135 revised July 30, 2021 EXHIBIT U Agreement on the State Outside Counsel Fee Fund Creation of a State Outside Counsel Fee Fund. Janssen and the Settling States agree to the creation of a state outside counsel fee fund to pay reasonable attorney's fees of Settling States with outside counsel in connection with litigation against Janssen (the "State Outside Counsel Fee Fund"). This agreement is a material part of the Settlement Agreement. All terms utilized in this Agreement shall have the same meaning as in the Settlement Agreement unless otherwise indicated. 2. State Outside Counsel Fee Fund Administration. The State Outside Counsel Fee Fund shall be administered separately from the Common Benefit Fund, the Contingency Fee Fund, the State Cost Fund, and the MDL Expense Fund. A committee of Attorneys General shall oversee the State Outside Counsel Fee Fund ("Fee Fund Committee"). The Fee Fund Committee shall initially consist of the following: (a) Arkansas; (b) Florida; (c) New Jersey; and (d) Puerto Rico. The Fee Fund Committee shall select a settlement fund administrator (who may or may not be different from the Settlement Administrator under the Distributor Agreement) (the "Fee Fund Administrator") who shall administer the State Outside Counsel Fee Fund according to the guidelines and directives of the Fee Fund Committee. State Outside Counsel Fee Eligibility. To participate in the State Outside Counsel Fee Fund, an outside counsel for a Settling State must have filed and be maintaining an action in the name of a Settling State or its attorney general against Janssen in a state or federal court as of June 1, 2021. No Settling State can draw attorney's fees from both the State Outside Counsel Fee Fund and the similarly sized fund to reimburse Settling State's without outside counsel. 4. State Outside Counsel Fee Fund Amount. Janssen shall pay funds in the State Outside Counsel Fee Fund according to the schedule set forth below, as part of its annual Global Settlement Attorney Fee Amount payable to the Attorney Fee Fund, subject to the adjustments described below: Payment Year 1 $32,391,518.74 Payment Year 2 $30,769,230.77 Payment Year 3 $ 4,146,942.80 State Outside Counsel Fee Fund Availability and Calculation of Amount. a. The State Outside Counsel Fee Fund shall be available to compensate private counsel for State Attorneys General for approved fees arising out of representation of the State pursuant to the schedule developed by the Fee Fund Committee and provided to Janssen. 136 revised July 30, 2021 b. Fees shall be calculated by adding two components: (a) a fixed amount consisting of fifty (501/o) of the amount allocated to a State utilizing the allocation percentage in the Settlement Agreement multiplied times 4.5%; and (b) a proportional percentage of the remaining fee due under that Settling State's contract assuming that fifty (50%) of the State's recovery is allocable to a Settling State (versus allocable to the Settling State's Subdivisions) so that the fees of all Settling States (minus the base amount that would have been due to any of Non -Settling States) exhausts the State Outside Counsel Fee Fund. The proportional share percentage will be the same for each Settling State included in the State Outside Counsel Fee Fund. All amounts paid will be less any costs or fees of the Fee Fund Administrator. 6. Payment by the Fee Fund Administrator. a. If a Settling State and a Settling State's outside counsel agree that the amount calculated in paragraph 5 above satisfies in full amounts owed to all Settling State outside counsel, then upon written notice of that agreement and counsel waiving in writing any entitlement to any additional fee, the Fee Fund Administrator shall pay that Settling State's outside counsel pursuant to the calculation and any schedule created by the Fee Fund Committee. b. If a Settling State's outside counsel does not agree that the amount calculated in Paragraph 5 above satisfies in full amounts owed by the Settling State, then the Settling State's share shall be placed in an interest bearing escrow account (less reasonable expenses of the Fee Fund Administrator) and held unless and until the Settling State and its outside counsel agree in a signed writing to a resolution of the amount outstanding or there is a final judgment entered that is no longer appealable. c. Upon being provided a signed, written agreement or the final non -appealable judgment, the Fee Fund Administrator shall release monies from the State Outside Counsel Fee Fund in either the amount held by the Fee Fund Administrator, if the amount of the agreement or judgment is equal to or more than the amount held, or the amount indicated in the agreement or in the final judgment, if the amount in the agreement or judgment is less than the amount held. d. Nothing herein, including the amounts listed in paragraph 5 above, shall prevent a Settling State from arguing in any proceeding with its outside counsel that (a) its recovery was less than fifty (50%) percent of the recovery in the Settlement Agreement down to and including fifteen (15%) percent of the total recovery; (b) any payment should be discounted by an appropriate discount rate commensurate to the risk of the Settlement Agreement and the timeline that the Settling State is receiving its payments; (c) the settlement amount should be lower because a Settling State's amounts were reduced because a Settling State's outside counsel failed to obtain joinder from a Settling State's Subdivision(s) who(m) the outside counsel also represented; 137 revised July 30, 2021 or (d) any limitation placed by Janssen bars payment of a higher fee to outside counsel. e. In the event the amount due to the Settling State's outside counsel from an escrow account is less than the total amount of funds escrowed on the account of the Settling State, the balance shall be paid to the Settling State. In no event, other than a State not being a Settling State, shall funds revert to Janssen. f. Amounts owed by Janssen to the State Outside Counsel Fee Fund shall be reduced and/or credited to Janssen by the amount specified in paragraph 7, below, for any Non -Settling outside counsel States. 7. Reversion or Reduction of Amounts owed to Non -Settling States. Amounts owed by Janssen to the State Outside Counsel Fee Fund shall be reduced on account of Non -Settling States as follows: a. If the State of Washington does not become a Participating State and eleven (11) of the other outside counsel States in the table below become Participating States, then the amount Janssen owes under paragraph 4 will be reduced by the State of Washington's Fixed Amount in the table below. b. If ten (10) outside counsel States in the table below become Participating States, then the amount Janssen owes under paragraph 4 will be reduced by the allocated Fixed Amount in the table below for each Non -Settling State. c. If nine (9) or fewer of the outside counsel States in the table below become Participating States, then the amount Janssen owes under paragraph 4 will be reduced by each Non -Settling State's allocated Fixed Amount plus half the difference between the Non -Settling State's full share of the "Fee Amount if all OC States Join" and the Fixed Amount for each Non -Settling State. 11 Allocation % JJ Payment Amount State Share Contract Rate Full Contract Amount Fixed Amount Fee Amount if all OC States Join Arkansas 0.9663486633% $44,048,604.48 $22,024,302.24 TIPAC $4,452,430.22 $991,093.60 $3,608,210.22 Florida 7.0259134409% $318,598,151.79 $159,299,075.89 TIPAC $11,464,953.79 $7,168,458.42 $10,417,038.57 Idaho 0.5254331620% $24,023,889.47 $12,011,944.74 10% $1,201,194.47 $540,537.52 $1,040,060.24 Kentucky 2.0929730531% $95,444,090.08 $47,722,045.04 TIPAC $4,636,102.25 $2,147,492.03 $4,029,130.22 Mississippi 0.8898883053% $40,549,243.09 $20,274,621.55 TIPAC $4,277,462.16 $912,357.97 $3,456,713.24 Nevada 1.2486754235% $56,896,524.63 $28,448,262.31 19% $5,405,169.84 $1,280,171.80 $4,399,082.82 New Hampshire 0.6258752503% $28,620,454.86 $14,310,277.43 27°% $3,863,761.41 $643,960.23 $3,078,451.90 New Jersey 2.7551354545% $124,934,796.18 $62,467,398.09 33% $20,614,241.37 $2,812,032.92 $16,272,038.83 New Mexico 0.8557238713% $39,104,404.67 $19,552,202.33 24 $ 4,692,528.56 $879,849.11 $3,762,616.04 Ohio 4.3567051408% $197,559,821.57 $98,779,910.78 TIPAC $8,438,995.54 $4,445,095.99 $7,464,883.44 Puerto Rico 0.7263201134% $33,083,484.37 $16,541,742.19 25% $4,135,435.55 $744,378.40 $3,308,356.71 South Dakota 0.2169945907% $9,948,315.49 $4,974,157.75 12% $596,898.93 $233,837.10 $505,909.15 Washington 1 2.3189040182% $105,153,378.36 1 $52,576,689.18 13.5% $7,097,853.04 1 $2,365,951.01 5,943,742.14 138 revised July 30, 2021 In the event that the Fee Fund Administrator has received from Janssen part or all of the amount that Janssen is entitled to offset under paragraph 7 above, the Fee Fund Administrator shall return to Janssen the amount so received. 139 revised July 30, 2021 # 27 NOTICE OF MEETING— 11/24/2021 27. Consider and take necessary action to declare Inventory No. 24-0407, a 1990 Fiat -Allis Motorgrader, Model 75-B, as Surplus/Salvage to be used as trade-in and remove from Precinct 4 R & B inventory. (GR) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 23 of 28 Gary D. Reese County Commissioner County of Calhoun Precinct 4 November 15, 2021 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 for November 24, 2021. • Consider and take necessary action to declare Inventory No. 24-0407; 1990 Fiat -Allis Motorgrader, , Model 75-B; surplus salvage and to be used as trade-in and remove from Precinct 4 R&B inventory. Sincerely, ,,Gary. Reese GDR/at P.O. Box 177 -Seadrift, Texas 77983 -email: gary.reesa a� calhouncotx.ore - (361) 785-3141 - Fax (361) 785-5602 Calhoun County, Texas SURPLUS/SALVAGE DECLARATION REQUEST FORM Department Name: 570 — Pct 4 R&B Requested By: Commissioner Gary Reese Inventory Reason for Surplus/Salvage NL I Description Serial No. Declaration 24-0407 1990 Fiat-Allic 68CO4379 TO BE USED FOR TRADE-IN Motorerader I FOR NEW EQUIPMENT # 2s NOTICE OF MEETING — 11/24/2021 28. Consider and take necessary action to transfer certain items of County property from the County Auditor's Department to other County Departments. (See Attached List) (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 24 of 28 November 16, 2021 To: Judge Meyer From: The office of the County Auditor Please place the following item on the Commissioners Court Agenda for November 24, 2021: Consider and take necessary action on transferring certain items of County property from the County Auditor's Department to another County Department. (See Attached List) (RHM) CALHOUN COUNTY, TEXAS DEPARTMENTAL INVENTORY TRANSFER REQUEST FORM Requested By: County Auditor Cindy Mueller Commissioners Court November 24, 2021 Inventory Transfer Number Description Serial No. From/To Department 495-0003 Chair - Padded (Brown with no arms) NA From: Auditor To: FIR 495-0023 Chair - Padded (Brown with no arms) 458 From: Auditor To: HR 495-0040 Chair - Padded, Vinyl/Fabric Seat with Arms 444 From: Auditor To: Treasurer NA Brown Leather Office Chair NA From: Auditor To: Maintenance # 29 NOTICE OF MEETING— 11/24/2021 29. Consider and take necessary action to declare the attached list of equipment from MMC as Waste. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 25 of 28 Calhoun County, Texas WASTE DECLARATION REQUEST FORM Department Name: Memorial Medical Center Storage Units - October 2021 page 1 Requested By: Jason Anglin, CEO Inventory Number Description Serial No. Reason for Waste Declaration t IT Cabinet No longer used 1 Black Office Chair No Longer UsedlBroken i Blue Office Chair No Longer Used/Broken 1 Blood Pressure Monitor No Longer Used/Broken 21V Poles No Longer UsetllBroken ^ Vital Machine No Longer UsedlBroken 1 Fish Picture No longer used 1 Hematology Machine No Longer UsetllBroken i Orange Stool No longer used 1 Wooden Cabinet No longer used 2 Microwaves No Longer UsetllBroken t White Mini Rotrigeratiors No Longer UsedlBroken 1 Black Office Chair No Longer Used/Broken 2 Metal 4 Drawer Filing Cabinet NO Longer UsetllBroken DCA Vantage Machine No Longer UsedlBroken 4 orange traffic canes No Langer UsetllBroken 16 Pink Boartlmom Chairs No Langer UsedlBroken 1 ER Stretcher No Longer Make Pans / Broken 1 MrIG Mmi-Fntlge Plain Operations No Longer Used/Broken # 30 NOTICE OF MEETING — 11/24/2021 30. Accept a report from the following County Office: I. Justice of the Peace, Precinct 4 — October 2021 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 26 of 28 11-15-21;10:45 ;From:Calhoun County JP4 To:5534444 ;3617852179 # 1/ 4 FAX COVER SHEET NOVEMBER 15, 2021 FROM: 1USTICE_.000RT PCT. 4, CALHOUN CQVNTY 103 W. Dallas Street P.O. Box 520 Seadrift, Texas 77983 PHONE! 361-785-7082 FAX: 361-785-2179 TO: Countviudeeoffice Ref; Money Distribution Report FAX: 361-553-4444 NOTE: The OCTOBER 2021 report is attached Please five me a call if you have any questions PAGES TO FOLLOW: —4— INCLUDING THIS COVER PAGE Thank you, judge Wes(ey J. -Munt 11-15-21;10:45 ;Frorn:Calhoun County JP4 To:5534444 ;3617852179 # 2/ 4 ENTER COURT NAME. ENTER MONTH OF REPORT"..' : JUSTICE OF PEACENO.4 ENTER'.YEAR'OF REPORT ,' ".' ,: OCTOPOR '. 2021 . :' •'COOEI :.. AMOUNT CASH PONDS .... REVISED 01/20/20 . ., .' ADMINISTRATION FEE•AOMF .. : .. .. •BRCATHALCCHOL'TE$TING'•BAT... C'CCONSOLIDATED CCOURTOST-2f20 STATE COST- 2020 33100..000 '.' LOCAL'CONSOLIDA7CD COURT COST-202D 70.00 ..., ..'.. , ..,:,::000RTHOUSESECURRY.CHS .. 31.00 ;'.:.. .. ... UP 2,00 .. "-'CIVIL' JUSTICE DATA REP'-MVFICJDR C00' .CORRECTIONALMANAGEMENT.INSYITUTE.CMI .. .. , . , .,. . .....:"' on ... . . .":`... ;. ..'•'.'CHILD SAFETY. 05 3.00 CHIL05EATSELTFEC-CSBF . CRIME:VICTIMS COMPENSATION=CVO ''OPSCIPAILURF TO -APPEAR - OMNI 6 DPSC - .. ADMINISTRATION. FEEFTNp.T0.0NA OMNI).2020 prLpp - .:.'CLEGTRONIC'FIUNOFEE•ECF S0,00 .;':FUOITIVE'ApPREHENSION•.FA GENERALIFISNUE.OR 'GRIM-INO'CEOAL$VG$SUPPORT• • lop la.00 . JWCNILECRIMESDELINOUENOY-JCO 'JUVENILE.CASEMANAGER FUND -JCMF 2000 'JUSTICE COURT PERSONNEL: TRAINING• JCPT 23,00 , JUROR SERVICE PEE-JSF .' �. 35.00 .' ,.. 1:.000AL ARREST FEES'. LAF „:. . .. ., LEMI LEDA ., ,. LEDO . OCL PARKSBWILDLIFEARRESTFEW PWAF 10.0o ' ;•: ' STATE ARRCSTFEES=OAF S00 SCHOOL CROSSINGICHILCI'SAFETY FEE '-SCF "r'•:'SUBTITLE.C:•SUGc FINE$• EST'0.1;10. STF 120.00 ',•' ' ,STATE.TRAFFIC .- TABC'ARREST FEES -TAF 162.55 TECHNOLOGY,FUND=:TF `TRAFFIC'-.TFC 12.00 '. LOCA0*17FICFINE• 2020 0.76 71MEPAYMENTrTIME 1Z0.00 .'TIMEPAYMENTREIMBURSEMENTFEE:12020r:. „• 'TRUANCYP,REVENIDNER FUNGF,TPDF 14.00 •;' "LOCAL& STATE.WARRANT FEES. -WANT . 300.00 " ' COLLECTION'SERVICE ,FEE. MVBA=.CSRV . ,..., 631.20 DEFENSIVEDRIVING DEFSRA5CCOURSE. -OFF ' '''".OEFERREO FEE: OFF ORIVNNO,CfAN)FEE=PROVDL !FS,WGFEE-.EPEE 12A00F. FILING FEE SMALL•CIAIMS•'FFSC CCPIESIOERTIFED CCPIES [ CC INDIGENT FEEF CIFF or INDF 1JUD0EPAY,,RAliE:KC•;JPAY 3000 6400 •SERVICEFEE'•SFEC 75.Do • OUTJOF:C,OUNEY SERVICC FEE "' EXPUNGEMENT FCC•.EXP,G ': • EXPIRED RENEWAL-WIR ' AOSTRACTOF:JUDGEMCNT•AOJ .. '. ALL WRITS-WOPIWOE OPSFTAPINE•DPSF ., •-LOCAL'FINES'• FINE 2,134A5 UCSNSE.4,WEIGHT,FEEB.• LIMP FARKS:;O WILOUFS FINES. . .. 'PWP 104,00 SEATBCLVUNRESTRAINED'CHILD PINE- +,SEAT JUDICIAL,e RAI COURT PERSONNEL TNINGJOPT ''• OVERPAYMENT.(S70B'OVER)'-OVER. l ",OVERPAYMENT.(LESSTHAN$10)-OVER RESTITUTION -REST . PARKS & WILOLIF&WATER SAFETY,FINES.WSF 104.0.D . ' C7VACMONEY RBCEIVED_ S&.1aa.20 . , .. TYPE: ..' ` AMOUNT . TOTALARRANTF ." ENTERLO,CALWA!Iimw FEES 300.OU REgq'IgoNTgiµaAUEgrNNL000NlareqrnieAONq.FEvoni .6TATE WARRANT.FEE$' EOAO FCCORDON MA PMO OF HILL COUNTRY SOPMAREMD, ILBOAT DUO TOOTI(GRSt.'.'r..i'�''-'' AMOUNT:'"''.. ` ..,. . 4UE 10C9I$9r90%Df FIR0.00 JV.gea00T. y'" AD 0.00 REACD INpU0E 0.RRFOUES9NDpeWMEMSM DUE TO DA RESTITIR'ION FUND' ."0.00 0.FASFlxggpE NRREDUFe4NOpS0URSFNENT REFUND OF OVERPAYMENTS1 1 , ' 0-00' FILMUNLLUDE O.fl. RE01p'i11NDDIDME[M@M OUY-OPCOUNTYSERVICEFEE""' ..'�,0,00'RFA301NQu0E DAROO1E60NOg190UMGEFNT GASH BgNO$\+.0.00 RLUMINCLUDE ORRFOUESNxDDISDURSEMEHipFREDpREH TOTAL'DUS TO OTHERS TREASURERS RECEIPTS FORMON7N:" AMOUNT•'•' CA MECX6, M, ,4NCR IT CARDS "TDTAVTREAS.RECEIP73 SP,122.20 CFIqulNp iremACTUALTneeNTSlF Roc.elple 612a.20 11-15-21;10:45 ;From:Calhoun County JP4 To:5534444 ;3617852179 # 3/ 4 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/2/2021 COURT NAME: JUSTICE OF PEACE NO.4 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2021 ACCOUNT NUMBER ACCOUNTNAME AMOUNT OR 1000-001.45014 FINES 2.165.28 OR 1000-001-44190 SHERIFF'S FEES 367.00 ADMINISTRATIVE FEES: DEFENSIVE DRIVING 0.00 CHILD SAFETY 3.00 TRAFFIC 21.76 ADMINISTRATIVE FEES 90.00 EXPUNGEMENT FEES 0.00 MISCELLANEOUS 0.00 CR 1000-001-44364 TOTAL ADMINISTRATIVE FEES 114.76 CR 1000-001.44010 CONSTABLE FEES -SERVICE 76.00 OR 1000-001.44084 JP FILING FEES 126.00 OR 1000-001.44090 COPIES / CERTIFIED COPIES 0.00 OR 1000-001.49110 OVERPAYMENTS (LESS THAN $10) 0.00 CR 1000-001.44322 TIME PAYMENT REIMBURSEMENT FEE 0.00 OR 1000.0OI-44145 SCHOOL CROSSINGICHILD SAFETY FEE 0.00 OR 1000.999-20741 DUE TO STATE -DRIVING EXAM FEE 0.00 OR 1000-999.20744 DUE TO STATE-SEATBELT FINES 0.00 OR 1000.999-20745 DUE TO STATE -CHILD SEATBELT FEE 0.00 OR 1000-999.20746 DUE TO STATE•OVERWEIGHTFINES 0.00 OR 1000-999.20770 DUE TO JP COLLECTIONS ATTORNEY 631.20 TOTAL FINES, ADMIN, FEES & DUE TO STATE $3,470.24 OR 2670-001-44064 COURTHOUSE SECURITY FUND $47.75 OR 2720-001.44064 JUSTICE COURT SECURITY FUND $7.75 OR 2719-001-44064 JUSTICE COURT TECHNOLOGY FUND $55.00 CR 2699-001.44064 JUVENILE CASE MANAGER FUND $20.00 OR 2730-001-44064 LOCAL TRUANCY PREVENTION & DIVERSION FUND $25.00 OR 2659.001-44064 COUNTY JURY FUND $0.50 STATE ARREST FEES DPS FEES 1.00 P&W FEES 2.00 TABC FEES 0.00 OR 7020-999-20740 TOTAL STATE ARREST FEES 3.00 OR 7070-999.20510 CCC-GENERAL FUND 38.70 OR 7070-999-20740 CCC-STATE 34830 OR 7070-999.10010 367.00 OR 7072-999.20610 STATE CCC- GENERAL FUND 31.00 OR 7072-999-20740 STATE OOC-STATE 279.00 DR 7072-999-10010 310.00 OR 7860-009-20610 STFISUBC-GENERAL FUND 6.00 OR 7860-999.20740 STF/SUBC-STATE 114.00 DR 7860-999.10010 120.00 CR 7860.999-20610 STF- EST 911/19- GENERAL FUND 6.50 OR 7860-999.20740 STF- EST 911/19. STATE 156.06 DR 7660-999.10010 162.56 OR 7950-999.20010 TP-GENERAL FUND 62.50 OR 7950-999-20740 TP-STATE 62.50 OR 7950.999-10010 125.00 Page 1 of 2 11-15-21;10:45 ;From:Calhoun County JP4 To:5534444 ;3617852179 # 4/ 4 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/2/2021 CR 7480-999.20610 OR 7480-999.20740 CR 7865-999.20610 CR 7865.999-20740 OR 797NB99-20610 OR 7970.999-20740 CR 7605-999-20610 CR 7505-999.20740 OR 7857-999-20810 OR 7857-999-20740 CR 7856.999-20610 CR 7856.999-20740 CR 7502-999.20740 7998-999.20701 CR 7998-999.20740 CR 7403-099-22889 REVISED 01/29/20 COURT NAME: JUSTICE OF PEACE NO, 4 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2021 CIVIL INDIGENT LEGAL-GEN. FUND 1.50 CIVIL INDIGENT LEGAL -STATE 28.50 DR 7480-999-10010 30.00 CRIM-SUPP OF ]NO LEG SVCS-GEN FUND 1.80 GRIM-SUPP OF IND LEG SVCS-STATE 16.20 DR 7865.999.10010 18.00 TUFTA-GENERAL FUND 0.00 TUFTA-STATE 0.00 DR 7970.999-10010 0.00 PAY -GENERAL FUND 540 DR 7505.999-10010 JPAY - STATE 48.60 54.00 JURY REIMB. FUND- GEN. FUND 3.60 JURY REIMB, FUND. STATE 32.40 OR 7657.998-10010 36,00 CIVIL JUSTICE DATA REPOS: GEN FUND 0.06 CIVIL JUSTICE DATA REPOS: STATE 0.54 DR 7855.999.10010 0.60 JUD/CRT PERSONNEL TRAINING FUND- STATE 0.00 DR 7502-999-10010 0.00 JUVENILE CASE MANAGER FUND 7.00 TRUANCY PREV/DIV FUND - STATE 7.00 DR 7998-999-10010 14.00 ELECTRONIC FILING FEE 50 00 DR 7403.999.10010 50.00 TOTAL (DisHib Req to OperAcco $4,945.40 DUE TO OTHERS (Dlstrib Req Attchco CALHOUN COUNTY ISO 0.00 DA - RESTITUTION 0.00 REFUND OF OVERPAYMENTS 0.00 OUT -OF -COUNTY SERVICE FE 0.00 CASH BONDS 0.00 PARKS & WILDLIFE FINES 88.40 WATER SAFETY FINES 95.40 TOTAL DUE TO OTHERS $176.80 TOTAL COLLECTED -ALL FUNDS $5,122.20 LESS: TOTAL TREA$UER'S RECEIPTS $5.122.20 OVEW18HORT) $0.00 Page 2 of 2 #31 NOTICE OF MEETING— 11/24/2021 31. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 27 of 28 O 0 0 0 0 0 w w Sim a 3 rn a 0 0 �_ 0 = ZZ =Z =W �L 1 =W =Q � i rn c 3 m c F c �Zu OF Z J LU u Fao Q` r r V i � a w O T Ifl O z F z CW C L W a U) 1- z m O t�7 a L g i o z O `I O y� N z W � o z Z m zlu � c a ) §�§ kU) k 2 Ez .Lu k§ � ( § � ( § j k § _ ■ S § \ ( �&G� § !� a »it =w oo■ o =z v . 00 F 2 \� )k ) § )� � * A0 - |LU o § �z B \\ | ■ k �z w °! \LLI / §� w Q |L § z ■°e juj � a z z § � L § \ z | ■ � )■ k )§ ■ 2 )§ § k� |■ o \Z § B � )L § o )§ � LLI §§§*®° §■■ m- �§=sa! §§ Ie§(! § _=M =0 z =F =z =W = JL =W =G Z LL J ICZ fx LU C9 g Z Z U- O M O O iD O O O C w o m V 0 7 0 m O Ld� N O dOl O W fR E9 fA fA fA EA CyQj O (p e M yy �fA fA O O O O M O 0 0 W V O V O m Y16.1 � O E9 Ln � N EZI N N E9 3 � � 0 0 0 0 0 0 0 0 eWI»ea F»f»F»v>(»cs C V 0 0 0 0 0 0 0 0 m 0 i zzQzQzQzQzzz: w K w K w K w I V y 0 0 0 0 0 0 0 0 f Z z z z z z z z z: e 2 m m m m m m m m< COI mmmmmmm m< m m m m m m m m< a � e a 43 W S Z U Q w a _ w C D:U W Q z O z > a D r w w O ►-_U w00 Ua U p Z e� U m U 5 j coIMM49��ii WEZ>m a w Ow Lu O vwi 0 i() m z (D W U O Z Z w 1 W n(9F-5Lu (!) 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C 0 o n Z _W w wrNno = Q O N q n iieii =_ � = CCyi �p N poi e H3 Eq LQ uJ W I W p W O EA N wc% 0 0 0 0 0 0 LL =WC o 0 =d LLI W fA fA fA M tl! f9 = C O O mi Ca B � = a x j o0 ti F IQ- z z V 00 oLLI _ ° c �00 z 2 a = 2~ w w WLU J J oo(o c 0 E j C ww f 000 z z z W 2 p > 2 =Z m p N z ee � O �rnsrn¢ _W F o N N �S w w rn W LL. ; LL m m a w z =14 W Z Q O ey 3 z 2 I� 5 W F z c� 00 ui m a WWw ¢ =z C WW'O O o-Z> w W W wz =W 7 �� z O w a lj _Z O z a w' � _� a 0 ��2QZ _z W U uJ OF > =W h LL LL W _� H w Q LL O LL W LLOU) =L �noro Z =W It a O O O � Z =p Z = Z L = Z =W =F =d =W =G =_ o Wg _ =z o�p O =W F _m M O =LL ti =W m =� =Z UJ a = IU W =Z LU E SCW 2 Q � v 2 2 =W � =G 0 H z O a O0 �II ut o w O w o w N N N N b M o m W N MN N �b MONO w�w�w J 0 0 z z w rc a w 0 0 z 0 N # 32 NOTICE OF MEETING— 11/24/2021 32. Approval of bills and payroll. (RHM) y_I u C�] RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese ADJ: 11:18 a.m. Page 28 of 28 November 24, 2021 2021 APPROVAL LIST-2021 BUDGET COMMISSIONERS COURT MEETING OF BALANCE BROUGHT FORWARD FROMAPPROVAL LISTREPORT PAGE 23 FICA MEDICARE FWH AFLAC PRINCIPAL FINANCIAL GROUP AT&T MOBILITY CITIBANK CITIBANK FRONTIER COMMUNICATIONS IF PETROLEUM GROUP PAYROLL FOR 11/24/21 11/24/21 $243,735.50 P/R $ 53,390.28 P/R $ 12,686.90 P/R $ 35,341.69 P/R $ 2,604.08 P/R $ 1,531.28 EMERGENCY MANAGEMENT TELEPHONE SERVICE A/P $ 201.87 DEPT CREDIT CARD CHARGES A/P $ 32,939.66 CRT AT LAW 1ST BOOK FOR STENO/CRT REPORTER SCHOOL A/P $ 230.40 RB2, RB4 & EMERGENCY MANAGEMENT PHONE SERVICE A/P $ 339.83 AIRPORT - REPLACED HAND PUMP WHOSE & NOZZLE, PISTON A/P $ 472.00 TOTAL VENDOR DISBURSEMENTS: $ 383,473.49 P/R S 320,680.04 �' TOTAL PAYROLL AMOUNT: $ 320,680.04 ✓ TOTAL INVESTMENT ACTIVITY AND TRANSFERS BETWEEN FUNDS: S CALHOUN COUNTY OPERATING ACCOUNT - TRANSFER FUNDS FOR HIGHER INTEREST RATE TO MONEY MKT TOTAL AMOUNT FOR APPROVAL: $ 704,153.53 k MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 24, 2021 TOTALS TO BE APPROVED - TRANSFERRED FROM ATTACHED PAGES TOTALPAYABLES, PAYROLL AND,ELECTRONIC BANKPAYMENTS _ $ r970;301.88' ✓ TOTAL TRANSFERS BETWEEN FUNDS $ 165,857.4fi' 'TOT4LNURSING HOME UPL EXPENSES TOTAL INT1.040VERNMENT`TRANSFERS $ "2341,974.43.; `� MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 24.2021 PAYABLES AND PAYROLL 111182021 Weekly Payables 552,855.09 11118/2021 Patient Refunds 1.363.84 1112212021 McKesson-340B Prescription Expense 8,901.55 11/22/2021 Amerisource Bergen-3408 Prescription Expense 517.41 11/22/2021 Payroll Liabilities -Payroll Taxes 99,026.39 11/2212021 Payroll 307,546.06 Prosperity Electronic Bank Payments 11115.11/19M Pay Plus Patient Claims Processing Fee 91,54 i,Q;fALPiA;YABLES,PAYROLLANDEIECTRON1C�0ANFCPA`FIVIEb173` $ _9ib,30188, TRANSFER BETWEEN FUNDS FROM MMC TO NURSING HOMES 11/98/2021 MMC Operating toSoiem-correction of NH insurance payment deposited into 20,995.17 MMC Operating in error 11/1812021 MMC Operating to Golden Creek -correction of NH insurance payment 14,133.60 deposited into MMC Operating in error 11/18/2021 MMC Operating to Gulf Pointe Plaza -correction. of NH insurance payment 2,609.30 deposited into MMC Operating 11118/2021 MMC Operating to Tuscany Village -correction of NH lnsurrace payment 1,357.18 deposited intoMMCOperating MEDICARE ADVANCE PAYMENT RECOUP 11/22/2021 Broadmoor to MMC Operating -correction of Broadmoor medicare recoup 181.45 taken from MMC Operating 11/2212021 Broadmoor to Bethany -correction of Broadmoor medical recoup taken from 11,883.91 Bethany 11122/2021 Crescent to MMC Operating -correction of Crescent medicare recoup taken 181 A6 from MMC Operating 11/2212021 Crescent to Bethany -correction of Crecent medicare recoup taken from 11,883.91 Bethany 11/2212021 Solera to. MMC Operating -correction of Solera medicare recoup taken from 161A5 MMC; Operating 11/222021 Solera to Bethany -correction of Solera medicare recoup taken from Bethany 11,883.91 11/2212021 Tuscany to MMC Operating -correction of Tuscany medicare recoup taken 181 A5 from MMC. Operating TRANSFER OF FUNDS BETWEEN NURSING HOMES 11/22/2021 Gulf Pointe Plaza -PP -correction of MMC insurance payment deposited into 10,129.82 Gulf Pointe Plaza -PP in error 11/22/2D21 Gulf Pointe Plaza -PP -correction of MMC Clinic insurance payment deposited 1.109.40 Into Gulf Pointe Plaza -PP in error 1112212021 Gulf Pointe Plaza -PP -correction of Ashford insurance payment deposited into 614.15 Gulf Pointe Plaza -PP in error 11122/2021 Gulf Pointe Plaza -PP -correction of Crescent Insurance payment deposited 480.00 into Gulf Pointe Plaza -PP in error 11122/2021 Gulf Pointe Plaza -PP -correction of Solera insurance payment deposited into 6,150.00 Gulf Pointe Plaza -PP in error 11/22/2021 Gulf Pointe Plaza•PP-carrection of Golden Creek Insurance payment 9,935.61 deposited into Gulf Pointe. Plaza -PP In error 11/22/2021 Gulf Pointe Plaza -PP -correction of Tuscany Insurance payment deposited into 61,665.50 Gulf Pointe Plaza -PP in error TOjAL;TRAN... S BETWEN FUND ii $t i76ftrS57:� r NURSING HOME UPL EXPENSES 11/2212021 Nursing Home UPL-Cantex Transfer 529,971.91 11/2212021 Nursing Home UPL-Nexion Transfer 89,882.32 11/2112021 Nursing Home UPL-HMG Transfer 29,145,94 11/21/2021 Nursing Home UPL-Tuscany Transfer 45,579.78 11/2112021 Nursing Home UPL-HSL Transfer 300,061.76 NURSING HOME BANK FEES 11115/2021 Ashford -Enhanced analysis fee 76.65 QIPP CHECKS TO MMC 11/22/2021 Golden Creek 48,039.77 11/22/2021 Gulf Pointe 28,399.19 TOTALNURSING'',HOME UPL-'EXPENSES $ 1f071,157,32' INTER -GOVERNMENT TRANSFERS 11/22/2021 IGTQIPP Year 5 to be paid December 03, 2021 2,344,974 43 TOTAL'INTE,,R'GOV',ERNMENTTRANSFERS $ 2$44,974.4.3' GRAND TOTAL DISBURSEMENT$ APPROVED November 24, 2621 $ 4,651,990,89 Page 1 of 18 NOV I 11/1812021 T'r.2:it7u::49t�5ux: �u t 1r_4#-:J: Vendor# Vendor Name 10950 ACUTE CARE INC ✓ Invoice# Comment INV459 "% MEMORIAL MEDICAL CENTER AP Open Invoice List Due Dates Through: 12/01/2021 Class Pay Code 0 ap_open_invoice.template Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 10131/2011/20/2011/30/20 1,400.00 0.00 0.00 1.400.00 .� Vendor Totals Number Name Grass 10950 ACUTE CARE INC 1,400.00 Vendor# Vendor Name Class Pay Code A1680 AIRGAS USA, LLC - CENTRAL DIV ✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 8963870355 ✓ 11/16/2010131/2011125/20 785,31 OXYGEN 9983870354,/ 11/16/20. 10/3112011/30/20 518.79 OXYGEN Vendor Totals. Number Name Gross A1680 AIRGAS USA, LLC -CENTRAL DIV 1,304.10 Vendor# Vendor Name Class Pay Code A1746 ALPHA TEC SYSTEMS INC ,z M Invoice# Comment Tran Dt Inv Dt Due Ot Check DPay Gross INV00099759✓ 11/16120, 11/03/2011/25/20. 218,55 SUPPLIES Vendor Total: Number Name Gross A1746 ALPHA TEC SYSTEMS INC 218.55 Vendor# Vendor Name Class Pay Code A2222 ARGON MEDICAL DEVICES ✓ .Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 211120686 ✓ 11/09/20. 11/0412012/01/20 391.00 SUPPLIES Vendor Totals Number Name Gross A2222 ARGON MEDICAL DEVICES 391.00 Vendor# Vendor Name Class Pay Code A0400 AUREUS RADIOLOGY LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 2362386 ✓ 10/31/20, 11/01/20 12/01/20 2,811.75 TRAVEL LAB STAFFING 2362188. ,/ 10/31/2011/01/2012/01/20. 2,680.00 TRAVEL LAB STAFFING 2362484 ✓f 10/31120 11101/20 12/01120 2,680,00 TRAVEL LAB STAFFING Vendor Total£Number Name. Gross A0400 AUREUS RADIOLOGY LLC 8,171.75 Vendor# Vendor Name Class Pay Code B1150 BAXTER HEALTHCARE ✓ W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 72675375 •X 11/15/20.11/01/2011/26/20 780.10 SUPPLIES 72638269 11/16/20 10/28/20 11/22/20 -20.35 CREDIT Discount No -Pay Net 0,00 0.00 1,400.00 Discount No -Pay Net 0.00 0100 785.31 ;f 0.00 0.00 518.79 ✓ Discount No -Pay Net 0.00 0.00 1,304.10 Discount No -Pay Net 0.00 0.00 218.55 Discount No -Pay Net 0.00 0.00 2.18.55 Discount No -Pay Net 0.00 0.00 391.o0 ✓ Discount No -Pay Net 0.00 0.00 391.00 Discount No -Pay Net 0.00 0.00 2,811.75' 0.00 0.00 2,680.00 0.00 0.00 2,680.00 Discount No -Pay Net 0.00 0.00 8,171.75 Discount No -Pay Net 0.00 0.00 780.10 ✓ 0.00 0.00 -20.35 file:IlIC:/[Jsersleheimanlepsi/memmed.cpsinet.comlu985471data 51tmp_cw5report8582... 11/18/2021 Page 2 of 18 Vendor Total; Number Name Gross Discount No -Pay Net B1150 BAXTER HEALTHCARE 759.75 0.00 0.00 759.75 Vendor# Vendor Name Class Pay Code B1220 BECKMAN COULTER INC t%J M Invoice# Comment Tran Dt Inv Dt Due or Check D, Pay Gross Discount No -Pay Net 7304826 tj� 10/31/20 11/01/20 11/26120 7,448.38 0.00 0.00 7,448.38 /SUPPLIES 109409219 V 11109/20- 11/0312011/28/20. 1,182.10 0.00 0.00 1,182.10 ✓ SUPPLIES i 109412083 11/09/20.11103/2011/28/20. 106.65 0.00 0.00 106.65 SUPPLIES / 109409257Y 11/09/20 11103/20 11/28/20 180.91 0.00 0.00 180.91 4/ SUPPLIES 109408463 -/ 11/09/2011/03/2011/28l20 164.90 0.00 0.00 164.90 SUPPLIES 109408199 JS 11/09/20. 11/03/2011/28/20 1,667.23 0100 0.00 1,667.23 SUPPLIES 109414049 ✓ 11/09/2011/03/2011/28120 475.83 0.00 0.00 475,83 ✓J SUPPLIES 109408105 ✓ 11/09/20 11/03/20 11/28/20 42.95 0.00 0.00 42.95 ✓` SUPPLIES 109410747/ 11/09/20 11/04/20 11/29/20 3,517.10 0.00 0.00 3,517.10.✓ SUPPLIES 109410739 ✓� 11/09/20. 11/04/2011/29/20 1,998.87 0.00 0.00 1,998.87 ✓ SUPPLIES 54489911// 11/09/2011/05/2011/30/20 6,249.42 0.00 0.00. 6,249.42 ✓ MAINT CONTRACT LEASE 109235830.E 1111PJ2008/13/2011126120, 183.90 0.00 0.00 183.90 V �UPPLIES 109358941 11/12l2010/19120.11l25/20 52.54 0:00 0.00 52.54 SUPPLIES 109159621 11/15/20.07/02/2007/27/20 946.02 0.00 0.00 946.02 SUPPLIES 109159622 ✓ 11/15/20 07/02120 07/27/20, 503.94 0.00 0100 503.94 SUPPLIES 109159623 11/15120 07102120 07/27/20 3.362.30 0.00 0.00 3,362.30 ✓ SUPPLIES 109159455✓ 11/15/20, 07/02/2007127/20 3.661.76 0.00 0.00 3.661.76 ✓ S�IPPLIES / 109173163 ✓ 11/15/20.07/i2/20 08/06/20: 88.06 0.00 0,00 88.06 ✓ FREIGHT 109182682 �/ 11/16/2007/15/2008/09/20. 1,288.45 0.00 0.00 1,288.45 �r LEASE/CONTRACT 7290536 .� 11/15/20 08/04/20 08/29/20 7,117.80 0.00 0.00 7,117.80 SUPPLIES 5444626 11/15/20 08/05/20 08/30/20 6,249.42 0.00 0.00 6,249.42 LEASE 109241819 11/15/20 08/17/20 09/11120. 1,093.10 0.00 0.00 1,093.10 SUPPLIES 109278205 �,,- 11/15/20 09/03/20 09/28/20 626.25 0.00 0.00 626.25 SUPPLIES file:///C:/Users/eheiman/cpsi/Menuned.cpsinet.corn/u98547/data_5/tmp_cw5re0ort8582... 11 /18/2021 Page 7 of 18 2868785 11/12/20 09/21/20 11/25/20 1,473,55 0.00 0.00 1,470.55 SUPPLIES 4158973 Y 11/16/20 11105/20 11/30/20 4,140.00 0.00 0.00 4,140.00 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net F1400 FISHER HEALTHCARE 7,633.66 0.00 0.00 7,633.66 Vendor! Vendor Name Class Pay Code 11183 FRONTIER v/ Invoice# Comment Tran Dt Inv Dt Due Dt Check Pay Gross Discount No -Pay Net 110221 11/10/20. 11/05/2011/25/20 1,181.78 0.00 0.00 1,181.78 �! TELEPHONE Vendor Totals Number Name Gross Discount No -Pay Net 11183 FRONTIER 1,181.78 0.00 0.00 1,181.78 Vendor# Vendor Name / Class Pay Code 14156 FUJI FILM ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net PJIN0180835 �/ 10126/20 10/15/20 11/25/20, 7,908.33 0.00 0.00 7,908.33 �%- SMA FEE Vendor Totals Number Name Gross Discount No -Pay Net 14156 FUJI FILM 7,908.33 0.00 0.00 7,908.33 Vendor# Vendor Name Class Pay Code 13960 G & S MANAGEMENT GROUP LLC V Invoice# Ce ment Tran Dt Inv Dt Due Dt Check D, Pay Gross Discount No -Pay Net ` 340383695 ii/15/201o/26/2011/15/20 254.42 0.00 0.00. 254.42 TRASH 340383694 r// 11/15120 11/10/20 11/20/20 336.88 0.00 0.00 335.88 TRASH SERVICE , Vendor Totals Number Name Gross Discount No -Pay Net 13960 G & S MANAGEMENT GROUP LLC 590.30 0.00 0100 590.30 Vendor# Vendor Name Class Pay Code 13980 GBS ADMINISTRATORS, INC Invoice# Comment Tian Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net 48100602•NOV 11/17/20. 11/17/20 11117120 1,819.09 0.00 0.00 1,819.09 ✓'` INSURANCE Vendor Totals Number Name Gross Discount No -Pay Net 13980 GBS ADMINISTRATORS, INC 1,819.09 0.00 0.00 1,819.09 Vendor# Vendor Name Class Pay Code 10283 GE HEALTHCARE V,, Invoice# Comment Tran Dt Inv Dt Due Dt Check O Pay Gross Discount No -Pay Net 6001986428 11� 11110/20. 11/01/2012/01/20, 61.67 0.00 0.00 61.67 W` MAINTENANCE CONTRACT 6001986427 ,jam 11/10/20 11101/20 12/01/20 86.67 0.00 0100- 86.67✓l MAINTENANCE CONTRACT 6001986426 e/ 11/10/20. 11/011201PJ01120 3,588.58 0.00 0.00 31588,58✓ MAINTENANCE CONTRACT , 6001986346 ✓ 1111012011/01/2012101120. 680.00 0.00 0.00 680.00 v' 6001986629 "" 1111012011/01/2012/01/20. 868.16 0.00 0.00 868.16 ij MAINTENANCE CONTRACT 6001986347 ✓ 11/10/2011/01/2012101/20 572.33 0.00 0.00 , 572.33 MAINTENANCE CONTRACT . file:///C:/Users/eheiman/cpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582... 11/ 18/2021 Page 8 of 18 6001986456 �/ 11/10/20. 11/0112012/01120 5,665.83 0.00 0.00 5,665.83 MAINTENANCE CONTRACT Vendor Totals Number Name Gross Discount No -Pay Net 10283 GEHEALTHCARE 11,523.24 0.00 0.00 11,523.24 Vendor# Vendor Name Class Pay Code W1300 GRAINGER M Invoice# Comment Tran Ot Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 9101481480 11/12/20. 10/27/2011/26120 182.04 0.00 0.00 182.04 �f SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net W1300 GRAINGER 182.04 0.00 0.00 182.04 Vendor# Vendor Name , Class Pay Code 12948 GREAT AMERICAN FINANCIAL SVCS �/ Invoice# Comment Tran Dt Inv of Due Ot Check D Pay Gross Discount No -Pay Net 1105E-1- 11/10/2011/05/2011/30/20 9,797.22 0.00 0.00 9,797.22 _Otis -'I COPIER LEASE {- Vendor Totals Number Name Gross Discount No -Pay Net. 12948 GREAT AMERICAN FINANCIAL SVCS 9,797.22 0.00 0.00 9,797.22 Vendor# Vendor Name Class Pay Code G0401 GULF COAST DELIVERY r Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 10312021 10/31/20. 10/30/2011/29/20. 125.00 0.00 0.00 125.00 DELIVERY (1)I-�- 14I�, I'�-�, Vendor Totals Number Name .Gross Discount No -Pay Net G0401 GULF COAST DELIVERY 125.00 0.00 0.00 125.00 Vendor# Vendor Name Class Pay Code G1210 GULF COAST PAPER COMPANY v / M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 2128934 11/12/20. 10126/2011125/20 676.84 0.00 0.00 676.84 V% SUPPLIES 2075075 11/16/20.07/21/2008/20/20, -51.35 0.00 0.00 -51.35 CREDIT 2084788 11/16120 08/11/20 09110/20 -58.20 0.00 0.00 -58.20 r✓ CREDIT 2107601,/ 1111612009121/2010/21/20 79.90 0.00 0.00 79.90 ✓ SUPPLIES 2116689"1/ 11/16/20. 10/05/2011104/20. 807.21 0.00 0,00 807.211/ SUPPLIES 2124669 �f 11/16120.10119/2011/18/20. 910.46 0.00 0.00 910.46 /SUPPLIES 2128689 r,/ 1111612010/26/2011/25/20 428.31 0.00 0.00 428.31 ✓'` SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 01210 GULF COAST PAPER COMPANY 2,793.17 0.00 0.00 2,793.17 Vendor# Vendor Name Class Pay Code 10804 HEALTHCARE CODING & CONSULTING ✓' Invoice# Comment Tran Dt Inv Dt Due Dt Check D' Pay Gross Discount No -Pay Net 11599 v'� 11/15120. 10/31/2011/30/20 404.75 0.00 0.00 404.75 �r SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 10804 HEALTHCARE CODING & CONSULTING 404.75 0.00 0.00 404.75 file:///C:/Users/eheiman/epsi/memmed.cpsinet.com/u98547/data 5/tmp_cw5report8582... 11/18/2021 Page 9 of 18 Vendor# Vendor Name Class Pay Code 11552 HEALTHCARE FINANCIAL SERVICES tf Invoice# Comment Tran Dt Inv V Due Dt Check DPay Gross Discount No -Pay Net 100533975 W! 11/0112010/27/2012/01/20. 4,610.52 0.00 0.00 4,610,62 ✓'- LEASE 100539944 ✓ 11/09/2011/06/2012/01/20 7,154.17 0.00 0.00 7,154.17✓ LEASE 100539946 V/ 1110912011/06/2012/01120 1,797.44 0.00 0.00 1,797.44 ✓ LEASE 100639945 .V/� 11/111201110612012101/20 7,447.86 0.00 0.00 7,447.86 jf' 100539943 V 11 /1112011/06/2012/O1120 4.919.41 0.00 0.00 LEASE Vendor Totals Number Name Gross Discount No -Pay 11552 HEALTHCARE FINANCIAL SERVICES 25,929.40 0,00 0.00 Vendor# Vendor Name Class Pay Cade H1227 HEALTHSURE INSURANCE SERVICES /' Invoice# Comment Tram Dt Inv Dt Due Dt Check D Pay Gross 2452 V,! 10126/2010/25/201PJ01/20. 400.00 PATIENT BONDS BETHANY LP Vendor Totals Number Name Gross H1227 HEALTHSURE INSURANCE SERVICES 400.00 Vendor# Vendor Name Class Pay Code 10530 HUMANAH EALTH CARE PLANS Invoice# Comment Tran Dt Inv Dt Due Dt Check.D Pay Gross 174976 11/15120 10/28/20 11/30/20 96.00 REFUND Vendor Totals Number Name Gross 10530 HUMANAH EALTH. CARE PLANS 96.00 Vendor# Vendor Name Class Pay Code 10922 HUNTER PHARMACY SERVICES „% Invoice# Comment Tran Ot Inv Dt Due Dt. Check D-Pay Gross 4640 t// 11/16/2010/31/2011/20/20 14,577.42 PHARMACIST Vendor Totals Number Name Grass 10922 HUNTER PHARMACY SERVICES 14,577.42 Vendor# Vendor Name Class Pay Code 11200 IRON MOUNTAIN v l Invoice# Comment Tran Dt Inv Dt Due Dt Check D' Pay Grass DZVC370 ✓ 10/3112010131/2011/30/20, 674.89 RECYCLE SERVICES Vendor Totals Number Name Gross 11200 IRON MOUNTAIN 674.89 Vendor# Vendor Name Class Pay Code 11264 iTA RESOURCES, INC f w Invoice# Comment Tran Dt Inv Dt Due Dl Check D Pay Gross MMC112021 //'- 11/16/20. 11/15/2011/30/20 25,152.92 REt IRATORY Vendor Totals Number Name Gross 11264 ITA RESOURCES, INC 25,162,92 Vendor# Vendor Name Class Pay Cade 4,919.41 s/ Net 25,929,40 Discount No -Pay Net 0.00 0.00 400.00 ✓"f Discount No -Pay Net 0.00 0.00 400.00 Discount No -Pay Net 0.00 0.00 96.00 4i Discount No -Pay Net 0.00 0.00 96.00 Discount No -Pay Net 0.00 0.00 14,677.42 ,r Discount No -Pay Net 0.00 0.00 14,577.42 Discount No -Pay Net 0.00 0.00 674.89 Discount No -Pay Net 0.00 0.00 674.89 Discount No -Pay Net 0.00 0.00 25,152.92 Discount No -Pay Net 0.00 0.00 25,152.92 file:///C:/Users/eheimanlepsi/memmed.cpsinet.com/u98547/data 5/tmp_cw5report8582... 11/18/2021 Page 10 of 18 s J0150 J & J HEALTH CARE SYSTEMS, INC ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D- Pay Gross 926985612 p,/ 11/0812011101/2012/01/20 76.26 SUPPLIES Vendor Totals Number Name Gross J0150 J & J HEALTHCARE SYSTEMS, INC 76.26 Vendor# Vendor Name Class Pay Code 11600 LEGAL SHIELD f Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross 111521 11/15/20. 11/15/2011/25/20 541.35 PAYROLL DEDUCT Vendor Totals Number Name Gross 11600 LEGALSHIELD 541.35 Vendor# Vendor Name Class Pay Code / L7640 LOWE'S HOME CENTERS INC W Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross 55348 ,/ 11117/2010/01/2010/30/20, 395.48 SUPPLIES Discount No -Pay Net 0.00 0.00 76.26 �' l Discount No -Pay Net 0.00 0.00 76.26 Discount No -Pay Net 0.00 0;00 541.35 ✓ Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0,00 110221 11/17/2010/01/2011128/20 24.06 0.00 INTEREST CHARGES 53717 ✓ 11117/20 10/01/20 11/28/20 296.34 0.00 SUPPLIES 55351 f 11117/2010/0112011/28/20 187.40 0.00 SUPPLIES 42830 11/17/2010/01/2011/28/20 5.66 0.00 �: SUPPLIES Vendor Totals Number Name Gross Discount L1640 LOWE'S HOME CENTERS INC 908.94 0.00 Vendor# Vendor Name Class Pay Code 11796 LUBYS FUDDRUCKERS RESTAURANTS ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount INV00004988 „/' 11/1112010/31/2011/30/20 24,249.06 0.00 FOOD SUPPLY Vendor Totals Number Name Gross Discount 11796 LUBY'S FUDDRUCKERS RESTAURANTS 24,249.06 0.00 Vendor# Vendor Name. Class Pay Code M1950 MARTIN PRINTING CO „'` W Invoice# Comment Tran Dt Inv Dt DueDt Check D, Pay Gross Discount 77802 ✓ - 11/0512010/26/2011/26/20. 248.41 0.00 SUPPLIES Vendor Totals Number Name Gross Discount M1950 MARTIN PRINTING CO 248.41 0.00 Vendor#Vendor Name Class Pay Code 11141 MEDICAL DATA SYSTEMS, INC. Invoice# Comment Tran Dt Inv Dt Due Dt Check D-Pay Gross Discount 164397 11/17/20 09/30120 10/25/20 8.75 0.00 ✓r Vendor Totals Number Name Gross Discount 11141 MEDICAL DATA SYSTEMS, INC. 8.75 0.00 Vendor#Vendor Name Class Pay Code 14188 MEDICAL DEVICE DEPOT 0.00 0.013 0.00 0.00 No -Pay 0.00 Net 541.35 Net 395.48 24.06 ' 296.34 l 187.40 5.66 / Net 908.94 No -Pay Net 0.00 24,249.06 No -Pay Net 0.00 24,249.06. No -Pay Net 0,00 248.41 No -Pay Net 0.00 248.41 No -Pay Net 0.00 8.75 `' No -Pay Net 0.00 8.75 file:///C:/Users/eheiman/cpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582.-. 11 /18/2021 Page 11 of 18 Invoice# ¢ommant Tran Dt Inv Dt Due Dt Check D Pay Gross A136946 %/ 1111112011/0112011/30/20, 182.97 SUPPLIES Vendor Totals Number Name Gross 14188 MEDICAL DEVICE DEPOT 182.97 Vendor# Vendor Name Class Pay Code 10613 MEDIMPACT HEALTHCARE SYS, INC. ,,/'- A/P Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross 111521 11/16/20 11/15/20 11115/20, 30.74 CLAIMS Vendor Totale Number Name Gross 10613 MEDIMPACT HEALTHCARE SYS, INC. 30.74 Vendor# Vendor Name class Pay Code M2827 MEDIVATORS M ✓% Involoe# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 91103485 v/ 11/09/20.. 10/28/2011/27/20 31.00 SUPPLIES 91105183 f 11/09/20, 10/29/2011128/20 229.07 SUPPLIES Vendor Totals Number Name Gross M2827 MEDIVATORS 260.07 Vendor# Vendor Name Class Pay Code M2470 MEDLINE INDUSTRIES INC M Invoice# Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross 1967435038 / 09/30/20 09/23/2010/17/20. 135.42 SUPPLIES 1971063282 11�' 10121/20 10/20120 11/14/20 36.71 SUPPLIES 1972756741 f 11/0a/201110212011127/20 44,58 SUPPLIES 1972765745 / 11/08/2011102/2011127/20 193.52 SUPPLIES 1972755743✓ 11/08/2011102/2011/27/20. 5,38 SUPPLIES 1972765748 11 /08/20. 1110212011 /27/20. 12.56 SUPPLIES 1972765746 11 /08/20 11 /02/2011 /27120 164.70 SUPPLIES 1972755744 ✓ 11/08/20 11/02120 11/27/20, 272.02 SUPPLIES 1972755740 ✓ / 11/0812011/02/2011/27/20. 82.86 SUPPLIES i 1972755742 „% 11N8/20.17/OZ2011/27/20 96.76 SUPPLIES Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0.00 0.00 0.00 Discount No -Pay 0.00 0.00 Discount No -Pay 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1972846658 11/09120.11/03/2011/28/20 1,975.38 a/ SUPPLIES 1972846662 v/ 11109/2011/03/2011128/20 117.87 0.00 SUPPLIES 19728466541J 11109/2011103/2011128120 2,002.01 0.00 SUPPLIES 1972846663 V`/ 11109/2011/0312011128120, 123.00 0.00 0.00 0.00 0,00 Net 182.97 ✓ Net 182.97 Net 30.74 v Net 30.74 Net 31.00 229.07 ✓ Net 260.07 Net 135,42 36.71 '_` 44,58 y% 193.52 5.38 v 12.58 / 164.70 ✓ 272.02 / 82.86 ✓ 96.76 1,975.38 ✓l 117.87�, 2,002.01 �°' 123.00 file:///C:/Users/eheiman/cpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582... 11/18/2021 Page 12 of 18 SUPPLIES 1972846660 �/' 11/09/20 11/03/20 11/28/20 287.27 0.00 0.00 287.27,j/ SUPPLIES 1964917836 ✓ 11/11/200910212011/25/20. 1,453.66 0.00 0.00 1,453.56 cJ SUPPLIES 1964917823 ✓/ 11/11/20. 09102/2011/25/20. 2,646,98 0.00 0.00 2,648.98 SUPPLIES 1965443116 ✓ 11/11/2009/06/2011/25/20 2,403.88 0.00 0.00 2,403,88 y� SUPPLIES 1966177885 ✓ 11/11/20 09/14/20 11/25/20, 28.34 0.00 0.00 28.34. SUPPLIES 1969028382 ✓ 11/11120 10106/20 11/25/20 37.48 0.00 0.00 37.48 SUPPLIES 1971985655 ✓ 11/11/2010/27/2011/26/20, 599.85 0.00 0.00 599.85 SUPPLIES 19719856661 11/1112010/2712011125/20. 784.02 0.00 0.00 784.02 SUPPLIES 1971985669 ✓ 11/11/2010/27/2011/25/20 4.75 0.00 0.00 4.75 SUPPLIES 1972652520 ✓/ 1Ill 5/2011/01/2011/26/20. 32.65 0.00 0.00 32.65 SUPPLIES 1972713903 11115/2011/02/2011/27120, 1,863.72 0.00 0.00 1,863.72 �/- SUPPLIES 1955248479 V% 11/16/20. 06/15/20 07/10/20 916.50 0.00 0.00 916.56 SUPPLIES / 1964917837 y/ 11/16/20A9/02120 09/27/20, 11.35 0.00 0.00 11.35 SUPPLIES 1964917827 ✓ 11/16/20 09/02/20 09/27/20. 213.34 0.00 0.00 213.34 SUPPLIES 1964917825y 11/16/20 09/02/20 09/27/20 479.12 0.00 0.00 479.12 ✓'� SUPPLIES 1964917826 1,/ 11/16/20 09/02/20 09/27/20 23.32 0.00 0.00 23.32 SUPPLIES 1964917824 e/ 11/16/20. 09/02/20 09/27/20 86.94 0.00 0.00 86.94 SUPPLIES 1971956066 „/ 11/16/2010/27/2011/21/20 1,499.10 0.00 0.00 1,499.10 ✓ SUPPLIES 1971985654 1/ 11/16/20. 10/27/20 11/21/20 43.28 0.00 0.00 43.28 v" SUPPLIES 1972473458 �/ 11/16/20, 10/30/2011124120 706.58 0.00 0.00 706.58 SUPPLIES 1972755747 vj 11/16/20 1110PJ20 11/27/20. 222.96 0.00 0.00 222.96 SUPPLIES 1972713902 ,� 11/16/2011/02J2011/27/20. 142.53 0.00 0.00 142.53 .% SUPPLIES Vendor TotalE Number Name Gross Discount No -Pay Net M2470 MEDLINE INDUSTRIES INC 19,752.37 0.00 0.00 19,752.37 Vendor#Vendor Name Class Pay Code 10536 MORRIS & DICKSON CO, LLC Invoice#/- Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 8324 ✓' 11/11/20. 11/08/2011/25/20 -4.99 0.00 0.00 -4.99 file:///C:/Users/eheimanlcpsilmemmed.cpsinct.con/u985471data_5/tmp_cw5report8582... 11/18/2021 Page 13 of 18 CREDIT 7623634 11/11/20.11108120 11/25120, 1,751.22 0.00 0.00 1,751.22 INVENTORY 7519488 ✓� 11/11/20 11/08/20 11/26/20 115.12 0.00 0.00 115.12 ✓ INVENTORY 7623633 11/15/20. 11/08/20 11/25/20 5,117.81 0.00 0.00 5,117.81 INVENTORY 7523632 ✓ 11/15/20 11/08/20 11/25/20 1,907.14 0.00 0.00 1,907.14 ✓� INVENTORY 7524390 11/15/20 11/09/20 11/25/20 98.78 0.00 0,00 28.78 TRANSFER 7527780 t/ 11/15/2011/09/20 11/25/20. 40.65 0.00 0.00 40.65 ✓� INVENTORY 7527781 ✓ 11115/2011/09/2011125/20, 732.87 0.00 0.00 / 732.87 ✓ INVENTORY CM86453 ;/ 11/15/2011109/2011/25120 -1.16 0.00 0.00 -1.16 ✓% INVENTORY , 7524319 11115/20 11/09120 11/25/20 5.20 0.00 0.00 5.20 �/ INVENTORY 7627782 V;' 11/15120. 11/09/2011/25120. 441.36 0.00 0.00 441.36 <% INVENTORY 7533145t/ 11/15/2011/10/2011126/20. 1.084,54 0.00 0.00 1,084.54 TRANSFER , 7633146 ✓" 11115/2011/10/2011/25/20 4,561.99 0.00 0.00 4,551.99 INVENTORY 7533147 ,,/ 11/15/2011110/2011/25/20 871.11 0.00 0.00 871.11 INVENTORY , Vendor TotalsNumber Name Gross Discount No -Pay Net 10536 MORRIS & DICKSON CO, LLC 16,641.64 0.00 0.00 16,641.64 Vendor* Vendor Name Class Pay Code 14124 MSH HEALTH SERVICES LLC ,i` Invoice* Comment Tran Dt Inv DI Due Dt Check OPay Gross Discount No -Pay Net MMC0003 ,�� 11111/2009/07/2011/25120, 2,232.00 0.00 0.00 2,232.00 y,r' TRAVEL NURSE STAFFING MMC0007 >' 11/11/20. 09/2012011/26/20 5,127.40 0.00 0.00 5,127.40 ✓% TRAVEL NURSE STAFFING MMC0011 „/� 11/11120 10/04/20 11/26/20 4,634,50 0.00 0.00 4,634.50 v' TRAVEL NURSE STAFFING MMC0012 ✓ 11/11/20 10/04/20 11/25120. 13,336.25 0.00 0.00 13,336.25✓ TRAVEL NURSE STAFFING MMC0006 ✓' 1.1/15120-02/14/2011/15/20 2,356.00 0.00 0.00 2,356.00 TRAVEL NURSE STAFFING. MMC0009 ✓r11/15/2009/28/2011115/20 1,516.25 0.00 0.00 1,516.25 v� TRAVEL NURSE STAFFING , MMC0010 ✓ 11/15/20.09/28/2011/15/20 2.402.50 0.00 0.00 2,402.50 TRAVEL NURSE STAFFING Vendor Total: Number Name Gross Discount No -Pay Net 14124 MSH HEALTH SERVICES LLC 31,604.90 0.00 0.00 31,604.90 Vendor# Vendor Name / Class Pay Code 00920 OFFICE DEPOT✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross Discount No -Pay Net file:l/l C:/Users/eheiman/epsilmemmed. cpsinet. corn/u98547/data_5/tmp_cw5report85 82... 11 / 18/2021 Page 14 of 18 206634594001 ✓� 11116/20 10/29/20 11/16120 284.96 0.00 0.00 284.96 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 00920 OFFICE DEPOT 284.96 0.00 0.00 284.96 Vendor# Vendor Name Class Pay Code 01500 OLYMPUS AMERICA INC. ✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check O Pay Gross Discount No -Pay Net 31746334 / 11/09120 11/02/20 11127/20 309.65 0.00 0.00 309.55 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 01500 OLYMPUS AMERICA INC 309.55 0.00 0.00 309.55 Vendor# Vendor Name Class Pay Code 11155 PARA Involce# Comment Tran Dt Inv Ot Due Dt Check D Pay Gross Discount No -Pay Net 9813 ,/ 11/17/20. 11/0112012/01120. 3,084.00 0.00 0.00 3.084.00 REVENUE INTEGRITY PROGR Vendor Totals Number Name Gross Discount No -Pay Net 11155 PARA 3,094.00 0.00 0X0 3,084.00 Vendor#Vendor Name Class Pay Code 10152 PARTSSOURCE, LLC ,! Invoice# Comment Tran Di Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 04083313 V/11/15/2010/28/2011/27/20 438.05 0.00 0.00 438.05 .% SUPPLIES Vendor TotalsNumbar Nama Gross Discount No -Pay Net 10152 PARTSSOURCE, LLC 438.05 0.00 0.00 438.05 Vendor# Vendor Name Class Pay Code 13988 PAYCHEX, ADVANCEf80 t/ Invoice# Comment Tran Or Inv Ot Due Dt Check DPay Gross Discount No -Pay Net 007505 / 11111/20. 11/10/20 11/25/20. 1,225,00. 0.00 0.00 1,225.00 ✓" TRAVEL NURSE STAFFING Vendor Totals Number Name Gross Discount No -Pay Net 13988 PAYCHEX, ADVANCE FSO 1,225.00 0.00 0.00 1,225.00 Vendor# Vendor Name Class Pay Code P2200 POWER HARDWARE W Invoice# Comment Tran Dt Inv Dt Due Dt Check D' Pay Gross Discount No -Pay Net A77433 yj 11/05/2010/01/2011/30/20 5.59 0.00 0.00 5,69 SUPPLIES A77598 ✓ 11/05/2010/07/2011/30/20 9.99 0.00 0.00 9.99 t/ SUPPLIES A77798 �/'` 11/05/20. 10/14/2011130120. 5.99 0.00 0.00 5,99 ..� SUPPLIES A78064 „/ 11/05120 10/21/20 11/30/20 29.61 0.00 0.00 29.61 ✓` SUPPLIES b64465 ,f 11105120 10/25120 11/30120 19.45 0.00 0.00 19.45 ✓ SUPPLIES 664484 ✓ 11/05/2010/26/2011/30/20 16.45 0.00 0.00 16.45,/ SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net P2200 POWER HARDWARE 87.08 0.00 0.00 87.08 Vendor# Vendor Name Class Pay Cede 11932 PRESS GANEY ASSOCIATES, INC. „/' file:/!/C:/Users/eheiman/cpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582... 11 / 18/2021 Page 15 of 18 Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net INOOOSO1981 10/31120. 10131/2011130/20. 2,523.79 0.00 0.00 2,523.79 ✓ SURVEY Vendor Totals Number Name Gross Discount No -Pay Net 11932 PRESS GANEY ASSOCIATES, INC. 2,523,79 0.00 0.00. 2,523.79 Venoor#Vendor Name Class Pay Code 12480 PRO ENERGY PARTNERS LP / Invoice# Comment Tran Dt Inv Dt Due Dt Check D• Pay Gross Discount No -Pay Net 2110-0600 j 11/16/20 11/10/20 11/26/20 4,178.13 0.00 0.00 4,178.13,Z' NATURAL GAS Vendor Totals Number Name Gross Discount No -Pay Net 12480 PRO ENERGY PARTNERS LP 4,178.13 0.00 0.00 4,178.13 Vendor#Vendor Name Class Pay Code 10896 QIAGEN INC'- Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net i 998077049 11/15/2011/08/20 tt/30/20 352.89 0.00 0.00 352,69 t/" SUPPLIES Vendor Totals Number Name Gross Discount No -Pay .Net 10890 QIAGEN INC 352.69 0.00 0.00 352.69 Ventlor#. Vendor Name Class Pay Code 11024 REED, CLAYMON, MEEKER & HARGET / Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 091621 11/17/20.09A 8l2009/16/20. 122.50 0.00 0.00 i 122.50 LEGALFEES Vendor Totals Number Name Gross Discount No -Pay Net 11024 REED, CLAYMON, MEEKER & HARGET 122.50 0.00 0.00 122.60 Ventlor# Vendor Name Class Pay Code 11252 RX WASTE SYSTEMS LLC .Z Invoice# Comment Tran Dt Inv Dt Due Dt Check D,Pay Gross Discount No -Pay Net 3436 1% 11109/21111/01/2011/26/20. 60.00 0.00 0.00 60.00 c/�f SUBSCRIPTION Vendor Totals Number Name Gross Discount No -Pay Net 11252 RX WASTE SYSTEMS LLC 60.00 0.00 0.00 60.00 Vendor# Vendor Name Class Pay Code S1001 SANOFI PASTEUR INC t W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 917156740 L/ 09/22/20. 09/07/2012/01/20- 13,908.79 0.00 0,00 13.908.79 ✓' INVENTORY 916812639 ,/ 09/30/2009/30/2012/O1/20. -1,265.10 0.00 0.00 -1,265.10 CREDIT MEMO 917386673 t/� 10108120.09/27/2011/26/20 347.36 0.00 0.00 347.36 INVENTORY Vendor Totals Number Name Grass Discount No,Pay Net S1001 SANOFI PASTEUR INC 12,991.05 0.00 0.00 12,991.05 Vendor# Vendor Name Class Pay Code 11296 SOUTH TEXAS BLOOD &TISSUE CEN 1-11/' Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Grass Dlscount No -Pay Net 107018236 f 10/31/20. 10/31/20 11/25/20 5,862.00 0.00 0.00 6,862.00 V/ BLOOD / CM5693 t/ 10/31/20. 10/31/2011/25/20 -2,607.00 0.00 0.00 -2,607.00 ✓.! CREDIT file:///C:/Users/eheiman/cpsi/memmed,cpsinet.com/u98547/data_5/tmp_cw5report85 82... 11 / 18/2021 Page 16 of 18 Vendor Totals Number Name Gross Discount No -Pay Net 11296 SOUTH TEXAS BLOOD & TISSUE CEN 3,255.00 0.00 0.00 3,255.00 Vendor# Vendor Name Class Pay Code 14100 STAFFING FIRST Invoice# C/pmment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 2110136 ✓ 11/15120. 11/06/2011/24/20 4,562.50 0.00 0.00 4,562.50 V TRAVEL NURSE STAFFING Vendor Totals Number Name Gross Discount No -Pay Net 14100 STAFFING FIRST 4,562.50 0.00 0.00 4,562.50 Vendor# Vendor Name Class Pay Code S$960 STERICYCLE, INC V/ Invoice# , Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 4010488366 ✓� 11/15/20.11/01/2012101/20 2,650.79 0.00 0.00 2,550.79 Vendor Totals Number Name Gross Discount No -Pay Net S3960 STERICYCLE, INC 2,550.79 0.00 0.00 2,550.79 Vendor# Vendor Name Class Pay Code 13528 STRYKER FLEX FINANCIAL f Invoice# Comment Tran Dt Inv or Due Dt Check D• Pay Gross Discount. No -Pay Net 226812 10/21/20 10/12/20 12/O1120. 1,358.97 0.00 0.00 1,358.97 RFA MACHINE Vendor Totals Number Name Gross Discount No -Pay Net 13528 STRYKER FLEX FINANCIAL 1,358.97 0100 0.00 1,358.97 Vendor# Vendor Name Class Pay Code S2830 STRYKER SALES CORP M Invoice* Comment Tran Dt Inv Dt Due Dt Check D Pay Grass Discount No -Pay Net 9201849905 ✓ 11115/2011/07/2011125/20 1,460.72 0.00 0.00 1,460.72 SUPPLIES Vendor Totals Number Name Gress Discount No -Pay Net 52830 STRYKER SALES CORP 1,460.72 0.00 0.00 1,460.72 Vendor# Vendor Name Class Pay Code T2539 T-SYSTEM, INC ,if W Invoice# Comment Tran Dt Inv Dt Due.Dt Check D Pay Gross Discount No -Pay Net 49671 ✓ 11/01/20 10/27/20 11126/20 431.42 0.00 0.00 431.42 ✓ ~ ERX LICENSE 49743 - 11117120. 10/31/2011130/20 5,699.00 0.00 0.00 5,699.001,i 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 T2204 TEXAS MUTUAL INSURANCE CO `'' W Invoice# Commynt Tran D1 Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 1003190541 r% 11/10/2011/0512011/27/20. 6,494.00 0.00 0.00 6,494.00 1% WORKERS COMP Vendor Totals Number Name Gross Discount No -Pay Net T2204 TEXAS MUTUAL INSURANCE CO 6,494.00 0.00 0.00 6,494.00 Vendor# Vendor Name Class Pay Code 10758 TEXAS SELECT STAFFING, LLC ✓z Invoice# Comment- Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 0018504540791N 1/f 11/11/2011/1012011/25/20. 10,092.10 0.00 0.00 10.092.10 TRAVEL NURSE STAFFING file:///C:(Users/eheiman/cpsi/memmed.cpsinet.com/u98547/data_5/tmp_cw5report8582... 11/18/2021 Page 17 of 18 Vendor Totals Number Name Gross Discount No -Pay Net 10758 TEXAS SELECT STAFFING, LLC 10.092.10 0.00 0.00 10,092.10 Vendor# Vendor Name Class Pay Code U1064 UNIFIRST HOLDINGS INC V/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 84003'80= 10/31/2011/0112011/26120. 55.83 0.00 0.00 55.83 , 1�6-'KLAUNDRY 8400330340 10/3112011101/2011/26/20 45.15 0.00 0.00 45A5 "i `lt 1 l LAUNDRY 8400380RX-T✓ 10131120 11/01/20 11/26/20 2,117.74. 0.00 0.00 2,117.74 ✓`- LAUNDRY r 8400380664 ✓ 11/05/20 11/04/20 11/29/20 76.82 0.00 0.00 76.82 ✓ LAUNDRY 8400380669 1j/ 11/05/2011/04/2011129/20. 199.32 0.00 0.00 199.32 LAUNDRY 8400380680 �z 11/05/20. 11/0412011/29/20. 79.43 0.00 0.00 79.43 L LAUNDRY 8400380686 �/ 11/05/20 11/04/20 11/29/20 1.498.62 0.00 0.00 1,498.62 LAUNDRY 8400380668 v,,� 11/05/20.11/04/2011/29/20 188.41 0.00 0.00 188.411.1_1� LAUNDRY 6400380667 v% 11105/2011/0412011/29/20 188.62 0.00 0.00 188.62 4,r LAUNDRY 8400380666 1% 11/0512011/04/2011/29120 137.13 0.00 0.00 137.13 i LAUNDRY ✓ 8400380699 �i 11/05/20 11/04/20 11/29/20 109.31 0.00 0.00 109.31 LAUNDRY L1� Vendor Totals Number Name Gross Discount No -Pay Net U1064 UNIFIRST HOLDINGS INC 4,696.38 0.00 0.00 4,696.38 Vendor# Vendor Name Class Pay Code U1056 UNIFORM ADVANTAGE �''� W Invoice# Comment Tran Dt Inv Dt Due Dt Check D' Pay Gross Discount No -Pay Net SIV11468992 Z 11116/20 10/12/20 11/11/20 226.95 0.00 0.00 226.95 UNIFORMS ERIN WISDOM SIV11468981 „!� 11/16/2010/12/2011/11/20 118.92 0.00 MOO 118.92 UNIFORMS BRITTANY RUDDIC SIV11469002 _,/ 11/16/2010/1212011/11/20, 220,93 0.00 0.00 220.93 UNIFORMS SAVANNAH HARLE Vendor Totals Number Name Gross Discount No -Pay Net U1056 UNIFORM ADVANTAGE 566.80 0.00 0.00 566.80 Vendor# Vendor Name Class Pay Code ! 14192 UNITED HEALTHCARE t Invoicek Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 168591 i' 11/15/20.1110312011/30120 ✓ .REFUND 2.56 0.00 0.00 2.56 f' 138261 r'' 11/15/20 11/03/20 11/30/20 80.00 0.00 0.00 woo REFUND Vendor Totals Number Name Gross Discount No -Pay Net 14192 UNITED HEALTHCARE 82.56 0.00 0.00 82.56 Vendor# Vendor Name Class Pay Code 10768 VICTORIA MEDICAL FOUNDATION file:///C:/Users/eheiman/cpsi/memmed. cpsinet.com/u98547/data_5/tmp_cw5report8582... 11 /18/2021 Page 18 of 18 Invoice# Comment Tran Dt Inv or Due Dt Check D Pay Gross Discount No -Pay Net / 150 ,% 1111512004/15/2011/25/20. 725.00 0.00 0.00 725.00 ANNUAL DUES FOR ARROYO - Vendor Totals Number Name Gross Discount No -Pay Net 10768 VICTORIA MEDICAL FOUNDATION 725.00 0.00 0.00 725.00 Vendor# Vendor Name Class Pay Code 13808 VITA PERSONA LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check 0, Pay Gross Discount No -Pay Net VP20212588„/'A 11/16/20.11/10/2011/16/20. 1.942.98 0.00 0.00 1,942.98 SUPPLIES Vendor T0lalENumber Name Gross Discount No -Pay Net 13808 VITA PERSONA LLC 1,942.98 0.00 0.00 1,942.98 Vendor# Vendor Name Class Pay Cade 11018 WEBPT, INC Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net INV163238 4/ 11/17/20 11/12/20 11/18/20 9,244.80 0.00 0.00 9,244.80 PROVIDER SUB Vendor Totals Number Name Gross Discount No -Pay Net 11018 WEBPT, INC 9,244.80 0.00 0.00 9,244.80 Vendor# Vendor Name Class Pay Cade 11110 WERFEN USA LLC Invoice# Comm/ent Tran Dt Inv Dt Due Dt Check orPay Gross Discount No -Pay Net 9111068551 / 1111212111110312011128/20. 983.00 0.00 0.00 983.00 SUPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11110 WERFEN USA LLC 983.00 0.00 0.00 983.00 Vendor# Vendor Name Class Pay Code 11400 WEST COAST MEDICAL RESOURCES Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross Discount No -Pay Net INVO76985 ✓ 10/3112010/27/2011126/20. 895.00 0.00 0.00 895.00 ✓ SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11400 WEST COAST MEDICAL RESOURCES 895.00 0.00 0.00 895.00 Report Summary Grand Totals: Gross Discount No -Pay Net 562,855.09 0.00 0.00 562,855.09 : ';•TIW?SHIP file:///C:/Users/eheiman/epsi/memmed.cpsinet.. corn/u98547/data_5/tmp_cw5report8582... 11 / 18/2021 R@i tlA'PEi-11SIf8�2P ' TIME: 10.05 PATIENT �'iNMBERt?tt Ir'PA'YEE?[�AME.t+i�:e.�i" ----------------------------- ---------------------------- ARID=0001 TOTAL TOTAL MEMORIAL MEDICAL CENTER PAGE 1 EDIT LIST FOR PATIENT REFUNDS ARID=0001 APCDEDIT PAY PAT DATE AMOUNT CODE TYPE DESCRIPTION GL NUM ---------------------------------------------------------------------------- 111721 34,77 5 REFUND FOR 111721 391.56 ✓ 2 REFUND FOR 111721 600.00 2 REFUND FOR 111721 279.11 ✓ 2 REFUND FOR 111721 58.40 2 REFUND FOR ......................................................... ___________ 1363.84 ---------------------- _------ ______.......... _----------- ___________________ 1363.84 MSKESSON STATEMENT As of: 11/19/2021 Page: 002 To anN1re proper=0 to your secant, drawn and return this campu,y: e000 stub with your n nittanee OC: ails A. of. 11/19/2021 Psgs: 002 Melt to: Canp: e000 MEMORIAL MEDICAL CENTER AMT DUE REMITTED VIA ACH DEBIT Territory. AP Statement for information only AMT DUE REMITTED VIA ACH DEBIT 815 N VIRGINIA STREET Customer. 632536 Statement for information only PORT LAVACA TX 77979 Date: 11/20/2021 Cust: 632536 PLEASE CHECK ANY q Dale: 11/20/2021 ITEMS NOT PAID (J) Ailing Due RMelvable allonal Account WIPE Cads Amount P Amount P ReeeNale late Data Number We.. Description DiseauM (floods) F (man F Number 'F column legend: P = Pad Due Rem, F =. Future Due Item, blank = Current Due Item 'OTAU Netlonal Acat 632536 MEMORIAL MEDICAL CEMTEi Subtatalm 9,083.22 USO knum Due: 0.00 Due If Paid On Time: / It paid By 1112312021. USE) 8,901.55 ✓ 'ast Due: 0.00 My This Amount: 8,901.55 USD Disc lost If paid late: 181.67 ast Payment 2,451.97 If paid After 1112312021, Due If Paid Late: 1810712017 Pay this Amount: 9,083.22 USD USE) 9.08/3.22 <y Brllu 1.0W d!5 ")111)1 ;'a=famlol:c <> _., _a,•c:�e�.•_.av1c For AR Inquiries please contact 800-867-0333 M ALbbuN STATEMENT As Of: 11/19/2021 a ,"; Nee OC: 8115 HED PHCY 0434/MEM MED PHS AMT DUE REMITTED VIA ACH DEBIT Territory: 400 MEMONAL MEDICAL CENTER Statement for information only VICKY KAUSEK Customer. 190813 815 N VIRGINIA ST Date: I1=2021 PORT LAVACA TX 77979 Page: 001 To ensure paper cmdk to your acccunt, detach and Mum this stub sah your remtNance As of: 11/19/2021 Page: 001 Moll to: CamP: 6000 ANT DUE REMITTED VIA ACH DEBIT Statement for Information cnly Curt: 190813 PLEASE CHECK ANY Ode: 1112012021 ITEMS NOT PAID (1) alwnal Account 8 piling Due Number ISMIS Amount P Amount P Numb,�inue 11 )me Gale Number Reference, Description OlscouM (gross) F (tlel) F Number :ustomer Number 190813 H® PHCY 04341MEM MED PHIS 1/19/2021 11/23/2021 7307270127 2017039206 1151m,wce 3.34 167.01 163.67 ,' 7307270127 'F column legman P = Past Due Item, F = ROure Due Item, blank = Current Due Item 'OTAL• Customer Number 19OB13 HES PHCY 0434IM@M MED PHS Subtolalc: 167.01 USD 'utum Due: 0.00 Due It Paw On Timor: It Paw By 1112312021. USO 163.67 'ad Due: 0.00 Pay'Thla Amount: 163.67 USD One lost It peld let.: 3.34 art Payment 9.543.86 If Paid After 1112312021, Due II Paw We: 111512021 Pay thla Amount: 167.01 USD USD 167.01 Y.'illalTU aFf ttiU'/ 2 2 2011 For AR Inquiries please contact 800-867-0333 MSKESSON STATEMENT camc�r: eoco CV6 PHCY 7475/MB4 MC PHS AMT DUE REMITTED VIA ACH DEBIT MEMORIAL MEDICAL CENTER &element for Information only VICKV KAUSE( 815 N VIRGINIA ST PONE LAVACA TX 77979 As of: 11/19/2021 Page: 001 To wasum Proper credit to your account, tlHemh and Mum this club with your MmiDanw DC: 8115 As of: 11 /1912021 Page: 001 Mall to: CanP: B000 Territory: 400 AMT DUE frm VIA ACH DEBIT Statement foror information only Customer:Cuomer: 835438 DOW 1-1/2012021 Cud: 835436 PLEASE CHECK ANY Date: 11/20/2021 LTEBS NOT PAID (s) tioust Account fi filling Due Nre Cash Amount P Amount P Fbeeivabte re )Me Data NumberumberblReference Description Disouunt (gross) F (not) F Number ;Uat mer Number B36438 CUE PHCY 7475/114E4 MC PHS 1450180 1151nvolce 367.83 360A7 7307207633 1/18/2021 11/23/2021 7307207633 7.30 'F adumn legend: P = Pest Due Item, F e wlme Due Item, dank = Current Due Hem 'OTAL• Cudatwr Number 835438 CVS PHCY 74T5/MEA MC pHs Subtotals: 367.83 USD :otuM Due: 0.00 Due It Paid On Tima: It Paid BY 11123/2021, USD 360,47 lest Due: 0.00 Pay This Amount: 360.47 USD 01eo lost It paid late: 7.36 ad Payment 9,543.86 If Paid After 1112312021, Due If Paid We: 111512021 Pay this Amount: 367.83 USD USD 367.83 For AR Inquiries please contact 800-867-0333 MSKESSON camvrx: eoso H® PHY PC 490/MEN MC PHS MBAORIAL MEDICAL CB4TER VICKY KALISE( 615 N VIRGINIA ST PORT LAVACA TX 77979 STATEMENT As of: 1111M021 Page: 001 To ensure proper Break to your axount, detaah and Mum this dub wbh your rembtanm DC: 8115 As of: 11/19/2021 Pogo: 001 ANT DUE REMITTED VIA ACH DEBIT Territory: 400 Mall to: Comp: 6000 Statement for Information only ANT DUE RBMIT7® VIA DEBIT Cudemer. 484450 Statement for information only Ode: 1112012021 Cud: 464450 PLEASE CHECK ANY Date: 11/20/2021 RBAS NOT PAID (v) tilling Due RecelvaMe atlonal Amount y16 Cash Amount P Amount P Receivable Iota Date Number Reference Desmlpuen Dlsc 1 (gross) F (net) F Number tudomer Number 454450 HES PHY PC 490/111EM MC Me 1/16/2021 11/23/2021 73064BO365 B2111-055.731026 11 Simmice 20.78 1.036.79 1,018.01 730480365 1/16/2021 11/23/2021 7306450367 B2111-055.731055 1151n.I.. 7.41 370.32 362.91 ✓ 730:480367 1/16/2021 11/23/2021 73064BO369 02111455-731071 1151nvolce 0.79 39.36 38.57/ 7306480369 1M812021 11/23/2021 7307005813 55x735790 1151nvelce 10.01 646.51 534.60./ 7307005813 1M9/2021 11/23/2021 7307266395 55040399 1151nvoice 0.02 1.D6 1.04 ,/ 7307266395 1/19/2021 11/23/2021 7307275254 55x740463 1151nvoice 6,02 301.11 295.09 /� 7307275254 W column legend: P a Pad Due Item, F > Fours Due Item, blank = Curren Due Item 'OTAU Customer Number 454460 HEB MY FC 490/MEW Me PHS Sumdale: 2.296.15 USD Mum Due: 0.00 Due 11 Paid On Time: If Paid By 11123/2021, Lim 2,260.22 ✓ lad Due: 0.00 Pay This Amount: 2,250.22 USD Dlse last It paid Ida. 45.93 ast Payment 9,543.86 It Paid After 1112312021, Due If PoItl We: 111S72021 Pay this Amount: 2,296.15 USD ////��\ ///�� ////U"SD 2,296.15 f�tlJt� i Ll r�l For AR Inquiries please contact 800-867-0333 MSKESSON STATEMENT Cw„arr: Mae CVS MCY 7008/MEMORIA MS ANT DUE REMITTED VIA ACH DEBIT MEMORIAL MEDICAL CENTER Statement for information only VICKY KAUSEK 815 N VIRGINIA POW IAVACA TX 77979 As of: l i/19/2021 Page: 001 To ensure proper eretla to your account, detach and Mum this club with your reMftence DC: oils As of: 11119/2021 Paga: 001 Man to: Can11: 8000 Territory: 400 AMT DUE REMITTED VIA ACH DEBIT Statement for Information only Customer 282252 Dale: 11/20/2021 Curt: 262252 PLEASE CHECK ANY Date: 11/20/2021 ITEMS NOT PAID (r) filling Dea RaeelvablO "lanai Account WV6 Ceah Amount P Am of P Receivable late Date Number Reference Description Discount (gross) F (rret� F Number II_II :uolomer Number 262252 CVS PHCY 7046/MEMORIA PIES 1/18/2021 11/23/2021 7307014926 1451281 1151moice 0.33 16.47 16.14 ✓/ 7307014926 O m column legend: P = Past Due Item, F = Future Due Item, blank = Current Due Item 'OTAL• customer Number 262252 CVS PNCY 7006/MEMOWA PHS Subtmals: 16.47 USD "Mum Due: 0.00 Due a Paid On Time: / If Paid By 11123/2021, USD 16.14 ✓ 2st Due: 0.00 Pay Thla Amount: 16.14 USD Dim last N paid late: 0.33 am Raymond 10,629.05 It Paid After 1112312021, Due It Paid We: IIOM021 Pay this Amoum: 16.47 USED USD 16,47 n1a For AR Inquiries please contact 800-867-0333 MSKESSON STATEMENT As of: "A9/2D2, Page: °°' To ensaure proper mans to your accoand, detach datum this stub w6 your resistance comeanr soon DC: 8115 As of: 11/19/2021 Page: 001 Mall to: CrBnp: 8000 WALMART W90/MEM MED HIS AMT DUE RBAIrTED VIA ACH DEBIT Territory: 400 MEMORIAL MEDICAL CENTM Statement for Information only AMT DUE RBv1 = VIA ACH DEER Statement for information only VICKY KALISEK Customer: 256342 015 N VIRGINIA ST Dete: 11/20/2021 PORT LAVACA TX 77979 Cum: 256342 PLEASE CHECK ANY Dale: 11/20/2021 REMS NOT PAID (1) filling Due ReeelvabTpatlonal Aecount ion 5N,16 Cash Amount P Amount P fkaelvable Me Date Number Refinerwe Description Discount (gross) F (rest F Number NWamer Number 256342 WALMART 1098IMEM MED PHS 1/13/2021 1112MO21 7306216506 1112210741 1151nvvice 0.01 0.63 0.62 ✓ 7306216565 I tl512021 11/23/2021 73DO148702 19147219 1151nvoice 30.84 1.549.14 1,511.30 ✓ 7300148702 1/15/2021 11/23/2021 7306148703. 19147219 1t51nvoiva 0.01 0.32 0.31,/ 7306148703 1/15/2021 11123/2021 7306148704 19214035 1151nv01ce 0.65 32.31 31.86 / 7308148704 1/15/2021 11/23/2021 7306337226 1112210750 1951nvoica 0.02 0.95 0.93 ✓ 7306337228 1/16/2021 11/23/2021 7306469278 19278953 1151nv01ce 5.38 268.04 263.46 ✓ 7306409278 1/16/2021 1123/2021 7306637305 1115210947 1151nvoice 3.10 158.05 154.89 7306537305 1/17/2021 11/23/2021 7306755381 19325449 1/51nvoice 10.76 537.96 527.20 / 7306755361 1/172021 11/23/2021 7306901421 1115210844 1951nvoice 0.01 0.57 0.56✓ 7308901,121 1/172021 11/23/2021 7306901422 1116210756 1151nvolee 0.12 0.12i 7306901422 1/18/2021 11/23/2021 7307020275 19398270 1151nvolce 9.74 467.16 477.42.1 7307029275 1/18/2021 11/23/2021 7307029276 19421167 1151nvn1ke 10.75 537.67 526.92 7307D29276 1/182021 1V23/2021 7307029277 19442509 1151nvvice 14.11 705.53 691.52 7307029277 1/18/2021 11/23/2021 7307162140 1117210703 1151nvvice 0.63 31.36 30.73 7307162140 1/19/2021 11/23/2021 7307269272 19471810 1151nvvice 13.49 674.54 661.05 7307269272 1/19/2021 11/23/2021 7307289273 19517186 1151nvvloe 6,38 268.98 263.60 �/ 7307289273 1/19/2021 11/23/2021 7307459435 1118210653 196lnvoice 5.59 279.55 273.96 / 7307459435 W column legend; P = Past Ow Item, F = Future Due Item, blank = Current Due Rem -OTAL QuamerNurnbeir256342 WALMAW 1094IMM MED PHS Subtotals: 5,526.78 USD Mural Dun: 0.00 Due If Patel On Time: If Paid By 11123/2021, USD 5,416.26 not Due: 0.00 Pay This Am4unU 416.25 USO loss: Disc lass: it Paid late: am Payment 9.543.86 If Pakl After 1112312021, Due It Pole Late: 1/15/2021 At<ITIT/87M Pay this Amount: 5,526.78 USD USD 5,526.78 'lt4 1n . NON 12 2O[1 �Gy� For AR Inquiries contact 800-867-0333 '.:51..'[2'34C :RAlxc•4'. -..: rSA+� please MSKESSON STATEMENT come�,y: eaoo WAI-MART 53151MWM MC PHIS AMT DUE REMITTED VIA ACH DEBIT MEMORIAL MEDICAL CENTER Statement lot Information only A/P 615 N VIRGINIA ST PORT IAVACA TX 77979 As of: 11/19/2021 Page: 001 To ensure Proper credit to your aceolmy detach and mum this real, with your remittance DC: 6195 As of: 11/19/2021 Page: 001 Mall to Comp: 8000 Territory: 98 AMT DUE REAITT® VIA DEBIT Statement for information only Customer: 945479 Date: 11/20/2021 Curt: 945479 PURSE CHEDK ANY Date: 11/20/2021 REAS NOT PAID (r) filling Due ReeelvabOatlonal Account WSP6 Cash Amount P Amount P Receivable W. Date Number Mr.". Desclptian Discount (cross) F (net) F Number :uatomer Number 946479 WAWAW 53161MMFIL MC PNS 1/17/2021 11/23/2021 7306807979 MH11162021 195lnvoice 14.18 708.98 694.80 ✓ 7306807979 O + column legend: P = Pap Due Item, F e Future Dag Item, blank = Current Due Item "MAL Customer Number 945479 WAIMART 5315/61FA1RL MC PHS Subtotals: 708.98 USD hture Due: 0.00 It Pald 8y 11123/2021, 'art Due: 0.00 Pay This Amount: 694.80 USD AM Payment 9,543.86 N Paid After 1112312021, 1/15/2021 Pay this Amount: 708.98 USD a("Pilla:om W 0J 7 A21 m pit: mmn::. For AR Inquiries please contact 800-867-0333 Due D Pald On Time: USD 694.80 ✓ Oise lop It pald late: 14,18 Due D Paid late: USD 708.98 � ,lilt✓ or 1j STATEMENT statement Number. 62006649 AmerisourceBergen- Date: 11-19-2021 AMERISOURCEBERGEN DRUG CORP WALGREENS#12494340B 1001352841037028186 12727 W. AIRPORT BLVD. MEMORIAL MEDICAL CENTER SUGAR LAND TX 774786101 1302 N VIRGINIA ST PORT LAVACA TX 77979.2509 Set -Prl Due in 7daye DEA: RA0289276 _ 866451-9655 AMERISOURCEBERGEN Not Yet Due: 0.00 P.O. Box 9D5223 CHARLOTTE NC 28290-5223 Current: 517AI Past Due: 0.00 Total Due: 517AI Account Salvo.: 517.41 Account Activity Document Due Reference Purchase Order Document Original Last Receipt Amount Received Balance Date Date Number Number Type Amount 11-15.2021 11-26-2021 3073811047 10669 Involve 35.14 0.00 35.14, 11-15.2021 11-26-2021 3073811048 163570 Invoice 12.36 0.00 12.36, 11-1&2021 11-26-2021 3073840065 163616 Invoice 117.58 0.00 117.58 11-18-2021 11-26-2021 307388369B 4515553587 Invoice 30.16 0.00 30.16 11-16,2021 1146-2W1 3073972991 163626 Invoivs 137.96 0.00 137.96 11-17-2021 11-26,2021 3074113277 163633 Invoice 164.45 O.OD 164.45 11-19-2021 11-26-2021 3074301126 163652 Invoice 19.76 0.00 19.76 Current 1 1-15 Days 16410 Days 3160 Days 61-90 Days 91.120 Days Over 120 Days 517.41 0.00 0.00 0.00 0.00 0.00 0.00 Thank You for Your Payment Date Amount 11-19-2021 (610.80) rr4Alo Sol / 2 20!1 DTanMTi' :,onaYC4:, Reminders Due Date Amount 11-26.2021 J517.41 ). Total Due: 517.41 IW TOLL FEE PHONE NUMBER: 1-800-555-3453 (EFTPS TUTORIAL SYSTEM: 1-800-572-8683) "ENTER 9-DIGIT TAXPAYER IDENTIFICATION NUMBER" 0"ENTER YOUR 4-DIGIT PIN" "MAKE A PAYMENT, PRESS 1'r ETENTER THE TAX TYPE NUMBER FOLLOWED BY THE # SIGN" FTIF FEDERAL TAX DEPOSIT ENTER 1" "ENTER 2-DIGIT TAX FILING YEAR" "ENTER 2-DIGIT TAX FILING ENDING MONTH" 15T 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" ET6-DIGIT SETTLEMENT DATE" "1 TO CONFIRM" ACKNOWLEDGEMENT NUMBER #### ENTER: 0 -� 21 �- 1z 0 0 $ 99,026.39 1 $ 50,060.08 $ 12,184.08 $ 36,782.23 CHECK S CALLED IN BY: CALLED IN DATE: CALLED IN TIME: =1 [3 # F1AP-Payroll FileslPayrall Taxes1202lW24 R1 MMC TAX DEPOSIT WORKSHEET 11 18.21 Rl.xls 11/2212021 qu1 Catt: '111912-. MEX'RIAL F:EB?CAL ".ENTER pace 111 Ti-:e: 3,.-- Pa;'rc'.1 Resister fi-ae? y -1- Pay Period 11/05I21 - 11116121 Rung I :final finery - - ;ayCd Description 3rs CTI S3 K. 1{01 Cel Gress I 'de_ A79pAr , •_.._---'--------------------------------- ........................... ------'................................ _...... '........... -: 1 RE�'1A.S. PAY-S1 9324.29 N J ;i 199314.7 .... 550.!6 A:R2 29.OG i'F.i 1 REGUI.;R PAY-S1 17i9.00 1! II 11 N 7606L40 A?a':A.'1C F.NAROS £il it 1 REGULAR PAY-51 366.7E Y " 11 10143.13 CAFE 3 CAFE - 1 CAFE2 :.cGCLAR PAY-S. :.uo :1 I; ., P, LLa :v: c-_ 'Z17_-4 ...._ _ 2 "REGULAR. PAY-S2 2P56.50 „ 11 I: 4P297.45 CAFE-C IS i 2 REGULAR PAY-S2 130.7E Y• 11 N 3320.39 C4FE-E. 205041.81 CAPE -I CAFE-L REGUUIR ?AY-53 1269.5: it I; 35625."4 CAP ,_ . G;";_:. CRILC 72C.47 RECUw4 PAY'-53 46.2E . N 1454.Si CLINK 3'O.00 COSa2l1 i00.6I CRED:T* C CALL PAY 2636.00 N 1 11 N 5272.00 DD WV DENTAL DEP-LF C COUBLE TIME '.7.`0 N I N N 906.26 9iS-LF _.. EATCS:^: COUBLE THE 31.00 N _ 11 S 2264.25 TECTi4 ?67o2.:i F'."I 6032.04 25G10.04 D DOUBLE TIME 29.66 N 3 t1 N 2206.64 FIRSTC FLEX S 3312.29 ?LX�FE a Sg;q. '4AGrc N .. ii .� 13<:, 6. 15 FORT D rsp. G?�. S i61.49 E:4 PA WAGER N 1 N s 394.00 GRANTr.•.P-I!1 92L FUNERAL LEAVE 16.00 N 1 N N 98a.46 KSP-i ID TFT LET.? - rycfPVv" 3i.00 N 1 N N 1096.94 LEGAL 2601E :11.;A' 95E.00 HE,15 710.CE Nt o ., 26i.,. MEi'!?f ._:.2: SIIS :•IiSCI F. E::TEN'DED-ILLNESS-MF6 404,00 N 1 N I1 NC0.56 MNC5911. NAT[IL 1753.01 OinER P PAID-TTN"t-OFF 2565% N N I1 ., 4414.27 P3I PRtu. P iIN ? PAiQ•°. "E-OFF ii Si.�S N 1 21 IT 36285.03 "RE-1-Ay _RlAY _AS1f X. CALL PAY 2 80.40 N 1 N N 160,00 SCRUBS_ SIGNON ST-Id Z CALL PAY 3 49.00 N 1 11 N 144.00 ETC!IDF W.;, ST0NE :TO!lu PRON2 6 DATA .. 1355.00 SA^Ja: SINACC 784.3E 11,1I11 ?33.6i , CO'VID-FFCRA 9.00 11 1 N 11 82.24 SLNIND 674.21 SUNLIF 126.24 EUNSTD 1203.3E 5'.7NI€ SURC'r,G 450.00 -,SA•1 :SA•2 TEA: , TSA . TSA-R 31071.4E TUTION LINIFCP. 526.3: DA lECS •-•-----•-----•------ Grad Totals: 1P423,32 --- :-ductions: i36727.5; Net: ID7546.06 I Cheeks ............... Coint:- FT 194 PT 9 Other 40 Female ................... •................ -lu- ', -........... Isle u4420.70 •' -.................. 11erA-,1 6 '........ ZeroNet ........................... Ten Total: 242 _........ PA 4_ MEMORIAL MEDICAL CENTER PROSPERITY BANK ELECTRONIC TRANSFERS FOR OPERATING ACCOUNT— November I5, 2021- November 21, 2021 Date Bank De44rlotion 11/19/2021 AMERISDURCE BERG PAYMENTS 0100007768 2100002 11/17/2021 PAY PLUS ACHTRAN54525792911010OD697236678 11/16/2021 PAY PLUS ACHTRANS 452579291101000696195162 11/16/2021 MCKESSON DRUG AUTO ACH ACH04804923 910000152 11/15/2021 PAY PLUS ACHTRAN5452579291101000694349336 11/1512021 TEXAS COUNTY DRS RECEIVABLE 0419 21000029924 P - Memorial Medical Center PROSPERITY BANK ELECTRONIC TRANSFERS FOR OPERATING ACCOUNT - ESTIMATED ACHS Date Descrlotion 12/8/2021 ACCRUED NH OIPP IGT Anthony Richardson, CFO Memorial Medical Center MMC Notes 340B Drug Program Expense -3rd Party Favor Fee -3rd Parry Payor Fee - 3408 Drug Program Expense - 3rd Party Payor Fee - Retirement Funding November 22, 2021 �I{{1jpW<d 11.11 21 6L �V Avp-v,a II�10.71 CC 22, 2021 MMC Notes CP51"Handwritten Amount $ 610.80 U G $ F' i'b11 �2�(•1J _4+# $ 9,543.86S VOW 'G 4 4 - $ 213476�d1 / -tfl kkl: ? 4 Q' 22%722.51 91 4 I hn Amount- $ 2,344,P74in9 6 • Ij isr;ielR5d �Y4 2021 Transaction Summary Transaction Complete Texas Health and Human Services Commission Memorial Medical Center Operating County Payment Total $2,344,974.43 Bank Routing and Account Number Settlement Date 12/8/2021 QIPP Amount $2,344,974.43 Entered By Marley Moehri Page No:1 of 1 Run Date: 11116/2021 Run Time: %.wo7 Cc: Regmi,Asha (HHSQ; HHSC PFD QIPP Payments Subject: QIPP Official Provider Notification 4 of 4 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. QIPP Year 5 NSGO Providers, HHSC has now received federal approval for QIPP Year 5 and is thus providing official notification of the suggested IGT for the second half of QIPP Year 5, The calculations for the IGT amounts can be found on the Provider Finance QIPP website in the document "QIPP Year 5 Estimated Component Values and Suggested IGr. Please note the component values will be updated once the state share has been calculated from the IGT deposits. The IGT must be entered into TexNet no later than close of business December 7, 2021 with a settlement date of December 8, 2021. • This settlement date Is non-negotiable. • The funds need to be placed in the "QIPP" Bucket. • The amount that needs to be entered into TexNet is on column Z of the tab named "Eligible NF & Enroll Status" of the "QIPP Year 5 Estimated Component Values and Suggested IGT" spreadsheet provided in the link above. • The IGT will be processed at that time and there will be no further revisions or redistributions of IGT suggestions should the aggregate IGT amount not fully utilize the available pool. Please ensure you double check the number while entering to ensure the correct number has been entered. Please transfer funds through TexNet. TexNet instructions are available here: https://comptroller texas gov/programs/systems/texnet oho Send an email with a screen shot or PDF of the confirmation/trace sheet to HHSCPFDQIPPPavmentsla)hhs texas. gov Please email any questions regarding this change or the calculation in general to QIPP@hhs.texas.gov. Thank you, HHSC Provider Finance Payments (Formerly Rate Analysis) Texas Health and Human Services Commission Attention: Provider Finance Department 4 North Austin Complex 4601 Guadalupe St Austin, TX 78751 Mail Code H-400 P.O. Box 149030 Austin, Texas 78714-9030 TEXAS Health and Human Services a.e. v... s x..ai� a.n.� ew ... mm rwaa x..�x. m..x.. we+,..mn.xme QIPP Year 5 1 QIPP Year 5 Eligibility Cut-off Point 65.00% Total Number of Nursing Facilities 912 Number of Qualifying NSGO Facilities 607 Number of Qualifying Private Facilities 305 Faclllty ID Facility Name Facility Owner Privately Owned, Non -State Government Owned (NSGO), or State Owned County 4628 FORT BEND HEALTHCARE CENTER MEMORIAL MEDICAL CENTER NSGO FORT BEND 4811 ASHFORD GARDENS MEMORIAL MEDICAL CENTER NSGO HARRIS 100806 GULF POINTE PLAZA MEMORIAL MEDICAL CENTER NSGO ARANSAS 102540 GOLDEN CREEK HEALTHCARE AND REHABILITATION CENTER MEMORIAL MEDICAL CENTER NSGO GRIMES 103462 TUSCANY VILLAGE MEMORIAL MEDICAL CENTER NSGO BRAZORIA 105006 SOLERA AT WEST HOUSTON MEMORIAL MEDICAL CENTER NSGO HARRIS 105314 THE CRESCENT MEMORIAL MEDICAL CENTER NSGO FORT BEND 105818 THE BROADMOOR AT CREEKSIDE PARK MEMORIAL MEDICAL CENTER NSGO HARRIS 110301 1 BETHANY SENIOR LIVING MEMORIAL MEDICAL CENTER NSGO CALHOUN Maximum dollars based on a fully funded program meeting 100% quality SDA Medicare Number NpI Most Recent Audited Cost or .Accountability Report Used Contract Number Used CR or AR Begin Date CR or AR End Date Total Medicaid Days Total Days of Service Medicaid percent Utilization 1ARRIS 675663 1730577503 2018 CR 1026586 1/1/2018 12/31/2018 11,357 16,538 68.67% 1ARRIS 675423 1326436289 2018 CR 1026516 1/1/2018 12/31/2018 28,095 37,258 75.41% VUECES 675892 1922092790 2018 CR 1 1021317 1/1/2018 12/31/2018 8,840 17,360 50.92% VUECES 676097 1588075964. 2018 CR 1028605 1/1/2018 12/31/2018 20,025 27,464 72.91% 1ARRIS 676201 1275717894 2018 CR 1016085 1/1/2018 12/31/2018 16,481 39,154 42.09% 1ARRIS 676310 1497143259 2018 CR 1026585 1/1/2018 12/31/2018 11,017 35,622 30,93% 1ARRI5 676323 1669860425 2018 CR 1026584 1/1/2038 12/31/2018 9,339 28,701 32.54% 1ARRIS 676357 1669860433 2018 CR 1026524 1/1/2018 12/31/2018 11,631 33,780 34.43% VUECES 676481 1538719836 No Data No Data No Data No Data No Data No Data No Data metrics Annulalzed Medicaid Days Percentof ComponentsI& 4 Percent of Components2 &3 Estimated Max Value of Component) Estimated Max Value Component2 Estimated Max Value of Component Estimated Max Value of Component4 Estimated Maximum Value from Components to Provider 11,357 0.104% 0.0647% $ 464,530 $ 112,764 $ 169,146 $ 182,370 $ 928,809 28,095 0.256% 0.1600% $ 1,149,156 $ 278,956 $ 418,434 $ 451,147 $ 2,297,692 8,840 0.081% 0,0503% $ 361,578 $ 87,773 $ 131,659 $ 141,952 $ 722,961 20,025 0.183% 0.1141% $ 819,073 $ 198,829 $ 298,243 $ 321,560 $ 1,637,704 16,481 0.150% 0.0939% $ 674,114 $ 163,640 $ 245,460 $ 264,650 $ 1,347,865 11,017 0.101% 0.0627% $ 450,623 $ 109,388 $ 164,082 $ 176,910 $ 901,003 9,339 0.085% 0.0532% $ 381,989 $ 92,727 $ 139,091 $ 149,965 $ 763,771 11,631 0.106% 0.0662% $ 475,737 $ 115,484 $ 173,227 $ 186,770 $ 951,218 - 0.00o% 0.0000% $ - $ - $ - $ - $ - ----rurarrurn:-- �om�n Total Year IGT Request 220077,000 $ ^_440,154,000 June IGT Request December IGT Request Total Request for (1/2 of total) (2/2 of total) Year $ 228,041.91 ..__........_.__________f__._________.__.__— $ 228,041.91 $ 456,083.82 $ 564,131.15 $ 564,131.15 $ 1,128,262.30 $ 177,502.03 $ 177,502.03 $ 355,004.06 $ 402,090.28 $ 402,0910.2.8 $ 804,180.56 $ 330,928.83 $ 661,857.66 $ 330,928.83 $ 221,214.91 $ 221,214.91 $�-. 442,429.82 $ 187,521.65 $ 187,521.65 I $ 375,043.30 $ 233,543 67 $ 233,543.67 $ 467,087.34 $ 2,344,974.43 $�, 2,3R'4,974{4 $ 4,689,948.86 Page 1 of 1 11/18/2021 MEMORIAL MEDICAL CENTER 09:59 AP Open Invoice List Due Dates Through: 12/0212021 Vendor# Vendor Name Class Pay Code 11828 SOLERA WEST HOUSTON t// Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross 110521 11/15/201110812012102120 20,995.17 TRANSPERj/� 1nSlMlltlP. putew .,,d (tq0so . {K-6 Vendor Totals Number Name Gross 11628 SOLERA WEST HOUSTON 20,995.17 Report Summary Grand Totals: Gross Discount 20,995.17 0.00 tir %'er r1>�@l 0 ap_open_invoice.tempiate Discount No -Pay Net 0.00 0,00 20,995.17 Discount No-PayOO Net 0.00 0.00 20,995.17 No -Pay Net 0.00 20,995.17 file:///C:/Users/eheiman/cpsi/memmed.cpsinet.com/tt98547/data_5/tmp_cw5report4212... 11 /18/2021 Page 1 of 1 MEMORIAL MEDICAL CENTER 11/18/2021 0 r�9c S8%ar.-.^_oy"iy <'t7aaii-ty1 AP Open Invoice List ap_open Invoice.template Due Dates Through: 12/0212021 Vendor# Vendor Name Class Pay Code 11836 GOL/DENCREEK HEALTHCARE ./ Invoice# Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 1108218 1111512011/08/2012102120 7,521.24 0.00 0.00 7,52124 TRANSFER ��111vi;t"+,+LCt NNyII+u.1 dr.(.t)si'�ecd Kib TW L UjiLYtiai�/ . 110821 11115/20 11/08120 12102120 5,793.90 0.00 0.00 5,793.90 p/ TRANSFER 11 1t 110821A 11/15/2011/08/2012/02/20 433,72 0.00 0.00 433.72 ✓ TRANSFER II if , 111521 11116/2011/15/2012/02/20 384.74 0.00 0.00 384.741,j TRANSFER McAi Lprt✓ il(f4jyNj,_4- . Vendor Total Number Name Gross Discount No -Pay Net 11836 GOLDENCREEK HEALTHCARE 14,133.60 0.00 0.00 14,133.60 Report Summary Grand Totals: Gross Discount No -Pay Net 14,133,60 0.00 0.00 14,133.60 t$�y mov .i 2!1121 file:///C:lUsersleheimanlcpsilmemmed.cpsinet.com/u98547/data_5/tmp_cw5report5O23... 11 /18/2021 Page 1 of 1 I � , .I P 9 0 ZVI' MEMORIAL MEDICAL CENTER 11/18/2021 —'10i'tlO tttl'`-`�'"'`i3> �s e?itt5� AP Open Invoice List 0 Due Dates Through: 12/02/2021 ap_open_invoice.template Vendor# Vendor Name Class Pay Code 12696 GULF POINTE PLAZA Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 110821 11/15Y2011/08/2012/02/20 508.85 0.00 0.00 508.85 TRANSFER �/} jftWq Lt. PAW;AJ oUPOCA& ik-b. iltimL- CPLA^ 110821A 11/15/2011/08/2012/02/20 2,100.45 0.00 0.00 () 2.100.45 TRANSFER I` Ir Vendor Totals Number Name Gross Discount No -Pay Net 12696 GULF POINTE PLAZA 2,609.30 0.00 0.00 2,609.30 Report Summary Grand Totals: Gross Discount No -Pay Net 2,609.30 0.00 0.00 2,609.30 A"r.`iNirrNh ot, VIV .. VIVO,'s,C"j d�ftisll{ItVp file:///C:/Usersleheimanlepsilmemmed.cpsinet.com/u98547/data_5/tmp_cw5report8776... 11 /18/2021 Page 1 of 1 11/18Q2'A 7 �' 7Q2€ MEMORIAL MEDICAL CENTER AP Open Invoice List 0 " 10I. ,.!j-,I, f-:osnrty :A-14UM -Vendor# Due Dates Through: 12102/2021 ap_open_Invoice.template Vendor Name Class Pay Code 13004 TUSCANY VILLAGE Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 110521 11/15/20 11/05/20 12/02/20 767.18 0.00 0.00 767.18 TRANSFER �}{ ivulv�vw! pbv�lyu,�,'j e�.( .'led jK1) TKyAL ay&Uk j . 110521A 11115/20 11105/20 12/02/20 590.00 0.00 0.00 590.00 TRANSFER v/ Vendor Total Number Name Gross Discount No -Pay Net 13004 TUSCANY VILLAGE 1,357.18 0.00 0.00 1,367.18 Report Summary Grand Totals: Gross Discount No -Pay Net 1,357.18 0.00 0.00 1,357.18 lot-: 3j file:///C:/Users/eheiman/cpsi/metmned.cpsinet.com/u98547/data_5/tmp_cw5report1453... 11 / 18/2021 Request for Transfer of funds LednSlelp: Oah RegYlstatl faYC! RequeIIetl by Requeet&s.null RegYelMfspllYne numb.! OlaniOor[ my fatlll .w 10a TS,IDGIRSIQ£S£Ef?l R fi.owamn R REO wrcnrSenYe O nnN TYxnrMamen! al—, y1 ,,n fhkftjunftr ARbpnaxMLM lane.l. m. N/A N/A 11/912021 E 1$g6.06 Eif6MR103 NUABBBW26B69 ] .36 BPOAOMOORATCPEEMIU N/A N/A 32/12nO21 M 1.1.01 Eg815101 WORPP, 6869 3803 BPOAOMOOP AT CBEEPSIOE tt1TAl 3,Ai0 ]B1A5 ul Q0PMe2rC.B d;0.Ml r�R. el XMe Re—: :lgAM0YAeIIOtlAiMuM02 M OR M I,CLIN1L ert rim, WflaMai9 E}alxi Ali- f::^Trt>.•-. Request for Transfer of Funds Transfer P: Bate Beque3 d ll/lB/$G3l Payer MODICUM Ileque.m., TATUM GGAOON- BOUNCES OFFICE MANAGER BegYe3tMF mull Eortlon9Ae1 anvl_grwn Ne9uer PRene number 36b98YMW Mstriat orCeunry Calhoun FA411W Ekh., Benlor UvM, paCanl Name 1 pees el4nYe Twen/pamr piee fi % nt 4X al Raelen neMM. aner bnFr Flv iue N/A WA 11/I6/202I FW FFT MS]33R CVXAROCW]f869 11.883.91 LAMBPF <flFEXBIBF PIIXIEURY NCE EMT ADVANCE MTAt 1 11.883,91 TPXGIIeXPutX Memmlal MCGkal4nter. Oaee.rq a 11 p Nppneeetl hY: MAAMMARLINES pate eE M1a^rtee: u2e2@t Fmm Fatlllry. OROA[ ] c Ta Fanllo, AmeV^L 31.88391 ^pwnNimrler ^ne Fiam3er. From. m{uNltle To Aaaw. A114upt: . v'.s1E1 k.Tdl� NO'/ C C 21,171 CYs9tib"i" in1f9 V3'J. (l5 'a!b4' kig3plRC 1k'YS:aI Request for Transfer of Funds Tranq[f X: wRPegYevtetl a+Yer aequ.d by wque[Igrp.m.n Requestof[pWne number aklrielarCeunly FaaulB MEMOPMLMENIMMNIC .NI.rtanararyry'mmta mesa,..%pW.prc .FwdYaery.w&I. b11am N.nr RF RFR wRN4rvtre UIREO jlysel3umeM �_ hyEypj apkeneeJnt.um hn�1Pt5^gN lw Hotes N/A HA ll/9/iwi FfT 3,S80.05 EFT0M8303r UDAA 019557 N3.36 YIIECRESENT N/A N/A 1111( 2 m 07.01 EM mlal WDMW]0MW 38.0 TNECRFSFNT TOiptI 3.173V I I mw Tgbe plkgqul Memg11a1Metlkal Qneer w Wpmvetl b9: MAYRAMARTINF 0aw oftrabhn 1f 3 F Fmmagllry: I.. ry: E 0 u4ME0atcuNc IUU 1 IV/ Amount 8 ; Rmmmm�.minmm Yx: 0ah efVanahr: pmm Fagliry: TO Fegliry: A4UMP3:R:� AmeYY3: E31 Request for Transfer of Funds rmmrer p: mm Pequenea 11/18/021 P.,, MEDICARE -libelled bY: TATUM WROON- BUSINESS OEfICE MMNGER Puyuula(s small pmtlmRbemnmIMno mm ReyeeNole he. number MTllE,05w .'...,.unry CA... wat, BNh.,Se.wrUm,., PaWM Re. NalenffeMee b t e Pa t Tvueaf Avnen! RvmeM Numbei pelbneeNe4Fmer (veb6fariwblel gVPIRmm N/A N/A 11/tb/302t c" EFT6157338 WOAPCL OSSi 11,813,91 THE CRf9fNT- AUY1WRY AWANCE PRAT ttT. i I I]LBB3.91 Tube fllkE outb Memaftlm"Hel Cenlea: lePw MEET App:we<b, MAY. MARIINU D.eeulf2Mhn 1 l fmm fully: CRESCENT TU lnft: RETNMx A...t: sr He,of neeM- n: D�tmpe'um,. . BaNiq: AmeunC 1!611 2 ) 2921 Request for Transfer of Funds itam(erp: Oah Reque d P." Re,CAR by RpYlatolsePbPne h. umm tnls numhea .W.laOwnry FatlINB PMxnlx.m! wteaaemm TY!lnrnm. PflmM. nagm-R.Wft ppYnnueNdW m.ee3An:wneem ' um WA N/A 11N3031 EFr MUM EFT6148203 NOARCC00381]0 ]93.36 603EMWEANOIIIMN WA VIA 11WI2011 tR 697.01 M601131 NOM80 MVO 38.0, SOIERAWi3TN003TON TOTAL 3,21i.07 MA3 TOWRI Eoutb Mematla)MeJWUnlen APOmYetlbY:� MAYNq MAPNNFE OMeorigM(en EI W ro FaxnM 'M APM mRcuN nnmYnr. - 1 r s. FaamNdit.: em.en.m..Pe�.n: wtl nnmRFren iaam Faallily: io uNL Amoune .Ulr9ffi15TSp, bfI Request for Transfer of Funds nanx erc D. R,..d llpe/xa11 >aye[ MEDICARE Reque9 dbr TATUMGONOON BUSINESS GIFICE MANAGER PepuealoJx emaO IemNonfnpedrenvllNne[pnl PepueibM1ppone nY mbex 3fi1-551-0SW Owctor[ounw CMheun wim, R.IM1anY fienlo,INing ulrvenve,0mmmwllava[a[om ne,®m mo [wn NWMNanre 9ahof Ne., EO ryn. airy .RI 1 pre[ Number KIRIMAumbor Mlan noelµ G lee Nna,Mw xlel M1 N/n N/A 1]118OGI1 EFT fFi 619]329 CVOPAGGWIBI)0 11.9B3.91 Spica WeR Nuulm .nNMW PY n[IYANEE iMi Li TOTAL gong Tobeflkdwtb Menwlal MedlalCbbn 1 2g 2W1 A,p.ed b, MAYMMAPTMEE bale pi2amrm: 2a 2m1 from FadllM io iatlliry: EIN AmeunF. 111.8 3.9 Mpnna M1RN(.Noxu iL pabpitltlW. r: ibm FAN, to faelllM :ua �ttld%!9fIV Anwuni: DMA Y�lE;`i 'l 2 2�21 �: f(ii4etii ;'igligil ]k Request for Transfer of Funds Transln b: OaiO RlQue[Lgtl Payer RequeRd by: ..,:.olbmaIf Requelo!: bone numbs! 01[tdttor Eounry iadllry OtNne Ne:m LNREO peNMRrvke f Tweefpnumn EFiL— � AUL&L.- 9MON-umby 99MMLOkEL MNxnwW en Enm. .xe.l �i141.36 N/A NM I]/9/l0]1 EEI 3M.m EFl61CB103 NOiRGMMTHS TU"y VIMP6E N/A N/A Wlvml EEI 6R7.01 EFl6151131 CVOARPA]0ms 3803 IUS NY Vb"Gfi TOTAL i 3273A7 MA5 ibbellledoutby Memorial Medlml Cemer. E Re[e.: 1 loi 1 AM..d 4: MFYRAMAR N N.NOEtraW.. 1 F.Fadliryt Tn iOtllily. URIAbMENICICNNC AmounF. IqS. e wwede.'. sax W. Iaiebitlffbr- NNmFaanry Amoum: 1T! I- t1b tTi' S311)diC^ a �y<p3N: S21NC.N.',!kx;�lil CNECK REQUEST p MEMORIAL MEDICAL CENTER Dai P. Requested 11/22/21 A Y �W14-y-M) E ARAOUNT $10,129.82 C.XPLA[qAT!ON: ECHO PAYMENTS OWED FROM GPP [OvQi-lr.S-171) BY! MAYRA MARTINEZ C/L NUMBER: AUTIJURIZED, BY: FOR ACCT, USE ONLY 0 Imprest Cash []A/P,':heck ElMall Check to Vendor FiReturn Check Lo DepL r, A ,.IS 1ECK REQUEST MM CLINIC Date Requested: 11/22/21 AMOUNT $1,109.40 EXPLANATION: ECHO PAYMENTS OWED FROM GPP )Lrml!qfsov - I Ift Ul NOV 2 2. 2c,,'zi G/i. NUMBER: FOR ACCT. USE ONLY Flimprest Cash nA/P Check E]Mail Check to Vendor 111letum Check to Depi, 10-0"JE5Tl-.Tj BY: MAYRA MARTINEZ AdTHORIZED BY: ... . . ........ ------- --- REQUEES-Ir P ASHFORD M16� Requested: 11/22/21 A FOR ACCT. USE ONLY [limp. est Cash �A/P Check 7 Mail Check to Vendur IlReturn Check to Dept AMOUNT $614.15 C-11 NUMBER: EXPLANATION: ECHO PAYMENTS OWED FROM GPP REQUESTED BY: MAYRA MARTINEZ AUTHORIZED BY: -- ----- — ------- p CRESCENT A Y E E AMOUNT $480.00 MEMeRiAE MED!f2ft &EN-F-f-R CHECK RE(UES-11- Bate Requested: 11/22/21 EXPLANATION: ECHO PAYMENTS OWED FROM GPP Aff'Mff tXt, lflj 4,10V � ?" 2021 GA NUMBFR: MAYRA MARTINEZ REQUFSTED BY: ALITI FI) FOR ACCT. USE ONLY 17 Imprest Cash []A/P Check []Mlil Check to Vendor FiReturn Check to Dept. 'IEPOORift HENE'Al. 11"FlIFFLER CHECK REQUEST P, SOLERA A y AMOUNT $6,150.00 EXPLANATION: ECHO PAYMENTS OWED FROM GPP R.LIQUESTEh By: MAYRA MARTINEZ Date Requested: '11/22/21 4m G/L NUMBER: FOR ACCT. USE ONLY F-1 Irnprest Cash []A/P Check 1-1 Mail Check to Vendor IlReturn Check to Dept AUTHORIZE'D BY: J CHECK REQUEST GOLDEN CREEK ibte Requested: A Y E APVl0Ut\,"r $9,935.61 EXPLANATION: ECHO PAYMENTS OWED FROM GPP 0.11. N U M B F R: -------- --- RD.-�U17:,TFI) BY: MAYRA MARTINEZ AUTHORIZED BY. 11/22/21 FOR ACCT. USE ONLY EI Imprest Cash []A/P Check Mall Check to Vendor Return Cheri; to Dept p TUSCANY A 11 1 -- 1, 'ER CHECK REQUEST Date Requested: AMOUNT $18,388.50 G/L NUMBER: EXPLANATION: ECHO PAYMENTS OWED FROM GPP RL-QUE-STLI) MAYRA MARTINEZ ALI-fJj(.)ItI7Ff.) BY: 11122/21 FOR ACCT. USE ONLY 1-1 Imprest Cash �A/P Check n Mail Check to Vendor FL-1-Return Check to Dept 0 TUSCANY A _.. __ Givif Cr1I':D" REQUEST Date Requested: 11/22/21 F-- AMOUNT $43,277.00 EXPLANATION: ECHO PAYMENTS OWED FROM GPP Po[!.)UF:iTI:D BY: MAYRA MARTINEZ f�3"•i1rP%r;Mq_ ner -�'M zzF ,'iliflYi � v4Y G/L NUMBER: FOR ACCT. USE ONLY LIrnprest Cash [�A/PCheck D Mail Check to Vendor 7j Return Check to 0epC AU€1-IUi11ZFDBY: Memorial Medical Center Nursing Home UPL Weekly CanteR Transfer Prosperity Acmunt5 11/22/2021 Auwm xuN x•m. x„mM. Pnrwra e•ppiNe Aw ux rn n.ra+ .TremNnln wndNR a a Tea✓r wRxnxe AmrMlluTnwxnrdnx.arM e.Nnn wnn 329,19L]3 329ASl.iL IDS.J91A9 ]O5.>Id.i] 305,636.30 BrnY RLlint! 185.]Ir.T � Wdanm Lavin Bahn[e 1W.W RouNnp Nl ulbnlwR[Alad6e,er,rr, ORIH1fR[ST {623 f/ , XOVIHIfR[]T OF<IXTFRFST atlluw &hneeRransiwRml lYs,6Y.W y AIM � a%1L6rG.9B p/110.196.6] V/3]A5L31 VV 110,310.Ik1 / 98,153.31 Rank Rplan[e 1)0,31000 ✓ Varlan[e 1.ap.auian[e 100.0o AMFMGROUPWOUPP MENWERFPAYMENTTOBFl11RXY 11,181.91 MFDICs Ri REPAYMENTTOMMCDXIC 181.45 ✓/ OCr INTEREST 11.33 / XWINtnuo, DEC011EREST Adlmt ulanwRnmleramt RerU1.R1 6],311.)b ✓ 62,131.6ir�29,O9.]9 ✓ - IFI,569.36 13],3)3.R4 Rank9alance 139.569.34 Virlanrr L.."NllM• View AMENGROUP(ROIPP / MfDIWERIIAYMEMT09El V 11,BR{.91✓ MEDICARE RFPAYMENTTO MIACNMIC IBl.45 f OCr INTFR6fT 10,14 ✓ NWIXIERETT osclrrtFREn Adieu whnreRun+rrrAml fn.1>1.w ./ 36A11.54✓,741.90/ I6,ML25 C6,9ga9 29,K1.50 WA Bdantr I6,H3.09 Vauant! llm Mulmry WpAQ AMMGROUP04QFP 16,971.65 =IN1am 2.74 NOVINTERFST OFCINTEREST AdIVOiluanRRlamler Amt 29,06L60 ti„ �,{ Itlj93.11✓ IW.DF9A3 ✓Y6,9B]TL ✓ ]91,998.89 J 09.331S.12 WkYhnR 111.558.61 VMOnw 1•rreMul.nu 10100 1_s 31idt 3:i9B' AMDRRRCUPDe01" IUi C. �ii- 19I J/ Ij I MFU)FwERAYMEXTFF7oB 1B3.tl1✓/ ? 11�1 y f :i _' � v MEBITARE REPAYMNITTO BETHNiY ll,BB391/ 11�i1 1941 DECINTEIHST IY jl .J Yf .: YIfI(YkP. �9, f '.f-9+[t rl ,{, 3.•:`'p. aalurt 0ahnuRnnt]rrAmt ITP.325.v +%'' .. . _. _ . TMu1RAXfPRIIi 128.911A2 ADPraved: rr C Mxe Gnyb.Nnmtapnr53.0WpmerverX/wxele M<mNMAlmr. Anthony Richardson, CFO 11/221la2i Nwrl: [wReemmt6no6XrbleM[�1fW [apIMMGIepNMlptyrnp0nnf. 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I1/1912w1 UHCMMMVNIWPLN IMPMry1MH1l91WW 1326.16 II/19/1Wl UH[WMM1INI"ILXCfJA1MIMI lIWN]19IO91 ba,}i M}] J0.71N0 IBM1.19 IO11115 _ MMcewtnan III IN ^_kP ? SL+O(t13N jpnilyr30 Cupp/CwnP1 aM/µEnP1 wpPlcnnp3 f4No arpn "ENUCCON ll/IS/2wl UHCWMMUNMPt MCMIMPMi]E6WN31910W L])5.11 1.715.81l 11/35/2WI UNCCOMMUNI"P4KMIMPMT)µWHA9%W 91914 Wlb/3W I MUMAMPINS W XCCUIMIMi3Me63l1aCN9]905 "6iIm - 911.I4 S,t"t. 11/le/2WI NnmMo9p 1%SCMKWMPMTJl6N1PO1111W 021.0" - 3AIDM 11116/2O1 VXCCOMMUHI"PLNCCLCIMPW?] 341191a - µpn.t6 - m.pa's IIIJP2w3 YHC[OMMYNIIYM1XCWIMpMi]g6WN11910i[O L669.30 1.069.10 11/I611031 NOWTKf 50lYipN N[CWMIMIW633011CCWW - $13.39 - 523A9 11/J6NOI MMPMCMIMPMT39W61J1WWO928910d5OATK 1YXOL - 1.410.64 11/17/1WI MPNAPµNONPna MN41MNI WO00K[OWLN3 t1 - 14g65.00 1,40.04) 11/1]/2wl XWUHHVeNN6V<MCC4IMIMT]AMN11i001} I,nB.96 - I:E]I,% 1111611W! [X11P 192.1E 1VNAw1 WIKOYTWN)pIMWTNGflFC[II)LRy III 91,504,28 HAVICUt II,691,00 - Il.P3.W No.lt 1Ulenwl apoO Isnm � e,PaW I1/I1112wl Amnlwoup TKScxCWWrMtNµas)93113M 1516.29 11/ll/1WI NOVRAS SOW"OH M[CWMPMTG1µ1012WW1W - i1;965.39 1.µ 9 11/1112WL CK1196 14PEI )6.9µ.2:]9 ll/19/WI1 C9119VOit" 166.96 - - II/19/1Wl UN - }6P,C0 W19(lwI CIOXq X[[IAIMPML I09]103E5991O001I016]22 CUMOCCOMMeHCfWMPMi191CON / 166930 ]{0A0 I0741641 It4913]6 .r - - 166950 I66.%2i1 TATMS 37JA1536 111266.56. - 618,]6559 11122/2021 Quick View Select Quick View Accounts Account Number/Name Account Type Saarrh All DDA Account Number Current Balance Number of Accounts: 16 $8.624,645.85 '4651 CAL CO INDIGENT 55,572.13 HEALTHCARE '4454 MEMORIAL MEDICAL I $138,033.60 NH GOLDEN CREEK HEALTHCARE '4365 MEMORIAL MEDICAL $535.92 CENTER - CLINIC SERIES 2014 '4357 MEMORIAL MEDICAL 56,287,219.14 CENTER -OPERATING '4373 MEMORIAL MEDICAL $431.46 CENTER . PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICAL $105.744.37 CENTER/NH ASHFORD •4403 MEMORIAL MEDICAL 5110,310.00,j CENTER/NH BROADMOOR '4411 MEMORIAL MEDICAL $129,549.34 ✓ CENTER/NH CRESCENT '4446 MEMORIAL MEDICAL $46.543.89 CENTER/NH FORT BEND '4438 MEMORIAL MEDICAL $191,558,89 CENTER / SOLERA AT WEST HOUSTON '2998 MMC -MONEY MARKET 51,108,86Z88 FUND 'S506 MMC -NH BETHANY $300,187.15 SENIOR LIVING '5441 MMC -NH GULF POINTE $29 252 17 PLAZA- MEDICAREIMEDICAID •5433 MMC -NH GULF POINTE $124.978.68 PLAZA - PRIVATE PAY '3407 MMC -NH TUSGANY $45,861.23 VILLAGE https;//prosperity,olbanking.com/oniineMessenger Treasury Center Select Group Groups Add Group Data reported as of Nov 22, 202 Available Balance Collected Balance Prior Day Balanc $8,992,509.10 $8,624.645.85 $8.293,917.1 55,572.13 $5,572.13 $5,572.1 5192,687.77 $138,033.60 5131,022 c $535.92 5535.92 $535 c 56,385,691.92 56,287,219.14 S6,046,165.9 $431.46 5431.46 5431.4 $108,372,50 5105,744.37 5101,829.E 5129,789.51 $110.310.00 $124,770.5 $172,530.79 5129,549.34 S132,701.E $68,066.67 $46,543.89 $61,394.' 5204,742,08 5191,558.89 $203,947.7 $1.108.867,88 51,108,867.88 51,108,867.E 5309,902.97 $300,167.15 5120,322,3 5101,091.00 $29,252.17 $26,5051 5158,365,27 S124,978.68 $176,125.7 $45,861.23 $45,861.23 $53.703.2 1!1 Memorial Medical Center Nursing Nome UPl Weekly Nezion Transfer Prosperity Accounts 21/22/2021 Preubue Alaount BaUnnlag Pendinz Tadayl Beginning Amount to Be Tnntiemed to Nuning N,,O,g HONIe Norther Bilin[! TfNNIM1O TteMlMn UB tltf mi... N.Nle B1,s93.88 ` 81,4$tV 537,333.09 ✓ - 138,033.W 99,982.32 Bank Boa. 138,033.W j V.,U. Nam OMVb.hW. fo.er$$000 Mllba ba..1Pn U,ffi.m.lpdhame. Now 2: Each amount has base batowe al$1W that MMC depaffiM to open ocmunt. L'IRN Weetly Tnnde..NNN UPI rrUnUr SammrryV42ARawmbU\NH UPLT—PIr%awm, 1.11.11.tln leave M Balame SVPERIOR,14WPP OCTINT8RM NOVINTORM OECINTEREST loom 4BA3BJ7 11.sl Adimt erlenn/GanAer Amt 8*88L32- AWtUWVRirhardmn, ac, Y "Y 11/11/1021 3" MMCPQRVONamel avP/C..A&L xx ,y m,,;u, u� ss IQOli9(4Yi }nxaLHn arv/Capv/Comex are/mmp] .p. appn PORnflx IVH/201115"/ FMT.KCOS]IMTSa3WNsse]691)9 - 2,141.9E 1,1493E 11/ISI/0l1 hhYneMM.ryma[fa[MONf63Na31411{Op, 91.0?9.m 37,181.61 AM" NA)S.n WASI Oil WIM.UT. MXIIGIMRaWIXXCPRN ]I/1p/IOit ppmfl - A.,ils.pl U.3KA1 11/10/1011 D.po.h pp14,0E - tS..,w II/10pO3i RH"X1FI05i 0Nf01ilMl5llpMSiSd>69V9 1.N3.50 ll/19/ta1 HtrHKU fIRWCCHC MPWSUM3411]9 a,s61.15 06I,M - 1]/39/3031 X(Al]MMIIFYxeVC xCCWMrM11M6W14113011E / E,M).1p ..310 ]N3.11 L•CeEJ] 13i,913.09 - )]10I.61 3p391,93 0019]] 09 N1JE 11/22/2021 Quick View Select quick View Accounts Account Number I Name Account Type r Search All DDA Treasury Center Select Group Groups Add Group Data reported as of Nov 22, 202 Account Number Current Balance Available Balance Collected Balance Prior Day Salam: Number of Accounts: 15 $6,624,645.85 $8,992,509.10 $8,624,645.85 $8,293,917,1 •4551 CAL CO INDIGENT 55,572.13 $5,572.13 $5.572.13 $5,572.1 HEALTHCARE '4454 MEMORIAL MEDICAL / NH GOLDEN CREEK $138,033.60 $192,687.77 5138,033.60 S131,0221: HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES $535.92 5535.92 5535.92 5535 c 2014 '4 57 MEMORIAL MEDICAL 56,287,219.14 56,385,691.92 56,267,219A4 56,046,185.E CENTER - OPERATING '4373 MEMORIAL MEDICAL CENTER - PRIVATE $431.46 $431.46 5431.46 5431.4 WAIVER CLEARING '4381 MEMORIAL MEDICAL $105.744.37 5100,372.50 5105,74437 $101,829,E CENTER/NH ASHFORD `4403 MEMORIAL MEDICAL CENTERINH $110.310.00 5129.789.51 $110.310.00 $124,770.: BROADMOOR '4411 MEMORIAL MEDICAL $129,549.34 $172.530.79 $129.549.34 5132,701.0 CENTER INH CRESCENT `4448 MEMORIAL MEDICAL $46,543.89 $68,066.67 $46,543,89 $61,394.1 CENTER/NH FORT BEND '4438 MEMORIAL MEDICAL CENTER !$OLERA AT 5191,558.89 5204,742.08 $191,558.89 $203,947.7 WEST HOUSTON '2998 MMC-MONEY MARKET S1.108,867.88 $1,108,867.88 51,108,867.88 $1,108,86TE FUND 'S506 MMC-NH BETHANY SENIOR LIVING 5300.187.15 $309,902.97 $300,187.15 S120,3222 •5441 MMC -NH GULF POINTE PLAZA- $29,252.17 5101,091.00 $29.252.17 $26,506E MEDICAREIMEDICAID -5433 MMC -NH GULF POINTE PLAZA - PRIVATE PAY $124,978.68 $158,365.27 $124,978.68 $176,125,7 407 MMC-NH TUSCANY VILLAGE $45,861,23 $45,861.23 $45,861,23 $53,703.7 hllps://prosperity.olbanking.com/anlinaMassenger 1/1 Memorial Medical Center Nursing Home UP1 Weekly HMG Transfer Prosperity Accounts 11/22/2021 BrMoua 4nounita 0e lawunt xTlnnlnF pmdir, TnroknWlt MUMn Nome W^Nee W.— Tnndmwt A—F-1. Vulkand w alta Ted aBr Innln BNuw NUNn Nomt 115,013.18 101.Id0.91 llx,Rsa.0 / neple3e - a/ xnxxkna usp)e.6e / Yukon kYavtln xknn 1aB.aD UNR)ENTIFIEO ECHO PAYMt" INO axaWIU OF WRMN F011I140AMDUM VM 3,W14e RHOPAYMEWTOMMC m,R9.Bx✓ MHOPAYMENTTOMSCUY 31.UIS0� ECHO PAYMEMTO MM cUNIC 1.10J0✓/ EOIOPAYMEATTOMFORD 611I0 / ECHO PAYMEM TO BROADMOOR EOEOPAYMFNTTOEOIFRA KHOPAYMNETTOCRESCFM 1,150M MAO✓, ECHOPAYMNUTO001OMDEER p.U5 it k/ NSEANYFIXOIUXpSTNATWiAET REXRFDINFMOR A"i". F,W... Amount Nunl Nomn •'�—`-' R•titlXe kaum W 1m bi EdlPdkk MNi: Non: OHl xlmm 0pro $5.W0 ni0wrronrnned!•fwnunNp home Npltx; FYd1pnCWt Xo)abwebWMM 01$10000 MMedrwr rdW cxlm vRCWt. i:Y(t16W'r��p dIC? 1:\NX WnYNTnnXM\XX Xll innaMSummary\)4)l\HwnnbH\NII BpbinnafnSummlryllSl.11.alu 6UPERWR0CWpp x4.199.59 OCTINTFREST W.C6 NOUINTFREST MCINIFRFR j Adjun xlmo•nnnd•aAmt Yt.Tm.691 S/ Rmevn)1ex whf q,q. Tlwkm! to Tada ex nn xome h. xx•me h91LSM Bank Balenro 19.151.m Wm... W.Wrxlsnte 1w.00 OCr..MUT eu / NWINIEREST CECIxTERESi AdluneWnnnnmkrAmt .15:11£91t � • /// x' V Apmam: Amb•mMixromn. cTO mnTlmm 1 Tnn43erOut 31/l5/]O31 HNB-ECHO HG[UIMPMi ]96Po313I MOPo0269&9 - Wis/9821 G!MP MHwlam6.�/GikOBBTK133¢i!�vitia3 ,. 11/15/1011 HUMANAM 0150 HPIMPMi61a962130000001324 ll/15/1021 HNB-tCH HCMIHCCUIMSON11 824200001321 NXB-fCHOHCMIMPMT746M3111440000221301 IIJI6/2021 I1/16/2021 HUB HA44MM221302 -ECHO HCCMMPMT745MMIZ 11/16/2021 HNB-ECHO HCCUMPMT 74600M1144WPo]31302 III 11/16/2021 NNB-ECHO HCWIMPMT740O3411440 O221302 - 11/16/2021 HMO-CCHOHCCUIMPMT9460094U1 WOOR1301 - 11/16/3031 NNB-ECHOHCCWMPMT)4600M11MW00221302 - 11/16/2021 HNB-ECHOHCGWMPMTT4606M1144W00211301 - Il/12/3921 HNB-EMONCWIMPMT)4WOMI344MM260105 - 11/P/2021 HNB-ECHOHCCIAIMPMT)4W031UMMM160105 I3/17/3021 HXB-ECHO NCCUIMPMi AE00MIlMPoW360105 - 11/I111011 NNB-ECHO HCCUIMPMT 74HO341144W00159369 - 11/lT/2021 HHB-ECHO NCCWMPMT)4W034114400W359369 - 11/lT/1021 HNB-KHOHCCWMPMT2460MI144Po00359369 - I1/ll/1011 HNB-ECHO M[CUIMPMi )4600l4114400W359369 - 11/1J/2021 HUB -ECHO XCCUMPMT - 74003413440000151169 11/1)/3021 HHB- ECHO HCCUIMPMT 14W0311144=0159369 - 1l/lagan HN0-FCNO HCCUIMPMT J4FWMlU4000W59369 - 11118/2W1 5,10.00 W18/3o21 "IND 11,33T.35 "INO CAID36 1,4D.30 IVIO/2021 11/IB/2a21 CH103 ),3W.50 111I8/2021 4,985.50 "1034 111001 CN10 4,914.00 1111812/3021 CR102 0,790.13 11/13/2031 4211Ws 1.59s.00 1U36/21121 PNFfCNO MCCIPIMPMi 74600341141W0119206940 - 11/19/3021 CANYON 2,651.W 11/19/2021 CA1837 4/A71.43 11/19/2021 CXEOH9 12,613.40 11/19/2021 moll 930,07 11/19/1021 HNB- ECHO HCCUIMPMT 246003411 M0000231716 MMCPORTION OIPP/0mP4B, NN Ten_(. fIM OIPP/Camp] OIpP/Comp% OIPp/COmp3 14pn OIPPlI PORTION 107.10 - 102,00 56,798,3T 1305589 U,L2N, 28.099.b 28d,99,Y9 1,403.13 - 1,422.13 2.971.60 2.07140 5,963.40 - 5.963.10 SM.11 514.14 555.13 555.13 784.86 - 784,06 367.35 - 36736 1.100.63 1,250,03 129.15 - I00.63 I,i25.69 - ],115.15 64 14.29 15.68 4,470.45 - 9,4H.29 420.16 - 00,15 6,O27.61 fi3OP,61 139.55 - I39.55 1.127.31 - 3.12181 497.94 - 407.94 203.36 - 203.36 IAW157 18,022.0) 715]5 - 715.75 % 6.440.07 / 644887 10ibB.M ✓ 2R054M �/ 22055,89 M.742.0 M899d9 •/ MAS$.16 MM[POmON OIPp/Cawpb NN I T..NW Out TMAEFB -In 2BPP/Comp% OIPP/COm01 OIPP/C.P3 lPpw OIPPTI PORTION 11/15/2011 WITH HUMAN SVC HCCUIMPMT 1246W341130112 - 186.01 066.01 II/10/ton "Im I4,890.21 11/1012021 WHXOUTHMG SERWCfS,LLC 13,617.37 , 12/14/2021 NPU4 - 25,513.69 ]8,51960 11/19/2021 HEALTH HUMAN WC HCCUIMPMT 1746Po341130132 2.746.25 l 174625 28,508,09 19.145.94 % 29.145M 131.39J,a3 141.0110.31 ans.19 34.742A8 L,B99,39 IM,b130 11/22/2021 Treasury Center Quick View Select Quick View Accounts Select Group Account Number l Name Groups Add Group Account Type Search F All (DDA Data reported as of Nov 22 202 Account Number Current Balance Available Balance Collected Balance Prior Day Balanc Number of Accounts: 15 $6,624,645.85 $8,992,509.10 $8,624,645.85 $8,293,917.1 '4551 CAL CO INDIGENT $5.572.13 $5,572.13 $5,572.13 $5,572.1 HEALTHCARE '4454 MEMORIAL MEDICAL 1 NH GOLDEN CREEK $136.03$.60 S192,68T77 S138.033.60 S131,022.f HEALTHCARE '4365 MEMORIAL MEDICAL CENTER -CLINIC SERIES $535.92 $535.92 $535.92 S535.£ 2014 '4357 MEMORIAL MEDICAL S6,287,219.14 S6,385,691.92 $6,287,219.14 $6,046,185.2 CENTER -OPERATING '4373 'MEMORIAL MEDICAL CENTER - PRIVATE $43146 S431A6 $431.46 S431.4. WAIVER CLEARING •4381 MEMORIAL MEDICAL 5105,744.37 S108,372,50 S105.744.37 $101,829.E CENTER NH ASHFORD `4403 MEMORIAL MEDICAL CENTER/NH S110,310.00 $129,789.51 $110,310.00 S124,770.E BROADMOOR '4411 MEMORIAL MEDICAL $129.549.34 S172,530.79 S129,549.34 S132,701.E CENTER INH CRESCENT '4446 MEMORIAL MEDICAL $46,543.89 $68.066.67 $46,543.89 $61,394.' CENTER/NH FORT BEND 44436 MEISOLERA AT MEDICAL CENTER ER/SO S191,558.89 $204,742,08 $191,558.89 S203,947.7 WEST HOUSTON '2996 MMC-MONEY MARKET S1,108,667.88 $1.108,867.88 $1,108.867,88 S1,108,86TE FUND `5506 MMC NH BETHANY SENIOR LIVING $300.187.15 S309,902A7 $300.187,15 6120,322.1 441 MMC -NH GULF POINTE PLAZA- $29,252.17 S101,091.00 $29.252.17 S26,505.f MEDICAREIMEDICAID '6433 MMC-NH GULF POINTE PLAZA - PRIVATE PAY $124.978.68 $158,365.27 $124,978.68 $178,125.7 '3407 MMC -NH TUSCANY VILLAGE $45,861.23 $45,861.23 $45,861.23 $53,703.7 https://prosperity.oi5enking.cam/anlineMessenger 1/1 Memorial Medical Center Nursing Home UPL Weekly Tuscany Transfer Prosperity Accounts 11/22/2021 Aueuns xwl xnmR n Note: Only bWanrn P)Pvcssepvxdpbncvm/nredm rAenwhpAamr. wea. FncA oaounlM1m a bmr b.W../SEGO Ih.,A#UCdem,W roawn RttaunA ;ILis/Itd�; IldJy -c4i.w"kiIP Amwvrpee u.Nsenre 1p eRne Mann <sA61.11� Vnimre 4m M eNMf INA) ARERPPAYMEWTOMMNHIC 1.1,H y� Adj. BA-n�l am I., .s'SM.T ✓ MMon�y Rl I.N'iwy 6O MMC PORTION gIPP/Compb Transfer -Out Tsansfes-In QIPP/C¢mpi gIPP(Camp2 QIPPjComp3 &laps¢ gIPP i1 NN PORTION i1R5/2021 Molina HCaf T2HCCUIIMPMTPN32757178944200 7.394.36 - 7,394.36 11/15/2021 NOVITAS SOLUTION HCCUeMPMT 676201420000125 - 398.19 - 398.19 11/18/2021 CKI000 192.37 - li/18/2021 WIRE 00 UNBAR ENTERPRISES, LLC 40,525A5 - 11/18/20210eposit 5,707.00 - 5,707.00 11/18/2021 Deposit - 29,118.7] - 29,118.77 li/1912021 CK1078 10,718.45 - - 11/19/2021 CK1079 266.98 - 11/19/2021 NOVTTASSOLUTION HCCIAIMPMT676201420000104 - 232.91 232.91 11/19/2021 KS PLAN AOMINIST HCCIAIMPMT 179111000024252 2,910.00 i 71910.00 51,]02.85 45,]61.M 45,761 3 11122(2021 Treasury Center Quick View Select Quick View Accounts Select Group Account Number l Name Groups Add Group Account Type Seareh All DDA Data reported as of Nov 22 202 Account Number Current Balance Available Balance Collected Balance Prior Day Balanc Number of Accounts: 15 $8,624,645.85 $8,992,509.10 $8,624,645,85 $6,293.917.1 '4551 CAL CO INDIGENT $5,572,13 $5.572.13 $5,572.13 $5,572.1 HEALTHCARE '4454 MEMORIAL MEDICAL I NH GOLDEN CREEK $138.033.60 S192,687.77 $138,033,60 5131,022.E HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES $535.92 $535,92 5535.92 5535 c 2014 '4357 MEMORIAL MEDICAL $6,287,219.14 56,385,691.92 $6.287,219.14 $6,046,185.2 CENTER - OPERATING '4373 MEMORIAL MEDICAL CENTER - PRIVATE $431.45 $431.46 $431.46 $431.4 WAIVER CLEARING '4381 MEMORIAL MEDICAL 5105,744.37 S108.372.50 5105,744.37 $101.829.E CENTER NH ASHFORD •4403 MEMORIAL MEDICAL CENTER/NH 5110,310.00 5129,789.51 $110,310.00 5124.770.E BROADMOOR '4411 MEMORIAL MEDICAL $129.549.34 $172,630.79 $129,549.34 $132,701.E CENTER INH CRESCENT '4446 MEMORIAL MEDICAL $46.543.89 $68,066.67 $46,543.89 561;394.1 CENTER/NH FORT BEND •4438 MEMORIAL MEDICAL CENTER I SOLERA AT 5191,558.89 5204,742.08 5191558.89 5203,947.7 WEST HOUSTON '2998 MMC-MONEY MARKET 51,108,867.88 $1.108.857.88 $1,108.867.88 91,108,867.E FUND •5506 MMC-NH BETHANY 5300,187.15 $309.902.97 5300,187.15 $120,322,-, SENIOR LIVING `5441 MMC •NH GULF POINTE PLAZA. $29252.17 S101,091.00 $29,252.17 526.505.E MEDICAREIMEDICAID 'S433 MMC -NH GULF POINTE $124,978.68 $168,365.27 5124,978.68 $176,125.7 PLAZA -PRIVATE PAY '3407 MMC-NH TUSCANY $45,861.23 ,� $45,861.23 $45,851.23 $53.703.7 VILLAGE r hops:ltprosperityelbanking.comtonllneMessenger ill Memorial Medical Center Nursing Name UPL Weekly MSUransfer Prosperity Accaunts 11/22/2021 rnNnu. i.na... Rm Be Fnoune 6q�Mrin6 Mealnry O.Mc rvumm xnme LM n n.r.om /Tr.nn.an aSti..Ma a. em Tne. le. anm R.w[. M.M...ln xnmin unm. .(+unity. I I6LRL34 16L695J3 ✓300.Ob1 i6 � 900,I5L1$ 0,06fA6 Nnt BSlmu 3W,IR].l9 LeaWr lnveln BShnu IW.W =IH)ex9$T ]$.19 NOVor"Re9T ..��OO666F1:IMR9ST aalxs5e.l.n[.11 Pmt� MA111,76 Nele: MlYOelm[x NarelS$KL wAl6afemilmretlro tM1enwlnp M1wne. lovrmM: � N01lS: FaNa[Sawtdo.odo.ebclannof$IWtM1otMM[dWevSN/roeYen e[uwl. PntAanyRldulMen, 60 11/SS/201I 1 _raT ; a$ f1.+i 'f,1fK11Y f: tlli:"' . 1:1xx WxSlylnmlmµHuxTrmSlerSumm.ryUW lµwnnMrµNNllrannw5ummnry 15A381+1v _ MMC PORTION QIPP/Camp{ Transfer4iut Ton r•I OIPP/Camp! OOP/Cam02 QIPP/Comps 6bpsa OIPP TI NN PORTION 11/15/2021 O.wAt - 1I,53S.W 17,523.00 11/15/2021 Deposit - 47,311.80 - 47,111.90 11/16/2021 Deposit - 3,862.50 3.862.50 11/16/2021 ACCENTCARE INC PAYABLE5999000]6602300W2]e - 51199.31 $'WRA1 11/17/2021 HEALTH HUMAN SVC HCCLAIMPMT 174600UI130162 6,112.79 61]12.]9 1U18/2021 WIRE OUT BETHANY SENIOR UVING, LTD 161,695.71 - - 11/18/2021 Deposit - 20,338.51 - 20,838.51 ll/IW2021 O4pmit 19,94941 - 10,949.01 21/19/2021 DePaA - 1,609.25 - 1,606.25 1]/19/2021 NOVITA$ SOLUTION HCCLAIMPMT 6764814200 0104 }]8,258.59 179,258.59 161,695.71 800,061.36 . / 980,061.T6 11/22/2021 Quick View Select Quick View Accounts Account Number / Name Account Type. Search All Account Number Current Balance Number of Accounts: 15 $8,624,646.85 •4551 CAL CO INDIGENT $5,572.13 HEALTHCARE '4454 MEMORIAL MEDICAL 1 $138,033.60 NH GOLDEN CREEK HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES 2014 •4357 MEMORIAL MEDICAL CENTER -OPERATING '4373 MEMORIAL MEDICAL CENTER - PRIVATE WAIVER CLEARING •4381 MEMORIAL MEDICAL CENTER I NH ASHFORD «4403 MEMORIAL MEDICAL CENTER INH BROADMOOR '4411 MEMORIAL MEDICAL CENTER INH CRESCENT '4446 MEMORIAL MEDICAL CENTER INH FORT BEND '4438 MEMORIAL MEDICAL CENTER I SOLERA AT WEST HOUSTON '2998 MMC -MONEY MARKET FUND *5506 MMC -NH BETHANY SENIOR LIVING 'S441 MMC -NH GULF POINTE PLA2A- MEDICAREIMEDICAID '5433 MMC -NH GULF POINTE PLAZA - PRIVATE PAY '3 07 MMC -NH TUSCANY VILLAGE htips://prosperity.olbanking.com/ontineMessenger 5535.92 56,287,219.14 $431.46 $105,744.37 $110,310,00 5129,549.34 $46,543.89 $191,558.89 51,108,867.88 $300,187.15 $29.252.17 $124,978.68 545,861.23 Treasury Center Select Group Groups Add Group Available Balance $8,992,509.10 $5,572.13 5192,687.77 5535.92 $6,385,691.92 5431A6 5108,372.50 5129,789.51 5172,530.79 $68,066.67 $204,742.08 S1,108,867.88 5309,902,97 S101.091.00 5158,365.27 $45,861.23 Dala reported as of Nov 22, 2D2 Collected Balance $8,624,645.85 $5,572.13 5138,033.60 5535.92 56,287,219.14 5431.46 5105,744,37 5110,310.00 5129,549.34 $46,543.89 $191,558,89 $1,108,867.88 5300,187.15 $29,252.17 $124,978.6B $45,861.23 Prior Day Balanc $8,293,917.1 $5,572.1 5131,022 5535.E 56,046,185.E $431.4 5101,829.E 5124,770.E 5132,701.E $61,394.1 S203,947.7 $1,108,867.E 5120,322.3 $26,505.£ 5176,125.7 $53.703.7 111 FI MEMORIAL MEDICAL CENTER A F. AMOUNT $48,039.77 EXPLANATION: SUPERIOR Q4 QIPP Mayra Martinez FO.,au r.s,m]BY: Vcr IC CHECr REGOEST %_ T N. I Dare Requested: 11/22/21 FOR ACCT. USE ONLY Imprest Cash �A/P Check Mail Check to Vendor Fjfl<_turn Check to Dept GA NUMBER: 10255040 ----------- AUT HORIZEIT BY: I ?Ft t- JI.Ct CALCHN-TRI CHECK R.E:t:: UES-r MEMORIAL MEDICAL CENTER DatF Requested: 11/22/21 _._._____��'."-6-'"tRl.: hEJAIw•A (, "..5ai'�_ii FOR ACCT. USE ONLY 17Imprest Cash I �A/P Check Mail Chcck to Vendor FiReturn Check to Dept AMOUNT $28,399.19 G/L NUMBER: 10255040 EXPLA ,IAl TON: SUPERIOR Q4 QIPP tiLUUFsrf:ri BY MaY ra Martinez AtJ iiRI F. 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