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2024-11-20 Final Packet
NO FICE OF MEETING - 11/1.3/2024 November 13, 2024 MEETING MINUTES OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Joel Behrens Gary Reese Anna Goodman By: Kaddie Smith The subject matter of such meeting is as follows: 1. Call meeting to order. Countyludge Commissioner Pct 1 Commissioner Pct 2 Commissioner Pct 3 Commissioner Pct 4 County Clerk Deputy Clerk Meeting was called to order at loam by Judge Richard Meyer 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. Bill Putnam expressed his concerns with electronic voting machines. Shannon Parker with TDEM explained future grant opportunities and FEMA grant increase for future disasters. Page 1 of 5 NOTICE OF MEETING-11/13/2024 5. Approve November 6, 2024 Commissioners' Court Meeting Minutes. (RHM) RESULT: APPROVEDs[UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct2 SECONDER;, Gary Reese,, Commissioner Pct 4 AYES: Judge Meyer; Commissioner Hall, Lyssy, Behrens, Reese 6. Consider and take necessary action to award qualified bidder on Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction. (GDR) Matt Glaze explained his recommendation. Court agreed to award the bid to Shirley and Sons Construction. RESULT: APPROVED [UNANIMOUS] MOVER Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 7. Consider and take necessary action to authorize utilization of $139,700 of GOMESA funds for the Matagorda Bay Mitigation Trust - Swan Point Bulkhead/Pier Project, Contract No. 034, due to increase of material costs. (GDR) RESULT: APPROVED'[UNANIMOUS] MOVER: David Hall, Commissioner Pct SECONDER: Gary Reese, Commissioner Pct,4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 8. Consider and take necessary action to authorize the use of Jail Telephone Commissioned Funds for the purchase to update the jail body camera system software with server. (RHM) table 9. Consider and take necessary action to authorize all four Road & Bridge precincts to apply for credit with Holt Truck Centers. (GDR) RESULT: APPROVED,[UNANIMOUS]' MOVER: Joel Behrens, Commissioner Pct 3 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 2 of 5 I NOTICE OF MFETING — 1.1/13/2024 10. Consider and take necessary action to award the bids for Insecticides for Mosquito Control, Bid Number 2025.01, for the period January 1, 2025 through December 31, 2025. (RHM) Court approved the award all low bids including the ones drawn for #9'and #10. Bid item #9: 1.) Clarke Mosquito Control Products Inc 2.) Rentokil North America, Inc. dba Target Specialty Products Bid item #10:' 1.) Es Opco USA LLC dba Veseris 2.) Rentokil North America, Inc. dba Target Specialty Products RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens,,,Commissioner Pct 3 AYES:: Judge Meyer, Commissioner Nall, Lyssy, Behrens, Reese 11. Consider and take necessary action to award the bids for Road Materials, Bid Number 2025.02, for the period January 1, 2025 through December 31, 2025. (RHM) Court approved to accept the bids. 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 award the bids for Asphalts, Oils & Emulsions, Bid Number 2025.03, for the period January 1, 2025 through December 31, 2025. (RHM) Court approved to accept the bids. 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 5 NOTICE OF MEET ING—11./13/2024 13. Consider and take necessary action to award the qualified bidder for Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County, Texas. (RHM) Scott Mason explained G&W's recommendation. The court awarded the base bid with owner's option to Rain Seal Master Roofing and Sheet Metal; Inc. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Oct 4 AYES:- Judge Meyer, Commissioner Hall; Lyssy; Behrens, Reese 14. Consider and take necessary action to award the Request for Qualifications for Engineering, Architectural and Surveying Services for the CMP Cycle 29 Grant, GLO Contract No. 25-003- 009-E702 — New Amenities at Bill Sanders County Park, RFQ 2024.11. (RHM) ering`. T: APPROVEDi;[UNANIMOUS] It: Joel Behrens, Commissioner Pct 3 DER: Gary Reese, Commissioner Pct4 Judqe Meyer, Commissioner Hall, Lyssy, Behrens, Re 15. Consider and take necessary action to issue a County credit card to EMS Assistant Director Clint Macek with a credit limit of $5,000. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: VernLyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 16. Consider and take necessary action to lift or retain the county burn ban. (RHM) pass Page 4 of 5 NOTICE OF MEETING - 11/13/2024 17. Accept Monthly Reports from the following County Offices: a) Justice of the Peace Pct 1- October, 2024 b) Justice of the Peace Pct 3 - October, 2024 c) Justice of the Peace Pct 4 - October, 2024 d) Justice of the Peace Pct 5 - October, 2024 e) County Clerk - October, 2024 f) District Clerk - October, 2024 g) County Treasurer - May and July, 2024 h) Sheriffs Department - October, 2024 i) Floodplain Administration - October, 2024 RESULT:" APPROVED [UNANIMOUS] MOVER; Vern Lyssy, Commissioner Pct 2 SECONDER: - David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese' 18. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED[UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: JoelBehrens, Commissioner Pct 3 AYES:` Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 19. Approval of bills and payroll. (RHM) MMC Bills: RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES:' Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County Bills: RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES:'' Judge Meyer,' Commissioner Hall, Lyssy, Behrens, Reese Adjourned 10:30am Page 5 of 5 L— All Agenda Items Properly Numbered V` Contracts Completed and Signed All 1295's Flagged for Acceptance (number of 12951s— }`�W All Documents for Clerk Signature Flagged (All documents needing to be attested to need to be signed day of Commissioner's Court.) On this % � day of 41 l4Ph'I -V /X 2024, the packet for the day of _ 4bWW4J4 kf , 2024 Commissioners' Court Regular Session was submitted from the Calhoun County Judge's office to the Calhoun County Clerk's Office. Calhoun CountyJudge/Assist AGEND 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 OTIcCE OF MEETING The Commissioners' Court of Calhoun County, Texas Nvill meet on Wednesday, November 13, 2024 at 10:00 a.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Finn Street, Suite 104, Port Lavaca, Calhoun County, Texas. AGENDA The subject matter of such meeting is as follows: A,.I " y FILED 1. Call meeting to order. NOV 0 7 20A 2. Invocation. IM r coup By ; i� . uNrr, x,yv : 3. Pledges of Allegiance. 4. General Discussion of Public Matters and Public Participation. 5. Approve November 6, 2024 Commissioners' Court Meeting Minutes. (RHM) 6. Consider and take necessary action to award qualified bidder on Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead &pier Construction. (GDR) 7, Consider and take necessary action to authorize utilization of $139,700 of GOMESA funds for the Matagorda Bay Mitigation Trust - Swan Point Bulkhead/Pier Project, Contract No. 034, due to increaseof material costs. (GDR) 8. Consider and take necessary action to authorize the use of Jail Telephone Commissioned Funds for the purchase to update the jail body camera system software with server. (RHM) 9. Consider and take necessary action to authorize all four Road & Bridge precincts to apply for credit with Holt Truck Centers, (GDR) 10. Consider and take necessary action to award the bids for Insecticides for Mosquito Control, Bid Number 2025.01, for the period January 1, 2025 through December 31, 2025. (RHM) 11. Consider and take necessary action to award the bids for Road Materials, Bid Number 2025.02, for the period January 1, 2025 through December 31, 2025. (RHM) Page 7 of 2 12. Consider and take necessary action to award the bids for Asphalts, Oils & Emulsions, Bid Number 2025.03, for the period January 1, 2025 through December 31, 2025. (RHM) 13. Consider and take necessary action to award the qualified bidder for Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County, Texas. (RHM) 14. Consider and take necessary action to award the Request for Qualifications for Engineering, Architectural and Surveying Services for the CMP Cycle 29 Grant, GLO Contract No. 25-003- 009-E702 — New Amenities at Bill Sanders County Park, RFQ 2024.11. (RHM) 15. Consider and take necessary action to issue a County credit card to EMS Assistant Director Clint Macek with a credit limit of $5,000. (RHM) 16. Consider and take necessary action to lift or retain the county burn ban. (RHM) 17. Accept Monthly Reports from the following County Offices; a) Justice of the Peace Pct 1— October, 2024 accepted b) Justice of the Peace Pct 3 — October, 2024 c) Justice of the Peace PCt 4 — October, 2024 d) Justice of the Peace Pct 5 — October, 2024 e) County Clerk — October, 2024 f) District Clerk — October, 2024 g) County Treasurer — May and July, 2024 h) Sheriff's Department — October, 2024 i) Floodplain Administration — October, 2024 18. Consider and take necessary action on any necessary budget adjustments. (RHM) 19. Approval of bills and payroll. (RHM) i r Richard H. Meyer, County Judge Calhoun County, Texas A copy of this Notice has been placed on the inside bulletin board of the Calhoun County Courthouse, 211 South Ann Street, Port Lavaca, Texas, which is readily accessible to the general public during regular business hours. This Notice shall remain posted continuously for at least 72 hourspreceding the scheduled meeting time. For your convenience, you may visit the county's website at www.caihouacotx.ora under "Commissioners' Court Agenda" for any official court postings. Page 2 of 2 NOTICE OF MEETING— 11/13/2024 November 13, 2024 MEETING MINUTES OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Joel Behrens Gary Reese Anna Goodman By: Kaddie Smith The subject matter of such meeting is as follows: 1. Call meeting to order. CountyJudge Commissioner Pct 1 Commissioner Pct 2 Commissioner Pct 3 Commissioner Pct 4 County Clerk Deputy Clerk Meeting was called to order at loam by Judge Richard Meyer 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. Bill Putnam expressed his concerns with electronic voting machines. Shannon Parker with TDEM explained future grant opportunities and FEMA grant increase for future disasters. Page 1 of 16 Calhoun County Commissioners Court Public Participation Form NOTE: This Public Participation Form must be presented to the County Clerk or Deputy Clerk prior to the time the agenda item (or items) Vou wish to address are discussed before the Court. Instructions: NAME: ADDRESS: 7 TELEPHONE: out all appropriate blanks. Please print or write legibly. PLACE OF EMPLOYMENT: /"vrl ` EMPLOYMENT TELEPHONE: Do you represent any particular group or organization? & NO (Circle one) If you do represent a group or organization, please provide the name, address and telephone Which agenda item (or items) do you wish to address? 7 -72 . Z- 1q( � In general, are you for or against the agenda item (or items)? I hereby swear that any statement 1 make will be the truth, and nothing but the truth, to the best of my knowledge and ability. Signature: Calhoun County Commissioners Court Public Participation Form NOTE: This Public Participation Form must be presented to the CountV Clerk or Deputy Clerk prior to the time the agenda item (or items) Vou wish to address are discussed before the Court. Instructions: Fill out all ate blanks. Please print or write legibly. �X- TELEPHONE: -�)�p\ --&J V —(D u, D PLACE OF EMPLOYMENT: EMPLOYMENT TELEPHONE: Do you represent any particular group or organization? YE NO (Circle one) V1 If you do represent a group or organization, please provide the name, address and telephone number of the group or organization: Which agenda item (or items) do you wish to a In general, are you for or against the agenda item (or items)? I hereby swear that any statement 1 make will be the truth, and nothing but the truth, to the best of my knowledge and ability. , Signature: # 05 NOTICE OF MEETING — 11/13/2024 5. Approve November 6, 2024 Commissioners' Court Meeting Minutes. (RHM) Page 2 of 16 NOTICE OF MEETING — 11/6/2024 Richard ]H . Meyer County judge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Clyde Syma, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 6, 2024, 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. Z&Lt:N�-� Richard Meyer, CoruAty Judge Calhoun County, Texas Anna Goodman, County Clerk Page 1 of 1 NOTICE OF MEETING—11/06/2024 November 6, 2024 MEETING MINUTES 9t�°'C OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Joel Behrens Gary Reese Anna Goodman By: Kaddie Smith The subject matter of such meeting is as follows: 1. Call meeting to order. County3udge Commissioner Pct 1 Commissioner Pct 2 Commissioner Pct 3 Commissioner Pct 4 County Clerk Deputy Clerk Meeting was called to order at loam by Judge Richard Meyer 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. n/a Page 1 of 4 NOTICE OF MEETING—11/06/2024 S. Approve October 30, 2024 Commissioners' Court Meeting Minutes. (RHM) RESULT APPROVED,[UNANIMOUS] MOVER. Vern Lyssy, Commissioner Pitt 2; SECO_ND£R; Gary Reese, Commissioner Pct 4 AYES: Judge Meyer;; Commissioner Hall, Lyssy;: Behrens„Reese 6. Consider and take necessary action to authorize the use of Jail Telephone Commissioned Funds for the purchase to update the jail body camera system software with server. (RHM) 7. Consider and take necessary action to authorize utilization of an additional $7,440 of GOMESA funds, due to increased environmental work, for the county match for CEPRA 1730 - Boggy Bayou Nature Park Shoreline Protection Phase 2 for budget increase amendment. (GDR) RESULT' APPROVED [UNANIMOUS]` MOVER Vern' Lyssy, Cprnmissioner Pct 2 �3ECONDER� David }salt, Commissioner Pct 1` AYES ;= 7udge Meyer, Corrimissloner 0011, L yssy; Behrens Reese 8. Consider and take necessary action to accept payment from GLO for 2024 Bilge Facilities in the amount of $1,000 and have placed in Precinct 4 Road & Bridge line item 1000-570-53S 10-999, Road & Bridge Supplies. (GDR) RESULT. APPROVED'[UNANIMOUS] MOi/EfR� Joef Behrens; Commissioner Pct -1 SECONDEi David Hallj. C mmissioner Pct 1 `„ AYES: 7udge Meyer,'.Comrnissit�her Hall; Lyssy, Behr- 2ns, Reese 9. Consider and take necessary action to accept anonymous donation to the Sheriff's Office to be deposited into the Motivation account (2697-001-49082-679) in the amount of $75.00. (RHM) RESULT APPR(fYED`NNANIMOUS] MOVER Vern Lyssy, Commissioner Pct . . SECONDER; laeI Behrens;: Commissioner Pct 3 =- s, AYES: Judge Meyer;;.CommiSSoner Hall, Lyssy, Behrens, Reese Page 2 of 4 I NOTICE OF MEETING—11/06/2.024 10. Consider and take necessary action to allow Commissioner Hall to complete and sign the Nucor Skyline Credit application. (DEH) RESULT APPROVED;[ UNANIMOUS] fpVERri�ryReese, Commissioner Pct 4 SE�ON[�ER' David Hall ,.Gommissianer Pct 1 AYES:' Judge Meyer;,;Comrniesoner Hall; Lyssy,'Behrens, `Reese .:.:. 11. Consider and take necessary action to approve the renewal Agreement between Calhoun County Justice of the Peace Pct. 3 and Sparklight and have Judge Dimak sign the agreement. (RHM) RESULT ApPROVED'UNANIMOUS]777 IGIOVR. Vern _Lyssy, Gorriitiisslgner Ptf 2 SECONDER _-. David Hall, CommiSsoner Pct 1 dYE$ Judge Meyer, Commissioner`Hall, Lyssy,-;Behrens, Reese 12. Accept Monthly Reports from the following County Offices: I. Texas Agrilife Extension Service — October, 2024 a. 4-H and Youth Development b. Agriculture and Nature Resources c. Family and Community Health d. Coastal and Marine RESULT. ,' APPROVED:;[UNANLMOUS]. rNOVER` - Vern Lyssy, Commissioner Pct 2 SECONDER:::: Qavitl Hall;'CommissionerPct 1 , AYES: Judge Meyer,.Commis_ one'f.HaIILyssyf Behrens,'Reese 13. Consider and take necessary action on any necessary budget adjustments. (RHM) Page 3 of 4 NOTICE OF MEETING— 11/06/2024 MMC Bills 7777 RESUL,T APPROVED [UNANIMOUS] -; MOVER Dey�d Hall, Cornmissloner Pet 1 SEQQ7VD�R. Vern LYssy, Commissioner Pit°2 AYES: Judge NCeyer,C9111miSsioner Hall, Lissy, Behrens, Reese Adjourned 10:25am Page 4 of 4 # 06 I NOTICE OF MEETING— 11/13/2024 6. Consider and take necessary action to award qualified bidder on Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction. (GDR) Page 3 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 October 31, 2024 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 13, 2024. • Consider and take necessary action to award qualified bidder on Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction. Sincerely, GaA.eese GDR/at P.O. Box 177 — Seadrift. Texas 77983 —email; aarv.reese( eaalhouncom.uru — (361) 785-3141— Fax (361) 785-5602 ♦�V RBAN e n g i n e e r i n g October 31, 2024 The Honorable Richard H. Meyer, Calhoun County Judge Calhoun County Courthouse 211 South Ann Street, 31 Floor, Suite 301 Port Lavaca, TX 77979 RE: Recommendation of Award U.E. Job No. E25470.00 Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction Seadrift, Texas Dear Judge Meyer: On October 10, 2024 at 2:00:00 p.m., public bids were opened forthe Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction. The following bids were received: Bidder Total Base Bid Calendar Days to Substantial Completion 304 Construction, LLC Incomplete Shirley& Sons Construction Co., Inc. $591,200.00 90 Shoreline Contractors, LLC $804,983.70 160 Derrick Construction Company, Inc. $1,561,569.00 180 Shirley & Sons Construction Co., Inc. submitted the lowest bid and stated a completion time of 90 calendar days. I recommend that the contract for the aforementioned project be awarded to Shirley & Sons Construction Co., Inc. for the Total Base Bid. (See attached Bid Tabulation) 304 Construction, LLC did not have an active registration with the System for Award Management. Therefore, their bid was determined to be incomplete. If you have any questions, please do not hesitate to contact me at (361) 578-9836 or by email at malaze(a)urbanvictoria. com. Sincerely, Matt A. Glaze, P.E. Vice President MAG/dmf Attachment 2004 N. COMMERCE, VICTORIA, TX 77901 • 361.578.9836 • URBANVICTORIA.COM • TREF# F-160 ...,.. .,■ - ��§�,m�,���. |(r«7|[|§\�.|!|!■||�E«|;�|■;'°` |�!!•!! !!!!E|!§ |3 |2 | /`) § ! ■|r ( (k�P; � \ 21 k 0k�§� \§ z■ §Jk #�8�..�,�...�� ■; ; -;!®a■q �p2 �§§!§/#§)§§§§§§ �.i3 )§§ ! _ |;,a■��;,..�..,e �■, 4 !� §)§!;4§!■4,§■ )§ § In - ■4■��o;�;.��- .. ■ ,,...�,2. .. fit ■§(\§§/4N■§§§§■$§§ i - ;a........;;o99- ■89 ■ ;k .............. ,. . § _ t§§,k§§!■;,§\) i§ §E! 7 w■■�;;...����, ■� ... ........,, §) ) |§/) § -� ! |,,.-...8..8..8 ■;. . SneotYlq\e'EiA BID SUBMITTED BY: =��'i5 �.�(',7''J®� BID OPENING: 2:00:00 PM, THURSDAY, OCTOBER 10, 2024 Bid Submittal Checklist (Submit one original and three copies of the following items): ❑ Bid Form ❑ Bid Security ❑ Schedule of Proposed Subcontractors ❑ Statement of Bidder's Qualifications ❑ Affidavit ❑ Conflict of Interest Questionnaire Form CIQ ❑ Certification Regarding Debarment & Suspension and Other Responsibility Matters ❑ Certification Regarding Lobbying ❑ Disclosure of Lobbying Activities and Instructions ❑ House Bill 89 Verification ❑ Residence Certification ❑ System for Award Management (Print out of search results) ❑ W-9 General Conditions for Calhoun County, Texas A copy of the General Conditions for Calhoun County, Texas is attached for reference and will also be included in the Project Manual in Section 00810. BID PACKAGE FOR BID NO. 2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION SEADRIFT, TEXAS PREPARED BY: URBAN ENGINEERING TREF# F-160 CONSULTING ENGINEERS 2004 N. COMMERCE ST. VICTORIA, TEXAS 77901-5510 U.E. JOB NO. E25470.00 f 101&1c7i41 PROJECT IDENTIFICATION: Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction Seadrift, Texas CONTRACT IDENTIFICATION AND NUMBER: Bid No. 2024.09 THIS BID IS SUBMITTED TO The Honorable Richard H. Meyer, Calhoun County Judge Calhoun County Courthouse 211 S. Ann Street, Suite 301 Port Lavaca, Texas 77979 1.01 The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an Agreement with OWNER in the form included in the Bidding Documents to perform all Work as specified or indicated in the Bidding Documents for the prices and within the times indicated in this Bid and in accordance with the other terms and conditions of the Bidding Documents. 2.01 Bidder accepts all of the terms and conditions of the Advertisement or Invitation to Bid and Instructions to Bidders, including without limitation those dealing with the disposition of Bid security. The Bid will remain subject to acceptance for 60 days after the Bid opening, or for such longer period of time that Bidder may agree to in writing upon request of OWNER. 3.01 In submitting this Bid, Bidder represents, as set forth in the Agreement, that: A. Bidder has examined and carefully studied the Bidding Documents, the other related data identified in the Bidding Documents, and the following Addenda, receipt of which is hereby acknowledged. Addendum No. Addendum Date B. Bidder has visited the Site and become familiar with and is satisfied as to the general, local and Site conditions that may affect cost, progress, and performance of the Work. C. Bidder is familiar with and is satisfied as to all federal, state and local Laws and Regulations that may affect cost, progress, and performance of the Work. D. Bidder has carefully studied all: (1) reports of explorations and tests of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the Site (except Underground Facilities) which have been identified in the Supplementary Conditions as provided in paragraph 4.02 of the General Conditions, and (2) reports and drawings of a Hazardous Environmental Condition, if any, which has been identified in the Supplementary Conditions as provided in paragraph 4.06 of the General Conditions. E. Bidder has obtained and carefully studied (or assumes responsibility for having done so) all additional or supplementary examinations, investigations, explorations, tests, studies and data concerning conditions (surface, subsurface and Underground Facilities) at or contiguous to the Site which may affect cost, progress, or performance of the Work or which relate to any aspect of the means, methods, techniques, sequences, and procedures of construction to be employed by Bidder, including applying the E25470.00- Bid Form 08/24 00410 - 1 specific means, methods, techniques, sequences, and procedures of construction expressly required by the Bidding Documents to be employed by Bidder, and safety precautions and programs incident thereto. F. Bidder does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the determination of this Bid for performance of the Work at the price(s) bid and within the times and in accordance with the other terms and conditions of the Bidding Documents. G. Bidder is aware of the general nature of work to be performed by OWNER and others at the Site that relates to the Work as indicated in the Bidding Documents. H. Bidder has correlated the information known to Bidder, information and observations obtained from visits to the Site, reports and drawings identified in the Bidding Documents, and all additional examinations, investigations, explorations, tests, studies, and data with the Bidding Documents. I. Bidder has given ENGINEER written notice of all conflicts, errors, ambiguities, or discrepancies that Bidder has discovered in the Bidding Documents, and the written resolution thereof by ENGINEER is acceptable to Bidder. J. The Bidding Documents are generally sufficient to indicate and convey understanding of all terms and conditions for the performance of the Work for which this Bid is submitted. 4.01 Bidder further represents that this Bid is genuine and not made in the interest of or on behalf of any undisclosed individual or entity and is not submitted in conformity with any agreement or rules of any group, association, organization or corporation; Bidder has not directly or indirectly induced or solicited any other Bidder to submit a false or sham Bid; Bidder has not solicited or induced any individual or entity to refrain from bidding; and Bidder has not sought by collusion to obtain for itself any advantage over any other Bidder or over OWNER. 5.01 Bidder will complete the Work in accordance with the Contract Documents for the price(s) on the following page(s): E25470.00- Bid Form 08124 00410 - 2 BID NO.2024.09 - CALHOUN COUNTY BILL SANDERS PARK -SWAN POINT BULKHEAD & PIER CONSTRUCTION (BIDDER) PREPARED BY: URBAN ENGINEERING ITEM NO. DESCRIPTION ESTIMATED QUANTITY UNIT UNIT PRICE TOTAL PRICE BASE BID GENERAL 1. Mobilization, Insurance and Bonds (Maximum 10%of Base Bid) 1 L$ $ L�5 9V0 $ c%�oaa 2. Barricading & Traffic Control (Furnish, Install, Maintain & Remove Signs & Warning Devices) (Includes Flagmen, Traffic Handling, Traffic Control Plan & Temporary Striping) 1 LS $ 5-00 o _ $ 00 a '" 3. Construction Staking 1 LS $ Ooc, $ ouu '- SUBTOTAL GENERAL $ IMPROVEMENTS Timber Pier 1 LS $ i0 �%�00 ' $ v02 uJ k. N Un I Bulkhead 336 LF $ 0 a $ k DC7 0Fish Cleanin Station 1 LS $ 000 $Bulkhead Cap 1,100 SF $ 20 $ Z2, 000 - 8. Concrete Sidewalk 590 SF $ ZO $ //7 S-0,5 " 9. ADA Parking 340 SF $ 2 O $ (" $ 8a ` 10. Curb Stop 1 EA $ 2a O - $ 2-d o 11. ADA Parking Sin 1 EA $ loom $ /d 00 " 12. ADA Striping 1 LS $ 2000 - $ z oao 13. Water Main It"Sch 40) 320 LF $ 1-1 $ 12" 14. Hose Bib 3 EA $ 200 '- $ C000 15. Remove & Install New Electrical Panel 1 LS $ 7JaJ - $ J l 00& 16. Pier Conduit& Wire 1 LS $ o0 0 " " Ovr, $ .Z3- 17. Fishing Light Green LED) 6 EA $ a -" $ ,^t, `Jp 000-- SUBTOTAL IMPROVEMENTS $ TOTAL BASE BID $ Unit Prices have been computed in accordance with paragraph 11.03.B of the General Conditions. Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities provided, determined as provided in the Contract Documents. E25470.00 - Bid Farts 08/24 00410 - 3 It is the intent of the OWNER to award a Contract for all work items and quantities listed on the Bid Form. In the event that the low Bid submitted by a qualified Bidder exceed the funds budgeted for this Project, the OWNER reserves the right to reduce the scope of the work so that the Project can be completed within the budgeted amount; this may be done by eliminating any or all parts of the Project. The Bidder hereby agrees to maintain the unit prices shown on the Bid Form should this reduction in the scope of the work be necessary. 6.01 Bidder agrees that the Work will be substantially complete within 60 calendar days (TO BE FILLED IN BY BIDDER) after the date when the Contract Times commence to run as provided in paragraph 2.03 of the General Conditions, and completed and ready for final payment in accordance with paragraph 14.07 of the General Conditions within 14 calendar days after the date of substantial completion. 6.02 Bidder accepts the provisions of the Agreement as to liquidated damages in the event of failure to complete the Work within the times specified above, which shall be stated in the Agreement. 7.01 The following document(s) are attached to and made a condition of this Bid: A. Required Bid Security in the form of iJroO (specify type of Bid Security: Bond, Cashier's Check, Certified Check); B. Schedule of Proposed Subcontractors to be identified in this Bid; C. Statement of Bidder's Qualifications with supporting data; D. Affidavit; E. Conflict of Interest Questionnaire Form CIQ; F. Certification Regarding Debarment & Suspension and Other Responsibility Matters; G. Certification Regarding Lobbying; H. Disclosure of Lobbying Activities and Instructions; I. House Bill 89 Verification; J. Residence Certification; K. System for Award Management (Print out of search results); L. W-9. 8.01 The terms used in this Bid with initial capital letters have the meanings indicated in the Instructions to Bidders, the General Conditions, and the Supplementary Conditions. �ti SUBMITTED on 0 L�jicr %r� Z`,, 2 State Contractor License No. . (If applicable) E25470.00 - Bid Form 08124 00410 - 4 If Bidder is: An Individual Name (typed or printed): By: Doing business as Business address: Phone No.: A Partnership Partnership Name: By: (Individual's signature) FAX No.: (Signature of general partner -- attach evidence of authority to sign) Name (typed or printed): Business address: Phone No.: A Corporation FAX No.: (SEAL) Corporation Name: Soy C onS—WtAc.'l'1oy'l (SEAL) State of Incorporation: n S Type (General Business, Professional, Service, Limited Liability): L r �c L abil' Y Umpctn By: -� \ J (Signature -- attach evidence of authority to sign) Name (typed or printed): _ M C m MtAi1 c Title: SUPe� /1sf>� (CORPORATE SEAL) (Signature of Corporate Secretary) Business address: Phone No.: 5' ? 1 i Y) - 1 zoo FAX No.: Date of Qualification to do business is V f-jC) C(A (a I'1 A 2.0 0 -3- E25470.00 - Bld Form 08/24 00410 - 5 A Joint Venture Joint Venturer Name: By: (Signal Name (typed or printed): Title: Business address: Phone No.: Joint Venturer Name: of joint venture partner -- attach evidence of authority to sign) I 0 By: (Signature -- attach evidence of authority to sign) Name (typed or printed): Title: Business address: Phone No.: yAMIRM Phone and FAX Number, and Address for receipt of official communications: (SEAL) (SEAL) (Each joint venturer must sign. The manner of signing for each individual, partnership, and corporation that is a party to the joint venture should be in the manner indicated above.) E25470.00- Bid Form 08124 00410 - 6 PENAL SUM FORM BID BOND BIDDER (Name and Address): SURETY (Name and Address of Principal Place of Business): OWNER (Name and Address): BID BID DUE DATE: PROJECT (Brief Description Including Location): BOND BOND NUMBER: DATE (Not later than Bid due date): PENAL SUM: (Words) (Figures) IN WITNESS WHEREOF, Surety and Bidder, intending to be legally bound hereby, subject to the terms printed on the reverse side hereof, do each cause this Bid Bond to be duly executed on its behalf by its authorized officer, agent, or representative. Bidder's Name and Corporate Seal 0 Signature and Title SURETY Surety's Name and Corporate Seal Signature and Title (Attach Power of Attorney) Attest: Attest: Signature and Title Signature and Title Note: (1) Above addresses are to be used for giving required notice. (2) Any singular reference to Bidder, Surety, OWNER or other party shall be considered plural where applicable. EJCDC NO. 1910-28-C (1996 Edition) E25470.00 - Bid Bond 0804 00430 - 1 PENAL SUM FORM 1. Bidder and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to pay to OWNER upon default of Bidder the penal sum set forth on the face of this Bond. 2. Default of Bidder shall occur upon the failure of Bidder to deliver within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents. 3. This obligation shall be null and void if: 3.1.OWNER accepts Bidder's Bid and Bidder delivers within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents, or 3.2.All Bids are rejected by OWNER, or 3.3.OWNER fails to issue a Notice of Award to Bidder within the time specified in the Bidding Documents (or any extension thereof agreed to in writing by Bidder and, if applicable, consented to by Surety when required by paragraph 5 hereof). 4. Payment under this Bond will be due and payable upon default by Bidder and within 30 calendar days after receipt by Bidder and Surety of written notice of default from OWNER, which notice will be given with reasonable promptness, identifying this Bond and the Project and including a statement of the amount due. 5. Surety waives notice of and any and all defenses based on or arising out of any time extension to issue Notice of Award agreed to in writing by OWNER and Bidder, provided that the total time for issuing Notice of Award including extensions shall not in the aggregate exceed 120 days from Bid due date without Surety's written consent. 6. No suit or action shall be commenced under this Bond prior to 30 calendar days after the notice of default required in paragraph 4 above is received by Bidder and Surety and in no case later than one year after Bid due date. 7. Any suit or action under this Bond shall be commenced only in a court of competent EJCDC NO. 1910-28-C (1996 Edition) E25470.00 - Bid Bond 08124 jurisdiction located in the state in which the Project is located. 8. Notices required hereunder shall be in writing and sent to Bidder and Surety at their respective addresses shown on the face of this Bond. Such notices may be sent by personal delivery, commercial courier or by United States Registered or Certified Mail, return receipt requested, postage pre -paid, and shall be deemed to be effective upon receipt by the party concerned. 9. Surety shall cause to be attached to this Bond a current and effective Power of Attorney evidencing the authority of the officer, agent or representative who executed this Bond on behalf of Surety to execute, seal and deliver such Bond and bind the Surety thereby. 10. This Bond is intended to conform to all applicable statutory requirements. Any applicable requirement of any applicable statute that has been omitted from this Bond shall be deemed to be included herein as if set forth at length. If any provision of this Bond conflicts with any applicable statute, then the provision of said statute shall govern and the remainder of this Bond that is not in conflict therewith shall continue in full force and effect. 11. The term "Bid" as used herein includes a Bid, offer or proposal as applicable. 00430 - 2 SCHEDULE OF PROPOSED SUBCONTRACTORS Bidder proposes the following subcontractors to be used for major portions of the Project. All major subcontractors must be listed and submitted with the Bid. Bidder may change subcontractors after Bid submittal only as approved by the Engineer. Major subcontractors are those who will do work having a total value of more than five percent (5%) of the Contract amount. The maximum total value of work performed by all subcontractors on the Project shall not exceed seventy-five percent (75%) of the Contract amount. Subcontractor Address & Telephone Number Speciality Subcontract Amount 1- i 3o'I 7%6-V,3 VI 7J✓/NI ZSU �a 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. E25470.00 - Schedule of Proposed Subcontractors 08124 00430 - 3 STATEMENT OF BIDDER'S QUALIFICATIONS All questions must be answered and the data given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he desires. Name of Bidder: JU V' V Address: aRF) �m (�1l' 1-01 ("ZACK-� -� IX. 19)(012, Date Organized: �Z� �' Date Incorporated: Number of years in contracting business under present name: I )X n (S CONTRACTS ON HAND: Contract Dollar Amount Completion Date Type of work performed by your company: 6unC-1-0JL C %� i I5, i3i1Ml rc.� Have you ever failed to complete any work awarded to you? 4-1) Have you ever defaulted on a contract? List the projects most recently completed by your firm (include projects of similar importance): Project C1,11 �/ 445�r102 how) - Lam, k1- Dollar Amount Mo/Yr Completed av, o 0a 00 E25470.00 - Statement of Bidder's Qualifications 08/24 00450 - 1 z Zt-� Major equipment available for this contract: 7 fenc/n �✓ /LI "S e l)cr..a Tya / 5 Executed this _� day of d L+do r y- 2-0 Z�. By -tr.-U l v�M t� �J�ts.P_ Adr thi,�-cafov, (Signature) (Title) VOrh C. MfU ttn (Print Name) State of O1S County of P rSworn to and subscribed before me this 0 day of "'• ASHLEYANN HANSON otary Signatu e My Notary ID # 132236098 °'.', oF:,<,'•' Expires November 1, 2027 — Printed Nalne -� In and for the State of (' Commission Expires E25470.00 - Statement of Bidder's QualifcaWns oai24 00450 - 2 STATE OF TEXAS {} AFFIDAVIT COUNTY OF �S�� �_ {} being first duly sworn, deposes and says: that he or she is (Type or Print Name) the l`ikl a-hrAnS VA rr Pik of JoH C�-t oA cvI" having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at_]b 5 i--:m 2 c1 CldGv' c+.e-e V_ %'7 '%Q?-ut-% (Type or Print Physical and Mailing who submits herewith to Calhoun County the attached bid/proposal; that he orshe is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that priorto the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. y Signature ant Opeoh»r15 M�Irt O 26� Printed Name and Title of Affiant 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 8111)— day of 0c,43Ia?? -- 20orl�_. 'il �;�"""•�'����ASHLEYANN HANSON c * My Notary ID # 132236098 :'`rcr; ��*.•`• Expires November 1, 2027 Notary tamp ea 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. jJ Name of vendor who has a business relationship with local governmental entity. C.d,�sJ•�„��id., L,L� 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.) 2J 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? F1Yes ENo B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? F1 Yes EZ/No s 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 Zo Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity A complete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.logis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code & 176.0010-a): 'Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code S 176.006(a) and (a-1) (a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021 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. K GVC, Waft, / ma, mmi n istr4or 2 o L Name and Title of Authorized Agent ate tti� S 'Anature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may retain for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Filial regulations shall be published within twelve months of the date of the guidelines. See. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. See. S. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. See. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. 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," 3bq �nc��i��s dr affirms the truthfulness and accuracy of each statement of its certifi ation 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 Contractors Authorized Official l dpm Mowth / Con"Of-or JUP-e✓v116r Printed Name and Title ofContractor's Authorized Official roI II 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 b. grant a. bid/offer/application b. initial award //�� a. initial filing J`7 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 N 4. me 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, ifapp/icable: 8. Federal Action Number, if known: 9. Award Amount, (known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address it" (if individual, last name, first name, MI): differentfront 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: f et'�"t'l by the tier above when this transaction was made or 11 entered into. This disclosure is required pursuant to 31 Title:ly. r -/2 t/ 16 Zate: U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: - Z*- /o 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) INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85`h Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) ��i� MeLA+V),doherebyverifythe truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/`divestment.php 30 Company Name Signature of Authorized Official Printed Name of Authorized Official Title of Authorized Official Date 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) 2 1 certify that ��q CbV1S (j C_IOn Ld. is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of A thorized Agent (`Strzt�"�r Printed Name and Title of Date INSERT SYSTEM FOR AWARD MANAGEMENT (SAM) RECORD SEARCH FOR COMPANY AND COMPANY'S PRINCIPAL(S) • Company, Corporation, Firm or Partnership, and its Principals, must not be debarred or suspended nor otherwise on the Excluded Parties List System (EPLS) in the System for Award Management (SAM) or the State of Texas Comptroller Debarred Vendor List and must have an active registration with the System for Award Management (www.SAM.gov). Include verification that your Company, Corporation, Firm or Partnership is registered and that the Company, Corporation, Firm or Partnership, and its Principals, are not listed (are not debarred) through the System for Award Management (www.SAM.gov). Include a printout of the search results that includes the required information and the record date. M. An official website ofthe United States government Here's how you know 00 Home Search Data Bank Data Services Help Account Details Saved Searches AM Adam Meuth Roles Followed Records admin@304construction.com Email Settings c®� Pending Requests o No available requests Notifications No available notifications Entity Information Reference Services Request Role �aimrr.22a;NRPNLI:`I.�`. ,'NIM Entity Information Entities See AU i600 0� Active ID Inactive Pending ID Work in Progress Submitted Registration Assigned Registration Assignment Registration Registration No Active Registrations Register Your Entity or Get a Unique Entity ID What do I need for registration? Get Started Reference Services System Accounts See All Renew/Update Your Entities Select Renew/Update to go to your entity workspace and renew/update your entities. How to renew or update an entity Renew/Update a 0 0 0 0 0 0 0 Active Draft Change Request Pending Deactivated Request A Role Select on the options below to request a new role. If you need a role that you do not see below, contact an administrator for your organization directly. Select a Role I verify I have a business need for this role. Request Role Feedback Our Website Our Partners About This Site Acquisition.gov Our Community USASpending.gov Release Notes Grants.gov System Alerts More Partners Policies Customer Service Terms of Use Help Privacy Policy Check Entity Status Restricted Data Use Federal Service Desk Freedom of Information Act External Resources Accessibility Contact 0 WARNING This is a U.S. Genera( Services Administration Federal Government computer system that is "FOR . OFFICIAL USE ONLY." This system is subject to monitoring. Individuals found performing unauthorized activities are subject to disciplinary action including criminal prosecution. This system contains Controlled Unclassified Information (CUI). All individua Is viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part 2002 and GSA Order CIO 2103.2 CUI Policy. SM e0v An official website of the U.S. General Services Administration W-9 Request for Taxpayer Give Form Form (Rev. October 2018) Identification Number and Certification to the requester. Do not Department of the Treasury Internal Revenue Service ► Go to www.irs.gov(Fomi for instructions and the latest information. send to the IRS. 1 Name (as shown an your income tax return). Name is required an this line; do not leave this line blank. 304 Construction LLC 2 Business nameldisregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name Is entered on line 1. Check only one of the 4 Exemptions (codes apply only to m following seven boxes. certain entitles, not individuals; see a p ❑ IndivltluaVsole proprietor or ❑ C Corporation ❑ S Corporation El Partnership ❑ TrusVestate Instructions on page 3); c single -member LLC Exempt payee code(if any) p6 A'* Q Umited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► `0 i? in Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC Is another LLC that is not disregarded from the code (if any) ac owner for U,S. federal tax purposes, Otherwise, a single -member LLC that c is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other law instructions)► fapgi.:roxw�nrsmelnrmreaouam•me us.� oo 5 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) N 1083 FM 820 19 8 City, state, and ZIP code Cedar Creek Tx 78612 7 List account numbers) here (optional) IoenTITICation Number Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid IS, 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 L TIN, later. Note: If the account is in more than one name, see the Instructions for line 1. Also see What Name and Fo�r, L:' Number To Give the Requester for guidelines on whose number to enter. F 3oe000000r Under penalties of 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 S. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (If any) indicating that I am exempt from FATCA reporting Is correct. Certification Instructions. You must cross out Item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are n�equired to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. at9r1 Signature of A L/ Here. U.S. person 1- Iv 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.irs.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 (MN), 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. ff 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) .4CC?Rf?� CERTIFICATE OF LIABILITY INSURANCE DAM /092024� 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: N the cert'dicate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 endomement(s). PRODUCER CONTACT Clint Roberts NAME: The Insurance Team f=.PHONE . (512) 376-5141 [ac, xo): (512) 398-1990 117 White Oak EAD RESS, clint@the-insumnce-team.com PO Box 1140 Lockhart, TX 78644 INSURERS AFFORDINGCOVERAGE NAICS INSURERA: Western World Insurance Company 13196 INSURED 304 Construction LLC INSURERS: 1083 Fm 812 Suite I-9 INSURER C: Progressive Insurance Company 24260 Cedar Creek, TX 78612 INSURER D INSURER E: Texas Mutual Insurance Company 22945 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 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 MAYHAVE BEEN REDUCED BYPAID CLAIMS. INSR LTR TyPE OF INSURANCE ADDL 6UBR POUCYNUMSER MMIDDYEFF PMIDDYYyP LIMBS A COMMERCIAL GENERAL LIABILITY CLAMS -MADE 12 OCCUR X X NPP9017410 10/10/2024 10/10/2025 EACHOCCURRENCE $ 1,000,000 PREMISES(Ea ocgm rce $ 100,000 MED EXP(Anyone person) $ 5,000 PERSONAL&ADVNJURY $ 1,000,000 GENL AGGREGATE LMMAPPLIES PER POLICY ❑ JECT PRO El LOC OTHER GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 $ C AUTOMOBILE LIABILITY ANYAUro OWNED / SCHEDULED AUTOS ONLY V AUTOS HIRED NON�GWNED AUTOS ONLY V AUTOS ONLY X X 953784310 11/19/2023 11/19/2024 EGeeal ED SINGLE LIMIT $ 1,000,000 BODLYNIURY(Perpemon) $ BODLYPUURY(Peracclder) $ PROPERTY DAMAGE Peraccida $ UMSRELLALIAB EXCESS LUIB OCCUR CLAMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ E WORKERS COMPENSATION AND EMPLOYERS'LNSILRY YIN IWYPROPRETOWPAPmER CUTNE OFRCERMEWER EXCLUDED? (Mandatory In NH) Myyeess asea r DESOtlThe RPTION OFvelOPERATIONS below NIA X 0002100757 10/10/2024 10/10/2026 SPER TATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICYLMIT $ 1,000,000 DESCRIPTION OF OPERATIONS ILOCATIONS /VEHICLES (ACORD 101, Addltlonel Remarim Schedule, may be aeachad Nmore apace Is required) Calhoun County 211 South Ann St 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. AUTNORDED REPRESENTATIVE „+y (c IOAR-2015 ACORD CORPORATION. All rinhts reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Conforms RWith of Architects, faAIA. Document t t tEdition) CONTRACTOR: (No 7 al surlus and address) 404 Construetior�,, t 1083 FM 812, Suite 1-9 Cedar Creek, TX 78612 OWNER: Cal�Na ! s utvs rnrd 11"'cssl. roun �o`t�"rt�yt 211 South Ann Street Port Lavaca, TX 77979 SURETY: (Name legal .slatusandprinciputplcaco CiId Republic Surety Company 445 S. Moorland Road Brookfield, WI53005 BOND AMOUNT: $650,000 PROJECT:'. vrari'f "ointf uY h°eao �co�fiS`3nau on" &TJob No E25470.0 The contractor .and for the prompt: payment difference; not to exceed this an agreement hetweco Lite Owner and Contractor to extend the time notice by the surety shall act apply to any extension exceeding sixty M (60) days. This document has impoftant legal eansequencos. Consultation with an attomay is encourageo with respect to its, ;c omph+bon or medficaGan. Any singular reference to Contractor Surety, Owner or other parry shalt he considered :*,rat where applimlefe. tvc, for the payment of which the successors and assigns, jointly and Owner accepts the bid of the Contractor nay be agreed to by the Owner and in accordance with the tests oi'sueh act Documents, with asurety admitted ie f sithful performance of such Contract tthoreol, or (2) pays to the owner the led in said bid and such larger amount f the work covered by studbid, then this The Surety hereby waives any notice of the Owner may accept the bid. Waiver o If this Bond is issued to connection avith a subcontractor's bid to a Contractor, the term Contractor in this Bond shall be deemed to be Subcontractor and the term Owner shalt be deemed to be Contractor. When this Bond has been furnished to comply with a statutory or other legal "iremeatIn the location of the project, any provision in this mind conflicting with said statutory or legal requirement shall be deemed deleted hereftom and. pmvisioas conforming to such statutory or other legal requirement shall be doomed incorporated herotii, When so furnished, the intent is that this Hand shall be coristraedas a statutory £Sued and not as a common law, bond'.. Signedaadecaluld s 9th dayof Ootober2024 {ff`itness �� � fFVitnussj ORSC 2 328 (W11). 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: 2024-1224656 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 304 Construction LLC Cedar Creek, TX United States Date Filed: 10/09/2024 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County Bill Sanders Park - Swan Point 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. 2024.09 Bulkhead & Pier Construction 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. 6 UNSWORN DECLARATION `_ My name is (° WAA V 1 and my date of birth is " My address is7-- (City)(state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in _NAM b_ County, State of , on the 9 day of /0 , 20 d . (month) (year) %nature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethlcs.state.tx.us Version V4.1.0.48da51f7 E BID SUBMITTED BY. WOOPENING: 2:W_:00 PIIA THURSDAY OCTOBER 10 2024 C. Bid Submittal Chackliist — / Form done oriaitml and lhme copies of the following items): 0_ Security of Proposed Subcontractors statemIs ent of Biddoes Qualifications p/Affidavit 0�,Conflict of Interest questionnaire Form CIQ 0- Certification Regarding Debarment & Suspension and Other Responsibility Matters Certification Regarding Lobbying Disclosure of Lobbying Activities Instructions and 13'�House Bill 89 Verification CK-Reiddence Certification atem for Award Management (Print out of search results) ❑ YV,9 General Conditions for Calhoun County Texas C A copof the General Conditions for Calhoun County, Texas is attataheiJ -will �r referegce mind also be included in the Project Manual in Section bb$ BID PACKAGE 4 A C a , FOR _ = BID N0 2024.09 - CALHOUN CQUNTY, BILL SANDERS PARK - SWAN POINT - BULKHEAD & PIER CONSTRUCTION ' SEADRIFT, TEXAS PREPARED BY:•'`, URBAN ENGINEERING " - TREE# F-160,y IFAutt CM�t' 11 tem, PA L ' CONSULTING ENGINEERS a iM n" N. COIYr MCE ST. VICTORW, TEXAS 77801••010 = ' t U.E. ,JOB E25470:.00 C 1 r a. Mos. &fthead & Pier Construction SeadrK Texas COMTRIIIICTURNTIMATI01111 Bid No. r y. BID IS SUBANTM The Honorable Richard H. Meyer, Calhoun County Judge Calhoun County courthouse 211 S. Ann Street, Suite 301 Port Lavaca, Texas 77979 1.01 The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an Agreement with OWNER in the form included in the Bidding Documents to perform all Work as specified or indicated in the Bidding Documents for the prices and within the times indicated in this Bid and in socerdence with the other terms and conditions of the Bidding Documents. - 2.01 Bidder, accepts all of the terms and co AM Instructions to Bidders, including without limitation those dealing with the Advertisement sement or Invitation to Bid and will remain subject to acceptance for BO days after the Bid openingposRiosuch ll of Bid security. The Bid ( Bidder may agree to in writing upon request of OWNER. , or for onger period of time that 3.01 In sub tting this Bid, Bidder represents, as seforth in the �esentst Agreement, that: � A. Bidder has examined and carefully studied the Bidding Documents, the other rel identated data ed in t $idding Documents, and the following Addenda, receipt of which is hereby acknowledged - Addendum No. s Adde_ ndum Date B. B,er has visited the Site and become fanxliar with and is satisfied as to the Site conditiont may affect rm cost progress. and perfoance of the Work: general, local and rr is familiar with and is satisfied as to all federal, state and local Laws and Regulations st, Progress, and Performance of the Work. r has cerafufly sludled --1111 reports offt raborts and tests of srbsrafaae conditions at MM at or Site and an contiguous t6u o Pal conditions in or relating to g surleca-or the :gee %cept tlndengrolund Fad) which how Evan Ccrrdfitiarns as provided inn Paragraph 402 of this General FK11110M 88 Provided in Condition, ifarM whm* Bees �g, Psaph 4.06 of the General C,orrriam ' has ablairned and carefyiiy yhxftd (or ads raspardbillty and es)eirS11rdiE5and dab Vanceaft pop irreseca cif the Milk or ohiich eel to d -ane S rntrk:tr nr>ryadfedi aft lb be- avd b�G Ord of nresrrs � B'rhter,;.iirmdlil�ing 004110-1 / to be by Bidder. and • �� �" the ( �t�t9erEta.. F Bidder does not consdar. teat any ffu@w exananalfiUM ar veallgaftis or data ae necessary for the delemainallor of this Bid far pediopme ce or the Vlakat the pdce(s) hid and wi hin the lines and it acconte hce win tide other terms and Conditions of the Bidding Docuenis, G. BMW's aware Of the general nature of work to be perforrrwd by OWNER and others at the Site that relates to the Work as ihdcafad it the Biddng Documents H. Bidder has Correlated the idarnation known to Bidder, itiormabon and obwm tons obtained from VMft to the -*As. reports and drawingS identified in the Bidding Doc nwMs, arid at additional exploratorns, ftwts. skxfts, and data with the Bidding Documents. I. Bidder has &an ENGINEER Mitten notice of all cordllds; errors. ambiguities, or ncies that Bidder has to Bidder has discovered in the Bidding Documents, and the writtenacceptaresolution thereof by ENGINEER is J. The Bidding Documents are generally sultcient to indtcets and convey understanding- of all terms and conditions for the Performance of the Work forwhich this Bid is submitted. 4.01 ndisclosed hBiderdtnyidual orAurther assents that this Bid is genuine and not made in the. interest of or on behat of any association, entity and is not submitted in confomdity with _any agreement or rules of arty gawp, organization or corporation; Bidder has not directly or indirectly induced or solicited any other refrain n Bidder to submit a false or sham Bid; Bidder has not solicited or induced any individual or entity to from bidding; acid Bidder has not sought by collusion to obtain for itself any advantage over any othersidder, or over OWNS. 5.01 Bnddere g pag k II complete the Work in accordance with the contract. Documents for tie.priCe(sa or4 the followin u� ppµry _ 4 tt ytt}lA� I L YVII 'N'•� 1�5 N y ryL SioHO.2ma M-CAUMOAxCouMrr SILL SPJK EM PARK -SOM P09ff BULKHEAD & P1ERC0XS11 CTMM PREPARED i URBA01 ENGMIEERAIG eeaM �-vESCRpnON EST�elre� CAMMlW MINT. IMTPRIM TDT/LPIWE SAMOD GENERAL L MiGzalGimm. ImsecaerRaad�Rmre� dot 1 .tSase ft 1 LS �{ Q 2 9arrlcadbag &'T aft Gor" (Fumgie,. Imo, hlaiaan S Reno eSon & Warning Deiicrs) (iaciWcs Flagnen, TrAk 1lanarM Tr�6c -Plan &TmwwdryS"W I LS UG fS 3. Constncaon staling 1 LS 9 3 GYu, $ 3 aw,' SUSTOTAL GENERAL 14gODU,'� IMPROVEMENTS - 4. Timber Pier 1 LS $ 0D,� .: S 219 140, 5. Vinyl Bulkhead 336 LF $ y�,� 3 2150go,�. 6. Fish Cleaning Station 1 LS t!t $ O[YJ+ $ 400,"'� 7. Bulkhead Cap11 SF $ $ 2 8. Concrete Sklewalk 590 SF $ 2, [?[, $-4.6—*," 9. ADAParldn 340 SF $ `0, Ca E -�D�r`. 10. Curb Stop 1 EA $ I""� 11. ADA PaddM Sign - 1 EA IS Zfx, 12. A St O, _ $ Saw, 13. Water Main I"Sch40 320 LF S 14. Hose Bib 3 FA r'! S. I O00, 15. Remove & Install New Electrical Panel_ 1 LS IS 16 'mer Gunduit& Wire ,. LS L s 13 0a2, 17. F Green LED -- a EA. S Z1000, SUSTOTALAWROVEMENTS - ... - .-` 06 - . TOTALSASESID _ _ ' lit iis to iimtent of the,0,WNER to award a Contract Ilor dill wookilams and quadifies ilisted an In Bid Form. lkn dre event that the Ilow Bid submitted iby a quallified Bidder,amsed the humds budgeted for this PffqeM *8 OWN E'R reserves an rm ,ft to reduce do scope of ft awk so that the Project can be completed wAm the budaeted amount this may be dam by eliminating any or am parts of In phVaot The Briddw hereby agrees to mainlaIn the unit prices sham an the Bid Form amuid this reduction in the scope of the YmFk be runessoy. SAI Bidder agrees Urg the Work Iml be substantially complete uOun JO- caleivilff drys (W BE F&JLW IN BY BUM" after the date When the Contract Times commence, to run as provided in paragraph 2.03 of the General conditions and completed and ready for IkW payment In accordance with Wagral3b 14-07 Of the G&Wd CCndffions within 14 calendar days after the date of substantial completion. 6.02 Bidder accepts the Provisions of the Agreement as to liquidated damages in the event of failure to Complete the Work within the times specified above, which shall be stated in the Agreement 7.01 The following document(s) are attached to and made condition this Bid: A. Required Bid Security in the form of (specify type of Bid Security., Bond, Cashier's Check, Certified Check); B. Schedule of Proposed Subcontractors to be identified in this Bid; C. Statement of Bidders Qualifications with supporting data; D. Affidavit; E. Conflict of Interest Questionnaire Form CIQ; F. Certification Regarding Debarment & Suspension and Other Responsibility Matters; G. Certification Regarding Lobbying; H. Disclosure of Lobbying Activities and Instructions; I. House Bill 89 Verification; J. Residence Certification; K System for Award Management (Print out of search resufla); L. Wng. -8-01 The terms used in this Bid with initial kcal lelters have the meanings IrKiloated in #16 instructions Band-the Supplemardary Corld to Bitters, the General condificna, and mom. -SUBMITTMon If Bidder is: An Individual Name (typed or per} By: (SEAL) ssignaftM) Odm business as: Business address - Phone No.: FAX No.: A Partnership Partnership Name: (SEAL) By: (Signature of general partner— attach evidence of authority to sign) Name (typed or printed): Business address: Phone No.: A Corporation FAX No.: Corporation Name: �d l f ��l \l`� r l Fn.o % vi%r7 ( (SEAL) State of Incorporation: Type (General Business, Professional, Service, Limited Liability): C-Vpm By: Name (typed or printed): Y `d u Tillie: Prey, h-t4 (GORP'URATE SEAL)- Gle,�[�>a 7x 77 232 AJbint Venture J tVnnturer Name:: V) (SWISWID afJONO aranhae er— of sch evzb.e ofaugw*,to s n) Mom (ice or innhm* Too - Business address: Phone No.: FAX No.: Joint Venturer Name: (SEAL-) By: (Signature — attach evidence of authority to sign) Name (typed or printed): Title: Business address: Phone No.: FAX No.: Phone and FAX Number, and Address for receipt of official communications: p.. !Bidder and Swraty, ;jointly and severally, bind tlhhieerrise'Ives., timir heirs, executors, adnrlinistrators, suooessors anxt asegns to pay to O'A'RaIER upon default of Bidder to penal :sum :set tixth .on the face of WE Bend. >, r . . r,, 57, 3. This obligation shall be null and void if 3.1.OWNER accepts Bidder's Bid and Bidder delivers within the time required by the Bidding PENAL SUM FORM jurisdtictimn located in the state iin liiidh the Project is locadea 8. Notices negUired hereunder shall be in writing and seat th Bidder and Smoky at f1w respective shmm on fhre face of Illiss Bore Such notices racy be said by penninat deltwery commercial canter or by United States Registered or Certified Mail, norm receipt requested, postage pre -paid, and shalt be deemed to be effective upon receipt by the party concerned. 9. Surety shall cause to be attached to this bond a current and effective Parer of Attorney evidencing the authority of the officer, agent or representative who executed this Bond on behalf of Surety to execute, seat and deliver such Bond and bind the Surety thereby. Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement 10, This Bond is intended to conform to all required by the Bidding Documents and any applicable statutory requirements. Any applicabfe performance and payment Bonds required by the requirement of any applicable statute: that has been Bidding Documents, or omitted from this Bond shall be deemed to be 3.2. All Bids are rejected by OWNER, or included herein as if set forth at length. If any 3.3.OWNER fails to issue a Notice of Award to provision of this Bond conflicts with any applicable Bidder within the time specified in the Bidding statute, then the provision of said statute shall Documents (orany extension thereof agreed to in govern and the remainder of this Bond that is not in writing by Bidder and, if applicable, consented to by conflict therewith shall continue in full force and Surety when rewired by paragraph 5 hereof). effect. 4. Payment under this Bond will be due and 11. The term "Bid" as used herein Includes a.Bid, payable upon default by Bidder and within 30 offer or proposal as applicable. calendar days after receipt by Bidder and Surety of written notice of -default from OWNER, which notice will be givetl- with reasonable promptness, identlfyfng this bond and the Project and including a statement of the amount due. 5. Surety waives notice of and any and all defenses base# on or arising out of any time extension to issue Notice of Award agreed to in writing by OWNER and Bidder, provided that the total time for ;issuing Notice of Award Including extensions shalt. not in the aggregate exceed 120 days from BK due date. without Surety's written consent. S. No suitor anion shall be comma iced under this Bond prio to 30 calends days ate the notice of default required in paragraph 4 above is received by Bidder and Surety and in no case Ian it= one year aft% Bid dire date. P. Arry snit ar action under an Bard sh uM be con1menced rn a emot of competent 0 -2 SCHEDULE OF PROPOSED SUBCONTRACTORS •'M„.R '� IAI;I:I .. k A A- .:-A4 II'�I.A ,1�.1. 11 1-\. :V. �:IR�.•..W �. 1 "I .L W:1- W..E-: w51 ��!:- lyy. :./' :f A -1 �L. I i:.�R �...:!'P? } 1.• :e. 1 I f I I a"iI 1•-1 1 Subcontractor Address & Telephone Number Speciality Subcontract Amount A kim Ids— 2 G ow, 2. IeXgS �1%S 1� 3. — 'z-3e)2 4. 5. 6. �Z 7. 8. s. 10. 11. 12. 13. 14. 15. 16. i8. 21}. C STATEMENT OF BIIDOBVS OUALIFICATIMS MR questions must be answered and the data given roust be clear and conpelmsive. This statement must be notarized. 9 necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional inibanation he desires. Name of Bidder J I (E-1 /'i) o,'az,)( t4a- I Date organized: - l 12 - ( Date Incorporated:y' 6 �r Number of years in contracting business under present name: CONTRACTS ON HAND: Contract Dollar Amount To, 3w i 11 iv v iA S 2 vri )1;� Completion Date Type of work performed by your company: & V V M P11K4 r)4 (M In4r 'u ✓1 Have you ever failed to complete any work awarded to you? (.y 6 Have you ever defaulted on a contracr I y o List the projects most recently completed by your firm ("include projects of similar importance): Project DollarAmount MOJYr Completed L t,& - r? & cnm K �0�0 7fzq S� ��� �41t✓ 2,� w,�►1 �e � 2�2� H29A�R10101-.3i4t6rcremt6R®Itltl§tl4:�IRuetihnei MW equipment available for this contract 7C Z 10 2-9 LoaLrr 33s SkI6 03-t 04)ZP-(' 3% I' v y ✓ 29G� 340xfa Executed this day of cc By: rlrbAV"" � SI t, (Signature) (Title) (Print)Name) State of I �cl County of� - Swom to qndI ubscribed beforeme this _0 day of oLL .P' LAUPAC. LEONARD Notary Signature - s NO ARY PUBLIC - ID410831264 1 Jy '' f State �� 04 17 2025 �yL�.��C{-,.�1� y1)�'p�fl1_..�1-.. -P n rvu In and for tfre State ®f le fLt 1JLQS _^) ff}9APNIOm-St§t§menttoB®Ii1H§d§Q1)e�IR'ualWire- - tl— STATE OF TEXASCOUNTYOF {} ' AFFIDAVIT r� ccj f p/�hg� ,.J1�16r1�"1 being {� (T,Np ©rlP>fnat Awff4 the. II 0s; 0 _ of SV(le'l grin ipal address at first ddlysvwonm, deposes and says: that he or she its IMrit namr affCiamrparViyrii'snmo0 trmmlPr�,nmkalamr��a6mrtg�nttlmegal having its who submits herewith to Calhoun County the attached bid/proposal; that he orshe is the person whose name is signed to the attached Wiff/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should, refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directiyorindirectly, seek by agreement, communication or conferences with anyone to raise or fixthe bid price/proposal of said bidder/proposer or of anyone else, or to`Faise orfix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown. -thereof, or the contents thereof, or dluulge information or data relative hereto, to any corporation, partnership, company, association, i organization,. bid depositary, or to any member or agent; thereof, to any individual or group of individua►s, or to any official; employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish ny and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions irements contained in the bid/proposal ;LAURAC.LEONARD - is°`�, NOTARYRUBLIC sign re ofAf IDN 10831264, ` State of Texas - - .Comm. Exp. 04-17.2025P ad name arad71tle offAillf SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the . ;Pbove are true and cornett, the .day of OC;b pr . ZO . fkbtlaerq,+3HamnW�/3aail CONFLICT OF INTEREST O UESTIONNAIRE For vendor doing business with I*ml governmental entity THRb qVIMIGMUNre nefleclis dmmjes :made In dw Iner by l :B. 23, 84th 9.eg.„ Roydar Session. loins aoasiiwmm ffe is bdhg Had iim =w1dance vw& Chadk, 176, Local Govemrmene „ by a vendor w ft has a bans ess ns[Wamft as datinred by 5ectlion 176.ertf(t-ai wvfth a'local goverrenensill y and tfra "Sells requirsnards order Soda n 176M61af.. OFlewthis (WaSbarxeire Pam beRed waethe r daqlocal 9wernmargat aft nor br dura 69 A h husimess day after *a data are vydw becomes amine of facts am raW" dre slarmund to be . Sae Sir 176.0e6(a-l). Local Government Ca& - Or ono etas a twstrtess relationship with local governmental entity. ilrlei i-vlS (V6+NdCU T,,,C- FORM CIO OFFICEUSECKY 17-1 Li Check this box ff 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 t��hjle Information is being disclosed. VZ T- Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section f76.003(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 No B. Is tine vendor receiving or likely to receive taxable income, otherthan investment income, from or at the direction of the focal government officer or a family member of the officer AND the taxable In ame is not received from the local governmental entity? FYes 1 1 No o0sarbusinessentirywith respect towhich the Beal govemmmn oiNtxr I maintains 9ftaeorporsdonor IFmoaa�xildadlAy�iEiaiitaieai®m rsxaw.azthiirssi.lCtcaez R�ri®i11VlNl�ffiil- CONFLICT OF INTEREST QUESTIO E 'For vendor doing business wilth local govenmielftl entity Acomplete copy ofChaptertabdthe Local GovernmentCode may befound athigpl//AvwwstattAes.legis. ik.ur�/ Docs/LG/hbW//LG.'176J*n.For easy referianca, below aresome ofthe sections cited onthis Imm. Local Government Code t* 176.001(1,a)_ 13USaaess rdationsW means aconnection between two or more parties basal on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered bya state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code 8176.0NUM-M and (B (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into: a contract with the vendor; (B) has given lo the local government.offim-or a family member of the officer one or more gifts that have an aggregate value of more than $1.00 in the 12-month period preceding the date -the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (it) the local governmental entity is considering entering into a contract with the vendor. Local Government' Code S 176 006(a) and (a-1) (a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business;relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, ore family member of the officer; described by Section 176i003(a)(2)(A); (2):;has given a local government officer of that local governmental entity, or a family member of the officer, one or more gals withthe aggregate value specified by Section 176.003(a)(2)(B) excluding any gift.desenbed by Section 176.003(a-1); or (3) Chas a family relationship with a local government officer of that local governmental entity. (a-1) The completed coriffict must be fled with the appropriate MCDrds adninlemw not later than the seventh business day after the laferoF (1) the date that the vendor. (A) begins discussions or rations to enter into a contract with the local gwrernnienntal entity; or (B) snbnBsmthelocal goverrnrentaNentilyan i response too requ estforproposals or bids, correspondence, er another writing nelMed to a potential contract with the local gotmaimentalerftor (2) the dale the vendor becomes aware: (A) of an employmen or other busiuness with a local goverivnent o1R'rxr, or a faw*nmmboreftheot mw.domedbymotion(a); (B) t im*evendurtasove nonaormomg desr by (a);,pr ( clafamihy wfralacd a i�mtlgylB=HM1i¢��eamin �au�.�ntiis�,..tW:u� t�i�tl1YI1V�n CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Execmav7e Rader 12549, thepraRmliveprunaryparticiparacertifies 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 stolenproperty; 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 Titl of Authorized Agent Signature o nllrmized Agent I am unable to certify to the above statements. My explanation is attached. Date {' DEBARMENT & SUSPENSION Executive Order 13549 Debar maent and Suspension wc'e_ The provisioMS Of Executive Order 1 W �9 of Feb_ IlS, 1986. appear at 51 FR 6-70. 3 CFR 1986 Comp_, P. 159. unless otherwise noted, By the authority vested in me as President by the Constitution and laws of the United States ofAmenca. and in order to curb fraud, n-aste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension ofparticipants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent perdmitted bylaw, Executive departments and agencies shall:: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow aparty to participate in any affected program if any Executive department or, agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or minded pane, to participate in a particular transaction upon a written determination by the agency head of authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infieguently. Sec. 3. Executive departments and agencies shall issue regulations governing their iniplementation of this Order that shall be consistent with the guidelines issued under Section 6.Ptoposed regulations shall be submitted to the Office ofManagement and Budget for review within four rocitift of the date of the guidelines issued mider Section 6 Ilie Director of the Office OfM21MI and Budget may rimurn for secOms"IetishOn Proposed regulations thin the Director believes are "niconsument wah dz gindeinieff. Final stall be PubHOWd witOrin Melve Morift of doe date cfftle goidehas. Sir- 4. There is horebyconstituted the Inneragency Committee an Debarment and .Suspension which shall mantor unplainenation of this Order. The Coni nittee shall consist of representativeS of agencies "designated byttheDuaeamroffTile Office of9 and Budget. Sec.'5.. The Director of the Office of Management and Budget shall designate a Federal agency to pefionn the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order periodically distribute the list to Federal agencies, and study the feasibility of automating the list coordinate with the lead agency responsible for go-mmment-wide debarment and suspension of contractors: chair the Interagency Committee established by Section 4, and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. i� Implementation In the PRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office%before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide asimilar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any: subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients offnuds directly made available by capiWization grants to ensure the accuracy of certifications" AddlWanal Rrkrmces t C 40 CYR. Part 32. EPA an Certification Regarding Lobbying (To be submililed With each bid or aft er«se±dirig $100,OM) (a) No Federal appropriated fund have been paid or WIN be paid, by or on behalf of the undersigned. to arry person for in lamming or attempting to influence an Ofilm or employee of an agency, a Member of Congress. an otfloer er 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 malting of any Federal loan, the entering Into Of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, ban, 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 tititering into this transaction imposed by 31, U.S.C. § 1352 (as amended by. the Lobbying Disclosure AdOf 1895). The Contractor, C certifies or affirms the truthfulness and accuracy of each statementof its certificat on and nd disclosure, if any, in addition, the Contractor understands -and agrees that the provisions; of 31 U. . § 3801 at seq., apply to this certification and disclosure, if any. Signature of Contrlacloes Authorized Official 00,APSViII�Ie, —r [Pre`, LV11 Printed Name and Title o Contractor's Authorized Official [o^f0, 2A Date Approved by OMB Disclas ure wMabbying Activities ConsIdeuethisConntodisclase 101100M azdivitiespursuant to31W&C.1.352 L. Type ofFederal Action: g L ed<ralAction: 3. Typez lfeolepp6con:m initial tiling — b- rams b. initial award b. ztmserial champ e moire affamment c poa-award d. loan e. hum guarantee For material cbaage only Year quana f. loan insurance Date of last repots 4. Name and Address of Reporting Eatity S. If Reporting Entity in No. 4 Is Sabawardee, Enter �Ptime Subawanlee Name and Address of Prime: Tier , if Known: S�tfle� 4-,(AS Cr�sfiv4�i�ea, Co- �. Gle[41?� s3Z,q Coa resdonal Distriet, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, !#'applicable: S. Federal Action Number, ifknown: 9. Award Amount, ##'known: S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if Individual, lost name, fits! name, Ml): dijj'erentfmm 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 offset open which reliance was placed Priat Name: d In, J in 1 by the tier above when this transaction was made or entered lots. This disclosure is required pursuant to 31 Title: U.S.C.1352. The information will be reported to the Csngrm semi mnuatiy and will be available for public Tdepheme Fla 2�2-7W1 Dap-- 16 - I G- L inspedlom. Any person who fails to file the required disetaare shell be:smbjeet to a"penalty of mot hen (ban SIB and no core shun S1MW" for each rod& faa ffe. Federal Use Oayr AmOorgmed for Loral Repradmetion Sun &dudFar se-LLLlaw. 7.M MST —RUCTIONS FOR COMFf:EAtOM'tDFSF,LLL., DISCLOSURE OF WB61YIMG ACTIVl1lES TNnis clisciosure form shell be completed by to mMning entity, vossibar sub awardee or prime Fiederai recipient at the initiation or race" of a c oared Federal action„ or a material diange In .a previous Mint pursuant to title 31 ,".C. section 135L The Ift of a frown is required fnr each payment or agreement m make payment to any Jobbying entity for Influencing or aftempling to Influence an officer or employee of any agency, a biamber of Congress, an efficer or employee of Corte, or an ea Vk"e of a Member ofCongress in connection wkh a covered Federal action. Complete ai ASMS that aPPk fur both 00 millet MV and material d ress report. Refer to the implementing guidance published by the Offica & Alanagernind and Budget for additional Information. 1. Identify the type of covered Federal action for which lobbying activity is ardor has bean secured to influence the outcome of a covered Federal action. 2 Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up reportcaused by a material charge to the iMomrabon previously reported, enter the year and quarter in which the change occurred. Enter the date of the fast previously submitted report by this reporting entity for this covered Federal action. 4. Ender the full name, address, city. State and zip code of the reporting entity. include Congressional District, if known. Check the appropriate classification of the ,reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the.tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known, 8. Enter the name of the federal agency making the award or loan commitment. Include,at least one ( organizational level below agency name, if known. For example, Department of TransponalforyUnited States \ Coast Guard. ;. 7. Enter the Federal program name or description for the covered Federal action (item 1) if known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements; towns, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number, Invitations for Bid (IFB): number; grant announcement number the contract, grant, or ban award camber; -the application/proposal control number assigned by the Fail" agency). Included prefixes, e.g., "RFP-DE-90.001:° 9. For a covered Federal action where there has been an award.or loan conrnitment by the Federal agency, enter the Federal amount of the awarditan commitment for the prime.entity Identified In item 4 or 10. (a) Enter the full name, address, clty, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the repot tg entity identified in item 4.to influence the covered Federal action. (b) Enter the 6A names of the indMd mf(s) performing service rend Include fulf address if ditterertC`tian 10(aj Enter Last Marne. First Name, and Middle Initial 11. Thecertifying; ofiirral shelf sign and data the form, pint hisfi arname, wa, and telephone number. HOUSE 811.1.89 VERIFICATION FORM Certification Requiliriedby Texas Gomelmneenit Code Section 2Z70.t11r1 The 9511 Teams Legislature approved new ktdation, effective September 1, 2017 *hrich amends Texas Local Government Code Section 1, Subtitle F Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter ,into a contract (which indudes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it-- 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 2270.001, Texas Government Code: I. "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, (authorized official) AUlng ldj do hereby verify the truthfulness and accuracy of the contents of the statements su mitted on this certification under the provisionsof Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott' Israel List located at https://compttodier texas itoviourchasi /publications divestment oho rl S CiS c Co .I C Comparry Ma SR,gnatuXe of Authorized Official Printed Mamie of Authadzed ®f odW tileof TiOfficial Doe ir RESIDENCE CER111I RCATICI N Pursuant to Texas Government Code §225.2.001 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) C3 I certify that . hl er .i�dis a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Au orized Agent 20.1 e 4psll Printed Name and Title of A40torized Agent --__ to -co- 2A = INSERT SYSTEM FOR AWARD MANAGEMENT (SAM) RECORD SEARCH FOR COMPANY AND COMPANY'S PRINCIPAL(S) ® Company, Corporation, Firm or Partnership, and its Principals, must not be debarred or suspended nor otherwise on the Excluded Parties List System (EPLS) in the System for Award Management (SAM) or the State of Texas Comptroller Debarred Vendor List and must have an active registration with the System for Award Management (www.SAM.gov). Include verification that your Company, Corporation, Firm or Partnership is registered and that the Company, Corporation, Firm or Partnership, and its Principals, are not listed (are not debarred) through the System for Award Management (www.SAM.gov). Include a printout of the search results that includes the required information and the record date. MILSAM,mv- Entity Workspace Results 1 Total Results SHIRLEY& SONS CONSTRUCTION CO., INC. Unique Entity ID: KPIKEPZY7H21 CAGE/NCAGE:03EAl Entity Status: Active Registration Doing Business As: SHIRLEY & SON CONSTRUCTION CO INC Physical Address: 15705 Hwy 787 West CLEVELAND.TX 77328 USA Expiration Date: Mar 06,2025 Purpose of Registration: All Awards Mar 28, 2024 06:40:26 PM GMT Lasr dwed by Ro.Id Shirley on Mar 06, 2024 nt 12:09 PM SAM.Gov® SHIRLEY& SONS CONSTRUCTION CO., INC. SHIRLEY & SONS CONSTRUCTION CO., INC. Unique Entity ID CAGE / NCAGE Purpose of Registration KPIKEPZY7H21 03EAI All Awards Registration Status Expiration Date Active Registration Mar 6, 2025 Physical Address Mailing Address 15705 HWY 787 West P.O. Box 429 Cleveland, Texas 77328 Cleveland, Texas 77328.0429 United States United States Doing Business as Division Name Division Number SHIRLEY & SON CONSTRUCTION CO INC (blank) (blank) Congressional District State / Country of Incorporation URL Texas 36 - Texas / United States (blank) Registration Dates Activation Date Submission Date Initial Registration Date Mar 26, 2024 Mar 6, 2024 Mar 26, 2002 Entity Dates Entity Start Date Fiscal Year End Close Date Apr 30, 1976 Apr 30 Immediate Owner CAGE Legal Business Name (blank) (blank) ( Highest Level Owner CAGE Legal Business Name (blank) (blank) Executive Compensation In your business or organization's preceding completed fiscal year, did your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) receive both of the following: 1. 80 percent or mom of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements and 2. $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? No Does the public have access to information about the compensation of the senior executives in your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) through periodic reports fled under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Not Selected Proceedings Questions Is your business or organization, as represented by the Unique Entity ID on this entity registration, responding to a Federal procurement opportunity that contains the provision at FAR 52.209-7, subject to the clause in FAR 52.209-9 in a current Federal contract, or applying for a Federal grant opportunity which contains the award term and condition described in 2 C.F.R. 200 Appendix XII? No Does your business or organization, as represented by the Unique Entity ID on this specific SAM record, have current active Federal contracts and/or grants with total value (including any exercised/unexercised options) greater than $10,000,000? Not Selected Within the last five years, had the business or organization (represented by the Unique Entity ID on this specific SAM record) and/or any of Its principals, in connection with the award to or performance by the business or organization of a Federal contract or grant, been the subject of a Federal or State (1) criminal proceeding resulting in a conviction or other acknowledgment of fault; (2) civil proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000, or other acknowledgment of fault; and/or (3) administrative proceeding resulting in a j finding of fault with either a monetary fine or penalty greater than $5,000 or reimbursement, restitution, or damages greater than $100,000, or other acknowledgment of fault? Not Selected Page I oj3 Last updated by Roanld Sh11I9 on Mar 06, 2024 al 12:09 PM SHIRLEY & SONS CONSTRUCTION CO.. INC. Electronic Business A P.O. Box 429 RONALD R SHIRLEY II Cleveland, Texas 77328 ssconstruction@earthlink.net United States 7132227881 IRIS SHIPPEY P.O. Box 429 shirleyandsons@earthlink.net Cleveland, Texas 77328 7132227881 United States Government Business 1. P.O. Box 429 RONALD R SHIRLEY II, President Cleveland, Texas 77328 ssconstruction@earthlink.net United States 7132227881 IRIS SHIPPEY P.O. Box 429 shirleyandsons@eartlink.net Cleveland, Texas 77328 7132227881 United States NAICS Codes Primary NAICS Codes NAICS Title Yes 237990 Other Heavy And Civil Engineering Construction IGT Size Metrics Annual Revenue (Rom all IGTs) (blank) Worldwide Annual Receipts (in accordance with 13 CFR 121) Number of Employees (in accordance with 13 CFR 121) C$18,000,000.00 34 Location Annual Receipts (in accordance with 13 CFR 121) Number of Employees (in accordance with 13 CFR 121) $18,000,000.00 34 Industry -Specific - Barrels Capacity Megawatt Hours Total Assets (blank) (blank) (blank) This entity did not enter the EDI information This entity does not appear in the disaster response registry. Mar 28, 202406:38:26 PM GMT httpsrIlsam.govlentitYIKPIKEPZY7H11kareD to?status=null Page3 j3 form Wo )Finv.'erPA7a) Request for Taxpayer hientification Number and Certification i►Ooft ww ftgore/Faar11/Yferirstrrwgonsandihetrd.slArRowonl�. Woeftrin to the 1 sgaseteu Do rat excite tow IRS. 1 ramre{�tshown On yaurin¢emrerrc 7+lam(eiyroq�iihsa®ntlnil�dit0fa l wethle nnaelann. E Bwnh r+nnmM(�le� Ct a4 t �s / 1i.f (-1')u" &A ! a ugack" bmmtrSsamaitmo dlmpasonmubmseeriwaeeelwdarbrl.Oerkaefyeamdae 4 E3M4dk indeeap*G*te raeeeesaemec. emALinrwlimr,ns9iseMda6rsem r CCarpm®anrr ❑SCMPM§on OPONW.10 0TnayM0012e arearu amnaekea) !$ i'+monpmPrlemmodstlso�,�, L ,s ❑ fieiad bh7iYampeq-Cbreerawlemdrrevamr(GCarpradam, aett>orpemlua Pepraeeslept► IMemrchadtereapproprWls ancMdrarabwafraa Yrpws}Bm6ard1M a3plHmmhmrammw. Dorettlmek Bempannfmr Walk LICYeerlCrachmok daaaskldrrrrecrrbrLlClhdis Iadmdeamseeernrssleassm mwrdtlm LLCb �iJ mrolhertLCtW krAt d msgw" ftm t oomw*wt.1<fedrlirpurpomea Oemrrdma,aaigWarrnhmrLLC come 4laM W dlaaerrltl loom arm avamr cloned mlreck tM mpprmprime tea ttr fits Mm deW leabn d as erlr. Otlref tdamlmanrmarre)► dyr`re®,e�W.s•eaYar+W d a Siren, and apt croft nos Seelostuaffam. ipgcesaie rrmMad adrer(opaamT G a- CALHOUN COUNTY 202 S ANN ST, PORT LAVACA TX 77979 e sty oats mwz� soon c/ 361-553.4610 FAX: 361-553-4614 7 Ust etxated number(a) two lopliomg EMAM Toqmw IdenUfloeblon Number Enter your nN In the appropdate box. The TIN provided neat match the name given an One 1 to avoid I social eeeuray number - m - backup withholding. For Individuals, this Is generally your social security number ($11M. However, for a resident alien, sole propdder, or disregarded entity, as the insbucaom for part I, later. For other entities, It Is your employer Identification number (EIN). H you do not haHo ve a number, am w to gar a 71N, later. Nate; Of the account Is In more than one name, as the Instructions for line 1. Also ace What Name and Number To Give the Requesrerfor guidelines on whaeeLnumb er to enter. MI�fIM �srunamran Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I sm 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 raNlWdby the kftmW Rawlnue Service PM that I sm autod to backup withholding as a result of a failure to report d inter t or dividends, or (a) the IRS has notlfirt me that I am no longer suWact to backup wftdding; and 3.1 am a U.S. cllban or other U.S. parson ""had below};. and 4. The FATCA co le(s) entered on this form Of any) Indketlng that I am exempt from FATCA reporting W correct. CariffloWen (rmbudkm a You must ones out Itsm 2 above ryou have been notified bythe WSfast you are warertyetrbject la backup withhddbg hearse you haam4aledlonpmtdInterest and dMdwdsmywrLxreluru.Fareeslsmsstra te,Item2doearotapply.Farmorka0►k paid, acquisition erabenddrenwdofassured goprly.concoctionddata, conalta rebeekldblduelradesnatseggarnert(1Rp), and granary;paimeft other than Interest and dfSdrab,you wend m**edbalgaltfecr a9en,bayou muetprqutdeyrruonect7lN.Sea, ldskebtaa5relkrPartO,-Mar. IIe1o® ( peen`►`i ! - caw►�� rear Gi instructions laaleORtjllsldrrda hafudegposnl4oensloelrareacbrl Swoon Salinas nosed. eForm109a MM(iodmslPpesafblecme„peteis,wsrute,argrase Mean deodopenevALFlorthe tiedkdrlaaerrabout dnwbnprrrenls bFa1niN-9and' i w umbrah4kag tllrerrcM a alerl9me)IwrepubSnlm4gDblrlMAsgoyTarmit9 WeassaftestMl' rNneublYblrrdeatenselfaeY6dlrer • Form 16110-8k maI base AesMaaYlrbwonw o Purpow of f'or= aFlaw 1S99.kg�tcaedamdtHdprtyertoaodcbeers�r� Am arwlNg{FaeagFBsspeoaMa$eAroksasgdbedbLsan •Fbw 1Mfmnwarreefagsitem1111W6-Efandwkban wMlmnMkeiR1111iraef"Wea msbapoll n IOWTOMMO Feel" rAlllfwltpMrekl'6eymaa'aodaIseesa�g�e I _ e1PosaA1t9e�C�nbafdidddp kn®Irkt wwapwillydt9aae-1 manberSTe1�,adWdf'mo sesFnMrFifteraoaifi-j- MONMOBRRMuotbw •Fbar 1999A lnarabrndaa-ro9eleseuretp bssaOrkommll - rnpill o smavmtpddlDpkaramw UbmFaisa9AFlaagpflFyauuaoes.HASPew� @eeebl'dad earreaar1 telAeem wdre�.siFlhTmartMam eflircJi,tapemmh�gurarasfreea11M0. - - sabanskmdeds,.ktame' I" 11 Ib,9se9dfuldIS ., lryavdbmet�mrrfirwgr�tbAmrugamearaa9bm)7tllggemer�4if •F� 4trtree��raiar�fp fe&saMm}l gaarlMkak�lYeaNatp a.,Monn'� BID SUBMITTED BY: SHORELINE CONTRACTORS, LLC BID OPENING: 2:00:00 PM, THURSDAY, OCTOBER 10, 2024 Bid Submittal Checklist (Submit one original and three copies of the following items): ® Bid Form M Bid SecurityCASHIER'S CHECK ® Schedule of Proposed Subcontractors ® Statement of Bidder's Qualifications ® Affidavit M Conflict of Interest Questionnaire Form CIO ® Certification Regarding Debarment & Suspension and Other Responsibility Matters ® Certification Regarding Lobbying M Disclosure of Lobbying Activities and Instructions ® House Bill 89 Verification M Residence Certification ® System for Award Management (Print out of search results) ® W-9 General Conditions for Calhoun County, Texas A copy of the General Conditions for Calhoun County, Texas is attached for reference and will also be included in the Project Manual in Section 00810. BID PACKAGE 4610 BID NO. 2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION SEADRIFT, TEXAS PREPARED BY: URBAN ENGINEERING TREF# F-160 CONSULTING ENGINEERS 2004 N. COMMERCE ST. VICTORIA, TEXAS 77901-5510 U.E. JOB NO. E25470.00 Page 1 of 25 BID FORM PROJECT IDENTIFICATION: Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction Seadrift, Texas CONTRACT IDENTIFICATION AND NUMBER: Bid No. 2024.09 THIS BID IS SUBMITTED TO The Honorable Richard H. Meyer, Calhoun County Judge Calhoun County Courthouse 211 S. Ann Street, Suite 301 Port Lavaca, Texas 77979 1.01 The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an Agreement with OWNER in the form included in the Bidding Documents to perform all Work as specified or indicated in the Bidding Documents for the prices and within the times indicated in this Bid and in accordance with the other terms and conditions of the Bidding Documents. 2.01 Bidder accepts all of the terms and conditions of the Advertisement or Invitation to Bid and Instructions to Bidders, including without limitation those dealing with the disposition of Bid security. The Bid will remain subject to acceptance for 60 days after the Bid opening, or for such longer period of time that Bidder may agree to in writing upon request of OWNER. 3.01 In submitting this Bid, Bidder represents, as set forth in the Agreement, that: A. Bidder has examined and carefully studied the Bidding Documents, the other related data identified in the Bidding Documents, and the following Addenda, receipt of which is hereby acknowledged. Add n_g dum No. Addendum Date gap y B. Bidder has visited the Site and become familiar with and is satisfied as to the general, local and Site conditions that may affect cost, progress, and performance of the Work. C. Bidder is familiar with and is satisfied as to all federal, state and local Laws and Regulations that may affect cost, progress, and performance of the Work. D. Bidder has carefully studied all: (1) reports of explorations and tests of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the Site (except Underground Facilities) which have been identified in the Supplementary Conditions as provided in paragraph 4.02 of the General Conditions, and (2) reports and drawings of a Hazardous Environmental Condition, if any, which has been identified in the Supplementary Conditions as provided in paragraph 4.06 of the General Conditions. E. Bidder has obtained and carefully studied (or assumes responsibility for having done so) all additional or supplementary examinations, investigations, explorations, tests, studies and data concerning conditions (surface, subsurface and Underground Facilities) at or contiguous to the Site which may affect cost, progress, or performance of the Work or which relate to any aspect of the means, methods, techniques, sequences, and procedures of construction to be employed by Bidder, including applying the E25470.00-BB Form 0824 00410 - 1 Page 2 of 25 specific means, methods, techniques, sequences, and procedures of construction expressly required by the Bidding Documents to be employed by Bidder, and safety precautions and programs incident thereto. F. Bidder does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the determination of this Bid for performance of the Work at the price(s) bid and within the times and in accordance with the other terms and conditions of the Bidding Documents. G. Bidder is aware of the general nature of work to be performed by OWNER and others at the Site that relates to the Work as indicated in the Bidding Documents. H. Bidder has correlated the information known to Bidder, information and observations obtained from visits to the Site, reports and drawings identified in the Bidding Documents, and all additional examinations, investigations, explorations, tests, studies, and data with the Bidding Documents. I. Bidder has given ENGINEER written notice of all conflicts, errors, ambiguities, or discrepancies that Bidder has discovered in the Bidding Documents, and the written resolution thereof by ENGINEER is acceptable to Bidder. J. The Bidding Documents are generally sufficient to indicate and convey understanding of all terms and conditions for the performance of the Work for which this Bid is submitted. 4.01 Bidder further represents that this Bid is genuine and not made in the interest of or on behalf of any undisclosed individual or entity and is not submitted in conformity with any agreement or rules of any group, association, organization or corporation; Bidder has not directly or indirectly induced or solicited any other Bidder to submit a false or sham Bid; Bidder has not solicited or induced any individual or entity to refrain from bidding; and Bidder has not sought by collusion to obtain for itself any advantage over any other Bidder or over OWNER. 5,01 Bidder will complete the Work in accordance with the Contract Documents for the price(s) on the following page(s): E25470.00 - Bid Form 0824 00410 - 2 Page 3 of 25 BID NO.2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION (BIDDER) PREPARED BY: URBAN ENGINEERING ITEM NO. DESCRIPTION ESTIMATED QUANTITY UNIT UNIT PRICE TOTAL PRICE BASE BID GENERAL 1. Mobilization, Insurance and Bonds (Maximum 10% of Base Bid) 1 LS $ 71,500.00 $ 71,500.00 2. Barricading & Traffic Control (Furnish, Install, Maintain & Remove Signs & Warning Devices) (Includes Flagmen, Traffic Handling, Traffic Control Plan & Temporary Striping) 1 IS $ 8.250.00 $ 8,250.00 3, Construction Staking 1 LS $ 8,250.00 $ 8,250.00 SUBTOTAL GENERAL $ 88,000.00 IMPROVEMENTS 4. Timber Pier 1 LS $ 379196.40 $ 379,196.40 5. Vinyl Bulkhead 336 LF $ 638.00 $ 214,368.00 6. Fish Cleaning Station 1 IS $ 13.530.00 $ 13,530.00 7. Bulkhead Cap 1,100 SF $ 45.65 $ 50,215.00 8. Concrete Sidewalk 590 SF $ 18.60 $ 10,974.00 9. ADA Parking 340 SF $ 18.60 $ 6,324.00 10. Curb Stop 1 EA $ 165.00 $ 165.00 11. ADA Parking Sign 1 EA $ 247.50 $ 247.50 12. ADA Striping 1 LS $ 165.00 $ 165.00 13. Water Main (1"Sch 40) 320 LF $ 22.34 $ 7,148.80 14. Hose Bib 3 EA $ 550.00 $ 1,650.00 15. Remove & Install New Electrical Panel 1 LS $ 16,500.00 $ 16,500.00 16. Pier Conduit & Wire 1 LS $ 13,200.00 $ 13,200.00 17. Fishing Light Green LED 6 EA $ 650.00 $ 3,300.00 SUBTOTALIMPROVEMENTS $ 716,983.70 TOTAL BASE BID $ 804,983.70 Unit Prices have been computed in accordance with paragraph 11.03.E of the General Conditions. Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities provided, determined as provided in the Contract Documents. 625470.00 -Bid Form 08124 00410 - 3 Page 4 of 25 It is the intent of the OWNER to award a Contract for all work items and quantities listed on the Bid Form. In the event that the low Bid submitted by a qualified Bidder exceed the funds budgeted for this Project, the OWNER reserves the right to reduce the scope of the work so that the Project can be completed within the budgeted amount; this may be done by eliminating any or all parts of the Project. The Bidder hereby agrees to maintain the unit prices shown on the Bid Form should this reduction in the scope of the work be necessary. 6.01 Bidder agrees that the Work will be substantially complete within &90 calendar days (TO BE FILLED IN BY BIDDER) after the date when the Contract Times commence to run as provided in paragraph 2.03 of the General Conditions, and completed and ready for final payment in accordance with paragraph 14.07 of the General Conditions within 14 calendar days after the date of substantial completion. 6.02 Bidder accepts the provisions of the Agreement as to liquidated damages in the event of failure to complete the Work within the times specified above, which shall be stated in the Agreement. 7.01 The following document(s) are attached to and made a condition of this Bid: A. Required Bid Security in the form of CASHIER'S CHECK/CERTIFIED CHECK (specify type of Bid Security: Bond, Cashier's Check, Certified Check); B. Schedule of Proposed Subcontractors to be identified in this Bid; C. Statement of Bidder's Qualifications with supporting data; D. Affidavit; E. Conflict of Interest Questionnaire Form CIQ; F. Certification Regarding Debarment & Suspension and Other Responsibility Matters; G. Certification Regarding Lobbying; H. Disclosure of Lobbying Activities and Instructions; I. House Bill 89 Verification; J. Residence Certification; K. System for Award Management (Print out of search results); L. W-9. 8.01 The terms used in this Bid with initial capital letters have the meanings indicated in the Instructions to Bidders, the General Conditions, and the Supplementary Conditions. SUBMITTED on OCTOBER 10, 2024 State Contractor License No. N/A . (If applicable) E25470.00-Bid Form 08/24 00410 - 4 Page 5 of 25 If Bidder is: An Individual Name (typed or printed): N/A By: (SEAL) (Individual's signature) Doing business as: Business address: Phone No.: A Partnership Partnership Name: FAX No.: By: (Signature of general partner -- attach evidence of authority to sign) Name (typed or printed): Business address: IWITO Ta01Gm A Corporation Corporation Name: SHORELINE CONTRACTORS, LLC State of Incorporation: TEXAS Type (General Business, Professional, Service, Limited Liability): LIMITED LIABILITY 13 -- attach evidence of authority to Name (typed or printed): AUSTIN GANDY (SEAL) (SEAL) Title: Uvv irrcr si to I (CORPORATE SEAL) Attest: RONNIE VAUGHAN, VICE PRESIDENT (Signature of Corporate Secretary) Business address: 16828B OAK LANE, CHANNELVIEW, TEXAS 77530 Phone No.: 281.383.3194 Date of Qualification to do business is FEBRUARY, 2022 E25470.00 - Bid Form 08/24 [rbPyN='1 FAX No.: Page 6 of 25 A Joint Venture Joint Venturer Name: NIA By: (Signature of joint venture partner -- attach evidence of authority to sign) Name (typed or printed) Title: Business address: Phone No.: Joint Venturer Name: FAX No.: By: (Signature -- attach evidence of authority to sign) Name (typed or printed): Title: Business address: Phone No.: FAX No.: Phone and FAX Number, and Address for receipt of official communications: (SEAL) (SEAL) (Each joint venturer must sign. The manner of signing for each individual, partnership, and corporation that is a party to the joint venture should be in the manner indicated above.) E25470.00 -Bid Form 08/24 00410 - 6 Page 7 of 25 SCHEDULE OF PROPOSED SUBCONTRACTORS Bidder proposes the following subcontractors to be used for major portions of the Project. All major subcontractors must be listed and submitted with the Bid. Bidder may change subcontractors after Bid submittal only as approved by the Engineer. Major subcontractors are those who will do work having a total value of more than five percent (5%) of the Contract amount. The maximum total value of work performed by all subcontractors on the Project shall not exceed seventy-five percent (75%) of the Contract amount. Subcontractor Address & Telephone Number Speciality Subcontract Amount 1' NO SUBCONTRACTS WILL BE ISSUED FOR 2. MORE THAN 5% OF THE WORK 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. E25470.00 - Schedule of Proposed Subcontractors 08124 00430 - 3 Page 8 of 25 STATEMENT OF BIDDER'S QUALIFICATIONS All questions must be answered and the data given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he desires. Name of Bidder: SHORELINE CONTRACTORS, LLC Address: 16828-B Oak Lane Channelview, TX 77530 Date Organized: FEBRUARY 01, 2022 Date Incorporated: Number of years in contracting business under present name: 5 YEARS CONTRACTS ON HAND: Contract Dollar Amount Completion Date A-11 PIPELINE REMOVAL, CALLAN MARINE / 2 5MM / JAN 2025 CS755 (CRANE ASSIST) / CALLAN MARINE / 360K / JAN 2025 DOCK REPAIR / BUFFALO MARINE / 350K / OCT 2024 Type of work performed by your company:MARINE CONSTRUCTION, DOCKS, BULKHEADS, DREDGING Have you ever failed to complete any work awarded to you? NO Have you ever defaulted on a contract? List the projects most recently completed by your firm (include projects of similar importance): Project Dollar Amount MoNr Completed DREDGING AT PORT OF CORPUS, CALLAN MARINE / 750K / OCT 2024 BULKHEAD REPAIR, BUFFALO MARINE / 250K/ SEPT 2024 MOORING DOLPHIN REPLACEMENT, BUFFALO MARINE / 285K/ SEPT 2024 CSS2 PIPELINE REMOVAL, CALLAN MARINE / 1.7MM / MAR 2024 E25470.00 - Statement of Bidder's Qualircations 08/24 00450 - 1 Page 9 of 25 Major equipment available for this contract: SEE ATTACHED EQUIPMENT LIST Executed this 10TH day of OCTOBER, 2024 By: _� J� OWNER/PRESIDENT (Signature- C AUSTIN GANDY (Print Name) State of County of. Sworn to and subscribed before me this. Zia day of ` 12" - Amber Coleman My Commission Expires Notary Signature 4129/2028 Notary lD134875704 Printed Name In and for the State of �a s Commission Expires E25470.00 - Statement d Bidder's Quali%.tione / 08/24 00450 - 2 Page 10 of 25 Item 2000 KS-526 Spud Barge Purchase Date 4/25/2022 Acquired Value $95,000.00 1982 57' Ricky Lynn (Old Name: Dana Robyn) Tugboat 7/31/2023 $53,280.00 1976 Elin Leigh: 44' UNITED SHIPBUILDING & REPAIR 6/3/2024 $150,000.00 1981 Kennedi Alyse: 47' LUIS G. ORTIS BOAT INC 6/3/2024 $150,000.00 1976 Jordyn Paige: 36' SABINE RIVER FUEL CO ONC 6/3/2024 $120,000.00 1982 Drake Thomas: 57' L&A IRON WORKS 6/3/2024 $120,000.00 1952 Gavin Lee: 43' WILLIAM L. WILSON 6/3/2024 $125,000.00 1968 Saylor Morgan: 41' BREAUX'S BAY CRAFT 6/3/2024 $125,000.00 1982 Discovery: 40' BREAUX'S BAY CRAFT 6/3/2024 $150,000.00 1980 Challenger: 40' BREAUX'S BAY CRAFT 6/3/2024 $150,000.00 1978 Kori Bell: 63' SUPERIOR LIFT -BOATS 6/3/2024 $175,000.00 1978 Everley Jayne: 60' ORANGE SHIPBUILDING COMPANY INC 6/3/2024 $375,000.00 1983 PM884: Barge 6/3/2024 $100,000.00 1970 CTCO2002: Barge 6/3/2024 $250,000.00 KS524: Barge 6/3/2024 $175,000.00 1990 GD894: Barge 6/3/2024 $150,000.00 1992 GD915: Barge 6/3/2024 $150,000.00 1990 GD897: Barge 6/3/2024 $150,000.00 1978 PM2020: Barge 6/3/2024 $700,000.00 PM1045: Barge 6/3/2024 $400,000.00 HBC701: Barge 6/3/2024 $150,000.00 BERTHA D: Barge 6/3/2024 1973 KS-526 Spud Barge 1110'752'x7.5' NEW NAME: SL SB 102 2/1/2022 $400,000.00 2022 Case CX130 Excavator w/36" bucket $185,780.86 Kobelco Crane w/ 100' boom 110 Ton GH03-02271 12/30/2021 $300,000.00 Kobelco Crane w/ 150' boom 110 Ton GH03-02279 12/30/2021 $350,000.00 1964 Crane Manitowoc 1964 3900 Crane 2/9/2023 1974 Crane Manitowoc 2/9/2023 1979 Crane Manitowoc 2/9/2023 2019 John Deere 450 2/1/2022 $100,000.00 2018 John Deere 210 2/1/2022 $140,000.00 2016 John Deere 130 2/1/2022 $95,000.00 2017 Bobcat 590 $32,000.00 2019 Bobcat Mini Hoe $25,000.00 Case Model CXT140E $176,600.00 Case Model CXT140E $176,600.00 Manitowoc MA 1320 base boom 30' 12/12/2023 $30,112.44 Manitowoc Crane w/ 110' boom, block & ball #41139 1/4/2024 $65,989.38 Manitowoc Crane w/ 110' boom, block & ball #41175 1/4/2024 $65,989.38 2023 Excavator - Case Model CX80C #3301, Coupler#100492 3/27/2024 $138,178.79 2020 Excavator - Case Model CX250D #1408 3/28/2024 $201,919.54 Manitowoc 3900 Vicon 6/3/2024 $150,000.00 Manitowoc 4000 Vicon 6/3/2024 $150,000.00 Manitowoc 4100 Vicon 6/3/2024 $200,000.00 5220 American 6/3/2024 $75,000.00 5299 American 6/3/2024 $75,000.00 599 American 6/3/2024 $50,000.00 BobcatT770 6/3/2024 $15,000.00 Cherry Picker D137064 6/3/2024 $15,000.00 100 Ton Linkbelt 6/3/2024 $100,000.00 2024 Case CX220E LR Excavator_ 8/29/2024 $268,500.00 2023 Case DL550 Compact Dozer Loader 5/23/2024 $157,500.00 2023 Case Bucket 84" XHD 1.25 yd3 w/BOCE 5/23/2024 $4,387.70 Case TR270B Compact Track Loader 9/8/2024 $64,250.00 Page 11 of 25 WRITTEN CONSENT OF THE SOLE MANAGER OF SHORELINE CONTRACTORS, LLC July 25, 2023 The undersigned, being the style manager (the "Manager"') of Shoreline Contractors, LLC, a Texas limited liability company (the "Camprtny") does hereby, pursuant to the provisions of Section 6.201 of the Texas Business Organizations Code C'TBOC"), consent to and approve the following resolutions and each and every action effected thereby by written consent; 1. Election of Officers. RESOLVED, that the following person is elected to serve in the office set opposite their name, to serve as such until his or her respective successors) are elected and qualified or, if earlier, until The,person's death, resignation or rej220va1: Ronnie Vaughan Vice President 2. Ccunte a s F simile Siaftatures_ RESOLVED, that this Written Consent may be sighed in two or more counterparts, each of which shall be deemed an original, and all of which shall be deemed one instrument: RESOLVED, that this Written Consent may be transmitted via facsimile or other similar electronic means and executed ray the undersigned, and a facsimile or electronic copy Of the signature of the undersigned shall be deemed an original signature for all purposes and have the sine force and effect as a manually -signed original. [Siptature Page to I,i2ffota,J 4,%2�6123-7618v.I Page 12 of 25 TN WITNESS WHEREOF, the undersigned Manager has executed this Written Consent to be effective as of the elate first above written. NLANAGER: Austin Gan d Siguawre Page to Wrixtvn Consent of 5hDmllnt E-'mtrutom. Lu.. 4g62.612.1.76t$v.t Page 13 of 25 DELEGATrON OF AUTHORITY 1, Austin Gandy, the sole manager of Shoreline Contractors, LLC, a Texas limited liability company (the "Company"), hereby grant full power and authority to Ronnie Vaughan, in his capacity as Vice President of the Company, to execute on behalf of the Company any commercial contracts, and all other documents necessary and appropriate to consummate or advance the transactions evidenced by such commercial contracts_ Executed the 25th day of July, 2023. Austin Candy, sole tanager — 4872-5994-0722v.1 Page 14 of 25 STATE OF TEXAS {} AFFIDAVIT COUNTY OF � 0 AUSTIN GANDY (Type or Print Name) being first duly sworn, deposes and says: that he or she is the OWNER/PRESIDENT of SHORELINE CONTRACTORS, LLC having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 16828-B Oak Lane Channelview, TX 77530-2944 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that priorto the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, orto any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. Signature of Affiant AUSTIN GANDY, OWNER/PRESIDENT Printed Name and Title ofAffiant 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 /Q day of r)U(6W 20-IY- . Amber Coleman Shl'; My Co4129/2 2 Expires 4I2912028 NoNotary 10134876704 Page 15 of 25 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176,001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176,006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. N/A 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. N/A 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 F-1 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? E7Yes FIND -5j 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 s ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 _gnzo Jm/�✓ 10/10/2024 Signature � of vendor doing business with governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021 Page 16 of 25 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. AUSTIN GANDY, OWNER/PRESIDENT Name and Title of Authorized Agent L 5 " Signature of Authorized 10/10/2024 I am unable to certify to the above statements. My explanation is attached. Date Page 17 of 25 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2.. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that parry from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee staring the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 18 of 25 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. See. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 19 of 25 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). SHORELINE CONTRACTORS LLC The Contractor, , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature of Contractor's AuthoriAid Official AUSTIN GANDY, OWNER/PRESIDENT Printed Name and Title of Contractor's Authorized Official 10/10/2024 Date Page 20 of 25 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: 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, if known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if' (ifindividual, last name, first name, M1): different from No. 10a) (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: AUSTIN GANDY by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: OWNER / PRESIDENT U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: 281.383.3194 Date: 10110/2024 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) Page 21 of 25 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85' Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) AUSTINGANDY,dohereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https•//comptroller texas gov/purchasing/publications/divestment php SHORELINE CONTRACTORS LLC Company Name DY Signature of Authorized Official Q Printed Name of Authorized Official OWNER/PRESIDENT 10/10/2024 Title of Authorized Official Date Page 22 of 25 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) X I certify that SHORELINE CONTRACTORS, LLC (Company Name) defined in Government Code §2252.001. ./ /" Signature of Authorized Agent AUSTIN GANDY Printed Name and Title of Authorized Agent 10/10/2024 Date is a "Resident Bidder" of Texas as Page 23 of 25 10/9/24, 2:48 PM SAM.gov s= M official webaite of the United States government Here's how y2ttkneny '!1.SAM.Gova < Core Data Entity Registration Core Data Business Information Entity Types Financial Information Taxpayer Information Points of Contact Assertions Reps and Carts (FARIDFARS) Reps and Carts (Financial Assistance) Exclusions Responsibility / Qualification Entity Reporting [/, Requests L Notifications oa Workspace ❑' Sign Out SHORELINE CONTRACTORS LLC :Unique Entity ID CAGE/NCAGE �.K6PSNJ18K3G5 9YKL6 Physical Address 16828B Oak LN Channelview, Texas 77530-2944, United States Mailing Address 16828B Oak Lane Channelview, Texas 77530, United States Purpose of Registration AIIAwards Version Actions Entity Information Active Registration Eepireui nUnle Jul 16, 2025 https://sam.govientitieslviewIK6P5NJ18K3G51coreData?status=Active&emrKeyValue=22717182--1719503723107233 Page 24 of 251/2 _ 9 Request for Taxpayer Give Form to the Fatm Identification Number and Certification requester. Do not IR ns;n;;o ct Doer 2p'81 ^rift :ne'IeB;ty send to the IRS. nte+nsl ae.-r.e5arres W Go to www.0rs.9ov(FormY/9 tar instructions and the latent Information. 1 Flan i ;iit,wn an jw, -cone tax rem. mj. Name i; regv'red On tilts Im;_ Oo rt•t n;a e 1 is 1.+tie bIBrN Shoreline Contractors, LLC 2 Ras,n=_ss n_Two ateca Joe enAv na•re. --I afk3m lion, ab:ve M O 3 Cased{ app°opra.e pox IGr federal lax c;asslictlhon Or 1^n pereo,i oipy5 nape a er:e d zn 6<E '. Check oll/ all, O° ire 4 Exempt ON* Icodes apGfy o^h Ic ^ilau f_ ^g se;=_n bars. ' OMlax't Cinnis 101 indrvaAii sw ill a , a..vxtuos an page 3) po L'J Inpn',d_al, sale prep etc, o, ElCCcrpp,al W% ❑ SCO'poraT,Dri El Partmish'p ❑ bust Bstale e argle-maT bi'U-0 Exempt Layne taws if 2r�y' ti e [1 'O0 El tI^1<EC 13o42y:Omodnj.En:erl"par, e tax aktss lfAlM :a fO'ali^n $c$CG'jYta'ICra CO P_Parinh fit O nC Note: Cneck i'te app•opnnt h^.x n I" Ire Bbove to, '.to Cfa.'.x h:a'i^n Ct the eing e.-meel er ovine•. CO net chaCh Eten letw, 4oa+'ATCA revorir3 i; c L_C . the LLC 5 class Joe as a single -member LLC --at is a vfrlardec lion tie nisei unless the owne-of tha LLC 15 coos c t any) 'p— anetrer LLC Jun is not clsregarCcc firm flip ,wner1^1U.S.'eb,st tax oueles.CihenVise.,t to ngln-memhe, I. LC that 1 ` is di•e93rceC Inc,, the Ow+Obr S"0.11 GnaCM Ill? E=praFr5le b?%fy 9r4 •ax ola3sifiCBP .n OI dS a.lOar, pq 4 C:har Isee lr5•r-c.onsl► r N ° 5 A,ddIGa3 jntA`eet are apb or s--,e ro.f, See n,jr ct one. Reovaller'e %5 na,lad add LS vp:�o a N 8602 Trl City Beach Rd 6 city. sta:a, and ZIP moda Baytown, TX 77523.9524 .�..... _ .__..... __. m .�.. _.,_.... _.. -_ 7 t.ia aLC l.r i i.,,h'be la I are lcpFc^a(! • TaxpayerldentificationNumber IN Enter your I IN In the appropoate Wet. I he TIN provided must, match the name giver. Or line t to a'Old T Social secunry number r 3Ckup Withhni olo For proprietor aal5, iga i5 gennrauy your social t 5pranty number Part ISSN). Forot er, to' a _ .� resldane a1 on, Bola proprietor or tliseagardad sillily, sue :ha Insiruct+ans for Pan I later. For other en.itios, 4 1s your employer Identification number (E % If y0 + do not have a number. son Novi to get a TIN, later. or Note: If the accou t a in more than one name seethe natricitons for line t. Also see Mlat Nauru and Embiloyer identification number M,nlbor To Gwvoo the Requester for quiootimes on whose number to ente°. +8'8I 0 5)9217 4 2 I Tho nunieer sho,en on this form is my correct taxpayer identification num-ber (or I arm waemg for a number to be issued to me): and 2. I an not subject to backup withholding because. (a) I am exempt +tom barkua withholding, or (b) I hake not been notified by the Informal Reverue Service IIRSI that I am subject to backup wRnholiting as a result of a failure :o report all interest or dwdonds. or (cl tl'e IRS has notd,ad me that I am no forge' Sti to backup withholdirg; and a. I aril a U.S. citizen or other U.S. person (defiled below). err, a The I-ATC.A coders) entered on this font (if any) indicalirg that I am exemot from FATCA resoridlg is correct. Certification Instructions. You must cross os1 Op. to 2 Shore it you have bee^ notified by this IRS that you are cuaently S cject to backup svithholo no because vuu have failed to °epos all interest &PC dividends on your lax return. Pat real estate irarsactions. Item 2 does not apply. For mortgage interest paid. acqu-sition or abanoonrrent of secured property, cancellation of metal, cortnbuhons to or in6ly cual retirement arrangement IIRA1, and generally, paymanls other the- mte'est aril divioeids. you Wu not cquirad to s"gnihe coif cal o� bet you -ins provide yo i, ca-recl TIN. See Ire inmtruclions Ip, Part 11, later, `,air Sieneture of �q 1 Here U.s.pereon► v..eF,Ar<••h.-, r.-.,-.,,♦nr/,t's Date ®o? ha „ O23. General Instructions Section re'erer:es are to the Internal Revenue Code unles> otherwise noted. Future developments. For the latest information about developmer is related to Fomi W 9 Will its irstructions, such as fact slafion enacted a`ter Ibey :vane pubi ahed. go io vvii-vi rs.go dForm4119. Purpose of Form An indivioual or curdy tForm V%1-9 requester) v: ho is requred to f le an riannat,wl return wdh file IRS must obta n your correct to xpayer identification number (TINT whim may he your social socurty number ISSN. Indivicual taxpayer identdicatior number (1TWi, Adoollon taxpayer denuficat,on number (ATINI, or employer identihcatton nuriloer (LIN), to report on an information return she amount pale to you. or other amount reportable on an infonnabon return. Examples of riforni ion returns include, but we not IN, to. the following. • Form 1099-INT (ethereal samec or pa dl • F®rat 1 W9-DIV (d v dends, in0ludn¢ ihp$e Iron stocks pr mutual fade) • Form 1 C99-MISC (varlous types of income, PnZIR5, aviard5 0' Dross Proceeds) • Form i G99-0 Istock or mutua: fund sales and certah uli-er transactions by brokels) • Form 1099-S ljoroceeds from real estate t•ansarlipns) • Form IC99-K (merchant card and third party nerwodr Irarsactions) • Form 109e wore morloage interest) 1098-E (student loan interest) 1096-T (tuition) • Form IC99-C (canceled debt) • Form' G99-A (acqulsitton u• abandonment at secured p,opedy) Use Foxm W-9 only if you are a U.S. oe°son ttndudinq a resident nhenl:'o pmvida yril,r correct TIN. ifgcu do rot return Fawn W-9 to Me requester iinth a TIN, you might De so4iocr to backup it'ithhwitiog. Sao Mat is backuD vrilhholding. rarer C_t.:x_. 11r31% Orrr.•�/`.�t?e,. 1+ 2o•.e1 Page 25 of 25 CONSTRUCTION CO TEXAS GULF COAST SEALED BID SUBMISSION PRINTED COPY 2 Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction, Seadrift, Texas BID DATE: October 10, 2024 BID TIME: 2:00 PM BIDDER: DERRICK CONSTRUCTION CO INC. 250 COVE HARBOR SOUTH ROCKPORT TX 78382 Honorable Richard H. Meyer, County Judge Calhoun County Courthouse 211 South Ann Street 3rd Floor, Suite 301 Port Lavaca, TX 77979 Derrick Construction Company, Inc. PO Box 1046 Rockport, TX 78381 Office (361) 729-2423 Fax (361) 729-1218 250 South Cove Harbor Rockport, TX 78382 w .derrickconstruction.net Email: serenity@derrickconstruction.net PROJECT MANUAL _•- BID NO.2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION SEADRIFT, TEXAS AUGUST 2024 PREPARED BY.. 99253 URBAN ENGINEERING °g�ass�NSGea' `a®OyA6E.; TREF# F-160 � CONSULTING ENGINEERS 2004 N. COMMERCE. ST. VICTORIA, TEXAS 77901-5510 U.E. JOB NO. E25470.00 BID SUBMITTED BY: Derrick Construction Company Inc. BID OPENING: 2:00:00 PM, THURSDAY, OCTOBER 10, 2024 Bid Submittal Checklist (Submit one original and three copies of the following items): 12( Bid Form Bid Security Schedule of Proposed Subcontractors Statement of Bidder's Qualifications 1Y Affidavit Id Conflict of Interest Questionnaire Form CIO Certification Regarding Debarment & Suspension and Other Responsibility Matters &i Certification Regarding Lobbying f� Disclosure of Lobbying Activities and Instructions House Bill 89 Verification Residence Certification Id System for Award Management (Print out of search results) V w-9 General Conditions for Calhoun County, Texas A copy of the General Conditions for Calhoun County, Texas is attached for reference and will also be included in the Project Manual in Section 00810. BID PACKAGE FOR BID NO.2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION SEADRIFT, TEXAS PREPARED BY: URBAN ENGINEERING TREF# F-160 CONSULTING ENGINEERS 2004 N. COMMERCE ST. VICTORIA, TEXAS 77901-5610 U.E. JOB NO. E25470.00 BID FORM PROJECT IDENTIFICATION: Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead & Pier Construction Seadrift, Texas CONTRACT IDENTIFICATION AND NUMBER: Bid No. 2024.09 THIS BID IS SUBMITTED TO: The Honorable Richard H. Meyer, Calhoun County Judge Calhoun County Courthouse 211 S. Ann Street, Suite 301 Port Lavaca, Texas 77979 1.01 The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an Agreement with OWNER in the form included in the Bidding Documents to perform all Work as specked or indicated in the Bidding Documents for the prices and within the times indicated in this Bid and in accordance with the other terms and conditions of the Bidding Documents. 2.01 Bidder accepts all of the terms and conditions of the Advertisement or Invitation to Bid and Instructions to Bidders, including without limitation those dealing with the disposition of Bid security. The Bid will remain subject to acceptance for 60 days after the Bid opening, or for such longer period of time that Bidder may agree to in writing upon request of OWNER. 3.01 In submitting this Bid, Bidder represents, as set forth in the Agreement, that: A. Bidder has examined and carefully studied the Bidding Documents, the other related data identified in the Bidding Documents, and the following Addenda, receipt of which is hereby acknowledged. Addendum No. Addendum Date n/a n/a B. Bidder has visited the Site and become familiar with and is satisfied as to the general, local and Site conditions that may affect cost, progress, and performance of the Work. C. Bidder is familiar with and is satisfied as to all federal, state and local taws and Regulations that may affect cost, progress, and performance of the Work. D. Bidder has carefully studied all: (1) reports of explorations and tests of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the Site (except Underground Facilities) which have been identified in the Supplementary Conditions as provided in paragraph 4.02 of the General Conditions, and (2) reports and drawings of a Hazardous Environmental Condition, if any, which has been identified in the Supplementary Conditions as provided in paragraph 4.06 of the General Conditions. E. Bidder has obtained and carefully studied (or assumes responsibility for having done so) all additional or supplementary examinations, investigations, explorations, tests, studies and data concerning conditions (surface, subsurface and Underground Facilities) at or contiguous to the Site which may affect cost, progress, or performance of the Work or which relate to any aspect of the means, methods, techniques, sequences, and procedures of construction to be employed by Bidder, including applying the E2a470.00-Old Fam 08124 00410 -1 specific means, methods, techniques, sequences, and procedures of construction expressly required by the Bidding Documents to be employed by Bidder, and safety precautions and programs incident thereto. F. Bidder does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the determination of this Bid for performance of the Work at the price(s) bid and within the times and in accordance with the other terms and conditions of the Bidding Documents. G. Bidder is aware of the general nature of work to be performed by OWNER and others at the Site that relates to the Work as indicated in the Bidding Documents. H. Bidder has correlated the information known to Bidder, information and observations obtained from visits to the Site, reports and drawings identified in the Bidding Documents, and all additional examinations, investigations, explorations, tests, studies, and data with the Bidding Documents. I. Bidder has given ENGINEER written notice of all conflicts, errors, ambiguities, or discrepancies that Bidder has discovered in the Bidding Documents, and the written resolution thereof by ENGINEER is acceptable to Bidder. J. The Bidding Documents are generally sufficient to indicate and convey understanding of all terms and conditions for the performance of the Work for which this Bid is submitted. 4.01 Bidder further represents that this Bid is genuine and not made in the interest of or on behalf of any undisclosed individual or entity and is not submitted in conformity with any agreement or rules of any group, association, organization or corporation; Bidder has not directly or indirectly induced or solicited any other Bidder to submit a false or sham Bid; Bidder has not solicited or induced any individual or entity to refrain from bidding; and Bidder has not sought by collusion to obtain for itself any advantage over any other Bidder or over OWNER. 6.01 Bidder will complete the Work in accordance with the Contract Documents for the price(s) on the following page(s): E25470.00- 9W F.. 004 00410 - 2 BID NO.2024.09 - CALHOUN COUNTY BILL SANDERS PARK - SWAN POINT BULKHEAD & PIER CONSTRUCTION (BIDDER) Derrick Construction Company Inc. PREPARED BY: URBAN ENGINEERING REM NO. DESCRIPTION ESTIMATED QUANTITY UNIT UNIT PRICE TOTAL PRICE BASE BID GENERAL t. Mobilksoon, Insurance and Bonds (MDdmum 1046 of ease B' 1 LS $ 156,000.00 $ 156,000.00 2. Banfcading & Traffic Comm, (Fumish, Install, Maintain & Remove Signs & Warning Devices) (Includes Flagmen, Traffic Handling, Traffic Control Plan & Temporary Striping) 1 LS S 3,500.00 $ 3,500.00 3. Constn ction Staking 1 LS $ 7,500.00 $ 7,500.00 SUBTOTAL GENERAL $167,000.00 IMPROVEMENTS 4. Timber Pier 1 Ls $ 607,940.00 $ 607,940.00 &. Vinyl BM=d 336 LF $1,725.00 $ 579,600.00 S. FishCleani Station t Ls $3,500.00 $3,500.00 7. Suftead Cap 1100 SF s35.50 s39,050.00 S. Concremsidewalh Soo SF $24.00 $14,160.00 S. ADAParldng 340 SF s30.50 $10,370.00 10. curb Stop 1 EA s 300.00 $ 300.00 tt. ADA Parking s n 1 FA $ 200.00 $ 200.00 12. ADnStriping 1 Ls $1,400.00 $1,400.00 13. Water Main 1"Sch40 320 LF $26.50 $8,480.00 14. Hose Bib 3 EA $ 27.00 $ 81.00 16. Remove & Install New Electrical panel 1 Ls $ 5,500.00 $ 5,500.00 16. Pier Condud&Wire 1 Ls $49,300.00 $49,300.00 17. Fishing Light Green LED S FA a 12,448.00 $74,688.00 SUBTOTAL IMPROVEMENTS $1,394,569.00 TOTAL BASE BID s 1, 561, 569.00 Unit Prices have been computed in accordance with paragraph 11.033 of the General Conditions. Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities provided, determined as provided in the Contract Documents. E26/70.00- Sid Fan =4 00410 - 3 It is the intent of the OWNER to award a Contract for all work items and quantities listed on the Bid Form. In the event that the low Bid submitted by a qualified Bidder exceed the funds budgeted for this Project, the OWNER reserves the right to reduce the scope of the work so that the Project can be completed within the budgeted amount; this may be done by eliminating any or all parts of the Project. The Bidder hereby agrees to maintain the unit prices shown on the Bid Form should this reduction in the scope of the work be necessary. 6.01 Bidder agrees that the Work will be substantially complete within 180 calendar days (TO BE FILLED IN BY BIDDER) after the date when the Contract Times commence to run as provided in paragraph 2.03 of the General Conditions, and completed and ready for final payment in accordance with paragraph 14.07 of the General Conditions within 14 calendar days after the date of substantial completion. 6.02 Bidder accepts the provisions of the Agreement as to liquidated damages in the event of failure to complete the Work within the times specified above, which shall be stated in the Agreement. 7.01 The following document(s) are attached to and made a condition of this Bid: A. Required Bid Security in the form of Surety Bid Bond (specify type of Bid Security: Bond, Cashier's Check, Certified Check); B. Schedule of Proposed Subcontractors to be identified in this Bid; C. Statement of Bidder's Qualifications with supporting data; D. Affidavit; E. Conflict of Interest Questionnaire Form CIQ; F. Certification Regarding Debarment & Suspension and Other Responsibility Matters; G. Certification Regarding Lobbying; H. Disclosure of Lobbying Activities and Instructions; I. House Bill 89 Verification; J. Residence Certification; K. System for Award Management (Print out of search results); L. W-9. 6.01 The terms used in this Bid with initial capital letters have the meanings indicated in the Instructions to Bidders, the General Conditions, and the Supplementary Conditions. SUBMITTED on October 10 2024 State Contractor License No. NSA . (If applicable) E25470.00. Bid Fon 0894 00410 - 4 If Bidder is: An Individual Name (typed or printed): N/A By: (SEAL) (Individual's signature) Doing business as: Business address: Phone No.: A Partnership Partnership Name: FAX No.: By: (Signature of general partner— attach evidence of authority to sign) Name (typed or printed): Business address: Phone No.: FAX No.: (SEAL) A Comoration Derrick Construction Company Inc. 4�0 Corporation Name: P y vO iq 'F �'O State of Incorporation: Texas � L2 1990 � " Type By: _ Service, Limited Liability): Limited Liability Name (typed or printed): Derrick Johnson Title: Director Of Operations I Treasure Business address: 250 S Cove Harbor Rockport, Texas 78382 �illri PO Box 1046 Rockport, Texas 78381 Phone No.: 361-729-2423 FAX No.: 361-729-1218 Date of Qualification to do business is 03.15.1990 EM70.00- BW FM OM 1111MfllM A Joint Venture Joint Venturer Name: N/A By: (Signature of joint venture partner — attach evidence of authority to Name (typed or printed) Title: Business address: Phone No.: Joint Venturer Name: FAX No.: By: (Signature — attach evidence of authority to sign) Name (typed or printed): Title: Business address: Phone No.: FAX No.: Phone and FAX Number, and Address for receipt of official communications: (SEAL) (SEAL) (Each joint venturer must sign. The manner of signing for each individual, partnership, and corporation that is a party to the joint venture should be in the manner indicated above.) E25470.00• Bid Fan 08024 00410 - 6 DERRICK CONSTRUCTION COMPANY, INC 250 South Cove Harbor Ll Rockport, TX 78382 www.derrickconstruction.net CORPORATE RESOLUTION DERRICK CONSTRUCTION COMPANY, INC. I HEREBY CERTIFY IT WAS RESOLVED BY A QUORUM OF THE DIRECTORS OF DERRICK CONSTRUCTION COMPANY, INC. AT THE MEETING ON THE 20TH DAY OF DECEMBER 2022, THAT PRESIDENT ROSE JOHNSON, VICE-PRESIDENT ROY M. JOHNSON, TREASURE & DIRECTOR OF OPERATIONS DERRICK JOHNSON & CHIEF FINANCIAL OFFICER SERENITY ALLEN BE AND HEREBY HAVE AUTHORIZATION TO EXECUTE ALL DOCUMENTS (INDIVIDUALLY OR TOGETHER) NECESSARY FOR THE TRANSACTION OF BUSINESS IN THE STATE OF TEXAS ON BEHALF OF DERRICK CONSTRUCTION COMPANY, INC. AND THAT THE ABOVE RESOLUTION WAS UNANIMOUSLY RATIFIED BY THE BOARD OF DIRECTORS AT SAID MEETING AND THE RESOLUTION HAS NOT BEEN RESCINDED OR AMENDED AND IS NOW IN FULL FORCE AND EFFECT; AND IN AUTHENTICATION OF THE ADOPTION OF THIS RESOLUTION, I SUBSCRIBE MY NAME THIS 20TH DAY OF DECEMBER 2022 SHANE JOHNSON, SECRETARY Or Derrick Construction Company Inc. Mailing Address I P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 1361.729.1218 PENAL SUM FORM SURETY (Name and Address of Principal Place of Business): .The Cinninnati Caeualty (:mmpanv 6200 South Gilmore Road Fairfield, Ohio 45014-5441 OWNER (Name and Address): Calhoun County Courthouse 211 S. Ann Street, Suite 301 Port Lavaca, TX 77979 BID BID DUE DATE: October loth, 2024 PROJECT (Brief Description Including Location): Bid No. 2024.09 - Calhoun County Bill Sanders Park - Swan Point Bulkhead $ Pier Construction Seadrift,. Texas BOND BOND NUMBER: nta DATE (Not later than Bid due date): c o er PENALSUM: Five Percent of the Greatest Amount Bid (5%G.A.B.) (Words) (Figures) IN WITNESS WHEREOF, Surety and Bidder, intending to be legally bound hereby, subject to the terms printed on the reverse side hereof, do each r(juse this Bid Bond to be duly executed on its behalf by its authorized officer, agent, or representUCfit, 0,% na BIDDER '%SURETY `c Derrick Constn^n.Company, Inc. Bidder's N m aV rporat Ely: Derrick Johnson reasurer Attest: L-1�4 Seal :CtOf OtlpE7tlOy��� Tricia Balolong Attorney in Fact 'neenl+11 (Attach Power of Attorney) _ Attest: -7-1 �a Officer Surety Witness Note: (1) Above addresses are to be used for giving required notice. (2) Any singular reference to Bidder, Surety, OWNER or other party shall be considered plural where applicable. EJCDC NO. 1910-28-C (1996 Edition) E25470.00- Bid eaM 0924 00430 -1 CINCINNATI, OHIO 1. Bidder and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to pay to OWNER upon default of Bidder the penal sum set forth on the face of this Bond. 2. Default of Bidder shall occur upon the failure of Bidder to deliver within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents. 3. This obligation shall be null and void it. 3.1.OWNER accepts Bidders Bid and Bidder delivers within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents, or 3.2. All Bids are rejected by OWNER, or 3.3.OWNER fails to issue a Notice of Award to Bidder within the time specified in the Bidding Documents (or any extension thereof agreed to in writing by Bidder and, If applicable, consented to by Surety when required by paragraph 5 hereof). 4. Payment under this Bond will be due and payable upon default by Bidder and within 30 calendar days after receipt by Bidder and Surety of written notice of default from OWNER, which notice will be given with reasonable promptness, identifying this Bond and the Project and including a statement of the amount due. 5. Surety waives notice of and any and all defenses based on or arising out of any time extension to issue Notice of Award agreed to in writing by OWNER and Bidder, provided that the total time for issuing Notice of Award including extensions shall not in the aggregate exceed 120 days from Bid due date without Surety's written consent. 6. No suit or action shall be commenced under this Bond prior to 30 calendar days after the notice of default required in paragraph 4 above is received by Bidder and Surety and in no case later than one year after Bid due date. 7. Any suit or action under this Bond shall be commenced only in a court of competent EJCDC NO. 1910-28-C (1996 Edition) 05470.00. ad IMM 0M PENAL SUM FORM jurisdiction located in the state in which the Project is located. 8. Notices required hereunder shall be in writing and sent to Bidder and Surety at their respective addresses shown on the face of this Bond. Such notices may be sent by personal delivery, commercial courier or by United States Registered or Certified Mail, return receipt requested, postage pre -paid, and shall be deemed to be effective upon receipt by the party concerned. 9. Surety shall cause to be attached to this Bond a current and effective Power of Attorney evidencing the authority of the officer, agent or representative who executed this Bond on behalf of Surety to execute, seal and deliver such Bond and bind the Surety thereby. 10. This Bond is intended to conform to all applicable statutory requirements. Any applicable requirement of any applicable statute that has been omitted from this Bond shall be deemed to be included herein as if set forth at length. If any provision of this Bond conflicts with any applicable statute, then the provision of said statute shall govern and the remainder of this Bond that is not in conflict therewith shall continue in full force and effect. 11. The term "Bid" as used herein includes a Bid, offer or proposal as applicable. 00430 - 2 CIHNCINNATI INSURANCE COMPANIES SURETY BOND SEAL ADDENDUM The Cincinnati Insurance Company and The Cincinnati Casualty Company ("Cincinnati") have authorized its Attorneys -in -Fact to affix Cincinnati's digital corporate seal to any bond executed on behalf of Cincinnati by any such Attorney -in -Fact by attaching this Addendum to said bond. To the extent this Addendum is attached to a bond that is executed on behalf of Cincinnati by its Attorney -in -Fact, Cincinnati hereby agrees that the digital seal below shall be deemed affixed to said bond to the same extent as if a raised corporate seal was physically affixed to the face of the bond. Dated this 1 st day of January, 2024. Stephen A. Ventre Senior Vice President on behalf of ate Insurd •o U; CINCINNATt 3 °c: OHIO ; ab `\coati CasUdi?` v ; CINCINNATI, lY OHIO ' J The Cincinnati Insurance Company The Cincinnati Casualty Company THE CINCINNATI INSURANCE COMPANY THE CINCINNATI CASUALTY COMPANY Fairfield, Ohio POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That THE CINCINNATI INSURANCE COMPANY and THE CINCINNATI CASUALTY COMPANY, corporations organized under the laws of the State of Ohio, and having their principal offices in the City of Fairfield, Ohio (herein collectively called the "Companies"), do hereby constitute and appoint William Blanchenl; James R Reid; Wiliam Mitchell Jennings; Aaron Endds; Tdda Balolong; Payton Blanchard; Jessica Turner, Caitlin Kelley; Lindsay Senior and/arTheresa Miller of Fort Worth, Texas their true and legal Attomey(s)-in-Fact, each in their separate capacity if more than one is named above, to sign, execute, seat and deliver on behalf of the Companies as Surety, any and all bonds, policies, undertakings or other like instruments, as follows: Any such obligations in the United States, up to Fifty Million Dollars and No/100 ($50,000,000.00). This appointment is made under and by authority of the following resolutions adopted by the Boards of Directors of The Cincinnati Insurance Company and The Cincinnati Casualty Company, which resolutions are now in full force and effect, reading as follows: RESOLVED,that the President or any Senior Vice President be hereby authorized, and empowered to appoint Attomeys-irl-Fact of the Company to execute any and all bonds, policies, undertakings, or other like instruments on behalf of the Corporation, and may. authorize anyofficer or any such Attomey4n-Fact to affixthe corporate seat; and may with or without cause modify or revoke any such appointment or authority. Any such writings so executed by such Attomeys-in-Fact shall be binding upon the Company as if they had been duty executed and acknowledged by the regularly elected officers of the Company. RESOLVED, that the signature of the President or any Senior Vice President and the seal of the Company may be affixed by facsimile on arty power of attorney granted, and the signature of the Secretary or Assistant Vice-president and the Seal of the Company maybe affixed by facsimile to any certificate of any such power and any such power of certificate bearing such facsimile signature and seal shall be valid and binding on the Company. Any such power so executed and sealed and certified by certificate so executed and sealed shall, with respect to any bond or undertaking to which it is attached, continue to be valid and binding on the Company. IN WITNESS WHEREOF, the Companies have caused these presents to be sealed with their corporate seals, duly attested by their President or any Senior Vice President this 10th day of March, 2021. rile 21 lu y0 mSE° EAL ono OHIO STATE OF OHIO )SS: COUNTY OF BUTLER ) THE CINCINNATI INSURANCE COMPANY THE CINCINNATI CASUALTY COMPANY On this 1Sth day of March, 2021 before me came the above -named President or Senior Vice President of The Cincinnati Insurance Company and The Cincinnati Casualty Company, to me personally known to be the officer described herein, and acknowledged that the seals affixed to the preceding instrument are the corporate seals of said Companies and the corporate seals and the signature of the officer were duly affixed and subscribed to said instrument by the authority and direction of said corporations. Keith C911161t, Attorney at Law Notary Public — State of Ohio fWF p��s III My commission has no expiration date. F OF Section 147.03 D.R.C. I, the undersigned Secretary or Assistant Vice -President of The Cincinnati Insurance Company and The Cincinnati Casualty Company, hereby cartify that the above is the Original Power of Attorney issued by said Companies, and do hereby further certify that the said Power of Attorney is still in full force and effect. Given under my hand and seal of said Companies at Fairfield, Ohio, this 10th day of October 2024 eamia e5A f BN-1457 (3121) CERTIFICATE OF LIABILITY INSURANCE DATE a2/2D2M THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 andomement s . PRODUCER Higginbotham Insurance Agency, Inc. PO Box 870 Corpus Christi TX 78403-0870 E Renee Terrell PxoxE , 3615614iFi237 Nn.361544-D101 E ss• rterrell9lihinginbotham.net INSURERS AFFORDING COVERAGE "Co INSURERA: State Auto Property & Casualty Insurance Company 25127 INSURED DERRCON-01 PC Box 1046 CODS1rULti0n Co., Inc. PO Bo INSURER a: Start Indemnity & Liability Company 38318 INSURSRC: Texas Mutual Insurance Company 22945 Ixsu: D: The Continental Insurance Coma 35289 Rockport TX 78381-1046 NSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1115726516 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. ILTR TYPEOFINSURANCE AWL SUM POUCYNUMBER POUCYEFF LIDO MMILIDDYIXP LIMITS D rXCO1 EXCIALGENERALUABILrry WMS MADE I I OCCUR ML97SG461 121312023 12/312024 EACH OCCURRENCE $1.000,000 PREMISES I& ocmrmnca $60,000 NED EXP one mon) $6.000 PERSONAL SADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JERC ❑ LOO OTHER; GENERALAGGREGATE $2000.000 PRODUCTS -COMPIOP AGO $2,000.000 s A AUTOMOSILELUUBLITY ANYAUTO OWNED SACHE AUTOS ONLY DULED UT09 HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY aAP248007704 12012023 12,312024 COMBINED SINGLE LIMIT FS accident $1,000,000 X BODILY INJURY(Pm pemon) S BODILY=tJRY(Paracddant) $ X PROPERTYUAMAGE P S $ B X UMBRELLALIAB EXCESS LIAB X OCCUR CWMSMADE MASILHS00087323 12/312023 121312024 EACHOCCURRENCE $6,000,000 AGGREGATE $5,000,000 DED I X I RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECURVE OFFICERIMEMBEREXCLUDEDI a (Mandalay In NH) 0 yyeaaa des 18U0nder DESCIkIPTION OF OPERATIONS below N/A 0001145792 12/312023 1218112024 X PT ER E.L. EACH ACCIDENT $1.000.000 E.L. DISEASE -EA EMPLOYE si.000.000 EL DISEASE -POLICY LIMIT 51000 000 09SCR0'TONOFOKMnONSILOCAMOnIWKICLES OCORDID1,Ad igmal Remarks SehaBuie,maybeaKae UmmapaftamqulmdI See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Calhoun County 211 S. Ann Street, Suite 301 Port L8VBC8 TX 77979 AUTMD�r LAZED yTWE ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2018f03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMBR ID: DERRCON-01 _ L C #- A O ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY - Hlgginbotham Insurance Agency, Inc. NAMEOINSURED Derrick Construction Co., Inc. PO Box 1046 Rockport T)(178361-1046 POLICY NUMBER CARRIER NAIL CODE EFFECTIVE GATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 2D FORM TITLE: ne General Liability policy includes a blanket automatic additional insured endorsement that provides additional insured status to the certificate holder only 1 there is a written contract between the Insured and certificate holder that required such status. (Manuscript Form). ne General Liability rill includes a primary & non-contdbutory provision only when there Is a written contract between the insured and certificate holder requires such provision. (Manuscript primary ne Genere6Liability policy Includes In Rem and Action Over Indemnity Buyback - Manuscript form. ne General Liability policy Includes Pollution Limitation Endorsement (Sudden & Accidental.Basis) - Pollution Buy Back- Manuscript form. policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the insured certificate holder that requires h. (Texas Business Auto Policy Plus Endorsement - Form SA 30 02 08)08). policy Includes a blanket automatic additional insured endorsement that provides additional insured status to the certificate holder only when there is a an contract between the insured and certificate holder that required such status. (Texas Business Auto Policy Plus Endorsement - Form SA 30 02 06108). provision that provides Primary Auto Liability Coverage for any liability assumed under an insured contract. (Business Auto Coverage — Excess Liability I s this feature ont of Cancellation - automatic additional insured endorsement that as it. (Additional Insured / Waiver of Subrogation xcess Liability ("Bumbershootl policy follows form of the underlying Commercial Marine Liability, Auto Liability, Employers Liability, Vessel Pollution wfion & Indemnity policies - Bumbershoot Liabilities. Compensation policy Includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract the insured and cerageate holder that requires It (Texas Waiver of Our Right to Recover from Others - Fom7 WC 42 03 048). policy includes Longshore and Harbor Workers' Compensation Act Coverage Endorsement (Form TM-LHW-2001) and Outer Act Coverage Endorsement (Forth TM-OCS-2001). Policy Period 12/31/23.24 Vessel Pollution: ny - Water Quality Insurance Syndicate ge $5.000,000 Per Occurrence, Policy# 58-83445, Policy Period 12/31/23-24 $1,000,000 Your Location / $2,b0(000 Aggregate, Policy# PECO06271101, Policy Period 12/31/23-24 Company y One Project UmiL Policy #UM00082119MA23A, Policy Period 1213123.24 2024.09- Calhoun County Bill Sanders Park -Swan Point id & Pier, Construction Texas' ACORD 101 ® 2008 ACORO CORPORATION. All riahts The ACORD name and logo are registered marks of ACORD 1. Bidder and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to pay to OWNER upon default of Bidder the penal sum set forth on the face of this Bond. 2. Default of Bidder shall occur upon the failure of Bidder to deliver within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents. 3. This obligation shall be null and void it 3.1.6WNER accepts Bidder's Bid and Bidder delivers within the time required by the Bidding Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement required by the Bidding Documents and any performance and payment Bonds required by the Bidding Documents, or 3.2. All Bids are rejected by OWNER, or 3.3.OWNER fails to issue a Notice of Award to Bidder within the Ems specified in the Bidding Documents (or any extension thereof agreed to in writing by Bidder and, If applicable, consented to by Surety when required by paragraph 5 hereof). 4. Payment under this Bond will be due and payable upon default by Bidder and within 30 calendar days after receipt by Bidder and Surety of written notice of default from OWNER, which notice will be given with reasonable promptness, identifying this Bond and the Project and including a statement of the amount due. 5. Surety waives notice of and any and all defenses based on or arising out of any time extension to issue Notice of Award agreed to in writing by OWNER and Bidder, provided that the total time for issuing Notice of Award including extensions shall not in the aggregate exceed 120 days from Bid due date without Surety's written consent. 6. No suit or action shall be commenced under this Bond prior to 30 calendar days after the notice of default required in paragraph 4 above is received by Bidder and Surety and in no case later than one year after Bid due date. 7. Any suit or action under this Bond shall be commenced only in a court of competent ed Bond PENAL SUM FORM jurisdiction located in the state in which the Project is located. 8. Notices required hereunder shall be in writing and sent to Bidder and Surety at their respective addresses shown on the face of this Bond. Such notices may be sent by personal delivery, commercial courier or by United States Registered or Certified Mail, return receipt requested, postage pre -paid, and shall be deemed to be effective upon receipt by the party concerned. 9. Surety shall cause to be attached to this Bond a current and effective Power of Attorney evidencing the authority of the officer, agent or representative who executed this Bond on behalf of Surety to execute, seal and deliver such Bond and bind the Surety thereby. 10. This Bond is intended to conform to all applicable statutory requirements. Any applicable requirement of any applicable statute that has been omitted from this Bond shall be deemed to be included herein as if set forth at length. If any provision of this Bond conflicts with any applicable statute, then the provision of said statute shall govern and the remainder of this Bond that is not in conflict therewith shall continue in full force and effect. 11. The term "Bid" as used herein includes a Bid, offer or proposal as applicable. SCHEDULE OF PROPOSED SUBCONTRACTORS Bidder proposes the following subcontractors to be used for major portions of the Project. All major subcontractors must be listed and submitted with the Bid. Bidder may change subcontractors after Bid submittal only as approved by the Engineer. Major subcontractors are those who will do work having a total value of more than five percent (5%) of the Contract amount. The maximum total value of work performed by all subcontractors on the Project shall not exceed seventy-five percent (75%) of the Contract amount. Subcontractor Address &Telephone Number Speciality Subcontract Amount 1.RW South Texas Concrete 329 E 1st Rockport TX 78382 1 361-533-6369 Concrete $57,140.00 2. Texas Road Work ElCampo Texas 77437 1979-987-1982 Painting Striping $1,276.81 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 05470.00 - SaMule of PMPo 5ubconbedon 004 00430 - 3 STATEMENT OF BIDDER'S QUALIFICATIONS All questions must be answered and the data given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he desires. Name of Bidder: Derrick Construction Company Inc. Address: Physical Address: 250 S Cove Harbor Rockport, Texas 78382 Mailing: PO Box 1046 Rockport Texas 78381 Date Organized: 1955 Date Incorporated: 1990 Number of years in contracting business under present name: 34 CONTRACTS ON HAND: Contract Dollar Amount Completion Date Shireley & Sons 2,268,650.00 10/11/2024 Type of work performed by your company: Marine Construction & Civil Construction Have you ever failed to complete any work awarded to you? No Have you ever defaulted on a contract? No List the projects most recently completed by your firm (include projects of similar importance): Project Dollar Amount MoNr Completed ACND Rockport Harbor Sewall Storm Damage & Adjacent Roadway $486,846.00 03/15/24 Lamar Improvement District Permeable Walkway, Retaining Wall, Drainage Improvement eat $765,001.00 03/14/2024 City Of Port Aransas Pier Reconstruction $4,012,859.40 01/09/2023 City Of Port A Pier Reconstruciton Roberts Point Pier & Charlies Pasture Pier $4,049,285.39 08/29/23 E264700o- stalement of adders auMmUoos OW4 00450 -1 Major equipment available for this contract: Excavator 300 Vibrohammer (IF)(as needed) Dozer, Skidsteer, Mini Excavator, Trench Roller, Long Reach Excavator Company Owned: Tugs, Truckable Tug & Barges ext... (See Attached Equipment List) Executed this 10 day of October 2024 29' By. Director Of Operations I Treasure 17 (Signature) (Title) Derrick Johnson (Print Name) State of Texas County of Aransas Sworn to and subscribed before me this 10 day of October 2024 M SERENITffY DAWN11898ALLEN ID D FGbnWs%M E25470.00- Statement of Biddees Qualilcations 004 NotaDtgignature Serenity Allen Printed Name In and for the State of Texas Commission Expires 0220.2025 00450 - 2 STATE OF TEXAS COUNTY OF Aransas Derrick Johnson AFFIDAVIT being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Director Of Operations ( Treasure of Derrick Construction Company Inc.. having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at Physical Address: 250 S Cove Harbor Rockport, Texas 78382 1 Mailing: PO Box 1046 Rockport Texas 78381 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun Countythe attached bid/proposal; that he orshe is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Aff)antfurther deposes and says: that priorto the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, rees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the con it ns and quirements contained in the bid/proposal. Signature of Aff) t Derrick Johnson Treasurer ( Director Of Operations Printed Name and Title of Affiant 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 10 day of October IS SERENITY DAWDAILEN ID #128911My CommissionFebruary 20. Notary Stamp/Seal 2024 . na uPe fNota Public Notary Sereniity Allen CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by N.B. 23, 64th 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. 1J Name of vendor who has a business relationship with local governmental entity. Derrick Construction Company Inc. a ® Check this box If you am 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.) 2J Name of local government officer about whom the Information is being disclosed. N/A Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and 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 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? FlYes a No 21 Describe each employment or business relationship that the vendor named In Section I 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. General Contractor BID 2024.29 - Calhoun County "Bill Sanders Park - Swan Point Bulkhead & Pier Construction - Seadrift Texas 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 des in S Ion 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 6&L 10/10/2024 Signature of vet r doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 1/1/2021 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity A complete copy of Chapter 176 of the Local Government Code maybe found at httpV/www.statutes.legis.state.tx.us/ Doca/LG/htm/LC3.176.htm. For easy reference, below are some of the;sections cited on this form. Local Government Code A 176.001(1-al: "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code A 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in tlje officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (I) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor, (B) has given to the local government officer or a family member of the officer one or more gifts - that have an aggregate value of more than $106 in the 12-month period preceding the datethe officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (fi) the local governmental entity is considering entering into a contract with the vendor. Local Government Code Ii 176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value speciffed by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the [oral governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Sub' ection (a); (B) that the vendor has given one or more giftddescribed by Subsection (a); or (C) of afamily relationship with a local government officer. Form provided by Texas Ethics Commission w .ethics.state.tx.us Revised 1/1/2021 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 excludedfrom 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. Derrick Johnson Treasurer I Director Of Operations 10/10/2024 Name and Title of Authorized Agent gignatureVof Authorized Agent I am unable to certify to the above statements. My explanation is attached. Date DEBARMENT & Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section S. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency) responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. i Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programsland activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelihes. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This' certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Adminisration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. 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 Infiuence 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). Derrick Construction The Contractor, Company 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. �2& Signature of gefitractors Authorized Official Derrick Johnson Treasurer I Director Of Operations Printed Name and Title of Contractor's Authorized Official 10/10/2024 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 a. initial filing _ b. grant b. initial award _ b. material change c. cooperative agreement c. post -award it. 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 X Prime _ Subawardee Name and Address of Prime: Tier_, if Known: Congressional District, if (mown: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, tfapplicable: S. Federal Action Number,ifknown: 9. Award Amount,fknown: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if Individual, last name, fitsinatne, MI): dierentfrmn No. 10a) Derrick Construction Company Inc. (lasi name, first name, M1): 250 S Cove Harbor Rockport, Texas 78382 It. information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material Derrick hnson representation of fact upon which reliance was placed Print Name: by the der above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: Director Of Operations I Treasure 361-729-2423 10/10/2024 Telephone No.: Date: U.S.C. 1352. This Information will be reported to the Congress semi-aunuaBy 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) INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material dhange to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all Items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a'follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. B. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number, Invitations for Bid (IFB) number, grant announcement number; the contract, grant, or loan award number; the appllcadon/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-9D-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to Influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless It displays a valid OMB control Number. The valid OMB control numbr for this information collecion Is OMB No. 0348. 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instruc5ons, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of Information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0346-0046 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85"' Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Derrick Johnson . do hereby verifythe truthfulness and accuracy of the contents of the statements submitted on this certification underthe provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https•//comptroller texas eov/purchasine/publications/divestment oho Derrick Construction Company Inc. Derrick Johnson of Authorized Official Printed Name of Authorized Official Treasurer & Director Of Operations 10110/2024 Title of Authorized Official Date 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. ❑ 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. 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 Derrick Construction Company Inc. Is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. - 0- -,?dl - Signature of Aut ized Agent Derrick Johnson Treasurer I Director Of Operations Printed Name and Title of Authorized Agent 10/10/2024 Date INSERT SYSTEM FOR AWARD MANAGEMENT (SAM) RECORD SEARCH FOR COMPANY AND COMPANY'S PRINCIPAL(S) Company, Corporation, Firm or Partnership, and its Principals, must not be debarred or suspended. nor otherwise on the Excluded Parties List System (EPLS) in the System for Award Management (SAM) or the State of Texas Comptroller Debarred Vendor List and must have an active registration with the System for Award Management (www.SAM.gov). Include verification that your Company, Corporation, Firm or Partnership is registered and that the Company, Corporation, Firm or Partnership, and its Principals, are not listed (are not debarred) through the System for Award Management (www.SAM.gov). Include a printout of the search results that includes the required information and the record date. Lwnrpdared by 5ereniry Allen on Jwr 20. 2024 ar 12:23 PM DERRICK CONSTRUCTION CONPANYLVC ,=,SAM.00ve DERRICK CONSTRUCTION COMPANY INC Unique Entity ID CAGE / NCAGE Purpose of Registration KNJXKB84GLD7 1U3V4 All Awards Registration Status Expiration Date Active Registration Jun 20, 2025 Physical Address Mailing Address 250 Cove Hbr N PO Box 1046 Rockport, Texas. 78382-7457 Rockport, Texas 78381-1046 United. States United States Doing Business as Division Name .Division Number (blank) Derrick Construction Company Inc (blank) Congressional District State Country of incorporation URL Texas 27 Texas I United States http:l/www.derrickeonstruction.net Registration, Dates Activation Date Submission Date Initial Registration Date Jun 24, 2024 Jun 20, 2024 Aug 28, 2001 Entity Dates Entity Start Date Fiscal Year End Close Date Mar 1, 1990 Doc 31 Immediate Owner CAGE Legal Business Name (blank) (blank) ' Highest Level Owner CAGE Legal Business Name (blank) (blank) Executive Compensation In your business or organization's preceding completed fiscal year, did your business or organization (the legal entity to which this specific SAM record, represented by aUnique Entity ID, belongs) receive both of the following: 1.80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperalive agreements and 2. $25.000.000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, andlor cooperative agreements? No Does the public have access to information about the compensation of the senior executives in your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) through periodic reportsfiled under section 13(a)or 15(d) of the Securities Exchange Act of 1934 (15U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Not Selected. Proceedings Questions Is your business or organization, as represented by the Unique Entity ID on this entity registration, responding to a Federal procurement opportunity that contains the provision at FAR 52,209-7, subject to the clause In FAR 52.209.9 in a current Federal contract, or applying for a Federal grant opportunity which contains the award term and condition described in 2 C.F.R. 200 Appendix XII7 Yes Does your business or organization, as represented by the Unique Entity ID on this specific SAM record, have current active Federal contracts and/or grants with total value (including any exemised/unexamised options) greater than $10,000,000? No Wthin the last five years, had the business or organization (represented by the Unique Entity ID on this specific SAM record) and/or any of Its principals, in connection with the award to or performance by the business or organization of a Federal contract or grant. been the subject of a Federal or State (1) criminal proceeding resulting in a conviction or other acknowledgment of fault; (2) civil proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000, or other acknowledgment of fault; and/or (3) administrative proceeding resulting In a finding of fault with either a monetary fine or penalty greater than $5,000 or reimbursement, restitution, or damages greater than $100,000, or other acknowledgment of fault? Not Selected Pnge 1 of5 Lwr uydmerl by Sr ..ii A. 202024 n112r23 PM DERRICK CONSTRUCTION COMP ANY MC Active Exclusions Records? No I authorize my enittys non -sensitive information to be displayed in SAM public search results: Yes Business Types Entity Structure Entity Type Organization Factors Corporate Entity (Not Tax Exempt) Business or Organization Limited Liability Company Profit Structure For Profit Organization SCclo-Economic Types Self Certified Small Disadvantaged Business Women -Owned Small Business Women•Owned.Business Check the registrant's Reps & Carts, If present under FAR 52.2123 or FAR S2.21&1 to determine If the entity Is an SBA -certified HUBZone small business concern. Additional small business Information may be found in the Si Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration. Accepts Credit Card Payments Debt Subject To Offset No No EFT Indicator CAGE Code 0000 1U3V4 Electronic Funds Transfer Account Type Routing Number Lock Box Number Checking •*""•76 (blank). Financial Institution Account Number CHARTER BANK ..05 Automated Clearing House Phone (U.S.) Email Phone (non-U.S.) 3617907676 csmithgcharterbankcc.com (blank) Fax 3617908920 Remittance Address DERRICK CONSTRUCTION CO., INC. PO Box 1046 Rockport, Texas 78381 United States EIN Type of Tax Taxpayer Name *`**•9812 Applicable Federal Tax .DERRICK CONSTRUCTION COMPANY INC Tax Year (Most Recent Tax Year) NameMile of Individual Executing Consent TIN Consent Date 2007 Vice President Jun 20, 2024 Address Signature 250 Cove Harbor S ROY M JOHNSON Rockport, Texas 78302 Accounts Receivable POC A Serenity Allen, Accounts Receivable Ocr 08, 202406:00:53 Pi GnPr://sanr.xm✓earOrYR�J.\'K884GLD7lcnnUnrn?emnu=null 1'uxe2ofS Lan npd01cdb)P Serenhy Allen on Jim 20.2024 a112:23 PM DERRICK CONSTRUCTION COAIPANY 1NC serenity($derickconstruction.nat 3617292423 Electronic Business 9 PO Box 1046 Serenity D Allen, CFO Rockport, Texas 78381 serenity@cIerrickconstructlon.not United States 3617292423 0 (Non -US Phone) Dylan R Turner, Project Manager Pn Sox 1046 dylan@denickconstmc0on.net Rockport, Texas 78381 3617292423 United States 0 (Non -US Phone) Government Business A PO Box 1046 Dylan R Turner, Project Manager Rockport, Texas 78361 dylan@derdckconstruction.net .United States 3617292423 0 (Non -US Phone) Serenity Allen, CFO PO Box serenity@denickoonstruction.net Rockport, Texas 78381 3617292423 United States 0 (Non -US Phone) Party Performing Certification POC S - PO Box 1046 Serenity D Allen, CFO Rockport, Texas 78381 serenity@derickconstmetlon.net United States 3617292423 0 (Nan -US Phone) Past Performance 9 PO Box 1046 Dylan Turner, Project Manager Rockport, Teems 78381 dylan@demckconstruction.net United States 3617292423 0 (Non -US Phone) Dylan R Tumor, Project Manager PO Box 1046 dylan@derdckconstmodon.net Rockport, Texas 78381 3617292423 United States 0 (Non-USPhone) NAICS Codes Primary NAICS Codes NAICS Title Yes 237990 Other Heavy And Civil Engineering Construction 213112 Support Activities For Oil And Gas Operations 235210 Industrial Building Construction 237120 Oil And Gas Pipeline And Related Structures Construction 238990 All Other Specialty Trade Contractors 483211 Inland Water Freight Transportation 483212 Inland Water Passenger Transportation 488310 Port And Harbor Operations 488390 Other Support Activities For Water Transportation 813312 Environment, Conservation And Wildlife Organizations Product and Service Codes 01108. 2024 06:00:53 PMGArr `MOu://sum gav/emigdKNJXKB84GLO]/mreDom7eralusanlAl Pnge 3nfs Lev r p*wdhy SemdIy A&,, mr Jun 20. 2024 nt12:23 PAr DERRICK CONSTRUCTION COMPANY INC PSC PSC Name P100 Selvage -Preparation And Disposal Of Excess/Surplus Property P300 Salvage -Marine Vessels P400 Salvage- Demolition Of Buildings P500 Salvage- Demolition Of Structures/Facilities (Other Than Buildings) P999 Salvage. Other V119 Transportation/rravGURelocatlon-Transportation: Other V124 Transportetionrrravel/Relocation-Transportation: Marine Charter Y1JZ Construction Of Miscellaneous Buildings Y1KA Construction Of Dams Y1KB Construction Of Canals Y1KF Construction Of Dredging Facilities Y1KZ Construction Of Other Conservation And Development Facilities YILS Construction Of Highways, Roads,Streets, Bridges, And Railways Y1LZ Construction Of Parking Facilities Y1PC Construction Of Unimproved Real Property (Land) Y1PD Construction Of Waste Treatment And Storage Facilities Y1PZ Construction Of Other Non -Building Facilities Y112A Construction Of Restoration Of Real Property (Public Or Private) Z1JZ Maintenance Of Miscellaneous Buildings Z1KA Maintenance Of Dams Z1KB Maintenance Of Canals Z1 KF Maintenance Of Dredging Facilities Z1 KZ. Maintenance Of Other Conservation And Development Facilities Z1L8 Maintenance Of Highways,. Roads, Streets, Bridges, And Railways Z1LC Maintenance Of Tunnels And Subsurface Structures Z1PC Maintenance Of Unimproved Real Property (Land) Z1PD Maintenance Of Waste Treatment And Storage Facilities Z1PZ Maintenance Of Other Non -Building Facilities Z1QA Maintenance Of Restoration Of Real Property (Public Or Private) Z2ED Repair Or Alteration Of Ship Construction And Repair Facilities Z2JZ Repair Or Alteration Of Miscellaneous Buildings Z2KA Repair Or Alteration Of Dams Z2K8 .Repair Or Alteration Of Canals' Z2KF Repair Or Alteration Of Dredging Facilities Z2LB Repair Or Alteration Of Highways, Roads, Streets, Bridges, And Railways Z2LZ Repair Or Alteration OF Parking Facilities 1GT Size Metrics Annual Revenue (from all IGTs) Oa 08. 202406:M.-33 PMGMT fnryu://mm.gav/ nRry /KNJXKB84GLD7/mreDum?slalu+=nrdf Alp 4o.f5 Lot updated by Screnln Allen on Jnu 30. 2024 at I?:25 PAf (blank) DERRICK CONS'TRUCTIONCOAIPANYINC Worldwide Annual Receipts (in accordance with 13 CFR 121) Number of Employees (in accordance with 13 CFR $6.00 121) 30 Location Annual Receipts (in accordance with 13 CFR 121) Number of. Employees (in accordance with 13 CFR (blank) 121) (blank) IndustrySpeciffc Barrels Capacity Megawatt Hours Total Assets (blank) (blank) (blank) This entity did not enter the EDI information Yes, this entry appears in the disaster response registry. Yes, this entity require bonding to bid on contracts. Bonding. Levels Dollars Construction Aggregate $30,000,000.00 Service Aggregate $30,000,000.00 Service Per Contract $10,000,000.00 Construction Per Contract $10,000,000.00 States Louisiana Mississippi Texas Counties (blank) Metropolitan Statistical Areas (blank) Orr 08. 2024 06. 00. 53 AW GAJP MIX .'Aw-&ovkmiry1KNJXKB84GLull P,x, 5, f5 Request for Taxpayer Give Form to the Form tob (Rev.Ocer2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to vinvur lrs.gov(FormW9 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. DERRICK CONSTRUCTION COMPANY INC 2 Business name/disregarded entity name, if different from above m. 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codesapply only to following seven boxes. certain entities, not individuals; see a p ❑ Ini ividuaysole proprietor or ❑ C Corporation 91 S Corporation Cl Partnership ❑ Trust/estate Instructions on page 3): aG single-membsr LLC Exempt payee code (if any) ao ,� � ❑ Umit¢d liability company. Enter the tax classification (C=C corporation, S=Scorporetioo, P=Pannership) ► `a 2 Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Donotchack Exemption from FATCA reporting to 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-membar LLC flat code Of 9 y) a .,0E is disregarded from the owner should check the appropriate box for the tax classification of its owner. 2 ❑ Other(ses instructions) ► wan •sroesume wmm oro dx mau.sl y 5-Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) m 250 COVE HARBOR SOUTH 6 City, state, and ZIP code ROCKPORT TX 78382 7 Ust account number(s) here (optional/ MAILING ADDRESS PO BOX.1046 ROCKPORT TX 78381 Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given online 1 to avoid I social security number backup withholding. For Individuals, this is generally your social security number (SSN). However, for a - m _ resident alien, sole proprietor, or disregarded entity, see the instructions for Pert 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 iderlW moon number Number To Give the Requester for guidelines on whose number to enter. r"n i]�C©©OF7[lfi�� 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, yore not required to sign the Certification, but you must provide your correct TIN. See the instructions for Part 11, later. 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 after they were published, go to www.irs.goviFormW9. 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► 1L.J i • Form 1099-DIV (dividends; including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant Card and third parry network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C(canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not 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) I)crrick Consh-liclion Compl-M.N. I I]c O-veriliew Derrick Construction (DCCI) has served the Texas coast for more than 60 years. DCCI is recognized as a diversified Marine and Civil construction company located on the Intercoastal Waterway allowing the means for expedited mobilization of all equipment to any region along the Texas Gulf Coat. Experienced in many faucets of Marine and Civil Construction, DCCI works in all bodies of water along the Texas Coast including bays, canals and estuaries. As a experienced Civil and Marine company, DCCI has ,V,RRJrCJ, completed many debris removals, derelict vessel i " removals, disposal projects, underwater oil and ' gas pipeline installation and removal projects. CONSTRUCTION CO DCCI has executed many regulated contracts TEXAS GOLF COAST with the Texas General Land Office, Texas Parks and Wildlife, Texas Railroad Commission and local Navigation districts. DCCI has been utilized as a general contractor for many various scopes of marine and civil construction, as well as facilitate with the contract's coordinator to determine the process and precautions to be taken removing hazardous debris. DCCI is a HUB certified woman owned and operated company comprised of more than 35+ highly skilled and trained personnel. A company who prides on their many years of trusted experience, the integrity of their work and the long standing relationships built with clients. Located in Rockport, TX DCCI always looks forward to serving the Texas Coast. Page I DERRICK CONSTRUCTION COMPANY, INC 250 South Cove Harbor Rockport, TX 78382 www.derrickconstruction.net Company Narrative: Derrick Construction Company, Inc. (DCCI) is in Rockport, Texas. Our headquarters lie on the Intercoastal Waterway which provides the means for expedited mobilization of all necessary equipment to any region along the Texas Gulf Coastline. DCCI is capable and willing to work in all regions along the Texas coast, including all bays, canals & estuaries located within those regions. All marine and land -based equipment needed for the proper removal and disposal of submerged, derelict, and abandoned structures as well as decommissioning and removal of offshore oil and gas facilities are readily available with Coast Guard approved & DCCI owned equipment. With our experienced and Certified Dive Team, we can complete bottom surveys to ensure the scope of work is completed. Our equipment is capable of mobilization into water as shallow as 2 1h ft. to deep waters along the coastline. DCCI is qualified and trained to decommission oil and gas facilities, remove, and dispose of pipelines and any submerged or derelict pilings and structures as outlined in this solicitation properly and safely. DCCI has over 50 years of experience in the marine & Civil construction industry. DCCI has executed many regulated contracts with the Texas General Land Office, Texas Parks & Wildlife, Texas Railroad Commission, and local Navigation Districts. DCCI has removed small & large platforms, boats, barges, vast pipelines, derelict pilings & structures. DCCI has strategically sunk barges for artificial reefs, built extensive bulkheads and marinas. DCCI is also very knowledgeable in the oil and gas industry. We have completed scopes of work from the maintenance of platforms, installation and/or removal of pipelines, plug and abandonment of facilities to emergency oil spill cleanups. DCCI has been utilized as a general contractor for all scopes of marine cleanup & construction, as well as facilitate with the contract's coordinator to determine whether and how hazardous debris should be handled and disposed of with regulations. After Hurricane Katrina, DCCI completed a contract with Vintage Petroleum in Louisiana to remove & dispose of debris (some hazardous) blocking & prohibiting production of pipelines/facilities in the Houma, LA area. DCCI removed, sorted, transported all types of wet debris from the area & disposed of debris as specified by contract owner and regulations. The compressor stations, platforms & pipeline ruins were transported by barge to a facility to dispose of in accordance to contract while other debris was transported via land based equipment to sort and transport all debris to the appropriate disposal sites and/or recyclable material sites. Some of the debris removed included hazardous tank batteries, asbestos insulation from destroyed tanks, creosote piling, laid over platforms, remrtants from Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 1361.729.2423 Fax 361.729.1218 Page 12 destroyed structures, platforms, pipelines, and natural gas compressors from the shallow bayous of South Pass and West Bay (2-8 ft depth). Hurricane Harvey devastated the Texas Gulf Coast with a direct hit to Rockport, Texas where DCCI's Main Office is located. DCCI's crews returned to work immediately after the storm had passed and started the cleanup process. DCCI salvaged many vessels and assisted with dock demolitions, repairs, and rebuilds. DCCI also assisted the electric companies with the removal of the broken power poles and power lines to the installation of the new power poles that had to be placed in the water for the surrounding towns. The Texas General Land Office awarded the debris clean up contract to DCCI to salvage and properly, dispose of vessels that were destroyed by Harvey. DCCI had project sites in the Rockport and Dickinson, Texas to complete the scope of work which involved almost 200 vessels along the gulf coast. DCCI has vast experience in marine derelict structure removal and cleanup as well as land cleanup and is equipped to handle any level of cleanup along the Texas Gulf Coast. With our fleet of marine vessels to gather and transport debris to a designated sort/lay down facility on land, and our land - based equipment to sort and transport all debris to the appropriate disposal sites and/or recyclable material sites, DCCI is experienced, equipped and prepared to facilitateany removal & cleanup projects. We at DCCI strive to maintain our project site locations with minimal environmental impact. DCCI completed a casing contract for BNP and the site was located within a sea turtle nesting zone on Maliki Beach north of Padre Island. During this experience, DCCI was instructed on patrolling for tracks and on many occasions, the job was "on hold" as crews would wait significant periods of time for turtles to cross, etc. Extreme precautions were made to protect the sea ,turtles and their environment. DCCI offers a variety of services including but not limited to: Civil & Marine Construction Tug and Barge Leasing Pipeline Burial and Removal Vessel Salvage & Disposal Platform Fabrication and installation Wellhead Hookups Mechanical & Hydraulic Dredging Sandblasting and Painting Pile Driving and Removal Maintaining Rig Locations Various Disaster Relief Efforts Bulkhead Construction Well Guard Fabrication and Installation Plug 4 Abandonment of Wells Construction of Marinas and Docks Shore Guard Erosion & Protection Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 13 All Derrick Construction Company, Inc (DCCI) equipment is Coast Guard approved and DCCI owned. Our equipment is capable of mobilization into water as shallow as 2 ih feet to the gulf waters. DCCI has executed many regulated contracts with the Texas General Land Office, Victoria Navigation District, Aransas County Navigation District, Texas Parks and Wildlife, Texas Railroad Commission, and other surrounding Navigation Districts. DCCI has removed small and large platforms, all sizes of vessels, submarines, barges, vast amounts of pipelines, derelict pilings, and structures. DCCI has strategically sunk barges for artificial reefs, built extensive bulkheads and marinas as well as emergency oil spill cleanup and P & A of wells. DCCI has been utilized as a general contractor for all scopes of marine clean up and construction, as well as properly disposing of hazardous debris. Whether considering the utilization of our large capacity cranes to lift sunken vessels, our experience in demolition and removal of buildings, vessels, platforms, pipelines, and various infrastructure remains after previous disasters, DCCI has the experience, capability and equipment needed to complete all aspects of the marine debris removal and disposal as well as all oil field related projects. DCCI has worked for many oil and gas companies such as EOG, Cinco Resources, Cheniere Energy, Southcross, Sabco, White Marlin, Vintage Petroleum, Lamar Oil and Gas, Magnum Engineering, Neumin Production, BNP, Petro Hunt, Matagorda Resources, Copano Resources, Kinder Morgan and Gold King among others. Over the last 50 years, DCCJ's main specialties have been pipeline installation, maintenance, and removal, bulkhead/boat ramp repair or replacement, vessel and debris removal and disposal, and mechanical/ hydraulic dredge work. DCCI is an environmentally conscious company that has not had any environmentally detrimental spills during operations. From the plugging jobs for the Texas Railroad Commission to the various projects we have completed for our oil and gas production clients, DCCI is extremely cautious when it comes to the environmental aspects of each project. Each project depicts its own unique environmental challenges and DCCI is well -versed in providing the proper equipment and procedures for each individual circumstance. DCCI has vast experience in marine derelict structure removal and cleanup as well as land clean up and is equipped to handle any level of cleanup along the Texas Gulf Coast. With our fleet of marine vessels to gather and transport debris to a designated sort/lay down facility on land and our land - based equipment to sort and transport all debris to the appropriate disposal sites and/or recyclable material sites, DCCI is experienced, equipped and prepared to facilitate any removal & cleanup projects. Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 14 Company Profile: Derrick Construction Company, Inc. (DCCI) is in Rockport, Texas. DCCI is HUB certified and Woman Owned (Certificate# 1 742569812700). We are bonded and fully insured for all Land and Marine Construction. Derrick Construction began its legacy in the !marine business in 1959 under the name Fulton Boat Yard. The company's name changed to Derrick Construction Company, Inc. and was incorporated under the laws of Texas in 1990. With many years in Marine Industry, Derrick Construction Company, Inc. has become extremely diversified in this field. DCCI is capable and willing to work in all regions along the Texas Gulf Coast, including all bays, canals and estuaries located in those regions. DCCI has successfully completed many debris removal, derelict vessel removal and disposal projects, and underwater pipeline installation and removal projects over the last 25 years. DCCI employs 30+ highly skilled and trained personnel,' all of which live near DCCI's office in Rockport, Texas. Of these employees, approximately 35+ employees can be assigned to any location along the Texas Gulf Coast. Derrick Construction Co, Inc. is HUB celtified (Certificate # 1742569812700). We are bonded and fully insured for all land and civil & marine construction. Derrick Construction Board of Directors Rose Johnson: President I Shareholder I HUB WO Owner Derrick Construction Company (199p - Present) Roy Johnson "Moose": Vice President I Shareholder I HUB Owner & Operator Derrick Construction Company (1967 - Present) • 45 years of experience working and supervising various types of projects throughout the Texas Gulf Coast within the Civil & Marine Construction Industry. Derrick Johnson: Director of Operations I Corporate Directo{ I Corporate Treasure I Senior Estimator • Derrick Construction Company (1994 - Present) • 25 years of experience working and supervising various types of projects throughout the Texas Gulf Coast within the Civil & Marine Construction Industry. Shane Johnson: Parts & Mechanics Superintendent 'I Corporate Secretary Project Material, Parts & Mechanic Purchasing & Inventory Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 1361.729.2423 Fax 361.729.1218 Page 15 Key Staffing Profile: Derrick Johnson Director of Operations I Senior Estimator I Senior Safety Officer • 25 + Experience Civil & Marine Construction Industry. • TWIC • First aid I CPR certified • OSHA 30 • E-Web OQ Certification's DylanTurner: Project Manager & Safety Manager I Marine Compliance GM I Junior Estimator[ • Project Manager & Safety Manager • Junior Estimator • TWIC • First aid/CPR certified • OSHA 30 • 10+ plus years of heavy marine construction. • 5+ years in civil construction • Specific Related Marine Experience: • USCG, OSHA, TX GLO Marine Compliance Manager • Marine Policy Analyst & Specialist Shane Griffith: Civil and Marine General Superintendent • OSHA 30 • First Aid/CPR certified • 100-ton Captain license and Meter towing endorsement • Over 25 years of civil and marine experience with Derrick Construction. 15 years of heavy marine construction and salvage. • OSHA 30 • First Aid/CPR certified Arthur Uehlinger. Logistics Manager, Quality Control & Marine Compliance • OSHA 30 • First Aid/CPR certified • 15+ years of experience working with barges, tugs, and vessels. Knows the Rockport waterway channels, bays and cuts. Landside equipment operations. Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 16 Reference Of Completed Projects: ACND • Rockport Harbor Pile Driving 2009 • Rockport Harbor Dredge Project 2009 • Fulton Harbor Marina Repairs - Pier Removal & Pile Drive 2010 • 140 N Cove Harbor Bulkhead Repair 2015 • Rockport Beach Boat Ramp Improvements 2016 • Rockport Harbor Maintenance Dredge 2017 • Hurricane Harvey Salvage - Cove Harbor 2017 • Leggett Channel Breakwater Repairs 2017 • Blevins Entrance Channel Repair 2021 • Cove Harbor Marina Storm Damage Repairs 2022 • Leggett Channel Light Storm Damage Repairs 2023 AIRPORT AND CHANNEL CORPORATION • Island Mooring - Dredge Port Aransas Texas - 2020 • Island Mooring - Dredge Port Aransas Texas - 2021 • Channel Light Replacement - Piper Channel - 2022 • Channel Light Replacement - Piper Channel - 2022 • Island Mooring - CM, Lights & Buoy Installation - 2023 BEPCO LP • San Jose Dredge 2019 • San Jose Island - Pile Removal & Replacement 2010 • Bass Harbor - Pulling Piling Cluster & Pike Driving 2010 • Mud Island Well Repair & Maintenance 2010 • Rockport Dock Repair's 2017 • San Jose Island Pier & Dock Fabrication & Repairs 2018 • Rockport Dock - Tie Back & Bulkhead Repairs & Fab 2019 BOPCO • Cutting and Removal, Hydro Blasting and Storage of Pipel}ne ST#390#12011 • Storm Choke Removal and Wireline & Testing of Wells2014-2016 CALHOUN COUNTY • Magnolia Beach Boat Ramp Project 2021 • Chocolate Bayo Boat Ramp Project 2022 CALLAN MARINE LTD • Pipe Line Removal & Dredge Assistance 2022 Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729,2423 Fax 361.729.1218 CABOT OIL & GAS Page 17 • Pulled Rig Pipe & Installed Wellhead, Well Cage, Flowline, & Instrument • Tubing ST#88-892011 CHAPARRALENERGY • Demolition & Removal of Platform ST 358#52009 • Pulled 6 Drive Pipe2009 • Pulled Bad 12" Section of Platform & Swedged 12 to 14" Then Piped into • Manifold2009 • Burying of Pipeline in Mesquite Bay ST 19-1 Well Guard with 40' Landing or • 20' Landing—1500-2000' a day to a depth of 3'2010 • Recovered a Sunken Vessel from Corpus Christi Bay2011 • Platform 466 Removal and Disposa12014 CHENIERE ENERGY • Platform and Pipeline Remova12016 CINCO (RILEY E)CPLORATION) • Well and Platform Repair — Buried 2.5 Pipeline @ Well for Risers2009 • Debris Removal 397 Platform2009 • Bury 6" Line for Redfish Bay Boat House2009 • Well Remova12009 • Compressor Remova12011 • Platform Repairs2012 • 343 Pipeline Repair2013 • Pipeline Leak Repair #3432014 C1TY OF ARANSAS PASS • Concrete Bulkhead Repairs 2015 CITY OF CORPUS CHRISTI • Packery Channel Dredge Project 2009 • Cole Park Fishing Pier Project 2010 • Packery Channel Marker & Piling Maintenance & Repairs 2010 • Columbus Ship NINA Project 2010 • CC Marina K-PIER Demolition 2010 • Harbor Del Sol Project H HANA 2010 Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 1 361.729.1218 Page I8 CITY OF PORT ARANSAS • Pier Demolition - Roberts Point & Charlies Pasture 2019 Pier Fabrication & Reconstruction - Roberts Point & Charlies Pasture 2022-2023 • Marina Maintenance Dredge Project 2022 - 2023 CITY OF PORT LAVACA • Bay Front Peninsula Pier Repair - 2019 • Smith Harbor Demo & Dredge Project - 2021 COASTAL CONSERVATION ASSOCIATION (CCAj • Artificial Reef Restoration - 2022 COUNTY OF ARANSAS • Saint Charles Bay Boat Ramp Project - 2017 • Goose Island Harvey Repair Project - 2020 G2CONTRACTORS • Fulton Texas Pier Rebuild - 2020 GULF COPPER • Multiple Dredge Project 2017 to 2022 ICE INLAND CONSTRUCTION & ENG • Installation of Aton Structure - 2017 • Matagorda Ship Channel Project - 2017 • Matagorda Bay Channel Marker Maintenance - 2018 • USCG Boat Demo - 2020 • USCG Port Aransas TX Dredge Project - 2021 • USCG Project Harbor Facility CC TX I Water Front Fab & Repairs 2022-2023 CM INLAND MARINE • Removal of Sunken Barge from Baffin Bay2014 COASTLAND OPERATION • Emergency Well Guard Removal from Collapse ST 141#1-';Matagorda Bay2012 EOG RESOURCES • P&A & Clean Up - Tree CH ST 688 JAVELER MARINE SERVICE • Debris Removal at Canyon Port2016 • Dredge Work2016 Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 19 JM DAVIDSON • UT MSI Pier Project — Pier Rebuild 2019-2022 • POCC Oil Dock 3 Dredge Project 2022 LAMAR IMPROVEMENT DISTRICT • Permeable Walkway, Block Retaining Wall & Drainage Improvements for The Reserve at St. Charles Bay — 2022 -2023 LAMAR OIL AND GAS • ST 706#1 Platform Repairs2009 • ST 690 #1 Compressor Remova12009 • Well Guard Repair — Well 690#42009 • ST 94 Well 3 Lay and Bury2010 • Removed Pipe from Well 99#32010 • Lay and Bury Pipeline2010 • Platform Repairs2010 • ST192 Gas Island Line PuI12012 • ST99#2 Lay and Bury Pipe Line2013 • P&A 318 & 3232015 • Well Head #22 & Line Removal 2017 • Well Services 2018 to 2020 • South Cove Harbor Dock Repair's 2023 LONG ISLAND OWNERS' ASSOCIATION • Port Isabel Dolphin Repairs • Port Isabel Swing Bridge Cluster Add On's — 2023 LUHR BROTHERS INC • Corpus Christi Ship Channel — Breakwater Repairs 2022 MAKO CONTRACTING LLC • Rockport County Club — Sheet Pile Installation 2023 NEUMIN PRODUCTION COMPANY • ST 85-2 Heater Removal2009 • ST 90-6 Removal of Structure and Equipment, Bury Flow Line and Sweep for Debris2009 • P&A Well ® Kellers Bay2010 • Rig Tending - Lavaca Bay2011 • Heater Removal — Test Wells ST 36#22012 • ST 85#2 Platform 140 Blow Down & Riser Repair2014 • Removal of Platform 140 and Disposa12017 Mailing Address P.O. Box 1046 Rockport, IX 78381 Phone 361.729.2423 Fax 361.729.1218 NEUMIN Cont... Page 110 • Removal & Disposal of South Pass Heaters, Steel Buildings, Oil Boom Contents, • & Seperator2017 PORT ARANSAS MARINA ASSOCIATION • Clines Break Water Improvement Port Aransas Project — 2020 PORT OF CORPUS CHRISTI AUTHORITY. • Shoal Dredge Project Turning Basin 2016 • Viola Basin Bulkhead Project 2017 • POCCA Rincon B Mitigation Project — 2018 • Harbor Island Demolition & Dock Project — 2019 • Clines Point Bulkhead Project — 2019 • Port Aransas Debris Clean Up • OD #10 Dock Timber Replacement • Bulk Dock Pile Drive • OD #3 Breasting Structure Removal and Replacement • OD #14 Mooring Structure Installation • OD #7 Pile Drive R.M. WALSDORF • Dredge Project — Brownville Texas - 2017 • Sub Sea 7 Dock Repair Project — 2018 • Port Of Browville Pile Installation Project — 2020 • Port Of Brownville POB — Bulk Cargo Dock Project — 2021 • Oil Dock #6 — Breakwater Protection & Bulkhead Repairs - 2022 itt•I.iNOIRS:r_�7. •.����wa • Rockport Harbor Project I Removing Two Piers & Old Dock — 2021 RUSSELL MARINE LLC • Accutrans CCC Group Bulkhead & Dredge Project — 2022 SAN PAT NAVIGATION DISTRICT NO.1 • Aransas Pass Texas Marina Repairs — 2011 SCHOENSTATT SISTERS OF MARY • Bulkhead Fab & Replacement — 2022 SFLG - Southern Fleet and Logistics Group • Port Of CC Turnign Basin — Mooring Pile Installation - 2023 I Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page i11 PETRO-HUNT CORP • Unburied & Removed 12,538' of Pipeline for ST 143#1 —Aransas Bay2012 c._t'_t•• • • P&A of 10 Wells — 455-12-05382012 • P&A of 20 Wells — 455-12-07672012 • P&A of Well 3 in Alligator Bayou2015 • Platform Repairs — 39#7, #3482016 SIGNET MARITIME CORPORATION • Debris Removal (Tires & Steel)2015 SOUTHCROSS ENERGY LLC • Burry St Charles Bay Pipeline2014 SOUTHERN WORK OVER RIG • Well Head Removal 459#62014 • P&A of Well 85-22014 • Rig Support & Equipment Services 1997 — On Going As Needed SUB SEA 7 • Port Isabel (1901 Port Rd) Dredge Project— 2015 • Dredge Ingleside Spool Basin & Pile Installation — 2021 • SBASE114-Spoo lBase Navigation Markers Ingleside — 2023 TERRACON CONSULTANTS, INC • Harbor Island Bore & Operation Support Project — 2019 • Coastal Bend Mooring & Marine — Water Boring — 2020 • CC Ship Channel Water Boring — 2022 • Core Support - CC Ship Channel — 2023 • Port of Corpus Christi Harbor Island VLCC Berths (2021) • Port of Corpus Christi Avery Bulk Dock (2022) • Port of Corpus Christi Multi -Dock Dredge Material Sampling (2022) • Port of Corpus Christi New Bulk Dock (2023) TEXAS A&M CORPUS CHRISTI • Artificial Reef Construction In Copano Bay —2011 • Artificial Reef Construction In Aransas Bay — 2012 • Artificial Reef Construction In ST Charles Bay — 2017 • Platform Removal & Pile Drive A&M Shoreline CC — 2020 • Aransas Bay Mission Estuary Reef's- 2020 • Goose Island Barrier Reef Installation — 2021 • Oyster Reef Rebuild Habitat Fisheries - St Charlies Bay (Crasspsta Virginica) — 2022. Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 112 Texas A&M Cont... • St Charles Bay - 5 -Oyster Reef Add On's - 2022 • Harbor Island Platform Project - 2022 • MODA/Enbridge I -Beam MOD and Bracket FAB - 2023 TEXAS GENERAL LAND OFFICE • Pier Removal Galveston2009 • Removal of Exposed Pipeline Trinity Bay2009 • Removal of Abandoned Vessel Laguna Madre2012 • Galveston Platform Remova12013 • Arroyo Colorado Structure Remova12013 • Cabin and Decking Removal Upper Laguna Madre2014 • Semi -Truck Recovery Galveston Bay2014 • Derelict Vessel Removal - Matagorda2015 • Vessel Removal - San Antonio Bay2016 • Multi Structure & Vessel Removal and Disposa12016 • Copano Bay Platform Removal 2023 • Derelict Vessel Removal 2023 TEXAS PARKS & WILDLIFE • Oyster Clutch RFP # 802-21-45259 THE ISLANDS OF ROCKPORT • Bubble Skirt Pile Project -Compressor - 2014 THE LIGHTHOUSE INN AT ARANSAS BAY • Pier Demo & Repair - Hurricane Hanna Project - 2020 THE RESERVES AT ST. CHARLES BAY • CANAL DREDGE PROJECT - 2018 TOLUNAY-WONG ENGINEERS • Core Drilling Support - Victoria Barge Canal - 2016 • Core Sampling Support - Point Comfort - 2017 • Core Sampling Support - Victoria Barge Canal - 2018 • Core Sampling Support - CC Ship Channel - 2018 • Core Sampling Support - Sherwin Docks - 2019 • Core Sampling Support - Multiple Location 2019 through �022 Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 113 TTL, INC • Civil Construction -Avery Point -Pipeline Removal Land & Earth Work- 2022 VICTORIA NAVIGATION DISTRICT • District Repair / Add Fenders - 2015 • North Gen Dock Repair on North Gen Dock & Fender - 2016 • Repair on North Gen Dock & Fender - 2016 • Port Of Victoria - Dredge Project - 2020 WHITE MARLIN OIL & GAS COMPANY LLC. • #49 Platform Removal and Disposa12015 Direct Client Reference's: Lavaca Pile Line Company Project Removal of Two Platforms and Line Flushing Project Contract Amount: $265,000.00 Start Date: 08/15/2019 Completion Date:10/18/2019 DCCI - Key Staff: Director of Operations, Project Manager, Safety & Quality Control, Superintendent, Operator's, Skilled Laborer's, Captain, and Deckhand. Client POC: David Gaskamp Email: davidgaskampCrftpc.fpcusa.com • Port Of Corpus Christi Authority Project 18-033B - HARBOR ISLAND - DEMOLITION OF EXISTING DOCKS Project Contract Amount: $5,403,065.68 Start Date: 01/14/19 Completion Date: 09/02/19 DCCI - Key Staff: Director of Operations, Project Manager, Safety & Quality Control, Superintendent, Operator's, Skilled Laborer's, Captain, and Deckhand. Client POC: Eileen Elizondo , Office: 361.885.6242 Email: eileen@pocca.com Riley Exploration Operating Company, LLC Project Platform Demolition & Removal 349-1 1 349-2 1 349-7 Project Contract Amount: $1,009,436.73 Start Date: 07/16/19 Completion Date: 09/10/19 DCCI - Key Staff: Director of Operations, Project Manager, Safety & Quality Control, Superintendent, Operator's, Skilled Laborer's, Captain, and Deckhand. Client POC: Harold Atkinson Office: 281.684.0969 Email: harold@rileypermian.com Major Subcontractor's In addition to the requirements, Derrick Construction will identify any major or minor subcontractors that will be utilized on this project in the forms in this solicitation. The percentage of performance for all subcontractors that may be used will be reflected in. Derrick Construction does not hold any financial interest in any of the major or minor subcontractors listed in this contract solicitation response. Derrick Construction will utilize all required forms as outline in this contract, if awarded this project. Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 fax 361.729.1218 Page 114 Litigation History Derrick Construction Company, Inc. is not involved in any current litigation; nor has it had any contract failures. Historical Underutilized Business (HUB) Derrick Construction [DCCI} is recognized as a state Underutilized HUB entity, in addition to being a HUB entity DCCI will utilize partners in the Comptroller's Mentor Protege Program when available. DCCI is CMBL registered in addition to SAM's active registration status. Conflicts DCCI foresees no potential conflicts of interest; including all existing or prior arrangements. DCCI does not currently have any activities of affiliated or parent organization and individuals to list in this sol. Annual Report Available Upon Request Safety Information Derrick Construction [DCCI} has implemented procedures and policies regarding safety to be utilized during day-to-day operations. DCCI has several protocols in place to ensure the safety for employee's and all personnel while conducting daily work operations. Each daily protocol is tailored to project specific information, which is utilized by the crew per each project. DCCI has several onsite and website training for all employees. All training certifications are maintained and currently up to date. Policies are available upon request. Derrick Johnson: Senior Safety Manager derrick@ derrickconstruciton.net Dylan Turner: Project Manager & Safety Manager dvlan@derrickconstruciton.net EMR Report — Available Upon Request Quality Control Program Derrick Construction [DCCI} is committed to providing expert ;quality work and have been applying this practice for over 50 years. DCCI's appointed Quality Control person is responsible the following but not limed to reviewing progress, operations, equipment, and materials used on projects daily with the companies Director of Operation, Project Manager, Project Superintendent and the DCCI staffed team. DCCPs objective is to guarantee performance of the work to the required contract standards for materials, workmanship, construction, finish, functional performance, and identification. In-house quality assurance requirements apply to both on - site and off -site fabrication, all construction materials, and operations, and specifically include all required inspections, tests and submittals per every solicitation and or contracts. Further information may be provided upon request. Arthur Uehhnger: Logistics Manager & Marine Compliance & Quality Control arthur@derrickconstruction.net Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 115 Cost Control Program Derrick Construction utilize all resources in effort to provide the best quality and cost-efficient material and or subcontracting services for all projects. For over 50 years DCCI has been able provide cost efficiency & quality of work and material to all our clients and perspective clients. Please assess the technical narrative for the cost control plan information for this solicitation. Non -Conclusion Affidavit Inserted Upon Solicitation Request Performance & Payment Bonds Upon award Derrick Construction will be able to provide the Performance & Payment bond as outlined in this solicitation. All bonds are generated through RLI Surety and in compliance with all requirements within this solicitation Attached {Insert} Derrick Construction's Bid Bond (If Required DCCI Insurance Carriers Information The Cincinnati Casualty Company I Surety State Of Corporation —Ohio 6200 South Gilmore Road Fairfield Ohio 45014-5441 Main 513-870-2000 1 Claims 1-800-635-7521 Starr Indemnity & Liability Company 399 Park Avenue, 9te Floor New York, NY 10022 Texas Mutual Insurance Company P.O. Box 12058 Austin, TX 78711-2058 State Auto Property & Casualty Insurance Company 518 East Broad StSreet Columbus, OH 43215 Continental Casualty Company CNA Plaza Chicago, IL 60685 Lloyd's c/o Trident Marine Managers 14425 Torrey Chase Blvd, Ste 200 Houston, TX 77014 Continental Insurance Company CNA Plaza Chicago, IL 60685 Water Quality Insurance Syndicate c/o Woodlands Insurance Services, LLC P.O. Box 8369 The Woodlands, TX 77387 XL Specialty Insurance Company 505 Eagleview Blvd, Ste 100 Exton, PA 19341-1120 Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 Page 116 Remaining Page Left Blank....... Mailing Address P.O. Box 1046 Rockport, TX 78381 Phone 361.729.2423 Fax 361.729.1218 DERRICK CONSTRUCTION COMPANY, INC 250 South Cove Harbor Rockport, TX 78382 , www.derrickconstruction.net Ai CORPORATE RESOLUTION DERRICK CONSTRUCTION COMPANY, INC. I HEREBY CERTIFY IT WAS RESOLVED BY A QUORUM OF THE DIRECTORS OF DERRICK CONSTRUCTION COMPANY, INC. AT THE MEETING ON THE 20TH DAY OF DECEMBER 2022, THAT PRESIDENT ROSE JOHNSON, VICE-PRESIDENT ROY M. JOHNSON, TREASURE & DIRECTOR OF OPERATIONS DERRRICK JOHNSON & CHIEF FINANCIAL OFFICER SERENITY ALLEN BE AND HEREBY HAVE AUTHORIZATION TO EXECUTE ALL DOCUMENTS (INDIVIDUALLY OR TOGETHER) NECESSARY FOR THE TRANSACTION OF BUSINESS IN THE STATE OF TEXAS ON BEHALF OF DERRICK CONSTRUCTION COMPANY, INC. AND THAT THE ABOVE RESOLUTION WAS UNANIMOUSLY RATIFIED BY THE BOARD OF DIRECTORS AT SAID MEETING AND THE RESOLUTION HAS NOT BEEN RESCINDED OR AMENDED AND IS NOW IN FULL FORCE AND EFFECT, AND IN AUTHENTICATION OF THE ADOPTION OF THIS RESOLUTION, I SUBSCRIBE MY NAME THIS 20TH DAY OF DECEMBER 2022 SHANE JOHNSON, SECRETARY OF Derrick Construction Company Inc. Mailing Address I P.O. Box 1046 Rockport, TX 78381 Phone 1361.729.2423 Fax 1361.729.1218 . ). 61117MM,40 1 , ►. SECRETAR Y OF STATE CERTIFICATE OF INCORPORATION T DERRICK CONSTRUCTION COMPANY INC. CHARTER 01146525 The undersigned, as Secretary of State of Texas, hereby certifies that Articles of Incorporation for the above corporation duly signed pursuant to the provisions of the Texas Business Corporation Act, have been received in this Office and are found to conform to law. ACCORDINGLY the undersigned, as such Secretary of State, and by virtue of the authority vested in the Secretary by law, hereby issues this Certificate of Incorporation and attaches hereto a copy of the Articles of Incorporation. Issuance of this Certificate of Incorporation does not authorize the use of a corporate name in this State in violation of the rights of another under the federal Trademark Act of 1946, the Texas trademark law, the Assumed Business or Professional Name Act, or the common law. Mfg 6 . Secretary of S GLENN'REGAR TEXAS COMPTROLLER OF PUBLIC ACCOUNTS The Texas Comptroller of Public Accounts (CPA) administers the Statewide Historically Underutilized Business (HUB) Program for the State of Texas, which includes certifying minority, woman, and service disabled veteran -owned businesses as HUBs and facilitates the use of HUBS in state procurement and provides them with information on the state's procurement process. We are pleased to inform you that your application for certification/re-certification as a HUB has been approved. Your company's profile is listed in the State of Texas HUB Directory and may be viewed online at https://mycpa.cpa.state.tx.us/tpasscmbisearch/index.jsp. Provided that your company continues to meet HUB eligibility requirements, the attached HUB certificate is valid for the time period specified. You must notify the HUB Program in writing of any changes affecting your company's compliance with the HUB eligibility requirements, including changes in ownership, day-to-day management, control and/or principal place of business. Note: Any changes made to your company's information may require the HUB Program to re-evaluate your company's eligibility. Please visit our website at http://comptroller.texas.goviprocuremenVprog/hub/ and reference our publications (i.e. Grow Your Business pamphlet, HUB Brochure and Vendor Guide) providing addition information on state procurement resources that can increase your company's chances of doing business with the state. Thank you for your participation in the HUB Program! If you have any questions, you may contact a HUB Program representative at 512-463-5872 or toll -free in Texas at 1-888-863-5881. Texas Historically Underutilized Business (HUB) Certificate CertiflcateNID Number: 1742569812700 Number. 004061 dolp'HUB Approval Dr Approval Date: 01-FEB-2021 1-FE Scheduled Expiration Date: 01-FEB-2026 Statelulde alnerleally UnderutBned Business Ress= The Texas Comptroller of Public Accounts (CPA), hereby certifies that DERRICK CONSTRUCTION COMPANY, INC. has successfully met the established requirements of the State of Texas Historically Underutilized Business (HUB) Program to be recognized as a HUB. This certificate printed 05-FEB-2021, supersedes any registration and certificate previously issued by the HUB Program. If there are any changes regarding the information (i.e., business structure, ownership, day-to-day management, operational control, business location) provided in the submission of the business' application for registration/certification as a HUB, you must immediately (within 30 days of such changes) notify the HUB Program in writing. The CPA reserves the right to conducts compliance review at any time to confirm HUB eligibility. HUB certification may be suspended or revoked upon findings of ineligibility. Statewide HUB Program Statewide Procurement Division Note: In order for State agencies and Institutions of higher education (universities) to be credited for utilizing this business as a HUB, they must award payment under the CertifioateNlD Number Identified above. Agencies, universities and prime contractors are encouraged to verify the company's HUB certification prior to issuing a notice of award by accessing the Internet (httpsa/myepa.cpa.state.tx.usitpasscmbisearchlindox.jap) or by contacting the HUB Program at 512-463-5872 or fall -free in Texas at 1-888.863.5881. R.Y. 06n9 1742' 9812700 004061 DERRI K CONSTRUCTION COMPANY, INC. PO BO 1046 ROCK , ORT, TX 78381-1046 COMPANY EQUIPMENT & CREW LIST rf2a , 250 Cove Harbor South PO Box 1046 Rockport, TX 78381 Office (361) 729-2423 Fax (361) 729-1218 °* "'- Tug & Push Boats Tu ar a/Crane/Crew Stand By Da Tug Crew 8 Hour Minimum Raymond 800h Miss Frankie 600h Pearl James (800hp) Miss Madal 800h Spud Barges 110x30x7 110 x 36 x 8.5 110x50x 120x52x7 120x55x 130x36x8.5 Other Barges Small Barge 55 x 22 x 3 Small Bare 10 x 30 x 3 aluminum Deck Barge Heavy Equipment 60 Ton Crane 100 Ton Crane 150 Ton Crane 230 Ton Crane Backhoe Crew Truck 16' Flatbed Front End Loader 65' Long Reach Excavator 95' Long Reach Excavator 450' LGP Bulldozer Company Personnel Director Of Operations Project Manager Superintendent Foreman Operator Laborer Mechanic Safety Quality Control Logistics Manager & Marine Compliance Welder (Single Hand) Welder (Rig) Electrician Dive Crew Boat Captain Boat Deckhand Subcontractor's (as needed based on project) Revised 2022 Derrick Cons(rtialon Compan.��, Inc Js ei fV`77 �'G d� TI. y=� Lc P ®l� Sri I /n� G® dsl �4 LI - a / - -_ Jul nl�El @i � 1 a'^�'� A� i� Lu®t - -^*'n "1ourTruSt('d CiNil &L\iarinc ConslruclionCOMIMItN" I NOTICE OF MEETING—11/13/2024 7. Consider and take necessary action to authorize utilization of $139,700 of GOMESA funds for the Matagorda Bay Mitigation Trust - Swan Point Bulkhead/Pier Project, Contract No. 034, due to increase of material costs. (GDR) Page 4 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 October 31, 2024 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 13, 2024. • Consider and take necessary action to authorize utilization of $139,700 of GOMESA funds for the Matagorda Bay Mitigation Trust - Swan Point Bulkhead/Pier Project, Contract No. 034, due to increase of material costs. erely, l/ � f, Gary D. Reese GDR/at P.O. Box 177 — Seadrlli. Texas 77993 — email: 9arv.reeseRcalhouncom.org — (361) 785-3141 — Fax (361) 785-5602 NOTICE OF MEETING—1.1/13/2024 8. Consider and take necessary action to authorize the use of Jail Telephone Commissioned Funds for the purchase to update the jail body camera system software with server. (RHM) Table Page 5 of 16 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: PURCHASE OUT OF PHONE COMMISSIONED FUNDS DATE: October 30, 2024 Please place the following item(s) on the Commissioner's Court agenda for the date(s) indicated: AGENDA FOR Selehev 30, 206d November 6, 2024 *Consider and take necessary action to authorize the use of Jail Telephone Commissioned Funds for the purchase to update the jail body camera system software with server. Sincerely, �Ua�e"e Bobbie Vickery Calhoun County Sheriff # 09 NOTICE OF MEETING - 11/13/2024 9. Consider and take necessary action to authorize all four Road & Bridge precincts to apply for credit with Holt Truck Centers. (GDR) RESULT: APPROVED [UNANIMOUS] MOVER: Joel Behrens, Commissioner Pct 3 SECONDER: `Gary Reese, 'Commissioner Pct 4 AYES:`.. Judge Meyer, CommissionerHall, Lyssy, Behrens, Reese Page 6 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 November 6, 2024 Honorable Richard Meyer Calhoun CountyJudge 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 13, 2024. • Consider and take necessary action to authorize all four Road & Bridge precincts to apply for credit with Holt Truck Centers. Sincerely, Gary, 6 Reese GDR/at P.O. Box 177 — Seadrik Texas 77983 —email; zary.reese(31.colhouncotx.ore — (361) 785-3141 —Fax (361) 785-5602 CREDIT APPLICATION Credit Application: )J� iHOLT TRUCK CENTERS" Customer Name Date of Application Assumed/Trade Name Fed Tax ID #/ Soc Sec # Tax Exempt? Yes [Attach tax form Credit Requested for [chock all applicable] Parts Body Shop Current customer? Yes No Service Requesting credit line increase? Yes No Credit Line Requested [req.hinn $ Dun & Bradstreet # [expetlites process] Contact Name for This Credit Application Title Phone Email Fax Owner/Officer Name Title Phone Email Fax Business Address (No P.O. Boxes) City State Zip Code .Business Description Phone Fax Legal Entity (Check one) Corporation Sole Proprietor LLC Non -Profit Partnership S-Corporation LLP Government State of Formation Date Established (If business) # Medium Trucks # Heavy Trucks Accounts Payable Contact Phone Email P.O. Required? Yes No Notes Individual(s) Authorized to Make Purchases CitEDITAPPUCATION 1 DISCLAIMER CONFIDENTIALITY NOTICE. This document, and any Information placed on or linked from this document, is intended for Holt Truck Centers, and may contain Information that Is privileged, confidential, proprietary, or otherwise protected by law. This notice serves as a confidentiality marking for purposes of confidentiality or nondisclosureagreements. Holt Truck Centers 1 5665 SE Loop 410, Bldg. #211 1 San Antonio TX 78222 Minimum of Minimum of 2 Credit and 2 Haul reference are required. Must include fax or email for each reference. Creditor* Address City State I ZIP Code Contact Name Phone Fax Email Business Term (Length) Average High Credit Amount $ Creditor* Address City State ZIP Code Contact Name Phone Fax Email Business Term (Length) Average High Credit Amount $ Creditor* Address City State ZIP Code Contact Name Phone Fax Email Business Term (Length) Average Price Per Haul $ Creditor* Address City I state T ZIP Code Contact Name Phone Fax Email Business Term (Length) Average Price Per Haul. $ * Trade references, not banks or other financial institutions See additional notes on following pages. This Credit Application is subject to and governed by the "Credit Terms" on the following pages. Those Credit Terms are incorporated Into this and any related credit application. Please read the Credit Terms before signing this Credit Application. Holt Truck Centers reserves the right to request that any customer complete and submit an updated Credit Application at anytime. ECOA NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter Into a binding contract); because all or part of the applicant's Income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC20580. Credit Terms: These Credit Terms are incorporated by reference in the accompanying Holt Truck Centers Credit Application. In this Agreement, the words "Customer," "you," and "your" mean the person identified in the Credit Application as Customer or Guarantor. The words "we," "us," and "our" mean Holt Truck Centers (see sections that follow). 1. Promise to Pay. You promise to pay us for your purchases of goods or services, together with all other charges mentioned below, according to the terms of this agreement. The purpose of this agreement is solely to allow you to acquire commercial goods or services from us on an open account basis; we do not loan or advance money. Payment is due on net terms stated in our invoice to you; in the absence of such invoice language, all terms are net thirty (30) days. DISUMMEa CONFIDENMLITy Noncs: This document, and any Information placed on or linked from this document, is intended for Holt Truck Centers, and may contain information that is privileged, confidential, proprietary, or otherwise protected by law. This notice serves as a confidentiality marking for purposes of confidentiality or nondisclosureagreements. Halt Truck Centers 1 5665 SE Loop 410, Bldg. #211 1 San Antonio TX 78222 2. Commercial Purposes Only. You warrant and represent to us any goods or services acquired from us are for commercial and business purposes only and NOT for personal, family, or household use. You understand thatwe do not extend credit for or allow delayed payment for any goods or services acquired for personal, family, or household use. 3. Payment. You may pay us by check, money order, or similar instrument. Payment must be in U.S. funds delivered to the address shown on our invoice or lease. 4. Returned Check Fee. To the extent allowed by applicable law, i f any check presented In payment by you is returned to us unpaid by your bank, we may charge a fee of $25.00 to cover our collection costs and bank service fees. S. Lien Rights. You acknowledge that we may have a lien under state statute or common law under which we may retain possession of your vehicle or equipment until we are paid in full for any applicable services. 6. Interest on Past Due Balances. Any unpaid balance past its due date to us will bear interest at the lesser of: the rate of 18% per annum, or at the highest rate allowed bylaw. 7. Default/Collection Costs. If you fail to pay any amount when due, we may recover our costs of collection from you. If we retain legal counsel for this purpose, then you will also pay our reasonable attorneys' fees and costs of collection. 8. Canceling or Limiting Your Credit. We may, at any time, limit or terminate your use of credit with us without giving you notice in advance, unless we are required to give you notice by applicable law. 9. Change of Address. You will notify us promptly in writing of any change of address. Until we receive notice of your new address, we will continue to send invoices and other notices to the address in our records. 10. Governing Law. You understand and agree that (subject only to applicable federal law and to local law govern- ing possessory liens) this Agreement is made under Texas law; it is not valid until we accept it in Texas. Any agreement to extend credit to you Is made by us in Texas. TEXAS LAW GOVERNS AND APPLIES TO THIS AGREE- MENT, without regard. to conflicts of law principles. 11. Jurisdiction and Venue. With respect to any unpaid balance over $1,000.00, you agree to submit to the jurisdiction of the courts of the State of Texas and the United States District Court for the Northern District of Texas with respect to any dispute arising under this credit agreement, including your obligation to pay us for goods and services acquired from us. Any suit to enforce your payment obligation to us may be filed In Beitar County, Texas, or if in federal court, the northern district of Texas. This does not limit our right or ability to file suit in any county in which. you maintain a place of business or in the county or federalcourt where you acquired goods or services from us. 12. No Additional Warranty. We make no additional warranty to you, either to express or implied, beyond that covered by any applicable manufacturer's warranty. The sole purpose of this agreement Is to provide for the terms and conditions under which we allow you to acquire goods and services from us on a delayed payment or open account basis. 13. No Jury. You and we both waive any right to a trial by jury with respect to any suit to enforce your obligationto pay for goods and services you acquire from us. 14. Severability. If any provision of this agreement is found by a court to be unenforceable or superseded by other law, the remainder of this agreement will remain in full force and effect. 15. Disputes. If you dispute any bill or charge reflected on any invoice or account statement, your dispute or inquiry must be directed to Holt Truck Centers, 5665 SE Loop 410, Bldg. #211, San AntonioTexas,78222. 16. Holt Truck Centers. Any reference to "Holt Truck Centers" includes Holt Truck Centers of Oklahoma, LLC, Holt Truck Centers of Texas, LLC, and Holt Truck Centers, LLC. 17. AUTHORIZATIONS: By signing below, I (individually and on behalf of any entity, as the case may be) hereby authorize: (i) Dealer and each other Financing Source to refer this Credit Application to, and share any credit information with, any other Financing Source; (ii) any Financing Source to request and obtain, and any credit reporting agencies, Applicants' banks or other third parties to provide, consumer reports, background checks and credit and other information regarding any Applicant or me individually; and (III) any Financing Source to execute and file UCC financing statements covering the Applicant's vehicles and/or other intended and related collateral, in anticipation of approval and extension(s) of credit. DISCLAIMER CONFIUeNTiAury Nonce. This document, and any information placed on or linked from this document, is intended for Holt Truck Centers, and may contain information that is privileged, confidential, proprietary, or otherwise protected by law. This notice serves as a confidentiality marking for purposes of confidentiality or nondisclosureagreements. Holt Truck Centers 1 5665 SE Loop 410, Bldg. #211 1 San Antonio TX 78222 18. Authorized Persons. Unless you instruct us in writing, we will rely on the apparent authority of your employees or agents to acquire goods and services on credit or delayed payment, 19. Grantor(s). Any person who signs a guaranty of your account is deemed to have read and agreed to be bound by the terms of this agreement. Any guaranty is a guaranty of payment and not collection, and it is unconditional and continuing. 20. Credit Information/Disclosure. You authorize us to acquire credit information from any source including credit bureau reporting agencies sand your bank, and further authorize us to refer to this application and share such information with any other financing source. The person signing this application represents that all of the information contained in this credit application is true, correct, andcomplete. OWNERSHIP INFORMATION. Provide a copy of government issued ID for all owners completing this section Name:_ Net Worth: of Birth: SSN: % of Ownership: Address: City: State: Zip: Annual Income: Name: Date of Birth: SSN: % of Ownership: Net Worth: Address: City: State: Zip: Annual Income: For snore than two owners, complete additional OWNERSHIP section and sign and submit with this application Signatures / Approval: Authorized Signature: Printed Title: Authorized Signature: Date: Printed Guaranty: For good and valuable consideration, including the credit or indulgence extended by Holt Truck Centers to the Customer identified on the Holt Truck Centers Credit Application accompanying this Guaranty ("Customer"), the undersigned guarantor ("Guarantor", whether one or more) ABSOLUTELY AND UNCONDITIONALLY GUARANTIES THE PROMPT FULL AND UNCONDITIONAL PAYMENT OF ALL OBLIGATIONS OF THE CUSTOMER TO Holt Truck CentersThis is an unconditional, continuing guaranty of payment, and notice of acceptance, protest, presentation, demand for payment or other notice is waived by the Guarantor. Hoit Truck Centers does not need to exhaust or enforce any other remedy against the Customer as a condition to enforcing this guaranty as against Guarantor. This guaranty is a continuing. guaranty, and it will continue in full force and effect until all obligations of the Customer have been paid in full and Guarantor is expressly released from his or her guaranty. This guaranty may only be revoked by Guarantor in writing delivered to Holt Truck Centers, and any revocation is only prospective (forward looking) and does not affect Guarantor's liability for previously incurred obligations, if any incurred by Customer. This guaranty is delivered to Holt Truck Centers to be submitted to its office in the State of TEXAS. Any action to enforce this Guaranty may be maintained in the State of TEXAS, and if In Federal Court, the United States District Court for the Northern District of Texas. Guarantor: Printed Name: Signature: Address: City, State, Zip: DISCLAIMER CONFIDENTIALITY NOTICE: This document, and any information placed on or linked from this document, is intended for Holt Truck Centers, and may contain information that is privileged, confidential, proprietary, or otherwise protected by law. This notice serves as a confidentiality marking fr purposes of confidentiality or nondisclosure agreements. #10 NOTICE OF MEETING — 11/13/2024 10. Consider and take necessary action to award the bids for Insecticides for Mosquito Control, Bid Number 2025.01, for the period January 1, 2025 through December 31, 2025. (RHM) nil' # 10. Page 7 of 16 Debbie Vickery From: demi.cabrera@calhouncotx.org (demi.cabrera) <demi.cabrera@calhouncotx.org> Sent: Thursday, November 7, 2024 9:32 AM To: Debbie.Vickery@calhouncotx.org Subject: Agenda Items Good Morning, Can you please place the following items on the agenda for Commissioners Court on Wednesday, November 13, 2024: Consider and take necessary action to award the bids for Road Materials, Bid Number 2025.02, forthe period January 1, 2025 through December 31, 2025. • Consider and take necessary action to award the bids for Asphalts, Oils & Emulsions, Bid Number 2025.03, for the period January 1, 2025 through December 31, 2025. I will have the back up and copies to you by the end of the day. Thank you, Dmi Cabrun Calhoun COuntg 'ZA63i6tant juditor 361-553-4613 361-553-4614 (fax) Calhoun County Texas at Utz o w o m 3 m m m 0 m 0 n y 0 S. m c� m$ m a 3 w 3 a� 3 m a 3 3 d 0 3� D D m w z y 2 m m n A = 2 m D z o zz N N � W x N 1+ O N W x N O N VI IA O O in N O O N to O N O N Z O 0 w � G1 y G1 m w in w — a — w — — G1 G1 O 3 O , O O y O vi O O O> O O > C m 1 3 3 01 w n � � o D z z r w N z a' c r v. z $ D b o o O viol O w ` Ft voi i.O1i w O A Q 3 0o s o g e o ° m a o � o - n a i m < m N N N o y m A 3 00 O NC O O O O O O O O m N f+ O O x O m w m w m m m m ti w r w v m o 3 y C 0 0 0 0 0 0 0 0 0 0 o z y O a zQ 00 o z _ A O r n y A m Z n Ax `m m y r n m �/+ Z z z w z o'o 'm n z z z z w m m v. 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If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS 5 Gallon Pail $ gg 70 /per 5 Gallon Pail 50 Gallon Drum $ 962.50 /per 50 Gallon Drum 55 Gallon Drum $ 1,058.75 /per 55 Gallon Drum 275 Gallon Tote $ 5,395.75 /per 275 Gallon Tote $ /per Page 29 of 59 Ingredients: Malathion 96.5%; Other 3.5% 2.5 Gallon $ 483.65 /per Case (Case = 2x2.5 Gal lugs) 5 Gallon Pail $ No Bid /per 5 Gallon Pail 55 Gallon Drum $ 5,064.95 /per 55 Gallon Drum 260 Gallon Tote $ 23,197.20 /per 260 Gallon Tote Ingredients: Malathion S /per $ /per $ /per 2 x 2.5 Gallon $ No Bid /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ No Bid /per 30 Gallon Drum 2.5 gl jug $ 195.10 /per 2.5 gl mug 50gl drum $ 3,692.00 /per _ Fyfanon EW is now packaged 50 gallons in a 55gl drum. S /per $ /per /per Page 30 of 59 Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 430.00 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ No Bid /per5 Gallon Pail 30 Gallon Drum $ 2,599.80 /per 30 Gallon Drum 55 Gallon Drum $ No Bid /per 55 Gallon Drum 275 Gallon Tote $ 24,158.75 /per 275 Gallon Tote /per $ /per Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ /per Case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $ /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ /per 30 Gallon Drum 275 Gallon Tote $ /per 275 Gallon Tote $ /per $ /per Page 31 of 69 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 $ 746.65 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 4,479.90 /per 30 Gallon Drum 275 Gallon Tote $ 41,065.75 /per 275 Gallon Tote $ /per $ /per $ /per Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 160.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ No Bid /per 30 Gallon Tote 55 Gallon Drum $ 1,870.00 /per 55 Gallon Drum 275 Gallon Tote $ 7,920.00 /per 275 Gallon Tote $ /per $ /per $ /per Page 32 of 59 7 z}T,� i.�kt �+',ay( ltry R ,. .t anti a List3lnsecneideaName j&O„ Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ /per 30 Gallon Tote 55 Gallon Drum $ /per 55 Gallon Drum 275 Gallon Tote $ /per 275 Gallon Tote $ /per $ /per 4�w,u4 c3-T .^?y"* ..y,.','-�Cy4 Bdl�tem�#9�Altos�d�30�=a�y�Brlqu�ets�;for�,Equlv,�ale'� �y�� �B,d��' Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ /per case $ /per $ /per g Bidltaem #10�AIosidyX�R B tendedRes dualB��l uets`or Eu)valentnlo al�5t InsectioaeSNameX` ivr1 }„!r Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ /per case $ /per $ /per Page 33 of 59 Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $ /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ /per 30 Gallon Drum 250 Gallon Tote $ /per 250 Gallon Tote $ /per N 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 $ /per $ /per 4.0% Fenpropathrin; 1.5% Abamectin; 1.0% C-8910. Remoa Tri 30 gl drum $ 9,000.00 /per 30 gl drum $ /per $ /per $ /per Page 34 of 59 11.61 % bti Vectobac 12AS 2x2.5 gl case $ 208.45 /per 2x2.5 gl case Vectobac 12AS 30 gl drum $ 1,250.70 /per 30 al drum $ /per $ /per 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 vendor, 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: 10/21/2024 Authorized Signature & Title: Andy Pierce, Sr. VP of Sales Printed Name & Title of Authorized Signature: Andy Pierce, Sr. VP of Sales Phone Number: (407) 328-6519 or (800) 367-0659 Email: aes.vectorbids(a@azelis.com Exceptions and/or Variations from Specifications and/or additional Notes: None Page 35 of 59 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: ADAPCO, LLC Address: 100 Colonial Center Parkway, Ste 170 Lake Mary, FL 32746 Remittance Address: PO Box 736662, Dallas, TX 75373-6662 Telephone: (407) 328-6519 or (800) 367-0659 Fax: (866) 330-9888 Email: aes.vectorbids@azelis.com Signature of Authorized Representative: Andy Pierce, Sr. VP of Sales Printed name of Authorized Rep: Andy Pierce, Sr. VP of sales ORDER - CONTACT INFORMATION Order Contact Name & Title: Ashlyn Nickell - Customer Service Order Contact Telephone: (877) 250-6509 or (800) 367-0659 Order Contact Fax: (866) 330-9888 Order Contact Email: aes.vectorordersna azelis.com INVOICES- CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Ashlyn Nickell -Customer Service Contact Telephone: (877) 250-6509 or (800) 367-0659 Contact Fax: (866) 330-9888 Contact Email: aes.vectororders@azelis.com Page 36 of 59 STATE OF TEXAS- Florida {} AFFIDAVIT COUNTY OF Seminole {} Andy Pierce being first duly sworn, deposes and says: (Type or Print Name) the Sr. VP of Sales of ADAPCO, LLC that he or she is having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 100 Colonial Center Parkway, Ste 170 Lake Mary, FL 32746 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he orshe is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiantfurther deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. Signaturecc.ffia Andy Pierce, Sr. VP of Sales Printed Name and Title of Affiant SWORN TO AND SUBSCRIBED BEFORE ME by the above Aff)ant, who, on oath, states that the facts contained in the above are true and correct, this 21 St day of October 20 24 Notary Public State of Florida Kathryn A Russell 1111 MyNH 1861791on Exp. 12/7/2025 Public Kathryn A. Russell Page 37 of 59 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at hftp://www.statutes.legis.state.tx.us/ Does/LG/htm/L(3L176.htm. For easy reference, below are some of the sections cited on this form. Type text here Local Government Code 6 176.001(1 -a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) atransaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of afederal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code 6176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (it) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (1) a contract between the local governmental entity and vendor has been executed; or (11) the local governmental entity is considering entering into a contract with the vendor. Local Government Code 6176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 38 of 59 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 riled. 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. ADAPCO, LLC 2 Check this box if you are filing an update to a previouslyfiled 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. Vector Control or Public Works Name of Officer AJ Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than Investment income, from the vendor? 0 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? Elyse © No 5 Describe each employment or business relationship that the vendor named In Section I 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. ADAPCO is a distributor of innovative insecticide products, technology, spray and monitoring equipment and surveillance equipment to the professional mosquito control industry. s ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 10/21/2024 i g en ing business wh he governmental entity Signature Date Form provided by Texas Ethics Commission www.ethics.slate.ix.us Revised 11/30/2015 Page 39 of 59 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I (c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 40 of 59 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 41 of 59 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Exec gtiye,Qrder,J 2.549, 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. Andy Pierce, Sr. VP of Sales Name and Title of Authorized Agent Signature of Authorized Agent 10/21 /2024 I am unable to certify to the above statements. My explanation is attached. Date Page 42 of 59 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 certificationand 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. Signatur actor's Authorize' d Official Andy Pierce, Sr. VP of Sales Pdnted Name and Title of Contractor's Authorized Official 10/21 /2024 Date Page 43 of 59 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The fling of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all Items that apply for both the initial filing and material change report. Refer to the Implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the Information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity Identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in Item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348• 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, Including time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of Information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046). Washington, DC 20503 Approved by OMB 0348-OD46 Page 44 of 59 Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse far nahlin harden disdnaurel 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. past -award it. loan For material change only: e. loan guarantee Year_ quarter_ f. loan insuranceNOne None 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: ADAPCO,LLC 100 Colonial Center Parkway, Ste 170 Lake Mary, FL 32746 Congressional District, if known: Congressional District if known: 6. Federal Department/Agency: 7. Federal Program NameMescription: None None CFDA Number, ffapplicable: B. Federal Action Number, ifknown: 9. Award Amount, ffknown: 10. a.Name and Address of Lobbying Registrant b. individuals Performing Services (including address tf (f individual, last nanre, first narue, MV.- dii ferenrfrom No. 10a) (last nine, first name, Ml): None None It. information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material Andy Pierce 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: Sr. VP of Sales U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public 10I21I2024 Telephone No.: �) 326-6519 or Date: _ Inspection. Any person who fails to file the required (800) 367-0659 disclosure shall be subject to a civil penalty of not less than S10,000 and not more than $100,000 for each such failure. Federal Use Only FAtulborized for Local Reproduction adard Form - LLL (Rev. 7-97) Page 45 of 59 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which_ states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goads or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) Andy Pierce, Sr. VP of Sales , do herebyverifythe truthfulness and accuracy of the contents of the statements submitted on this certification underthe provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.r)hD ADAPCO, LLC Company Name Andy Pierce Signature d$A*thdGzed Official Printed Name of Authorized Official Sr. VP of Sales Title of Authorized Official 10/21 /2024 Date Page 46 of 59 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. X I certify that ADAPCO, LLC is a "Nonresident Bidder" of Texas (Company Name) as defined in Government Code §2252.001 and our principal place of business is (City and state) ❑ I certify that is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Au orized Agent Andy Pierce Sr VP of Ralps Printed Name and Title of Authorized Agent 10/21 /2024 Date Page 47 of 59 Request for Taxpayer Give Form to the Farm V�o Identification Number and Certification requester. Do not (Rev. October 2018) Depa'Mem of the Treasury send to the IRS. Intemal Revenue Service ► Go to www.lrsgov/F6rmW9 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. ADAPCO LLC 2 Business name/disregarded entity name, if different from above y3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not Individuals; see a instructions on page 3): Cp ❑✓ Individuaysole proprietor or ❑ CCorporation ❑ SCorporation ❑ Partnership ❑ Tmst(estate single -member LLC Exempt payee code (ff any) 0 ❑ limited 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 for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting �i LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code if an y) another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that a u !E is disregarded from the owner should check the appropriate box for the tax classification of its owner. m ❑ Other (see Instructions) ► (Aopl�em•ccum6mtinre4retlwta'tle tlm us.) to 6 Address (number, street, and apt. or suite no.) See Instructions. Requesters name and address (optional) n 100 Colonial Center Parkway Suite 170 6 City, state, and ZIP code Lake Mary, FL 32746 7 List account numbers) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given online 1 to avoid I Social security number backupwithholding. For Individuals, this is generally your social security number (SSN). However, for r residenident 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 Requesterfor guidelines on whose number to enter. 5 9 — 1 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 It, later. Signature of n Here U.S. person► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.lrs.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 (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) Date► Z-1/1ZUL9' • 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 ,1099S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only it you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not 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) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2025.01 January 1, 2025through December 31, 2025 Vendor's Name & Address Veseris . Keith L. Haas, 1919 Jacintoport Blvd, Houson, TX 77015 • Please Type arPrint^.i# Wbitewtisnetacceptable, • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS 5 Gallon Pail $ n) A /per 5 Gallon Pail 50 Gallon Drum $ 525.00 /per 50 Gallon Drum 55GallonUrum $ 577:52 /per55'Gallon Drum 2756allon Tots $ 2884 75 /per 275 Gallon_ Tate 1000gallonsbulk$ $10.10 /per gallon $ /per Page 29 of 59 Ingredients: Malathion 96.5%; Other 3.5% 2 x 2.5 Gallon $ 469.59 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ 'NA /per 5 Gallon Pair 55 Gallon. Dru m $ NA /per 55. Galion. Drum 260 Gallon Tote $ NA /per 260 Gallon Tote 1000or+gallons $ 63.2 /per_ gallon $ /per $ /per Ingredients: Malathion 2 x ZS Gall'on $ NA /per Case ('Case = 2x2.5 Gal'Jugsj 30•Gallon-Drum $ NA /per30'Gallon Drum. $ /per. $ /per $ /per $ /per $ /per Page 30 of 59 M t 9 xni �,' ,... �` •. t �4k&*ry m°� sn. .b + yt �. r x s + ' ti �. -t /:_,�> ^ Active Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 446.42 /per Case (Case = 2x2.5 Gal Jugs) '5'Gallon Pail $ NA, /per5 Gallon Pall 30 Gallon.Drum $ 2557.14 /per 30 Gallon Drum 55 Gallon Drum $ 4865.00 /per 55 Gallon Drum 275 Gallon Tote $ 23682.86 /per 275 Gallon Tote $ /per $ /per �'�fr'' ril t i%i x� •4A m t .el;txT1 Bid�ltem�#5 ��3�1 66�U4�/� Active Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x I Gallon $ na /per Case (Case = 41 Gal -Jugs) 2 x 2.5Gallon. $ na. /per Case (Case= 2x2.5 GaI.J.ugs). 3Q GaRan.-Onim. $ 4800 /per3Q Gall4n..Dr..um. 275 Gallon Tote $ 44,000 /per 275 Gallon Tote * 30 gallon drums $ 3673.54 /per_30 gallon drum while supplies last special pricing on limited $ /per stock $ /per Page 31 of 59 Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ NA /per Case (Case = 4x1 Gal Jugs) 2x2.5Ga1lon $ 8665:62 /per Case (Case =W-5Gatlugs) 3GGallon Drum. $ 5199.98 /per 30 GallonUrum 275 Gallon Tote $ 47,670.23 ]per 275 Gallon Tote $ /per $ /per $ /per Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 120.73. /per Case jC'ase =2x2.5 Gallugsj 306anon-Tote $ 697.29. /per3015allon-Tate 55 GaA.Qn.J2rym. $ 1257.14 /pe[55 Gailan.Drum. 275 Gallon Tote $ 6089.29 /per 275 Gallon Tote $ /per $ /per $ /per Page 32 of 59 x i 5 Y ,j4 Btd�ltem #8 �4 8 ULVx �orrEqulvalent « � � '<7� r ^ } v tt�+ , '4> ti �i r' ," �ListlnsectladeName � � > Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% - 2 x 2.5 Gallon $ NA /per Case (Case = 2x2.5 Gal lugs) 30Gallnn Tote $ NA. /per30 Gallon Tote 55:Gallon.Drum. $. NA. /per.55.Gallon.Drum 275 Galion Tote $ NA /per 275 Gallon Tote $ /per $ /per z ' i sy, >4 Btl�ltem #9 Altostd 3dDay Briquets, 'aorbEgw�ralent x rs. Sk St Al", seCdckde Name , r d : ' Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ 552.00 /per case $ /per $ /per :' �, ,� .� '�§ x"""? K 3 s�rr �sY. sz ,+ �'� 's7�,k s s'. d9.�^�-'z ,Gad F a z'SitR�'-•�� �'�"�.^x"�i+' � c skSa,S�Yr ids � su.� 2 "�F s r�N, � i Bid�ltem #10k,�Aitosid XR�Extended�ResidualjBriquets �or,Equi�ialents��" �� � ustlnsectic��i�Nameq„+,° ,; s >w �` k 2 re #j; � `� fk .n..113'fuy`sY '� y7� /�y'�s frtvasra�� n, n'�A� ,t`�zru �i1�e, �?SM:Y'." k e�'z�Sf'-az`s "5 'sg y�� '��•,�- f� -`Y' z-tY�,i � r '� z � z 3 i{F` p Y'Y � l .. Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ 866.80 /per case $ /per $ /per Page 33 of 59 Bid Ite�i� #11 ,De1�taGar"�dyy a nor Equivalent � x; ` `� � 3 � ;, �"� >.� �'' r +� P�' :�•-'LieLinsec[icldeNeine7� Active Ingredients: Deltamethrin 2% 2x2.5Gallen $ -NA /perCase- (Case=2x2.5Galdugs) 30Gallan..Dcum. $ NA /,Qer...30Gallan.iZrum. 250 Gallon Tote $ NA /per 250 Gallon Tote $ /per $ /per y�,i] +„'.. y � .� n ,� -� rxyrq ] "4' n ✓� rk ar �T _y - i n 6 t v 1„ Bd�item�#1*2 ° FourS�ar Susta�ned�Re�ease 45j90j180 Day3Mlcro6lai�Br�q�tets � ` �N Y � ' 3 Eq�r �� .y v r : r' p{� 1 ,g r a— tISLflrf3aMlC(�le Name < � JiV��Eilt t�;.-°"•' aN� �cf a s "'! -� ri Y y F'r 'rNy i !t n U v . 6v9�,r � ,§ " 0c -. i t r t {] ' v f) ni4 � r 4w.J i..ol V `: tl.�°evS; �:�1 n�t✓, ..a � cf b��i� ir`LL+. <3.:.�5• { h{ l� � x.xi� U` �Fk d.-a Vr ��. � � • 1 � _ F. ! v 'x` ..l£. �..�Q Active Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecies israelensis 1% 45 Day ----- 200 Per Case $ NA /per case 90 Day ----- 200 Per Case $ NA /per case 180 Day----200 Per Case $ 41A /'per case $ /per $ /per J x < vS:"s �H SVZ➢G.lY � i�fii �.ia��i.��4d ]i� > .i� �'d Fsv kl..? i4f #"4� 1 �H �Y �� fa��� � ��r��\�PLi1 �l-,��33�S��.l...r u}fi AMive Ingredients: Bacillus thuringiensis subspecies israelensis 10.31% Summit BTI Briquets 100 pk $ 108.00 /per _package Summit BTI Briquets 6 pk $ 9.13 / per package Summit BTI Briquets 2pk $ 5:95 , per package / $ Page 34 of 59 re ingredients: Pyrethrin 5%'+PB02S% (rotational product, no OP odor, no corrosion) C ; Evergreen ULV 5-25 Ground $ 11,705.88 /per 55-Callon drum /per /per /PLC Theundersignedaffirms that theyar.A dulyautharized to eececutethis Bid and that this cam. pany,. CQrparGtian firm,. partnership or individual has not prepared this Bid in collusion with any other vendor, 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 openinq 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 em:ployment,. gift,._loan,. gratuity, special. discount,.trip. favor.,. or. service to. any4offidal,. employee or agent of Calhoun County in connection with this Bid. The undersigned affirms that they have read the entire invitation. to. Bid Packetand fully understands. and has. followed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Authorized Signature & Title: Printed Name & Title of Auth Phone Number: I Q- Z 03— oq 3 (0 P,I'sf Email: keeiPt?iS_�6Wj Exceptions and/or Variations from Specifications and/or additional Notes: C A h b r ^4 i aA C If r„ p to .y Page 35 of 59 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: ES OPCO USA LLC, DBA: Veseris Address: _10804 Pecan Park Bivc1#-300 Austin, TX 78750 Remittance Address: ES Opco USA LLC P.O. Box 7410137, Chicago IL 60674-0137 Telephone: _713-203-0436 Email: keith.haas@veseris.com Signature of Authorized Representative: Printed name of Authorized Rep: ORDER — CONTACT INFORMATION Order Contact Name & Title: _Keith L. Haas, Public Health Specialist Order Contact Telephone: 713-203-0436 Order Contact Fax: Order Contact Email: keith.haas@veseris.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact _Name & Titl.e: Keith L.. Haas,. Public. Health. S.pecial:ist Contact Telephone: 713-203-0436 Contact Fax: Contact Email: keith.haas@veseris.com Page 36 of 59 STATE OF TEXAS {} 11 AFFIDAVIT COUNTYOF t\Q—Vr�S {} Keith L. Haas being first duly sworn, deposes and says: that he or she is (T.ype.or Printriame). the _Public Health Specialist of_Veseris having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at _10800 Pecan Park Blvd #300, Austin, TX 78750, (Type or Print Physical and Mailing Address) who submits herewith to Calhoun Countythe attached bid/proposal; that heorshe is the personwhosertameis signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes-and.saysc thatthe bidder/proposer has not directly orindirectlyby.agreement,communication. or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiantfurther deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bidprice/proposal of said'bidder/proposer or of anyone else, or to raise or fix any overhead; profit or cost element of their price/fee or of that of anyone else; d.) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further. deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded'and upon the cond Fi and'r it is co a ed in thebid'/proposal'. Gz..b S_IzgnatureofAffiant_ _Public Health Specialist Pdnted•Name and Title -ofAffiant SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the a +y` .day of O 6-0 YSe't- 20 '11 MELISSA A. WEEKS z°°.+�A7 Notary Public, State of TexasE. 9r 0. Comm. Expires 03-01.2025 1 11Va1 °;, Notary ID 13100795-2 Signature of Notary.15ublic Notary Stamp/Seal Page 37 of 59 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 it 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. Ve se a , s 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 71h business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Nlq Name of Officer IJ Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts Aand -Bfor each employment orbusiness relationship described. Attach additional pages to this Form CIO as necessary. Nk A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other thaninvestment. income, from the vendor? N A E]Yes ElNo 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? N E.Yes E]No 5 Describe each employment or businessrelationshiplhat the vendor named irtSection 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. NA 6 I —I 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). N 7 Signat re of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethfcs.state.tx.us Revised 11/30/2015 Page 39 of 59 DEBARMENT & S.US.PENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws ofthe United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension ofparticipants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I (c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts. of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 40 of 59 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SPX'Programs A company or individual who is debarred or suspended cannot participatc in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter .into. any tnizisaction. withaperson. who. is. proposed. for debarment .suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly. enter intoa, contract with anyone who is ineligible under the regulatiom to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In. addition to. actions. takea under 40 C.RR- But 32, there. are a.widerange. of other sanctions. that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients offunds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 41, of 59 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 athree-yearperiod precedingthis proposal been convicted of orhad a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attemptingto 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 causa of -default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a—d) ofthis certification. AaJ YWU� C_ Hrr�lk��J2c:k1;5� Name and Titleof Authorized. Agent 1 c� ignature of Authorized Agent .)-4 0c% ?0"?q Hate I am unable to certify to the above statements. My explanation is attached. Page 42 of 59 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 appropriatedfurift'haverbeenpald or -wilt bar paid, by-orDyttietialf 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 wittrthe 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 efficeroremployeeof Congress, Oran employee of a MemberofCongressirt connectiorrwiththis 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 af- subreeipients shalt certify' and disclose accordingly. ThfscertificatfonlsamaterialTepresentationoffactnponwhich reliance wasplacedwherr thistransaction 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, JPS e R \ 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 theprovisfsionso31' U.S.,C. § 3801 at seq., appiytcthiscerti k*dIonand disclosure, if any. jnattuLre 1of Crto�tlntractoesDAuthorized Official ,r,1{µ I{ •y y//� yr e21 Oe+ 20ai] Date Page 43 of 59 INSTRUCTIONS FOR COMPLETION OF SF-LLL,_ DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C.section1352. The filing ofafomrfsrequired for eachpayment- oragreement tomake payment toany lobbying entity 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 a couered.Federal.actlon.. Complete- alLItems. that apply .for..both. the. initial. filing.and.matedal.change.report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this reporL If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last -previously submitted report bythis reporting entity for this covered • Federal. action. 4. Enterthe full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting, entity, that designates if it is, or expects to be,. a. prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5: Ifthe organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient Include Congressional District, if known. 15. Enter the. name. of the federal. agency, making the award or -loan commitment. include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action Identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract; grant, orloarraward number, --the application/proposal control numberassigned by the Federal. agencyy. Included prefixes, e.g., "RFP-DE-90-001." 9-. Fora -covered Federal.actionwherethere.has.been.an.award.orloan.commitmentbytheFederal agency, enter the Federal amount of the awardAoan commitment for the prime entity Identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying. Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and Include full address if different from 10(a). Enter Last Name, First Name, and'Middlelnitiaf (fill). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of Information unless it displays a valid OMB control Number. The valid OMB control number for this Information collection is OMB No. 0348- 0046. Public reporting burden for this collection of information Is estimated to average 10 minutes per response, Including time for -reviewing instructions, searching existing dale sources, gathering and maintaining the data needed; and campletihg and reviewing the collection of Information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348.0D46),. Washington,,DC 20503 Approved by OMB 0348-0046 Page 44 of 59 Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nubTfe burden discYnsurel 034MD46 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: NA 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... N' e. loan guarantee tT 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: N� NW Congressional District, if known: Congressional District, if known: 6. Federal Department/Ageney: 7. Federal Program Name/Description: NA w�A 1 tt CFDA Number, tJapplicable: S. Federal Action Number, ifknown: 9. Award Amount, ffknown: N $ NA 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if .((fbidiuidual,:lost name fastmm�e,.MQ: .. dffferentf:nmiVD-10a). (last name, first name, MI): tv� NA 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: �O disclosure oflbbbying activities is a material representation of fact upon which reliance was placed Print Nam • 42 by the tier above when this transaction was made or entered hate, Thlsdisdosureis require6pursuantta,3.1 Title= U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public �13-z o3.,o�136 �� Telephone No.: Date: e24 u ct 20 inspection. Any.person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) 1q Page 45 of 59 HOUSE R I1 99 VEWICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85m. Texas Legislature approved new legislation, effective September 1, M7, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract iwhich includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2). 10Lillnotboycott israet during the term of the contract Pursuant to Section 2270.001, Texas Government Code: 1. "Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any actioa that is inte-nded to penalize, inflict econonak hwm on, or limit commerrW 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, limitedliabilitypartnership, or arty limited Nability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company or affiliate of those..entities..o.r.: business.:assariatious..thatexist to..makea profit. 1,:(auth4rized.official.),_g42''FL. L • 0 4'e, -5,dohereby. verify the truthfulnessend, accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term ofthe contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List focatedatbfts-/feomptroilertexasgov/ourchasine/aublications/divestment nha eseR; s Comp ny Name Lo,� I.0 NeA'PL;pL Z nature of Authorized'OfficiaT Printed Name of AutTd Official e;t-L L-uaas a4 0c4 20aq Title of Authorized Official Date flage46of69 RESIDENCE CERIIFICATION 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 i?' f certify that (City and State) Jes,e,z� S (Company Name) de-fkned+n Gave-rnme-nt C&§2252.DGI. _a4 o C+ 2oa L Date is a "Resident Bidder' of Texas as IrtI"5¢ Page 47 of 59 W=9 Request for Taxpayer Give Feint to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Dapwvmrx orOkeTreasuy T-14-M send to the IRS. Inlemal Revenue ► Go to www.irs gov/FormW9 for instructions and the latest information. 1 Name (as shown on your Income tax return}. Name is required on this line: do not leave this line blank. ES OPCO USA LLC 2 Business namerdisregarded entity name, if different from above dba Veseris m m 3 Check appropriate box for federal tax classification of the person whose.name is entered on line 1. Check o pprop' my one ai the 4 Exemptions (codes apply only to m following seven boxes. certain entities, not Individuals; see a cc ❑ IndMduaVsde proprietor or R) C Corporation ❑ S Corporation ❑ Partnership ❑ Trustlestale instructions on page 3): esingle -member LLC Exempt payee code if any) ❑ Limbed liability company. Enter the tax classification (C-C corporation, S=S corporation. P=Partnership) ► Note: Check the appropriate box in the On above for the tax classification of the shtife nun, bar owner. Do not check Exemption from FATCA reporting s '€ 5 LLC it the LLC Is classified as a single -member LLC that Is disregarded from the owner uniess the owner of the LLC Is LLC is code gl any) o' another that not disregarded from the owner for U.S, federal lax purposes. otherwise, a single�rnember LLC that ¢ Ti is disregarded from the owner should check the appropriate box far the tax dassl0cation of 0s owner. ❑ Other (we instructions)► PsrKe.ro.rm..nm hre:,wmauewus� 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 10800 Pecan Park Blvd STE 300 6 City. state, and ZIP code Austin TX 78750-1477 7 List account numbers) here (optional Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN.provided must match the name given on pine 1 to avoid I Social security number this is generally your social security number (SSter. However, for a backup len,sole withholding. For individuals,rdisregarded resident alien, sole proprietor, or disregarded entity, see the Instructions for Pan I, later. For other - m - entities, ff is your employer identification number (EIN). If you do not have a number, see How to get e TIN, later. or Note: If the account is in more than one name, we the instructions for line 1. Also see What Name and I Employeridentificatlon number Number To Give the Requester for guidelines on whose number to enter. 8 4 - 3 6 S 9.5 8 1 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am wailing 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 QRS) 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 amexempt 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, 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. Htan Sl ports n n_ "t �- / Here. u.s.pereon► /refs (�t/B7L�- 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.imillav/FormM. 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 (RIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (Interest earned or paid) Cat. No. 10231X • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-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 network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tuition) • Form 1099-0 (canceled debt) • Form 1099-A (acqueltion 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. Fan W-V (Rev.10.2018) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2025.01 January 1, 2025 through December 31, 2025 Vendor's Name & Address Clarke Mosquito Control Products, Inc. 675 Sidwell Court St. Charles, IL 60174 • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS 5 Gallon Pail $ NO BID /per 5 Gallon Pail 50 Gallon Drum $1,141.20 /per 50 Gallon Drum 55 Gallon Drum $1,223.20 /per 55 Gallon Drum 275 Gallon Tote $6,872.80 /per 275 Gallon Tote $ /per $ /per Page 29 of 59 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 Ingredients: Malathion $ /per $ /per 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum $ /per /per $ /per Page 30 of 59 Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 564.50 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ NO BID /per 5 Gallon Pail 30 Gallon Drum $ 3,234.00 /per 30 Gallon Drum 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $29,645.00 /per 275 Gallon Tote $ /per $ /per Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 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 $5,040.00 /per 30 Gallon Drum 275 Gallon Tote $46,200.00 /per 275 Gallon Tote $ /per e. $ /per Page 31 of 59 Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ NO BID /per Case (Case = 41 Gal Jugs) 2 x 2.5 Gallon $NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per 30 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote $ /per $ /per Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 220.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $NO BID /per 30 Gallon Tote 55 Gallon Drum $1,848.00 /per 55 Gallon Drum 275 Gallon Tote $ 9,240.00 /per 275 Gallon Tote $ /per $ /per $ /per Page 32 of 59 �'?-'��n �d»i k3F zt a' � s5 'Y�"'aixi ,i��7 '�1.? rk. 5 sy q�5�yc r 4=.,'� -s "sr, zip,.. �i "1� s ?_.s a l �#'i3".NP �x`Y�'.� `�'f ✓ � �L V�f': +" a a,y � 4 z � r t✓ +f 4 SFr p ,q� n s �5x t.. s s +Y Y Bld��tem$I$ 4$�L�U �OrE Ulualent � �c� '` c `�rartjlistlnecE�eideNaroa�Y� Active Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ NO BID /per 30 Gallon Tote 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote $ /per $ /per €zt is Ya s"'aii i,a'?L$i`A`'p r r'jr., rs Xa `Yv�.�z ta..:# 4'a. 3(�t. v' ", t .a 'x a aR �' . " %,7,g �` m"'x 4 a-��*- ' z, a 4x� i n+ P rP'. -�"t� �'„•a.x •> n v € '�ir �t'�z � ��z:.-�".-t'� t ",�x',�*, t Y' x ,., b*'•" k t*i F aX ,rM`X '"a.."'t�t`aT{. .btis�x, ritibOx'ii4vn sY�i'tF«i' Btd Items#9,r Itostd�30 Daysr�uye�tsorEqu�ualent�iAltosld30 ®a, rBn uts��stseetcltlen��e r qa =, "v'C '+ >t+ �r` '`r'° -r G s•v Active Ingredients: (S) Methoprene 8.62% 400 Per Case $ 552.00 /per case $ /per $ /per TWWWAM :M1'a� .� s , - , t :' '=s. iT`r,�' a13 fir, tglfosldRBrlquetsF3 Bid=items#�,°0 �Altostd�XRgExtended�Restdt�al�Brtq�uets,�s�or�Equroalent�'� .� � €^ s'YS� a-a,� � '£i," �,,,z, �.a �.� �,. ��sr� ' �•- t� '�' �" <: ='dc����"',,�� °� �`��'': �-a rw t �x� �•z�a�r-stern a ,�.. 'v8kirn'z.�i,.2e��w?o'�aa._�...r,:�'`'^*�a.-....,.::>.tL'�ats�s�i rz."-.L'ir......��.:�r, L��7"x'.�Yu><kw, ���u^:x.�+..'��i«.x1�w�'tt.ax�;w.;��t� na..a ,.ur✓..zP] tY <'a"�3 Active Ingredients: (S) Methoprene 2.1% 220 Per Case $ 866.80 /per case $ /per $ /per Page 33 of 69 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 $ /per /per Ingredients: Bacillus sphaericus 6%; Bacillus thuringiensis subspecies israelensis 1% 45 Day ----- 200 Per Case $338.00 /per case 90 Day ----- 200 Per Case $ 562.00 /per case 180 Day-----200 Per Case $876.00 /per case $ /per $ /per Spinosad 2.5% Natular G30 WSP $481.28 /per 500 count case $ /per $ /per Page 34 of 59 Ingredients: $ /per $ /per /per $ /per 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 vendor, 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 & Printed Name & Title of AuthorizedSignature: Miranda Schield, VP Marketing Phone Number: 630-671-3190 Email: customercare(c@clarke.com Exceptions and/or Variations from Specifications and/or additional Notes: none Page 35 of 59 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: Clarke Mosquito Control Products, Inc. Address: 675 Sidwell Court St. Charles, IL 60174 Remittance Address: 675 Sidwell Court St. Charles, IL 60174 Telephone: 630-671-3190 Fax: Ema Sign: Printed name of Authorized Rep: Miranda Schield ORDER — CONTACT INFORMATION Order Contact Name & Title: Doug Carroll, Control Consultant Order Contact Telephone: 817-600-5353 Order Contact Fax: n/a Order Contact Email: dcarroll@clarke.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Carrie Aitken Contact Telephone: 630-671-3139 Contact Fax: n/a Contact Email: caitken@clarke.com Page 36 of 59 STATE OF ILLINOIS {} AFFIDAVIT COUNTY OF Kane {} Miranda Schield being first duly sworn, deposes and says: that he or she is (Type or Print Name) the VP, Marketing of Clarke Mosquito Control Products, Inc. having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 675 Sidwell Court St: Charles, IL 60174 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun Countythe attached bid/proposal; that he orshe is the person whose name issigned to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposeror of anyone else, or to raise orfix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid prices) pr p ed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, a e o furnish any and/or all items/services upon which bid prices or proposed fees'are awarded and upon the con it o nd requirem nts contained in the bid/proposal. ignatur of ffriant Miranda Schield, VP Marketing Printed Name and Title of Affiant SWORN TO AND SUBSCRIBED BEFORE ME by the above A�fflant, who, on oath, states that the facts contained in the above are true and correct, this �� day of h e.� 2�. Official Seal TRACYJ LULLO Notary Public, State of Illinois A�Q��olnmrs'sfb�FxpYres Mayat, 20I8 Page 37 of 59 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. n/a 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. 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-1 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes 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. 6 ❑Check t is b x if the vendor has given the local government officer or a family member of the officer one or more gifts as des i ection 76.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 10/23/2024 ' nature of endor doing busines th the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11130/2015 Page 39 of 69 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. Miranda Schield, VP Marketing 10/23/2024 Name and Title of Authorized Agent Date /7/J Si 4iarre of Autho i ed ent I am unable to certify to the above statements. My explanation is attached. Page 42 of 59 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 subreciptents shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Clarke Mosquito Control Products, Inc. The Contractor, , certifies or affirms the truthfulness and accuracy of each stateme its rtificati and disclosure, if any. In addition, the Contractor understands and agrees that the pro v 'o f 31 U.S . § 3801 at q., apply to this certification and disclosure, If any. igna re ontractor's Authorized Official Miranda Schield, VP Marketing Printed Name and Title of Contractor's Authorized Official 10/23/2024 Page 43 of 69 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 n/a 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: Con sessional District, if known: Congressional Dist ct, 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 (incbiding address if (f individual, last name, fuit nanre, Ml): die,unrfiom No. 10a) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Si ature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed Prb, me:Miran Schield by the tier above when this transaction was made or VP, Marketing entered into. This disclosure is required pursuant to 31 Title: - - 6306713190 10/23/2024 Telephone No.: Date: 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) Page 45 of 59 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Miranda Schield do herebyverifythe truthfulness and accuracy of the contents of the statements submitted on this certification underthe provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.php Com Authorized VP, Marketing Title of Authorized Official Miranda Schield Printed Name of Authorized Official 10/23/2024 Date Page 46 of 59 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 thatClarke 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 60174 (City and State) ❑ I certify that (Company Name) defined in Government Code §2252.001. Miranda Schield, VP Marketing Printed Name and Title of Authorized Agent 10/23/2024 Date is a 'Resident Bidder" of Texas as Page 47 of 59 Request for Taxpayer Give Form Form (Rev. October Identification Number and Certification to the requester. Do not Department of the Treasury send to the IRS. Intemal Revenue Service ► Go to wwwJrs.gov1FormW9 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. Clarke Mosquito Control Products, Inc. 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 p y 4 Exemptions codes apply onlyto p ( pp y m following boxes. 9 certain entities, not individuals; see o. cc El Individual/sole proprietor or ❑ C Corporation ID S Corporation ❑ Partnership ❑ Trustlestate instructions on page 3): m ti c single -member LLC Exempt payee code (if any) ❑ 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 a LLC If the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the for U.S. code (if any) a o tc owner fedeml 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. w ❑ Other (see instructions)► 1 (Mpves 0 aecaumsmamiansee„mee the U.S,) y 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) y 675 Sidwell Court 6 City, state, and ZIP code St. Charles, IL 60174 7 List account numbers) here (optional) Number Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other 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)1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, 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 of Here I U.S. person► (), _ .;'� pate► 2024 General I nstructio- -_ 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. Iryou 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-g (Rev. 10-2018) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR INSECTICIDES FOR MOSQUITO CONTROL Bid Number: 2025.01 January 1, 2025 through December 31, 2025 Vendor's Name & Address Rentokil North America Inc., dba Target Specialty Products 1225 N. Post Oak Road, Houston TX 77055 • Please Type or Print. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS 5 Gallon Pail $ 89.00 /per 5 Gallon Pail 50 Gallon Drum $ 600.00 /per 50 Gallon Drum 55 Gallon Drum $ 655.00 /per 55 Gallon Drum 275 Gallon Tote $ 3,080.00 /per 275 Gallon Tote $ /per a $ /per Page 29 of 59 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 Ingredients: Malathion $ /per $ /per 2 x 2.5 Gallon $ 350.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ NO BID /per30 Gallon Drum $ /per $ /per /per $ /per $ /per Page 30 of 59 Ingredients: Permethrin 30%; Piperonyl Butoxide 30% 2 x 2.5 Gallon $ 459.20 /per Case (Case = 2x2.5 Gal Jugs) 5 Gallon Pail $ 453.60 /per 5 Gallon Pail 30 Gallon Drum $ 2,610.00 /per 30 Gallon Drum 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ 23,512.50 /per 275 Gallon Tote $ /per Ingredients: Permethrin 31.28%; Piperonyl Butoxide 66%; 4 x 1 Gallon $ 600.00 /per Case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $ NO BID /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 4,200.00 /per 30 Gallon Drum 275 Gallon Tote $ 38,830.00 /per 275 Gallon Tote $ /per $ /per Page 31 of 59 Ingredients: Permethrin 31.15%; Piperonyl Butoxide 66.85% 4 x 1 Gallon $ NO BID /per Case (Case = 4x1 Gal Jugs) 2 x 2.5 Gallon $ NO BID 30 Gallon Drum $ NO BID /per Case (Case = 2x2.5 Gal Jugs) /per 30 Gallon Drum 275 Gallon Tote $ NO BID /per 275 Gallon Tote $ /per $ /per Ingredients: Permethrin 4.0%; Piperonyl Butoxide 4.0% 2 x 2.5 Gallon $ 190.50 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $ NO BID /per 30 Gallon Tote 55 Gallon Drum $ 1,591.75 /per 55 Gallon Drum 275 Gallon Tote $ 7,850.00 275 Gallon Tote $ /per $ /per /per Page 32 of 59 Ingredients: Permethrin 3.98%; Piperonyl Butoxide 8.48% 2 x 2.5 Gallon $ 276.50 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Tote $1,581.00 /per 30 Gallon Tote 55 Gallon Drum $ NO BID /per 55 Gallon Drum 275 Gallon Tote $ 12,718.75 /per 275 Gallon Tote $ /per $ /per Ingredients: (S) Methoprene 8.62% 400 Per Case $ 552.00 /per case $ /per $ /per Ingredients: (S) Methoprene 2.1% 220 Per Case $ 866.80 /Der case /per $ /per Page 33 of 59 Ingredients: Deltamethrin 2% 2 x 2.5 Gallon $1,430.00 /per Case (Case = 2x2.5 Gal Jugs) 30 Gallon Drum $ 8,370.00 /per 30 Gallon Drum 250 Gallon Tote $ 69,250.00 /per 250 Gallon Tote $ /per $ /per Ingredients: Bacillus sphaericus 691; Bacillus thuringiensis subspecies israelensis 1% 45 Da 200 Per Case NO BID Y----- $ /per case 90 Day ----- 200 Per Case $ NO BID /per case 180 Day-----200 Per Case $ NO BID /per case Page 34 of 59 Ingredients: 2 x 2.5 Gallon Case $ 190.00 /Per Case (Case = 2x2.5 Gallon Jugs) (Fallout LQ) 30 Gallon Drum $ 1,140.00 /per Drum (Drum = 30 Gallons) (Fallout LQ) 25 lb Drum $ 662.50 /per Drum (Drum = 25 Ibs) (Fallout WDG) $ /per 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 vendor, 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: 1019512094 Authorized Signature & Title: Printed Name & Title of Authorized Signature: Kirsti Rodney - Vector Customer Service Representative Phone Number: 225-999-8307 Email: Kirsti.Rodney@Target-Specialty.com Exceptions and/or Variations from Specifications and/or additional Notes: Page 35 of 59 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: Rentokil North America Inc., dba Target Specialty Products Address: 1225 N. Post Oak Road, Houston TX 77055 Remittance Address: P.O. Box 14084, Reading PA 19612 Telephone: 844-366-8366 Fax: Email: Signature of Authorized Representative: &4:� Printed name of Authorized Rep: Kirsti Rodney ORDER — CONTACT INFORMATION Order Contact Name &Title: Chris Fredregill Order Contact Telephone: 713-306-0566 Order Contact Fax: Order Contact Email: Chris.Fredregill@Target-Specialty.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Chris Fredregill -Vector Specialist or Kirsti Rodney -Vector CSR Contact Telephone: 713-306-0566 - Chris & 225-999-8307 - Kirsti Contact Fax: Contact Email: Chris.Fredregill@Target-Specialty.com & Kirsti.Rodney@Target-Specialty.com Page 36 of 59 STATE OF-E%AS-L OLV<) GJtG� r & , COUNTY OF L�: u nl2 AFFIDAVIT Kirsti Rodney being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Vector Customer Service Representative of Rentokil North America Inc., dba Target Specialty Products having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 11301 Industriplex Blvd, STE 100 Baton Rouge, LA 70809 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiantfurther deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; .c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. SWORN TO AND SUBSCRIBED BEFOREYE by 1 above are true and correct, this day e StampMBTNEYFLOYD Notary Public State of Louisiana Notary ID,Y 131865 My Commission is for Life Page 37 of 59 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code S 176.0010-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code 4176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code S 176.006(a) and (a-1) (a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 38 of 59 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. N/A - No known relationship z Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. 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). A115p describe any family relationship with the local government officer. Complete subparts A and B for usi as relationship described. Attach additional pages to this Form CIO as necessary. /'er A. Is the local governmily member of the officer receiving orlikely to receive taxable income, other than investment inndor? �Yeo 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 F-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 s KriL2tG /?BGG1Z? 10/28/2024 Signature of vendor doing bu ess with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 39 of 59 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have govemment-wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has .debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 40 of 59 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 41 of 59 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.�s�ome)S S�futee Name and Title Authorized Agent 1Ze P Signature of Authorizect&ent I am unable to certify to the above statements. My explanation is attached. Date Page 42 of 59 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). Rentokil North America Inc., dba Target Specialty Products The Contractor, , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. tgnature of Contracto r ruthorized Official Kirsti Rodney - Vector Customer Service Representative Printed Name and Title of Contractors Authorized Official 10/25/2024 Page 43 of 59 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all Items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional Information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identttythe appropriate classification of this report. If this is a follow-up report caused by a material change to the Information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee;' then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. a. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in Item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(s). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this Information collection is OMB No. 0346- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 Page 44 of 59 Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nubile burden disclasurel 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: NA Congressional District, if known:Y Congressional DI tric4 if known: 6. Federal DepartmentlAgency: Feder 1-Program Name/Description: C LDA Number, ifapplicable: 8. Federal Action Number, ifkiown: 9. Award Amount, tJ'known: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (Jindividual, last name, fuel name, Ml): dierent from No. 10a) (fast tame, first name, MI): 11. Information requested through this form is !/_ •. _y n_ A authorized by title 31 U.S.C. section 1352. This Signature: /CbG�iL2!' disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: KlfStl ROdfley by the tier above when this transaction was made or Vector Customer Service Rep 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..225-999-8307 Date: 10/28/24 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 Farm - LLL (Rev. 7.97) Page 46 of 69 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) Kirsti Rodney do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.php Rentokil North America Inc., dba Target Specialty Products Company Name ��t Kirsti Rodney Signature of Authorizeq Official Printed Name of Authorized Official Vector Customer Service Representative 10/25/2024 Title of Authorized Official Date Page 46 of 59 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) I certify that Target Specialty Products is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized ff9ent Kirsti Rodney - Vector Customer Service Representative Printed Name and Title of Authorized Agent 10/25/2024 Date Page 47 of 59 W�9 Request for Taxpayer Give Form Form (Rev. October2018) Identification Number and Certification 1 to the requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to ww Jm.govffib=W9 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. Rentokil North America, Inc. 2 Business name/disregarded entity name, if different from above Target Specialty Products w mP 3 Check appropriate box for federal tax classification of the person whose name is entered online 1. Check only one of the Y 4 Exemptions codes apply only to P ( vidY Y � following seven hones. certain entities, not Individuals; see n o ❑ Individual/sole proprietor or 2 C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate tnstmctions on page 3): n a;c single -member LLC Exempt payee code (if any) 5 's ❑ 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. Donotcheck Exemption from FATCA reporting 6 u 'c LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code if an ( y) a another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. vo ❑ Other (see Instructions))-WppheSwaccapue farneowu riot usl U 5 Address (number, street, and apt. or suite no.) See instructions. Requesters name and address (optionag in P.O. Box 14084 6 City, state, and ZIP code Reading, PA 19612 7 Ust account number(s) here (optional) Number Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get 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 coned. 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. Sign Signature of Here U.S.person► Date► 01/01/2024 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/FomtW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) NOTICE OF MEEi1NG—11/13/2024 11. Consider and take necessary action to award the bids for Road Materials, Bid Number 2025.02, for the period January 1, 2025 through December 31, 2025. (RHM) Page 8 of 16 Debbie Vickery From: demi.cabrera@calhouncotx.org (demi.cabrera) <demi.cabrera@calhouncotx.org> Sent: Thursday, November 7, 2024 9:32 AM To: Debbie.Vickery@calhouncotx.org Subject: Agenda Items Good Morning, Can you please place the following items on the agenda for Commissioners Court on Wednesday, November 13, 2024: Consider and take necessary action to award the bids for Insecticides for Mosquito Control, Bid Number 2025.01, for the period January 1, 2025 through December 31, 2025. • Consider and take necessary action to award the bids for Asphalts, Oils & Emulsions, Bid Number 2025.03, for the period January 1, 2025 through December 31, 2025. I will have the back up and copies to you by the end of the day. 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Do not click links or open attachments unless you recognize the sender and know the content is safe. fadapendenf Sfaff K. andAn&lyiI, U.S. Energy Information i a Aelministrarion On -highway diesel prices, by week and PADD (Self service cash price in dollars per gallon, including taxes) Date 10/14/24 10/21/24 10/28/24 U.S. 3.631 3.553 3.573 PADD 1 - East Coast 3.586 3.590 3.605 PADD 1 a - New England 3.766 3.760 3.753 PADD 1 b - Central Atlantic 3.861 3.816 3.804 PADD 1c - Lower Atlantic 3.464 3.489 3.516 PADD 2 - Midwest 3.651 3.543 3.569 PADD 3 - Gulf Coast 3.337 3.199 3.230 PADD 4 - Rocky Mountain 3.635 3.636 3.655 PADD 5 - West Coast 4.274 4.210 4.206 PADD 5b - West Coast less CA 3.874 3.785 3.791 California 4.734 4.698 4.682 Data source: Gasoline and Diesel Fuel Update PADD=Petroleum Administration for Defense District In � Like EIA on Faoebook ENFallow us on Twitter 13 Watch EIA on YouTube in., Follow EIA on Linkedln Got this as a forward? Sign up to receive our future emails. U.S. Energy Information Administration ( 1000 Independence Avenue, SW, Washington, DC 20585 1 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • 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 I em Cigted or Equlva°lent) k a Bid ltem ' Limestone -1/2 Inch To DuWdI Equivalent y ' ' Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct Ton Precinct Ton Precinct 4-PI Ton I Precinct 4-S I Ton Remarks: Bid Item #2-.. Limestone.=' 3/4 Inch To Dust or Equivalent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precincts Ton Precinct 2 I Ton I Precinct 3 Ton Precinct 4-P ; Ton Precinct4-S ; Ton Remarks: Page 31 o163 �h ]tOM 247, Type A Limestone, Grade 2 [13/4 Inb!JI f.or'Equivalent 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 Precinct 1 Ton Ton Item.247, Type kOrnestOlne, Grade 3 [13/4slnch] or Equivalent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton I I Precinct Ton , 4-P I Ton 4-51 Ton it 26572.2 FIy Psti or: "Equivalent See Specifications, Bid Item #5 for more information on this. material Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDE i Precinct 1 Ton Precinct 2 Ton Ton Ton Page 32 of 63 Bid Item #6: Ite`m 275, Cem�entor EquiViBlent . 27521 Hydiaullg6nnentType1,BULK°(Pneumatic Tankers; Spreader Bar Needed) ulic 275 2 1, Ht�tl Cement Type 1, y4T 16 Bag(Cost perPalletiist # of 47lb Bags on a Pallet Price per unit delive y p / p / delivery to Count Stock ile and orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I 1 of 47 lb .1 Bags on Pallet I Precinct 2 Ton _ of 47lb I Bags on Pallet 1 Precinct Ton 1 of 47lb j I Bags on Pallet ; 1 precinct4-P I Ton : of 47lb I Bags on Pallet I Precinct 4-S 1 Ton _of 47 lb 1 11 Bags on Pallet 1 Remarks: Bid Item #7: Item 302;'Type M%Gpade 3 (P.re,tCoated Rb (c} or Equivalent. Price Parton/delivery price to County Stockpile and/orJobsite TMATIRIAL MINIMUM LOCATION Unit DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 Ton Precinct Ton i Precinct4-P 1 Ton Precinct 4-S I Ton - Remarks: Page 33 of 63 �m #8 It m 302, Type PB, Grade 4 (Pre -Coated Rock) or Equivalent Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 Ton I Precinct 2 Ton Precinct 1 Ton i Precinct 4-P i Ton Precinct 4-S i Ton ' Cs: ,ms 4 Item 302, Type PE, Grade 3 (Pre Coated Rock) *IV(aterial Source outo# or Equivalent Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precincts Ton i Precinct 2 Ton Precinct 3 Ton i Precinct 4-P I Ton I Precinct 4-S Ton I :s: m #10 Item 302, Type PE, Grade 4(P e=nCoated Rock) *Material'Source oufiiof * or Equivalent Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY - TOTAL LOAD/ORDER Precinct 1 Ton Precinct Ton Precinct3 Ton Page 34 of 63 Bid Item #11: Item 302, Type E, Grade 5, lee or Equivalent` Price per ton / delivery price to County Sto LOCATION Unit MATERIAL I Precinct 1 Ton 45 Ton (Non -Coated Limestone Only) ind/or Jobsite MINIMUM DELIVERY TOTAL LOAD/ORDER Item 330, Type D (Pre Mnt Limestone) or Equivalent` Price per ton / delivery price to County. Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOADJORDER Precinct 1 Ton Ton Ton Remarks: Intentionally Left Blank Page 35 of 63 Item 33Q D, Pothole Repairjimestone`Rock Asphalt (LRA) roc EquLualent See Specifications, Bid Item #13 for more information on this material Price per unit / delivery price to County Stockpile and/or Jobsite (Ton and/or 50 Ib Bag) MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton 50 Ito Bag Precinct 2 1 Ton I i 50 lb Bag Precinct 3 Ton I I II 50 lb Bag Precinct 4-P ' Ton 50 lb Bag Precinct 45 { Ton I 1 50 lb Bag 1 Im #14: Item Typ6ji) HotAft Cold aid Asphalt Concrete Pave 4y" or Equ�alenf r . See Specifications, Bid Item #14 for more information on this matere. Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION I Unit I MATERIAL I DELIVERY TOTAL Precinct 2 j Ton Precinct 3 Ton Precinct 4-P I Ton Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM 0 MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton 1 110.00 150 1 hn.qx 7,5 -rm Precinct 2 Ton �) �.00 0.Ra 225 Tont Precinct3 Ton Precinct 4-P; Ton �,� 0,80 0.%0 1 Tosas _.__.. 1Irs Do /—n 4n tit.. Page 36 of 63 Bqd Item #10� ,Item 432,A""' p, Section 2,3 Stone Riprap, l2'ttliimestone G ., °or Equ talent Price Parton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton Precinct 2 Ton ' I Precinct 3 Ton Precinct 4-P I Ton I ' Precinct 4-5 I Ton I Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Authorized Signature & Title: Type Name &Title ofAuthorizedSignature: ROD r2AW5(-VJ VICE A-VC:F.) oc-Arr Phone Number: 9 r9— bZ(,— 7075 Email: 11Jj'De9 :1(MA-PALt . COIK Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible A•• • r „ +.2 r 'Q Remittance Address: 22010 GAl2.Ea by#JCC RD 1*MP5-G-AD,7eVAS `7-14LLS Telephone: 914- Mb- 707,4�— Fax: A/LA Email: I AIFv @ WCASPj*arr. &,H t Signature of Authorized Representative: Printed name of Authorized Rep: �EIJ7 �AwfSor�J ORDER - CONTACT INFORMATION Order Contact Name & Title: SANU,4 OH3 QM CE 144NMER Order Contact Telephone: TZq- 8ZJD - 7o7.T Order Contact Fax: Order Contact Email: /AIFQ C) V /CASPML'C.CoA INVOICES - CONTACT INFORMATION For Invoice Inquiries: Contact Name &Title: 1p,44 U/ OFFICE N"CZc-j� Contact Telephone: q7q-M-7075- Contact Fax: ContactEmail: !A fl WMSWALT. 60M Page 38 of 63 STATE OF TEXAS 0 AFFIDAVIT COUNTYOF W4LLe?, 0 IZO D DDAW Soul being first duly sworn, deposes and says: that he or she is (Type or Print Name) the VIM 92e&11)aTr ofz1AU0_ dauwRr/dSP1iA� /.JG having its (Type or Print Title) (Type or Print Name of Company/firm) principal address at22010 Roft9Dua.0s �D,_11ati1f�T�1D,ZacAS ?7`f�Fi (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees sttoo furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. Sign ure of A iant�_ ROD DAINSW vlUP&4r WT Printed Name and Title of Affiant 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, Notary Stamp/Seal G.R.M.GaryIDLENDA 11174 EN�Nry ID X11174365My Commission ExpllrsFebruary 15, 2027 Page 39 of 63 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code § 176.001(1-a):'Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity oran agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state orfederal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer ora family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (1) a contract between the local governmental entity and vendor has been executed; or (it) the local governmental entity is considering entering into a contract with the vendor, (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the l2-monthperiod preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (if) the local governmental entity is considering entering into a contract with the vendor. Local Government Code § 176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family memberof the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.eth ics. state. tx. us Revised 11/30/2015 Page 40 of 63 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 flied in accordance with Chapter 176, Local Government Code, by a vendor who Dale 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 7111 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. WALL- CCUArrY Aspi4AL,-% /4C. 2 Check this box if you are filing an update toapreviously 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 off fear about whom the information is being disclosed. ti3bN E 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 foreach employment or business relationship described. Attach additional pages to this Farm 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? MYes E-No B. Is the vendor, receiving or likely to receive taxable income, other than investment income, from or at the direction or the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? FlYes EiNo 6 Describe each employment or business relationship that the vendor named in Section l 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. /Jba1G s ElCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 p �p ZdZ Signal re doing business of vend r with the governmental entity Dale Form provided by Texas Ethics Commission www.ethics.state.tx. us Revised 11/30/2015 Page 41 of 63 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 19, 1986, appear at 51 FR 6370, 3 CPR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in nnc as President by the Constitution and laws of the United States of Amcrica, and in order to curb fraud. waste, and abuse in Fedcral programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Fedcral programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I (c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected prograns. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders, This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debased. suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party fionn participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the rcason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 42 of 63 See. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. - Sec. 5. The Director of the Office of Management and Budget shall designate it Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participationunder this Order, periodically distribute the list to Federal agencies, and study file feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and. set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly trade available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 43 of 63 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 / proposalhad 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. RIID DAWSp4 V1a= �-:&t rT D Z Name and Title of Authorized Agent 1 D to 2 Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Page 44 of 63 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,WAQt?,tat t V ASAblL n certifies or affirms the truthfulness and accuracy of each statement of its certification- , 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 j3a1> 4WSurJyltxm�tarar Printed Name and Title of Contractor's Authorized Official / 01 to 12oz4 Date Page 45 of 63 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The fling of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the Her of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee;' then enter the full name, address, city, State and zip code. of the prime Federal recipient. Include Congressional District, If known. 6. Enter the name of the federal agency making the award or loan commitment. Includeat least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or descdpllon for the covered Federal action (item 1), If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. - For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in Item 4 to influence the covered Federal action- (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (hit). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No.0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the office of Management and Budget, Paperwork Reduction Project (0348-0046). Washington, DC 20503 Approved by OMB 0348-0046 Page 46 df 63 Approved by OMB Disclosure of Lobbying Activities Complete this fours to disclose lobbying activities pursuant to 31 U.S.C. 1352 (Sec reverse for nublic burden disclosural 0348-0046 I. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing g_ b. grant ,L b., initial award _ 1 b. material change c. cooperative agreement c. post -award d. loan For material change only: c. loan guarmnce Year quarter_ f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Sabawordee, Enter f�prime Subawardee — — Name and Address of Prime: Tier_, if Known: wkuwit cco& a Ask?"L'Tr too, -=010 all" ovu05 RU Ha%tfsXQ0tZ2iW5 77qqi- Con ressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number. ifapplicable: S. Federal Action Number, ifknou'n: 9. Award Amount, ifknowi: 8 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (findividual, last name. first nanne. Ml): d(fereut fimm A. 10a) (lass name, that "ante, MI).• It. Informationrequested 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: p aQV�54J by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title: _'V j. (!. !PRZ>\QLAi( U.S.C. 1352. This information will he reported to the Congress semi-annually and will be available for public yr� / � Telephone No.: l !T '��SDatc:[p/h/2V 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) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85ch Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a companyfor goods or services unlessthe contract contains a written verification from thecompany that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) Peln DAWSOAJ do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptrollertexas gov/purchasing/publications/divestment php WALLZI2. Counrl ( ASAtfi a i*jC of Authorized Official Printed Name of Authorized Official Title of Authorized Official Page 48 of 63 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) 19'l certify that VVALL L CO)uTQ IT- MSG is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signatire of Authorized Agent prat hAwsuJ Vier- 'Aia sic ac Printed Name and Title of Authorized Agent /o Ito /2o2-4 Date Page 49 of 63 Wass Request for Taxpayer Porn Ple'Onexter2e19) Identification Number and Certification Give Form to the requester. Do not Dspadmem of ma Treasury ImemalRw Mon.co LCo to w%vw.1mgowrFormW9 forinstrue0ons and the latest information. send to the IRS. 1 Name [in shown on your income tax Mum). Name is required on this line; do not leave this lino blank. WALLAv ASOM 2 Businew nameltlisregartled aniiN name, iltlidereni from above ro m 3 ChmkappmpdateboxfortMemiluelms iimtlondtmorse follovring seven boxes. a^whose namols entered on line 1. Check only ono olthe 4Extractions (ownZ<apply only to a o mainamipes, not Marches;see c ❑ IndivlduaVcolepropdatoror 12GCogenstlon ❑SCo son moro Pennership ❑TmsVeslete insimdidman page 9}: pm. o ongle-mamber LLC ElUnited llabiNty Exempt Payee once i f anYl company. Enter the tea desslficetion(C=C coryoreficooperation, P=Pannership)li� `0 �2 w Note: Check the appropdata box in the line above forms tax classification of the single -member owner. Conotchock " Ifthe LLClsciaefiged asaain91>mernber LLCOatlsdisragmdsdfromtneawnerunlewiheowneroilhe LLCis Exemption(rom FATCArepining s= anether LLdbl C Nat is net egadedfrom m the owner tar U.S. federalW no,ces. Nhsiwisa. a sln9le-embw LLC that code gf any) Is demanded from me ownorahpald check the appropriate box for the tax donfineation of its owner. o Nher(saohvWek.)> Pwv. w.nomn„w.+.mawa seer rn aAtldrcw(aembea streat.mdept. or aeitano.} Sea Instruction.. Raqusster's name and adtl.kjetfurk y ZZOIO .,,r{ igoopi Qs �. CALHOUN COUNTY e CRY. state, and LP code 202 S ANN ST, PORT L AVACA TX 77979 �19M �i'ys- 361.553.4610 FAX: 361-553-4614 T Uat account harmerO here tefoons9 Note: If the account is in more than one name, see the Incantations for line 1. Also see. What Nams and I Fmployeridentlfies, number Number To Give the Requesterfirr guidefrisson whose numberto enter. I—I1 f—TTTI—'f—1 1. The number shown on this farts IS my curet taxpayeridentificatlon number for Iran waiting for a number to be Issued tome): and 2. I errs not subject fo backup withholding because: (a)1 am exempt from backup whinhelding, or (b) I have not been notified by the Internal Revenue Service (IRS) that i sm 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 cadefs) entered on this farm )1 any) Indicating that I shin exempt horn FATCA reporting Is correct. Certification Instructions. You must fames out Item 2 above dyou have been notified by the IRS that you are currently subject to backup Withholding because you have felled to report all Interest and dividends on your tax slum. 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 one not required to sign the certification, but you must provide your corm TIN. Sea the instructions for Pan I. later. Generallnstructihns T Form 1099-DIV(dividends, Including those from stocks or mutual o Section references are to the Internal Revenue Cade unless otherwise unds) •For 1 099-MISO (various types of income, press. awards, or gross tion about developments Future fated developments. For the latest Information such audit as legislation enactetl Farm W-9 and itsInstructions,to proceeds) • Form 1099-B (stock or mutual fund sales and certain other after they wtvions, after they were published, go to wvrvy.lrsgovlFormW9. transactions by. brokers) Purpose of Form •Form 1099S(proceeds tram real estate transactions) • Form 1099-K (merchant card and third party network tremeacbons) An Individual or entity (For W-9 requester) who is required to file an • For 1098 (home mortgage Interest),1098-E (student loan interest), Information return with the IRS must obtain your correcttaxpayer 1098-T(tultion) Identification number MIN which may be your social security number (SSM, Individual taxpayer identification number(MM, adoption •Farm 1099-C(canceled debt) taxpayer identifiootlon number All", or employer Identification number .Far 1099-A (acquisition or abandonment of secured property) q P P rty) (EIM, to report on an intora0an return the amount paid to you, or other Use Form W-9 only if you are a U.S. Person (including a resident amount reportable on an infonnatlon return. Examples of information allan), to provide your cormTlN. 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 • Form 1099-INT (Interest earned or pair) be subject to backup withholding. Sea What Is backup withholding, later. Cat. N. IM31X Foan W-9 (Rev. 10-201 a) Page 50 of 63 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address �}JI( d\ l(lY\`L�((A r�1�1�Sj LGL (Old! let Ai(,In I�GtC2 Ste Sc� 5GY\ /din im,(T) I X lY>Zl • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT ROBD LS z(BI Ite, Llsted,i�r� Equivalent) Bid lti!hl ,.-.. Gm tone -4 2 Inch o Dust equivalent AM.' or Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct ; Ton I 1 Precinct 2 Ton I 1 1. I Precinct 3 1 Ton t 1 1 Precinct 4-P 1 Ton 1 1 1 I I Precinct 4-S ; Ton I I I ' Remarks: Bid Item #2 Limestone 3j4�nchTo.Dust or ivalen q J.Eu„ Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton i I ' Precinct 2 ; Ton Precinct 3 Ton 1 I Precinct 4-P I Ton I ; Precinct 4-5 j Ton 1 1 Remarks: Page 31 of 63 Bid Item #3: Item 247;`Type I Price per ton ( delivery LOCATION Unit Precinct 1 I Ton I Precinct 2 Ton Remarks: Remarks: Remarks: 4-P I Ton I 4-S Ton Price per ton / delivery LOCATION Unit I Precinct 1 1 Ton 1 Precinct 2 ' Ton Precinct 3 ; Ton I Precinct 4-P I Ton Precinct 4-5 Ton rieitone, Grade 2 [1i3/4' to County Stockpile and/or Jobsite MATERIAL I DELIVERY to County Stockpile and/or Jobsite MATERIAL I DELIVERY See Specifications, Bid Item #5 for more information on this material Price per ton / delivery price to County Stockpile and/or Jobsite TOTAL TOTAL MINIMUM MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 j Ton I I I Precinct 2 Ton i Precinct 3 Ton Precinct 4-P I Ton I I I I Precinct4-S ; Ton ! ', Page 32 of 63 th `.. t Bid Item fR AI' 275; Cement or EgUlvalent x 275 2 1, ffy raulfc Cement Type l,.Bulk (Pneu 'at Tankers;'Spreader Bar Needed) z - 275 2',.1� H ilraullt Cefnent Type 1{ 7 ib Bag(CQ i'per Pallet List N of 47 Ib Bags on a Palle ' Price per unit/delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 I Ton ' of 47 lb I Bags on Pallet i I I i i Precinct 2 I Ton I i � i I i i i I i of 47161 i Bags on Pallet i i I i i Precinct 3 Ton I ; I _ of 47 lb ; I Bags on Pallet I i Precinct 4-P 1 Ton ' of 47 lb 1 1 f i Bags on Pallet i i i f Precinct 4-S ; Ton of 47 lbl Bags on Pallet Remarks: {Iteni # Bid7 -Item 302, Type PB, Grade 3 (Pre -Co NEW �quroalen., Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton -1� ��,ry �✓ . iV 1 y7`l�o.�� i Z� ions ' �,/j I i 55 Z� Precinct 2 Ton ; W t� ; J OY) Precinct 3 i Ton i —1 d iIZ 3 I. �l� I `N i�.1-l�. � S (�2 I "1 �� 'Z Precinct 4-P; In ; j ; ; () I 0r)S y� I ' �� �� ' Ll S Precinct 4-5 I Ton ` ,J (%^ Remarks: Page 33 of 63 (Remarks: ;. r?`t Xv. 1 Item 302, Type P6, G`rade 4 (Pre Coatet Rock) or Equivalent .r Price per ton / delivery price to County Stockpile and/or Jobsite. MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton �v1� I 55 TvNNnn I � K) It—i I ((I��Yl• t4V\5 Precinct Ton Precinct I Ton G I J�.20 j 1Dii..26 I ZLI S Precinct 4-P I Ton IS I 1 J I I -I O I/D1 C�/1$ Precinct 4-5 ; Ton LV) 55 ' �9% i ZLI ko-n<, Item,301, Type PE, GF de 3 (P,Coate ock) f; *Material Source out�bf 5... `* or Equivalent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL I DELIVERY TOTAL LOAD/ORDER 2 i Ton 1 3 ; Ton 4-P I Ton I 4-S I Ton 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 I I I Precinct 2 ' Ton ' I Precinct 3 I Ton I I I ' Precinct 4-P I Ton I ; I I Precinct4-S I Ton I I I I I I Page 34 of 63 Bid Item #11 Ite302, TYPe!E; Grade 5, Ice Rock (Non Coated' Limestone Qnly) oi'�f�gwva��nt ' Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I Precinct 2 Ton I I I I I Precinct 3 I Ton I I i Precinct 4-P I Ton i I i I i I I I Precinct 4-S ; Ton' I I I I Remarks: ,. 4T 55 �w Bid Itemi#12 �Itemk330, Type D (Pre-MIx;Lime�ne) oEqulvalent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' L 2 (y I 131 lD L�A -Ions Precinct L Ton I a I J ✓ •-i� • I Precinct ' Ton Q ��V I i � 55 � 2 ZI If i�J3,00' -l7(w� �� I 4�7 (fit l.� + Precinct ; Ton ✓ I-� '1,}J.I� `"IiM'J Precinct 4-P Ton Precinct 4-S ; Ton Pr `V j �5 I��y 7 J J 12-�5 Remarks: Intentionally Left Blank Page 35 of 63 lRemarks: rks: s' ar Ali" Item 330`D, pothole Repair, Limestone Rock Asphalt (LRAjt or Equivalent,ti;'�n See Specifications, Bid Item #13 for more information on this material Price per unit / delivery price to County Stockpile and/or Jobsite (Ton and/or 50 lb Bag) MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' I Precinct 1 1 Ton I ' I I ' 50 lb Bag I Precinct 2 ; Ton I ' I I ' 50 lb Bag Precinct 3 I Ton i 50 lb Bag I I Precinct 4-12I Ton I I i 50 lb Bag 1 1 I I i Precinct 4-S 1 Ton I '.. 1 SO lb Bag 1 ; 1 , I See Specifications, Bid Item #14 for more information on this materia. 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 I I Precinct 3 Ton Precinct 4-P I Ton Precinct 4-S I Ton Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I I Precinct 2 Ton Precinct 3 I Ton I i I - Precinct 4-P; Ton Precinct 4-Sl Ton Page 36 of 63 _/ r id Item #16 Iter i 432, R'i ap, Section I kiprap, 12" Limestone or'Eiuivient' Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit =MATERIALDELIVERY TOTAL LOAD/ORDER I Precinct 1 I Ton I I I I I I i I Precinct 2 Ton I I I I Precinct 3 I Ton I ' I I i Precinct 4-P I Ton I I I , Precinct 4-51 Ton I I I Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Z 1 l2'I Authorized Signature & v 1 ` Type Name & Title ofC Authorized Signature: �U 11%l � i fcl\(- Ay-y( W c,, �I� Phone Number: A0--q(,Os—btf19 Email: qAy ay- P'J(nLMaIL,LU/V-\ Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: \1t)�CCKY\ Wn5MA-A- 10n NkMl?X'IUIS LZ-C. Address: _ IDIQt k P.UV1f (X1 Pke_ 5}e, '5QQ 50A A-bAiD TX -7bZI Id Remittance Address: % Box Nq 131 -NAIL(k) D 75-Vt4 Telephone: 2-10 - (4(O- — CM 19 Fax: ZIO-SZW 3!555 Fri Signature of Authorized Representative - Printed name of Authorized Rep: ORDER — CONTACT INFORMATION Order Contact Name & Title: Order Contact Telephone: Order Contact Fax: Order Contact Email: INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Contact Telephone: 210 _ SW - 7-6q` 1 V Contact Fax: Do - 5(A- °�555 Contact Email: Page 38 of 63 STATE OF TEXAS {} AFFIDAVIT COUNTY OF Q. Gl {} Jo O, being first duly sworn, deposes and says: that he or she is (Type or Print Name) `t the Anak, of �1,iVan C0V--N9(U(A1(n MUNefi(JIS L4-( havingits ype or Print Title) (Type or Print Name of Company/Firm) principal address at 10101 f2��m1C:V1 Plal2 cS411 500 50rt Anky) i n 0 7?)2,(G (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise orfix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association; organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. s' nature of Affiant Jlia i:avyaf vk Printed Name and Title of Affiant 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 '75 day of 20 „p bl �41a�y pUy,, TAYLOR WITTEN Notary Public, State of Texas Signature of Notary Public AY Expires t2-02-2026 Notary ID 133471642 Page 39 of 63 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity A complete copy of Chapter 176 of the Local Government Code maybe found at htip://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code § 176.001(1-a):"Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code § 176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of afamily relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 40 of 63 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 Dare 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 [he 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. JWVA bri 5WUCAJIOA WktK UkS LL C. 2 Check this box It 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. Y l�� 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 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? F7 Yes E-1 No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? E7Yes F7 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 Sign ture of VqQcer doing business with Ire governmental entity Date Form provid Texas Ethics Commission www.ethics.state. tx.0 s Revised 11/30/2015 Page 41 of 63 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370. 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America. and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I (c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements. contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities. direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying infonmation concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affectedi program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may retool for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 42 of 63 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives- of agencies designated by the Director of the Office of Management and Budget. See. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a Current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. See. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order. prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office'of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud. waste. and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 43 of 63 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. J 1A Taffac Ar� �1t Name and Title of Authorized Agent 7 "v ��— Sign azure of Authorized Agent to ZS z� Date I am unable to certify to the above statements. My explanation is attached. Page 44 of 63 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). .O kGh (C vn5kvv l c" The Contractor, bk(A AwAS . I.e-C 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. Page 45 of 63 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING. ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous riling, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make. payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawanls include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFS) number; grant announcement number; the. contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90.001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity Identified in Item 4 or 5. 10. (a) Enter the full name, address,. city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this Information collection is OMB No.0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (034"046), Washington, DC 20503 Approved by OMB 0348-0046 Page 46 of 63 Approved by OMB \: 0348-0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 See reverse for public burden disclosure 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application 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, linter _ 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, tfapp/ieable: 8. Federal Action Number, ifknawn: 9. Award Amount, ifknowm: S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if indivHim 1,, last name, first name, M!): different l-anr No. 10a) (last name, first name, M!): 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) Page 47 of 63 Certification Required by Texas Government Code Section 2270.001 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F; Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) k JJ'« -V&g rCW do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptraller.texas.gov/purchasing/publications/divestment.php Company Name re bf.Authorized Official Title of Authorized Official Printed Name of Authorized Official Date Page 48 of 63 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) certify that 1J li(C V\ (Of\54VU(A(Y\ is a "Resident Bidder" of Texas as (Company Name) W\ ,, ,TWLLL defined in Government Code §2252.001. 1 signature ofAGthorized Agent I--o'kY r Printed Name and Title of Authorized Agent Date Page 49 of 63 ® 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.irs.govIFormW9 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. Vulcan Materials Com an 2 Business name/disregarded entity name, if different from above Vulcan Construction Materials, LLC (EIN: 63.1211833) 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 m following seven boxes, certain entities, not individuals; see a p ❑ IndividuaUsole proprietor or ❑' C Corporation ElS Corporation ❑Partnership ❑ TmsVestate instructions on page 3): ai c single -member LLC Exempt payee code (if any) 94 ❑ Limited 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 for the tax classification of the single -member owner. Donotcheck Exemption from FATCA reporting 'Y c c LLC'd the LLC is classified as a sin le -member LLC that is disregarded from the owner unless the owner of the LLC is LLC that is disregarded from the for U.S. federal tax Otherwise, -member LLC that code d t any) ac another not owner purposes. a single is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ❑ Other (see instructions) ► (xp,,Yes ro..I.mxvl dWm&n mo u.SJ m 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) w P.O. Box 385014 1200 Urban Center Drive 35242 6 City, state, and ZIP code Birmingham, AL 35238-5014 7 List account numbegs) hem (optional) Taxpayer Ident'ffication Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social security number backup withholding. For individuals, this generally your social security number (SSNHowever, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other -m -� entities, It is your employer identification number (EIN). If you do not have a number, see How to gets TIN, later. or Note: If the account is in more than one name, see the Instructions for line 1. Also see What Name and I Employer identifieationnumber Number To Give the Requester for guidelines on whose number to enter. 2 0 - 8 5 7 9 1 3 3 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued tome); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b)1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a resultof 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 codes) 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. aryn I Signature of Here U.S person General Insti Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published,go to www.im.gov/Fomim 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) Data' 1/6/2024 • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form 11tf-9 (Rev. 10-2018) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address &AtH( QC WX oqq 1 C(41Moo X Z-7u37 • Please Type. if handwritten, must be in ink and legible. White out is not acceptable. • 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 Ite'th Llstdt , )E4u1y# Ibnt)VZM ,t z N IN Bid Iiiam #1 t.imestorie =1/2 inch To Dust or Eg401E<nt Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton q.Ltj CTt q o.&D Precinct Ton I ,W ,GU I ptj -tmi Precinct Ton illbo j rf Z.a ' /�r�,L6' 40,A 9L( lvnj i Precinct 4-P I Ton I (N, cO 977 /tI 9 L( • ztil I �( Precinct 4-S; 1-on i il•� �6. lV I /' "LQ.W 1 94 It", Remarks: �:+ Bo Item`#2: E Limestone - 3/4 Inch To Dui# or Equivalwen Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton I ,Gd I E,aj G 1,LU ay v Precinctl � Ton � ,�(J I UtJ,� I Gl1 I �� i�S Precinct Ton I�,u% I v,(-GCi `-Lo W qq l"-tj I I [precinct 4-P I Ton [ i , L!/ � 7 1Z L , "'d I ., �% `{ �z Precinct 4-S Ton �'i , /ii� C/3 t t,{} I p tI Remarks: Page 31 of 63 rks: #3: Item 247, Type,A i,imestone, Grade 2 [1314Inch] or Equivaleitt` Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit DELIVERY T{GTAL LOAD/ORDER ' Precinct 1 I Ton /MATERIAL l .(.(� 6d Precinct ; Ton Precinct 1 Ton I i`j, ; r/('1 cTi I /�(1,/�' I �N t,I Precinct 4-P I Ton ( Gu [•} I Ali.;-o?L� '�'c✓I.J Precinct 4-S i Ton I W, 6U .. Cf y6.0 Item 247, Type A Elmestone, C�add 3 [13J4 !rich] or Equivalent Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct ' Ton I I 1 l Precinct 2 Ton I 1 G(/ i �� �ti� i qo I Precinct 3 ` Ton G. Gp L46.9 funs Precinct 4-P , Ton 'J Precinct 4-51 Ton l�r.G� ��.. Gil t Item 265,2.2 Fly Ash or Equivalent See Specifications, Bid Item #5 for more information on this material Price per ton / delivery price to County Stockpile and/orlobsite LOCATION Unit MATERIAL DELIVERY TOTAL , I I Precinct 1 Ton I 7 Precinct Ton 1\j 1- ( ' I Precinct 3 I Ton ; Precinct 4-P I Ton � t Precinct 4-S j Ton MINIMUM I LOAD/ORDER Page 32 of 63 Remarks: MINIMUM MATERIAL I DELIVERY I TOTAL Precinct 1 1 Ton j ' of 47lb ' Bags on Pallet j Precinct I Ton i 1 i i of 471bi Bags on Pallet 1 Precinct 3 1 Ton = ! i 1 of 47lb! i Bags on Pallet I ! 1 Precinct 4-P I Ton I I ! ! i _of471b ' Bags on Pallet I i Precinct 4-S Ton ! ! I of 47lb Bags on Pallet Item 302; Type, S, Grade 3,(pre Coated Rock) dr Equivalent Price per ton / delivery price to County Stockpile and/or.lobsite MINIMUM LOCATION Unit DELIVERY TOTAL LOAD/ORDER MATERIAL Precinct 1 1 Ton Liz) p U 3- A I 1 1 Precinct 1 Ton it �`/e !! ! lS(� j �3.w Precinct 1 Ton ! L�,(,� 1 %Yj.CRI Ton Precinct 4-P i GB.� i p '1 Precinct 4-SI Ton �i l�_iN 7b `�� 14�.tiv i , UO, uI � Page 33 of 63 Item 302, Type PB, Grade 4 (Pre -Coated Rock) or Equivalent Price per ton/ delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct Ton 1 69.Gt, 1 is LP1 d IU'`7S Precinct2 ; Ton (7$.Cd 1 (`J, co Uqq()3-Li} 3-G�1 c.`7 A Precinct { Ton /oo 6p.6z ( 1�. i� 1 G/ t7p„(.� ! dr �✓J Precinct 4-P I Ton f 68,60 I i � q, GU 1 p�7 Q /, co� I l ,,l Precinct 4-Sl Ton 1 GSr .l.6 I ��,� 9 b. GO I q Remarks: Bid Item#9: Item'302, TVP'e P,E, Grade 3 (Pre -Coated Rock)" *Material Source out.of *°or Egpi Price per ton / delivery price to County Stockpile and/oFJobsite LOCATION Unit MATERIAL DELIVERY TOTAL i i Precinct 1 Tor. I , u Precinct2 Ton 1 1 i Precinct 3 I Ton � I 1 Precinct 4-P 1 Ton 1 ' I i Precinct 4-S Ton I i (Remarks: lent MINIMUM *Material Source-0 ",,,or Eualent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 Precinct 1 Ton 1 i y I t 1 1 Precinct 1 Ton 1 l 1 1 1 Precinct 3 Ton i Precinct 4-P ; Ton 1 , Page 34 of 63 Item#11: Remarks: Item 302 T yp, Grade 5, Ice`Rock (Non -Coated Limestone Only) k: " orEg4ivalent '1> Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct ' Ton I I SQ.GU I 37, 6d / 6 ,GU J q iVhS Precinct 2 Ton 6- vJ ; { Z, cG I 67 6 % I mo! Precinct Ton I Q,(](] I l7. W j 6 ,G(/ 'I ,/ it'll Precinct 4-P 1 Ton 50 W ; j � , W I rj /, f0 Precinct 4-S Ton I 1 3O.di1 l). u1 I B7 a) rq z✓)S Item 330, Type D Price per ton / delivery p LOCATION Unit Precinct 1 Ton Precinct 2 1 Ton I Precinct 3 I Ton i Precinct 4-P Ton Precinct 4-S 1 Ton mix Ltni stone) of =E "I ivalE;n County Stockpile and/oriobsite MINIMUM MATERIAL I DELIVERY TOTAL LOAD/ORDER FA Intentionally Left Blank Page 35 of 63 Bid Item`#13: Iter or See SI Price LOCATION Unit Precinct 1 1 Ton 50 lb Bag Precinct 2 1 Ton I 50 lb Bag Precinct 3 1 I Ton -- 1 50 lb Bag Precinct 4-P Ton 1 50 ib Bag precinct 4-S i Ton ' 50 lb Bag 1Remarks: for more information on this mate to County Stockpile and/orJoi MATERIAL I DELIVERY Iterrl"334, Type D Hot Mix Cold aid' C or'(q��tivaient See Specifications, Bid Item 414 for more information on this materia. Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION I Unit MATERIAL DELIVERY Precinct Ton %Uii,UJ ly,cd Precinct 1 Ton (06_40 Precinct 3 1 Ton ; f O V Ut} 1 Precinct 4-P I Ton (04 LO 17,0 I Precinct 4-S I Ton 1 106 _ W , j /, C/o , rks: Price per ton /delivery LOCATION Unit Precinct i ' Ton Precinct I Ton i Precinct Ton Precinct 4-P I Ton Precinct 4-S 1 Ton Remarks: to County Stockpile and/or Job MATERIAL I DELIVERY Asphalt.(LRA), , (Ton and/or 50 lb Bag) MINIMUM Icrete Pavement MINIMUM TOTAL LOAD/ORDER 1 u�Gd I ds�S IG.w 1 �S 'hmS lix or= Equivalent ', MINIMUM TOTAL LOAD/ORDER Page 36 of 63 Bid Item416 iten^432, Riprap, Section 2.3 Stone Riprap, l7":Limestone ortquivaterit y Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' I 1 Precinct 1 ' Ton ! ' Precinct 2 I Ton II Precinct 3 Ton I I Precinct 4-P ITon I i i Precinct 4S I Ton I I Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Authorized Signature & Title: �-j vl-% _ Type Name & Title of Authorized Signature: Q NF l n �JQ,- Q BPS%(�P io-Jf Phone Number: S 4,j iiy W Email: 61Im, K. ce/,+ Exceptions and or Variations from Specifications and/or additional Notes: NOTE: ALL DELIVERIES ARE IN END DUMP TRAILERS. BELLY DUMP TRAILERS CAN BE REQUESTED AND PROVIDED IF AVAILABLE. Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: O khi-Li { i 9 t f1 Address: V o lky l2Y (Z, rnln Tx 77H37 Remittance Address: S Qtvl�? Telephone: c 72 5q:3 qq" Fax: �7 Y SU 3 Sdis$ Email: de (d a4�;{v�1GFUii,ft _ ('w"i t _ Signature of Authorized Representative: Printed name of Authorized Rep: ORDER — CONTACT INFORMATION Order Contact Name &Title: 1 t ) ter Yfpsjea Order Contact Telephone: ' 77 (4,� L q(I ) Order Contact Fax: z7 4 su;) bgK Order Contact Email: INVOICES — CONTACT INFORMATION For Invoice Inquiries: nn Contact Name & Title: Contact Telephone: ' 77 50,3 Llyotf Contact Fax: 'i?7 S-LI Contact Email: U Page 38 of 63 STATE OF TEXAS {} AFFIDAVIT COUNTY OF W (I q Rion {} S� C F ) AU d C being first duly sworn, deposes and says: that he or she is (Type or P I Name) �\ the c°St F4 T 1u of 49k,( hFV4 Al; yk,-1,A6.having its (Type or Print Title) peor Print (Tyof Company/Him) principal address at ��,G'� (�, hJQ Godt 0� Q6 Ba /2L(4 ��� (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, onto any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditioltA�II^^''pl re IIIIments contained in the bid/proposal. SignatureII//II AeAil�t---�llyyy'����ttt...��y111 r4'�'n d �leSi(�<'✓t� Printed Name and Title of Affiant SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states th t the facts contained in the above are true and correct, this _� day of i 20 r tPfaWle�6bYWTax�e Signature of Notary Public MtY S�rmnMlion fakes 3tam 11� Page 39 of 63 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doing business with focal 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 racords 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 176.0061 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. 3QU I j l-y f�j h Z�, sP-4 Sndo- 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. / v J t l 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. P 1'14 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 F1 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? FYes F-1No 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. I " f 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 action 17 .003(a)(2)(8), excluding gifts described in Section 176.003(a-1). 7 -U -� I _ 10 i6I,; Signature of ve dr dortp nsiness with the governmental entity Date Form provided by Texas Ethics Commission www.etbics.state.N.us Revised 11/30/2015 Page 41 of 63 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. T��V* SnVAEr 1 f g)oQ,, fi Name and Title of Authorized Agent Sig fire' Authorized Agent tot fob g Date 1 am unable to certify to the above statements. My explanation is attached. Page 44 of 63 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 anv 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). i The Contractor, U� ` c & - ' t, (, 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 provislWs of 31 UA..C. § 3801 at seq., apply to this certification and disclosure, If any. Signaturd,of C6ritractor7s Authorized Official Printed Name and Title of Contractor's Authorized Official to l(v()q Date Page 45 of 63 Approved by OMB / V ( 0348-0046 Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing _ b. grant b. initial award _ b. material change c. cooperative agreement c. post -award d. loan For material change only: e. loan guarantee Year_ quarter_ f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. if Reporting Entity in No. 4 is Subawardee, Enter _Prime _Subawardee Name and Address of Prime: Tier if Known: Congressional District, if known: Congressional District, if known: 6. Federal DepartmentlAgency: 7. Federal Program Name/Description: CFDA Number.. fapplicab/e: 8. Federal Action Number, ifknownr 9. Award Amount, ifknomn: S 10.a. Name and Address of Lobbying Registrant b. Individuals Performing Services ftneluding address if (ifindividual, lost name. first name. Ml): dierentfrom No. Joe) (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: P ff5 /dQU;'( U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public p p 77 Telephone No.: L7LSy.l °)f� Date: i td(,�q 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) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85`b Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) T� t�-��(�er do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at htt s comptroller texas aov/purchasing/publications/divestment oho Company Name n Signature of A4or&d official Printed Name of Authorized Official Qfn)(ImI /Oj(G ay Title of Authorized Official Date Page 48 of 63 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) fib' 1 certify that twzg(i ly �ix �W— e, is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. ou� & Signature of A orized Agent S�% snj - rea;t�zvl r Printed Name and Title of Authorized Agent Date Page 49 of 63 � Request for Taxpayer Form (Rev. Catober2018) Identification Number and Certification Give Form to the requester. Do not stein iFomien�9arvl�— ►Go to www.irag0V1FmmW9 for instructions and the latest Information. send to the IRS. 1 Nomo(assho yen yourinoome tax Mum). Name is required an Nis one; do not leave this sloe blank JI( 2 Businassnamerdieregerced nutyname,ildihere above a 3 Check W1xQP6meboxforfedereltaxclessMgOon W&B press whose name is entered on line 1. Check on oneofthe N 4Fxem lona¢odos M ( ePptyonyto m followingseven boxes. certain entities, not indnidude; eae n o r—�// ❑ Indh1duaVaole prepdotoror CCamomuon 03Ca moration ❑ Partnership ❑ Trust/eetele insimegona an page 9]; d c singlo-member LLC Exempt payee catle (If any) �e $ ❑ Umhad llaWllty company. Enter 0u lax clsssifica:ion(C=C aorpom8an,8=S c¢rymaeon, P=PerlrarsNp)r `o Note: Check me eppmpdale boxinthe line sbweforthe lax classification ofthe sinrle-memherowner Do noleheck racempdonnono FATCA reporting LLC k the LLO is classified asa singlememrsr LLC that is disregarded from the owner unless meownero1 h. LLCis anothart-Ultatts m fromthefor U.S..S. enolher LLC metlanm tlaregametliremtae owner for i¢demltexpumdsa9-COlemisa, 6 single -member LLCthm tax coda(famt S owrmarded Issues] toeosas,ftedofita owner. Clh¢r (eaa lneiNe¶oM)r (.tylu b,mvC mdlW,:IaAISn•VSJ es SAddmss(nu ar, sbea anti apt. aravde no.)Sae lnatrac:lone. Requeslm'snamemdeddress(apgono y (-,v CALHOUN COUNTY e City. Waco, andzip aoee -� Ell, 7u� 202 S ANN ST, PORT LAVACA TX 77979 6^A -D L 7 361.553.4610 FAX: 361-553.4614 7 Uct account numbed.) me. Coptlonap Note: If the account is In more than one name, see the instructions for line 1. Also sea What Name and IPmPloyermenadeatton cumber Numbsi-Tis Give the Requasterfor8uldelines on whose number to enter. 1-1 �rl 1 1. The number shown on this form is my canectterpayer Identification number (or I am waking 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 (a) the IRS has notified me that I am no longer subject to backup withholding; and 3.1 am a U.S, crown W other U.S. Penton (defined below); anti 4. The FATCA code(s) entered on this form (ti any) Indicating that I am exempt from FATCA reporting Is correct. Certification insbuctiorim You must show 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, Bent 2 does not apply. For mortgage Interest paid, aequlsigon or abandonment of secured party, cencellatmn of debt, contributions to ai Individual retirement anangament (IRA), and generally, payments other than Interest and dividers ds,you of iequlmd to sA the modification, but you must provide your correct TIN, See the Instructions for Part (I, later. Here I u1pares i, I V,N General Instruction Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments relaretl to Farm W-9 and its Instructions, such as legislation enacted after they ware published, go to www.frs goV/FormW9. Purpose of Form An individual or entity (Form W-9 requested who is required to file an Information return with the IRS must obtain Your correct taxpayer Identification number MN) which may be your social security number (SSN), individual taxpayer Identification number (ITiN), adoption taxpayer identification number (ATIN), or employer Identificagon number (Elf(, to report on an Information return the amount paid to you, oruther mra amountroportable on an Information return. Examples of irdon returns Include, but are not limited to, the following. • Form 1099-INi(ntemst earned or paid) eater /1���� • Form 1099-DIV (dividends, Including lhase from stake or mutaal funds) • Farm 1099-MISO (various types of Income, prizes, awards, or gross prooeeds) • Forts 1099-B (stock or mutual fund sales and certaln other transactions by brokers) • Form 1099-S(proceeds from real estate transactions) • Farm 1099-K (merchant card and third party network transactions) • Form 1D98 (home mortgage Interall 1098-E (student loan Interest), 1098-T (tuNon) • Form 1099-C (Canceled debt) • Form 1099-A (acquishfon or abandonment of secured property) Use Form W-9 only 0you are a U.S. person (Including a resident alien), to provide your ormact TIN. Ifyau do not return Fonn W-9 to the requester with a TIN, you might be .ablest to backup withholding. See What Is backup withholding, later. Cat No. 10231X Form W-9 (Re, 10-2015 Page 50 of 63 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address ` /V1 art,k J AA a.,e-k 1 r'J LK Was VI, Zlxe- o�ba [•r«nk AA arc-k I C, r Icir.c • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT yy ROi D NI TERIALS (Bid Itdq Lis d or Equiyolent) Bidiltern #1: Limesto i X21n#ch<To Dust or Equiyalentt ; , Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 Ton I' i 1 Precinct 2 Ton I Precinct 3 Ton 1 Precinct 4-P i Ton Precinct 4-S; Ton ' Remarks: Bid Item #2' LI'u one; 3/4 inch To DUst.Qf Equ valesRr Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit IMATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 Ton t!O .� �j 3) . 10 1 3 S I S TnS Precinct ' Ton 3).10 1 3 , gs 'a.5 Tns !r Precinct 4-P ; Ton I (o .-� S ; 3 (.10 3%, FS 1 aS Tf\. Precinct 4-S Ton 1 % S L7 3� gs 1 5 1--aS Remarks: Page 31 of 63 rks: Or 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 I Ton I t 1j o 3 5 a 5 TrNs Precinct 2 Ton Precinct 4-P : Ton I ?J i - (`� 13� , 35 1 a 5 t �1.,• I Precinct4-S I Ton 1'-0 -'t�o 73 3S I aS l Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL I DELIVERY TOTAL LOAD/ORDER 2 1 Ton 3 ; Ton 4-P ; Ton 4-S I Ton See Specifications, Bid Item #5 for more information on this material Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton ' 1 I I I Precinct Ton Precinct 3 Ton t Precinct 4-P I Ton 1 Precinct 4-S : Ton Page 32 of 63 BM1�d Item #6 Item 275, Cement or Equivalent Y�,�, r 1 275=21; Hydraubc Cement Type i, Bulk (Pneumatic Tankers'S', Bader Bar Needed), ; 275-2 1, H)rdraulic Cement Typeei, 47 Ib1Bag(Cost per Pallet List # of 47lb Bags on a Pallet R Price per unit / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 1 Ton i —of 47lb1 1 Bags on Pallet Precinct 2 1 Ton I' I i I _of 47lb� j 1 Bags on Pallet 1 1 i 1 Precinct 3 1 Ton 1 1 1 1 _of471b 1 I 1 1 i Bags on Pallet I 1 I Precinct 4-P I Ton I of 47 lb 1 ' ' I ' Bags on Pallet 1 i Precinct 4-S I Ton 1 I _ of 47lb ' I 1 Bags on Pallet 1 Remarks: Bid Item`#7 item 302, Type Pt Made 3 (Pre Coated Roek) or Equivalent 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 I Precinct 2 Ton 1 I I I 1 Precinct Ton 1 I I 1 1 I 1 i Precinct 4-P Ton 1 1 I Precinct 4-S 1 Ton 1 Remarks: Page 33 of 63 Bid Item #8 Item 302, Type PB, Grade 4 (P a GoateB Rock} or EgLrlvalent Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I 1 Precinct 1 I Ton I l l Precinct Ton I I Precinct Ton I ' Precinct 4-P I Ton I I Precinct 4-5.1 Ton ; Remarks: x >� item 302, Tjrp'�e=,E, Grade 3 (Pre Coated ock) , Bid Item *Mater,ial Source out of *oF`Equivalent5 Priceper ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit TMATERIAL DELIVERY TOTAL LOAD/ORDER � I Precinct 1 Ton I I I I I Precinct 2 Ton I j I I I I Precinct3 Ton I l I I Precinct4-P Ton l ' I i � Precinct 4-5 ; Ton I I I Remarks: °y 11302,,Type PF, Gr de 4 (Pre Coated Rack) B d Item #10 31JI aterial Soured out - * or E{ ii t alenf Of _ Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I I Precinct 1 Ton I l i i I Precinct 2 Ton I I Precinct 3 Ton l I I I I I I Precinct 4-P I Ton I I Precinct 4-S ; Ton Remarks: Page 34 of 63 a Bid Item #11r Item 302 Type E, Grade 5, Ice Rock (Nqn-C'oated,Limestone Only) or quWont " Price. per ton / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i I t I Precinct Ton ' I � I Precinct 2 Ton I I t I I I I Precinct 3 i Ton ' I Precinct 4-P I Tort Ii I 1 Precinct4-S I Ton I Remarks: y Bid Item,412 Item 330, Type 0 (Pre=Mix Umeston�'oF EgUient; 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 Precinct Ton i I I I Precinct Ton I ' I I Precinct 4-P ' Ton ' Precinct 4-S ; Ton I Remarks: Intentionally Left Blank Page 35 of 63 (Remarks: rks: Item 33OD, Pothole Rep�lr`; Limeston:� Rock AsphaltLRA) or Equivalent, See Specifications, Bid Item #13 for more information on this material Price per unit / delivery price to County Stockpile and/or Jobsite (Ton and/or 501b Bag) MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton t I I I i ' 1 I SO lb Bag ! I I Precinct 2 1 Ton i , 501b Bag 1 I Precinct3 1 Ton 1 i I 1 5016 Bag i I I ' Precinct 4-P 1 Ton I , 1 50lb Bag I1 1 ' Precinct 4-S ' Ton . 5016 Bag 1 1 See Specifications, Bid Item #14 for more information on this materia. 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 Precinct 2 Ton I Precinct 1 Ton I I1 I Precinct 4-P I Ton 1 , 1 Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton Precinct 2 Ton Precinct 3 ' Ton ' 1 Precinct 4-P 1 Ton ( I Precinct 4-S I Ton , Page 36 of 63 „#E S J Bld Item #16 Item 432, Riprap, Section 2 3 Stotieii Rlp"r” 51 ,4.r2 'Limestone or Equivalent Price per ton / delivery price to County Stockpile and/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 1 1 Precinct 1 1 Ton i 1 I 1 Precinct 2 1 Ton i 1 i i I i i 1 i Precinct 1 Ton 1 I Precinct4-P 1 Ton I Precinct4-S Ton Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 1— � I Authorized Signature & Type Name & Title of Authorized Signature: Flc a.n < U).Mar e'y' T C'PS IA 2 - Phone Number: It"19—Sn13:�k Email: [Y1_MaYGQV h0�..l�rc� Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 1y/XL11797;TALIOX91:13747ILII&]7IT,le1I[a]0111101NLTiI Please Type. if handwritten, must be in ink and legible M a,,r CV d- M cLrE.l( T- U c,fc Vendor's Name: A6CL E-r Rk Mcs-rLk 'Tcuc Lii q Address: �')-) E. M,r\ cer,,Lftc E\ (,a.�g TX -7-)L{37 Remittance Address: 0- 50X qLk Telephone: C -)°l-SLA3- 3-1`1l Fax: 9--)CA- 543- 5L223 Email: Signature of Authorized Representative./,�J " l . i. IN N'Qw� Printed name of Authorized Rep: W. Ma.re.1C ORDER - CONTACT INFORMATION Order Contact Name & Title: i' C'e.5 i A ef%,+ Order Contact Telephone: Order Contact Fax: 91 a - 5 LA—�- 5(o g3 Order Contact Email: rn��r� ,h.o(7. C-arr-% INVOICES CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: J en n` der PrAy, was - i)ff--,reContact Telephone: q—)g—S43-(,If�1 Contact Fax: q -t 9 - 51A 3- 5 (e H 3 Contact Email: Page 38 of 63 STATE OF TEXAS {} AFFIDAVIT COUNTY OF _ W ha.r FOCI {} Fr R n k to, m ey _reAc being first duly sworn, deposes and says: that he or she is (Type orPrint Name) µ feA< d 6^/1 arek I rick W"k, IhC , pre the S i A of A h n M are,lc T r✓c lc; Cvy having Its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at J'�M l:. CY\ ncr A*C I P.r?i 6o)C q4--)l Q %rnrJ�Tr k -71fT? (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made In the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that priorto the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, In any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions d requirements contain m the bid/proposal. Signature of Affiant l� f�r'rxaV Lx?. CYlrcrcl YreSiCi 2n� Printed Name and Title of Affiant 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 (to h- r' .20 Zq. JENNIFER PAVLAS My Notary ID # 3609768 Expires October26,2026 Signatu a of Notary Pubic Page 39 of 63 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, 64th 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 governmen I gntity. lv1 w� �k d- th cv--e,k Truc1� Wash, �, � ba z Check this box If you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. 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 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 FIND 6 Describeeach employment or business relationship thatthe vendor named In Section l maintains with 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. s ❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 n� S ature of vendor doing business With the govern oral entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 41 of 63 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. Fcani< ls). Mae-r,K - Y(eSilAert Name and Title of Authorized Agent :: I-,-) N%C Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Date Page 44 of 63 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). E The Contractor, Frrxnl< to. f���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 - ���t< tu. Pre s i P� t 4rinted Name and Title of Contractors Authorized Official 10-aa-aH Date Page 45 of 63 Approved by OMB ' " / R 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. bidlofferlapplication a. initial filing _ b. grant _ b. initial award _ b. material change c. cooperative agreement c. post -award it. 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 (mown: Congressional DisMat, if known: 6. Federal DepartmentlAgency: 7. Federal Program Name/Description: CFDA Number, ifopplicable: 8. Federal Action Number, ifknown. 9. Award Amount, ifknown. S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services(including address if (rfindividual, last name,frrst name, Ml): differentfrmn No. I0a) (last ionic, first name, Ml): 11. information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: 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 (allure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 851' Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which Includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) i�Yac�.�G IA), Ma_rdc.dohereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract, and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https•//comptroller texas gov/ourchasing/publications/divestment ohp M Beak d- Mccr-e,4C T c-u c k Wa_r. ki, XrLC . A V)� frcee\ k m ee re.k i r u c K i r,c) Signature of Authorized Official Printed Name of Authorized Official Title of Authorized Official Date Page 48 of 63 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) ( rtct e k d lrareK�cu�k ttkes�f The' cd bu M"' I certify that C-ra r� k (' ac-e_k Tradci � is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Frrtny io, m���IC - PfGSi pn� Printed Name and Title of Authorized Agent to - )C1- �)M Date Page 49 of 63 Farm�� Request for Taxpayer Give Form to the (iaw Octobw2ma) Identification Number and Certification requester. Do not 9epapmeMthe Trees, IMema RemnofmsaMw ►Go to wevw.hagov/FormW9 forinstruedons and the latest Information. send to the IRS. t Name(assnown on your income tax Mum). Name is required on this One: do notleavathis line blank 2 e yeas nema/tliaregertletl aptly nwne,Htlilfarantf mabave ctrt I fvdc Flu 3 Chwkappmpriateboxfortedorallaxolasslgwtlonofthepersonwhom nsmelsen online l.Checkonlyortaofthe 4 Exemphone(wdes apply coy to $ fog nern, savor boxes. ordain and., not IndNldusis; see n c �/ ❑ Individualfw1a proprietor or Lam] CCognmtion ❑ SCogwmtion ❑ Partnership ❑ Tmslyfamde InaWctions on page 3): single -member LLC Exsmptpaywwda(HarW_ ❑ Wnkeeliebiliy, company. Enlerthataxclesslgwlion(C=C wmoration,S=Swmomtlon, P=Padnarshlp)► `Ili g Note: Chat the appropriate be,xinee line above(orthetexclassecadan afthe single -member owneo(bnolcheck Exemplimhorr FATCArepomng t= I 1.1.0"a, LLCM damiffed masingl6member LLCNatisdimegaMd fromlheownerunlamlheowmrofihe LLCis another LLD that b net disregarded from the owner for U.S. forkad tax purposes. Otherwise, a single- member LLCthat code an9) is disregarded from the owner should cheek the appropriate box for the tax elaestfiwtim of its owner. ❑ Olher(sae insauclione)► 4Yns.. ro.aemumwmenaaeue, u. vat as 6Adndress(numSortwt, and set. or suite no.) Sea Instructions. P• I LO Requester's mns and address(epeanal) y o , CALHOUN COUNTY 202 S ANN ST, PORT LAVACA TX 77979 a City, state, and LP code (Lt.rn O -T)C -743i 361-553-4610 FAX: 361-553.4614 T lJs[ewcuntnunasadahare.(aptlomg WItIM Tamenhar Identification Number (TIN) ErlteryourTlN In the appropriate box. Ths nN provided must match the name given on line 1 to avoid I actual security number withholding. For Individuals, third gamily, see the social security numbetr(SSh). However, fora resident alien, sale resident entity, see the for Pert esFarothar. ordisregardednumber amities, it Is your employer Identification number IEIM.If you do not have a number. seeHow ro Data employer Id do number. 77N, later. Note: If the mmurt la In morethan one name, see the Inebuctionsforllne 1. Also sea WhatNetne and NumberTo Give the Requesterfor guidelines on whose number to enter. 1. The number shown an this form Is my correct taxpayer Identification number (or I sm welding fora number to be Issued to me); and 2. lam not subject to backup withholding because: (a)1 am exemptfrom backup withholding, or (b) I have not been notified ay the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that 1 am no longer subject to backup withholding; and 3.1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA codes) entered on this form Of any) indicating that I am exempt from FATCA reporting Is carted CerOcation Instructions. You must cross out hem 2 above Ifyou have been hedged by the IRS that you are currently s you have felled to report all interest and dividends on you fix return. For real estate transactions, Item 2 does not apply. acquisition or abandonment of secured properly, cancellation of debt, contd6utions to an Individual retirement=Moem Interest and dMdends, General Instructions Section references we to the Internal Revenue Code unless otherwise noted. Future developments. For the latest intonation about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to www.hs gcv/FbmrW9. 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(7IN) which may be your accial security number ISSN), Individual taxpayer Identification number (TIN. . adoption taxpayer Idendfi a lon number (AM ), 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 Inforraton returns Include, but are not limited to, the fallowing. • Fatty 1099-INT (Interest earned or paid) Cat No. 10221X must provide Date► tID-29-2'i • Form 1099-CIV (dividends, including those from stocks or mutual funds) • Form 1099-MISO (various types of income. Adzes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by bmaere) • Faro 1099-S (proceeds from real estate transactions) • Farm 1099-K (merchant card and third parry networktrenseellons) • Fenn 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T (tultion) • Form 1099-C (canceled debt) • Farm 1099-A (acquisition or abandonment of secured property) Use Form W-9 only Ifyou are a U.S. person (Including a resident Wien), to provide your turned TIN, Myou do not return Form W-9 to the requester with a 77N, you might be subject to backup withholding. See What Is backup withholding, later. (Rev. 10-2018) Page 50 of 63 CALHOUN COUNTY, TEXAS I1►T7L�I�L�II•� i�]:31177�7:�1►rI ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT R7 k ATERI (BIk'tem Llste or I!( nt) Bl tart 41. Limestone = /2 Inch = us wualent ' .:. �., ,. Price Parton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT TMATERIAL DELIVERY TOTAL LOAD/ORDER Precinct I Ton Precinct Ton I Precinct Ton I ' i Precinct 4-P I Ton I I I Precinct 4-S I Ton Remarks: y.,- y, x:y Bld Item #2 im4,tone - 3/4 Inch To st or EqulVa nt s" Price Parton / delivery price to County Stockpile and/orlobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I ' Precinct 2 Ton I Precinct 3 Ton ' I Precinct 4-P I Ton I ' I I I Ton I ' Precinct 4-S I Remarks: Page 31 of 63 E Item;#3 1, 47, hype A lames o0% e 2 [13%41nch] or Equtdalent -- ., Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit =MATERIADELIVERY TOTAL LOAD/ORDER i i Precinct 1 Ton i Precinct 2 Ton 1 i i i Precinct 3 Ton Precinct 4-P 1 Ton 1 Precinct4-S 1 Ton 1 Remarks: ME #4 Item 247, Ty A Limb stone, Grade 3ji 3J41 ch]'or Equ vatent ss* �d�itkm • Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct Ton 1 ' Precinct Ton I I ' I I I Precinct4-P; Ton It i Precinct4-S 1 Ton I1 ' I Remarks: Bidllte #5 I 265-2.2 14 As Equi 4 lt See Specifications, Bid Item 85 for more information on this material Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I i Precinct ; Ton ; I I Precinct 1 Ton I 1 I Precinct4-P 1 Ton I 1 1 I Precinct4-S ; Ton Remarks: Page 32 of 63 Y B�dg`te ix It!n0275, CementQhaEqu T 521HydraullcCert)ett prti anker re BarN a �`' Hydraulic Cement T ye 1; Ib eagle per Ple st # 71'" P et Price per unit / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton ' I _of4716i I I Bags on Pallet I I � I Precinct 2 1 Ton of 47 lb Ii 1 ' Bags on Pallet I i I Precinct Ton I 1 _of47lbj I ' I Bags on Pallet i p i i I I Precinct 4-P I Ton I of 47 lb I ' Bags on Pallet I I F ct 4-S 1 Ton i I of 47 lb� I Bags on Pallet Remarks: YA WE 45RM"' Aw Bid item #7 It 302, Type PGr`ade 3Pre C d Rcfcj pr Egwalent 14 Price per ton / delivery price to County Stockpile and/orJobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct I Ton I Precinct 2 ' Ton Precinct 1 Ton Precinct 4-P ; Ton c Precinct 4-S I Ton ' Remarks: Page 33 of 63 ON Bld Item # � Itrgm 902, Type PB, Gr e 4 ((xre Coated,R k) or Equl Jale t i' ` Price per ton J delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER , i Precinct 1 I Ton I I I Precinct 2 ; Ton Precinct 3 ' Ton Precinct 4-P I Ton I I Precinct 4-5; Ton I I Remarks: Btd Ittn #9 in 0 Type PE. grade 3 (Pre Coated Rock) ' ' ai Source oYlt O * or Equivalent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit TMATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton i Precinct 2 ' Ton i ` I Precinct I Ton Precinct 4-P I Ton I Precinct 4-S ; Ton I Remarks: Item02, T , Gr ex4 (Pre ock) r 110 B tern `#�.(]: r x'"3 x",x *Material outro * or Equry ent,rtn Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' I Precinct 1 Ton I I I Precinct 2 I Ton I I I I I Precinct 3 Ton I I I Precinct 4-P I Ton 1 I I I I I I I Precinct 4-S 1 Ton I I Remarks: Page 34 of 63 Bid Item #1T Ite 302, Type 'a E, Gr§, i % Ice Rock (ion Coated Li o a - I or.6 lent Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 I Ton I I I I I I I Precinct 3 ' Ton I Precinct 4-P I Ton ' i I Precinct 4-S I Ton I Remarks: 5.�,. ,dry x2 i'y* 4y �5 Type D r Equ ent,;, Bt 3lterh #12 ItemMb, (Pre-Mlx limestdi : Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I ' Precinct 1 Ton II Precinct 3 Ton i 1 1 I Precinct 4-P; Ton I I I Precinct 4-S ; Ton I ' I I Remarks: Intentionally Left Blank Page 35 of 63 B ItEsfn#13. Item 330 D o AlcRepair, Limestone RookA ph LR 20 'r. or Equlwahent r .. see Specifications, Bid Item 4113 for more information on this material Price per unit ( delivery price to County Stockpile and/or Jobsite (Ton and/or 50 lb Bag) MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER 1 I 1 Precinct 1 I Ton ' I ! 50 lb Bag y I c Precinct 2 Ton r 1 50 lb Bag ' Precinct 1 Ton 50 lb Bag i J'wd Precinct4-P 1 Ton ' 50 lb Bag I 13.0 •u'° Precinct4-S ! Ton 5016 Bag I�1,l;0 4or d7 Remarks: x Bid Item #34 Is em 3 Type D Hot Mix,Coldld Asp onePaOr ' air Eq I, a ht" ,.. ." See Specifications, Bid Item #14 for more information on this materia. Price per ton / delivery price to County Stockpile a nd/or lobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton II ! Precinct 2 Ton ! ! Precinct I .Ton i ,Precinct 4-P I Ton II ! Precinct 4-5 ; Ton Remarks: gJd Item # 5V3 m� PP92AHPee€ Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit TMATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 ! Ton I I Precinct 3 I Ton ! i Precinct4-P; Ton i Precinct4-S p Ton ! Remarks: Page 36 of 63 I'ddxlten tt16 Item 432, RlprapSection 2.3 Stone Lirristone; 3 or Equroal3 , erit . 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 Precinct 2 I Ton Precinct 3 Ton i I I { I Precinct 4-P I Ton ' I I i Precinct 4-S ' Ton I Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: W-\l'a Authorized Sign Type Name & Title of Authorized Signature: �ThoMAS �0'N�A4� /'� Phone Number: �� D ` �� �' �� O� l Email: \ laON11 P" N CpGVU S Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: Address: Remittance Address: "3 �-" m \A 0`3 'U va1� Telephone: �L \ 0 - 6-\{ Fax: 1630`\- Sci -�i Email: i�01V rN cC oc�ay���a�� . use. Signature of Authorized Represent i Printed name of Authorized Rep:O�,dYs��U�7J ORDER — CONTACT INFORMATION Order Contact Name & Title: ynAS N�®NRiw z flv��2cr l� p Order Contact Telephone: Order Contact Fax: X 30 591- Order Contact Email: -Vbory INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Contact Telephone: at�s 3410 WKD`1 Contact Fax: W30 S'\- Contact Email: ILON1Y. Page 38 of 63 STATE OF TEXAS AFFIDAVIT COUNTY OF'Ll v a I01L o [If1ol`no-" .�'•�C f1c_V'� Type or Print Name) li the -r N — � t`� �i of � (Type or Print Title) principal address at first duly sworn, deposes and says: that he or she is having its (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directlyor indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees.to-furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upn�etoriditjo4rements c tained in the bid/proposal. Printed Name and Title of Affiant 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 I'9bh day of O Ck)h0 i , 20 4 JO ANN LERMA MY COMMISSION EXPIRES Notary St 08130/2027 NOTARY ID: #134534486 12 Signature of Notary Public Page 39 of 63 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, 841h Leg., Regular Session. OFFICEUSEONLY Date Received 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. t Name of vendor who has a business relationship with local governmental entity. 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 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? FlYes ® 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 me er of the officer AND the taxable income is not received from the local governmental entity? Yes No S 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. i`7 6%-c 6 ❑Che vendor has given the local government officer or a family member of the officer one or more gifts 3ectien in Section 176.003(a-1). s described ink 176.003(a)(2)(B), excluding gifts described 7 ng bust ass will a governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 41 of 63 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 42 of 63 See. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of finds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 43 of 63 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. MomV4s nI " o-il Name and Title of Authorized Agent Date Signature of Authp ' gent ed i 1 am unable to certify to the above statements. My explanation is attached. Page 44 of 63 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 includedin the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, � certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. ;Ignature of Contractors Authorized Official Il0A1P2 �'�Y�rt N �J��tt� � Printed Name and Title of Contractor's Authorized Official b-\-7 Oo� Page 45 of 63 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form Is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report, Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name,address,city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime Is the tat tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number, grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the Individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No.0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, Including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 Page 46 of 63 N � 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. initiat filing _ b. grant _ b. initial award _ b. material change c. cooperative agreement c. post -award d. loan For material change only: o. loan guarantee Year_ quarter_ £ loan insurance Data 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: 8. Federal Action Number, ifknown: 9. Award Amount, ifknown: S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (ifindividual, last name,firctname. MI)., dierenifimn No, 10a) (last name, first name, MI): It. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material •� .^') representation of fact upon which reliance was placed Print Name: \ hmtv,ia-S SOW by the tier above when this transaction was made or ,A ` A entered into. This disclosure is required pursuant to 31 Title: U'A �.10 311, 7. V N(KD r{ U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public Telephone No.: Date: S_ o _tid- 1 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) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 8511 Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) 'V\-\OMN'S do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at httl)s•//comptroller texas gov/purchasinglpublications/"divestmenl&h2 7pany Name enature of A)4- ' Title of Authorized Official Printed Name of Authorized Official Date Page 48 of 63 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) 19' I certify that I1R� )V t�'T `— \-'Zis a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Printed Name and Title of Authorized Agent 1®-\-I ay Date Page 49 of 63 Form YM®9 I Request for Taxpayer ( Give form to the (Rev. March2024) Identification Number and Certification requester. Do not Department of the Treasury Go to www.Irs. cv/FbnnW9 for instructions and the latest information. send to the IRS. Internal Revenue Service 9 Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below. t Name of enllfy/Individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name online 1, and enter the business/disregarded entity's name on line 2.) Blades Group LLC 2 Business name/disregarded entity name. 0 different from above. cl 3a Check the appropriate box for federal tax classification of the enaty/indivldual whose name is entered on line 1. Check 4 Exemptions (codes apply only to only one of the following sown boxes. certain entitles, not Individuals; c ❑ Individuallsole proprietor ❑ C corporation ❑ S corporation ❑ Partnership ❑ Tmsthestate sea instructions on page 3): 0 m � ❑✓ U.C. Enter the fax classification (C = C corporation, S = S corporation, P =Partnership) $ Exempt payee code (II any) p Note: Check the "LLC" box above and. in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless It is a disregarded entity. A disregarded entity should instead check the appropriate Exemption from Foreign Account Tax o, box for the tax classification of its owner. Compliance Act FATCA) .reporting ❑ Other (see Instructions) cotle (If any) a u o {Applies to accounts maintained 31, If on line 3a you checked "Partnership" or'TrusVestate," or checked "LLC" and entered "P" as its tax classification, e and you are providing this term a trust, wrote In which you have an ownership interest, check instructions ❑ outside the United Sfates.J rn rs, owners, this box if you have any foreign partners, owners, or beneficiaries. See ar fl 5 Address (number, street, and apt, or suite no.). See Instructions. Requester's name and address (optionalt 3 FM 1403 6 City, state; and ZIP code Uvalde, TX 78801 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 backup withholding. For individuals, this is generally your social security number (SSN). However, for a I social security number resident affen, sole proprietor, or disregarded entity, see the Instructions for Part I, later. Forother entities, it is your employer Identification number (EIN). If you do not have a number, see How to get a or TIN, later., c,.,..r..,...,w."ne...a.... ,,,,.,i,.. Note: If the account Is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. 4 5 — F2 r711 W6T5 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 Intemal 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 retum. 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 Sion the certification. but you mLst provide Your correct TIN. See the Instructions for Part 11, later. Signature of Here 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/FonnW9. What's New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that Is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the "LLC" box and enter its appropriate tax classification. Date New line.3b has been added to this form. Aflow-through entity Is required to complete this line to Indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow -through entity In which it has an ownership Interest. This change is intended to provide a flow -through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K3 (Form 1065). Purpose of Form An individual or entity (Form W-9 requester) who (s required to file an information return with the IRS is giving you this form because they Cat. No. 10231X Form W-9 (Rev, a-2024) CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 na Vendor's Name _&Address tK% c7i!1oice2DBA I�A cl+cLjOrdf%�Gyjc1 VCh�. ai6maD kx+UG,lu Tx`1�41`f • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT ROA[? M iTERIALS Llsted y 1 (Bldxltern or riC} Bld-Item Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct ; Ton 7, 659 , to ,y_�%(�' LN�II ✓ 5"f'ons Precinct 2 Ton , � r,' i , //O; ,� ' 5 Precinct 3 Ton �, i 1V 5 ns Precinct 4-P I Ton 1 / 1 . IQ5 , w No 1a la5 -1 on5 1 Precinct 4-S I Ton '7 65 a9.W 137,625 !95-601`16 Remarks: Bidltem #2 314 iii6ii Td Dust.Or Equl"Ient § , ,I.ifhe#giie ^> Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct i Ton ,45 laq,10 136r,J" 1.25 +on5 Precinct 2 1 Ton 5 • �0 75 n Precinct 3 I Ton , 1� , I 1371 Precinct 4-P ; Ton 5 13Q, (00 ��7j'T W, Gl5 {f)n5 Precinct 4-S ; Ton 1 -65 12 GO 137, GI.J fi Io Remarks: Page 31 of 63 Item"�47;Type A Llrriestone; Grade 2 [13h]`or �quivlenY Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit DELIVERY TOTAL LOAD/ORDER Precinct Ton f7MATERIAL IIn''�/'15 �1 IQ'g9r1/�� IZipta,5 IG1'�/Q/%tl�c Precinct l 1 Ton In112 I ;t��^-I •�U ;�J�iaS ; ; I ;i:,j,J �}�C j��t,� Precinct 3 Ton �'D ;3(�, r75 ;CX J CQ%� Precinct 4-P I Ton �'}} 1745 !! I p7 r l(�� aSC,.{(��nnCs Precinct 4-5 1 Ton G� i 1 - 1 J /�/� el-(5 19q. 66 136 • / 5 105 Ems Price per ton / delivery price to County Stockpile and/or Jobsite MI LOCATION I Unit I MATERIAL ( DELIVERY I TOTAL I NIpDER I Precinct 1 Ton , 1� ; I 3 Ton 4-S See Specifications, Bid Item p5 for more information on this material Price per ton / delivery price to County Stockpile and/or Jobsite MIN LOCATION Unit MATERIAL DELIVERY TOTAL AD/ORDER Precinct 1 ' Ton i i Precinct 2 Ton Precinct 1 Ton Precinct 4-P 1 on ' I ' Precinct 4-S Ton i Page 32 of 63 � Bid Item #6 Item`275, e ri�ent oil-q alent s F #t� ;'42,6 2 1, Hydraulll eni Type 1,�BDIk (Ps f fTe'nkers Spreader Bar Needed] �' �v rcr n �275 2 1, H' d ' " t Gertient Type 1, 47 1� 8 Gosf Pallet List#;bf 4716 Bags Raj f' , per on a Price per unit / delivery price to County Stockpile and/or Jobsite MINIMU LOCATION Unit MATERIAL DELIVERY TOTAL LOAD ER Precinct 1 Ton _ of 47 lb 1 1 Bags on Pallet 1 i Precinct 2 Ton i i ' _of 47161 ' 1 Bags on Pallet 1 i Precinct 3 1 Ton of 47lb.j i I Bags on Palle i Precinct 4-P 1 on 1 _ of 47 lb i 1 Bags on Pallet 1 ;re cinct 4-5 1 Ton of 47 lb i Bags on Pallet Remarks: Bid item #7 Item 3llType PB, Grade 3 (Pse Goeted:Rock►=oY'Egwvalg,� Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/OR i 1 i I Precinct 1 1 Ton i Precinct 2 1 Ton i I Precinct 3 Ton i i Precinct 4-P ; T 1 1 Pre ' 4-S 1 Ton Remarks: Page 33 of 63 Bid item`#8 Item 3O2,1y�ae PB, Gad �} (?re Coa#edlto�15)kr.'Equ4a�ent Price per ton / delivery price to County Stockpile and/or Jobsite UM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton i I Precinct I Ton ; i Precinct 3 I Ton I; I ' Precinct 4-P I on recinct 4-S I Ton i Remarks: Bld Item:#9 It 3O2, Type�E �rade3re>Coated'Rock)f e , , a£erim So�urc out Of *y k drEqutxsilent Price per ton / delivery price to County Stockpile and/or Jobsite TMATERIAL MINIMUM LOCATION Unit DELIVERY TOTAL LOAD/O R Precinct 1 Ton I t t Precinct 2 Ton f I Precinct 3 Ton i Precinct 4-P' Ton t i Precinct 4- I Ton Remarks: Btd Item #10 t" 02. TY,Pe E, Gratle 4 pre Cdji A ,Rock) :rtatertal Souhe out of * or.Egutugeht" _ Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD ft I i Precinct I I Ton I i I Precinct ; Ton ; I I Precinct 3 ' Ton i 7 I Precinc Ton I ' ' Precinct 4-S ; Ton I t 1 Remarks: Page 34 of 63 6td Item ¢#1 Item02, Tyye E, Cwr eIcRock (Noll Coated Limestone Oniy� 77 or,Equlvalent 4�a, Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL TOTAL LOAD/ORDER ' }DELIVERY � /C) li Iq 6 Precinct I Ton 1�� r10 q , 1180 %6 , Precinct 2 1 Ton n '�iJ 7� �yy{ ' Precinct 3 Ton - ;y0 ,7/D^� vV . lO Q/� , �(J n '�C5 ; !ao �o 2 8 � 2 30 �n,/115 &415 Precinct 4-P Ton . r ;J, l./ of 16?9,V/0 30 Precinct 4-Sj Ton /® ;..Jt/t 'C?,5-&15 Remarks: Bid Item #1Yem3QType D (Pre=Mix LimestO or , uir�lent 4., Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOT LOAD/ORDER i i i Precinct 1 Ton f Precinct 2 j Ton Precinct 3 Ton I I I Precinct 4-P I oni i i ' , Pr ' ct 4-S I Ton Remar Intentionally Left Blank Page 35 of 63 Page 36 of 63 Bid Item #16 Item43� R��irap, Section 2 3=tone Rt dap, 12" �r Limeston'e` x °r kc�alenf Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ ER Precinct 1 I Ton I I Precinct 2 Ton I 1 1 I Precinct 3 1 Ton 1 Precinct 4-P 1 n ' anct4-S 1 Ton Remarks: 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: Authc Type Phone Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: Address: 13 !c2 514 35 5 Remittance Telephone: Fax: I Email: ftArimci- U me r1baw Address:j I !-Q 5H 355 Signature of Authorized Represei Printed name of Authorized Rep: ORDER — CONTACT INFORMATION // % Order Contact Name & Title: A (�1(,Lr'JQLG 5Ck5u1A JQ15>7(LWA/ S 1" Order Contact Telephone: g79-3c? 3 to 11 re tt 361- 611- yj 53 Order Contact Fax: Order Contact Email: a)-n tf1GU`D) /hCM INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Contact Telephone: ejq - 5y1- 6 j q9 Contact Fax: �— Contact Email: Itool Page 38 of 63 STATE OF TEXAS {} II _I AFFIDAVIT COUNTY OF a+a Q(C10,) ICU AM n&�fh i�J1,i being first duly sworn, deposes and says: that he or she is F� ITppeprrPPrmt Name) q / r Mrdulo the I sDCi.�U, I.. Jcdp--. of VC l_�,gg�SpAyf6[.,D8H 1►Ia�maUrCir_ lans'�ru.�lOx. , lhrafving its (Typdlor Print Title) �^t (Typpe otr Print Name of Commp'a1/Firm) principal address at U/a 5N ,35 S I�LtU ;KP,,'TX 71'tlq (Type or Print Physi& and who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiantfurther deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else;. d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the ditions an uire ents contained in the bid/proposal. SiHature of i nt = I%1.5Da Printed Name and Title of Affiant r� 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 1't, ° \day of OiutU Kaa �-- , 20 O� `i. ignature of Notary Public Notary stamp/Seal :•=<"�6.. DENISEMOtJ AGUE :€� �?+ NOTARY PUBLIC ^r� y IOk 133022673 .k,;: State of Texas Ige 39 of 63 '•For,.. Comm. Exp. 0408202g CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code § 176.0010-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A)and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer ora family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (fi) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or afamily member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (il) the local governmental entity is considering entering into a contract with the vendor. Local Government Code § 176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/3012015 Page 40 of 63 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. jJ Name of vendor who has a business relationship with local governmental entity. 2 ❑ Check this box if you are filing an update to a previously filed questionnaire: (The law re fires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th busin s day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccur a.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4 Describe each employment or other bu Iness relationship with the cal government officer, or a family member of the officer, as described by Section 176.003( (2)(A). Also describe an family relationship with the local government officer. ach emplo me r business rel lonship described. Attach additional pages to this Form Complete subparts A/fficer CIO as necessary. A. Is thernment / fficer family member of the officer receiving or likely to receive taxable income, other thant income, fr the vendor? Yes � NoB. Is theei " g or likely to receive taxable income, other than investment income, from or at the direction of the locnt officer or a family member of the officer AND the taxable income is not received from the local goventity? Yes � No 6 Describe each a ployment or business relationship that the vendor named in Section 1 maintains with a corporation or other busines entity with respect to which the local government officer serves as an officer or director, or holds an ownership if Brest 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 It)Dater ignature of ve dor doing business with the governmental entity Form provided by Texas Ethics Commission www.ethtcs.state.tx.us Revised 11/30/2015 Page 41 of 63 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18. 1986, appear at 51 FIR 6370, 3 CPR, 1986 Comp, p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section I. (a) To the extent permitted by law and subject to the limitations in Section I (c). Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and eovernment-wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant io Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended. or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. See. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within lour months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 42 of 63 Sec. 4. '['here is hereby constituted the Interagency Committee on Debarment and Suspension. which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designaled by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions; maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb Baud. waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510. the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 43 of 63 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 tinder a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, thefl, 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 ( I ) (a — d) of this certification. �JYIt�^�I tleofA �s/ gent Ps Ltr r�rxq Name and Title of Authorize Agent l Date Signatt •e of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Page 44 of 63 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 (includingsubcontracts, 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 n((/qa�s amended by the Lo bying,D,"��5 clQQsuretAct of 1995). . i0.TR40rG')AG`6-�,7v fv lYlu,TPl fr� The Contractor,iGea5eSuyire.%iR, ertifi s 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 cJ 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Page 45 of 63 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. i. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal. action, 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants, 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 Page 46 of 63 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. ype of Federal Action: a. contract 2. Status of Federal Action: I,rr o. bid/offer/application 3. Report Type: a. initial filing b. grant b. initialialaward b. material change C. cooperative agreement 'ft\Itjll,tp-'— c. post -award d, loan F r 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 Prime _Subawardee Tier_, if Known: Name and ddress of Prime: P � 1' Con ressi )no[ District, if known: Congressional District, if known: 6. Federal epartmentlAgency: 7. FederalPr rr/{mn Name/Description: CFDAI ifapplicable: 8. Federal coon Number, ifknowu: 9. Awar0 ount, ifkrm+wc 10. a. Nanle and Address of Lobbying Registrant b. Individ als Performing Services (including address if flfind(vi lual, Tarr mm�e, first unme, +Nl): d fferent ftoin No. 10a) (lastname, +rstvmn+e, Ml): 1:1. Informafio 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 vy1 Print Name: r r t: by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 Title; ( 6 A Lo q , / Telephone No.479�t�3" "! ��I Datr, U y Z `l 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) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) �Y OJZC[C. SU�Ntk do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas. Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.php i Name Signature of Authorized Official Printed Name of Authorized Official Title of Authorized Official Page 48 of 63 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. ❑ 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) d I certify that hVC4,w6el Ulce DBA is a "Resident Bidder" of Texas as )Company Name) defined in Government Code §2252.001. Printed Name and Title of Authorized Agent I �d l�I ail Date Page 49 of 63 FormMe Detu rle!0IM11-.01re!"S'Lly Dapaal Revemle. Imemsl Revenue Service Request for Taxpayer Identification Plumber and Certification Give Form to the o not requester. IRS. SBp(1 t0 the IRS. i Nat^o {at- Sho vn on nw inco.nr tali r. wmj. tl no oquBed or thin Imp. do nc Ifrthe Ihu-Ifno blank. V CASE '1-ViGIP ; r o, 2 f3u irre name disragml d e Vn} + 1 d ilo rw n t .bov' i �_ 6� Ct n'SltiC { i 0 ri — re a Duet, aoprup atu ba, tar +ecru tl I la.n r p, tn.uk crrhs�lmm ut the tallo n ,seen uuxpz: 4 Exemptions footles apply only to 0 Irtthrxluallsolo prdp,mm, or GCoilYinallur. ❑SCdrporatipn ❑ Partnershp r�lro&Uosrte certain onlihes,not indivrtluals:see lnssuctions- on page 3J. a c Q, .4 sin9lamdmber LLC Limited hatrlig con-- Curiosity. Gnfer the tax clansd cat or v; G cc aomhon S - corporation P=pe b ership) t� Erampt Payee code 9f any! `o p Nola, our a n glc member ILL. ffrat:Z do too! c Iet P i (C. c i w ha. owopnare Loa' 1 ti,:+hne above fill Exemption Imm FATCA reporling a is the lax re widicalio+ of in,, ngir neUM,Ic ter. 'Ode (If am:) s 0 o ❑ Oth . (:.ec m:tarctic i,I ...., ^.a. t ., ., ¢F1 1313 G Adders (number, snmhl, and apJ, ar su:re nor etv ostei s name and address.. (open,) m 6 C:rty.:: rtc. am?21P code '� to iS { xCk "1 i LA 7 List arcuunt rumbeds) here ;apeOrA, — - - Taxpayer Identification Plumber (TIN) Enter your TIN in the appropnatn box, llie 'TIN provided must malgh the Wane gryen on Jlne 1 to avoid social security number backup resident when, sale opFor ie or, or ls.die this n generally yc n rooittl so,,, -Wily number ISSN) I lawgc _ r for a -m _ resident alien sole proprietor, or dieter rded notify Se e Part I istro bons on p Iqc 8 1 pr pth 0 entities, It Is yea ernployel identiflcation naotber (L)N It 7 ou do not h rve a mrtnl' er Sep/'dew to yet it TIN on page 3. or Note. It the amount Is in more Than ono eats, see the Instroioons for line 1 and the chart on page d for I Employer identification number guidelines on Whose nurnber to enter. Under penalties of perlup=, I certify that: 1. The number shown on this form is my correct taxpayer Identitirabgn number (or I am v:a9Wn for a nurnher to be issuod to may and 2, tam not suUjact to bankuP wlthholtlhly because: (a) I am exempt (roe, oacl;up wittlholcfing, or ibi 1 hrtva ;tot been ngtibed by the Internal Ravenup Service (IRS) that I am subject to backup withholding as a result of o failure to raper all wterest of ervIdends. or (c) the IRS has notified me that I inn no longer Subject to backup withholding; and s 1 am a U.S. citizen or other U.S. person (defined below): and 4. The FATCA codefsf entered on this loan (if any) r1dicutinr) that 1 On, exempt from FATCA. reportiric Is correct, Certification instructions. you must cross out item 3 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 d v'dends on your tax relum. For real estate itansictions. item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property. cior:ellaGon of debt, cordributlonc to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends,. you are not required to sign the Certificationbut you must provide your correct TIN. See the instructions on pace 3. Signa Her ( U.S. person of { �.% It } ,i U5=4if 4-A:�...� Date Y I .-.. _- ( I rX�l Here U.S. parson P t General instructions Section refemrces are to the Inwoml Revenue Late Urlleus owerwfeo notaa. Future developments. information about revetopmonUr nllseorp Fnim W-9 faucil as leglastg oo enacted after we release, lip is It owwry escrow"i/9. Purpose of Form An mdWiduol or entity (Form W-g rcquceed echo is required to tile an Ifoleabla, return Wan lhu IRS must obtain Your correct laxpuyer rdenlihaptlon number 171Nj r:hidh may be yodr.social security number I$SN) ridgy dual eup%t lank-I;o on number 011 Nl ado pllon Iosoayv Id aid nu ,r ^r; Al IU) r ,n1 F1., r IUsrltlficat! on our, oerI N} ip report on an Infernal I or rerun lire nmr n: peld io you, or other amount reportable On a11 :ntommlian rnwn. l xlln III I1 o1 1io•11z%ion returns include, but are not nson to. Ste follms ng: • Form 109111-INT firarnest emneu or pall) • Form IC9e-DIV (dividends, IncfAing more Prow 3 odk;v or i, itual Wndal • Form 1o9atv11SC (various types of •ncome. prizes, a\VIlds. or gross a¢.ceerM • Farm 1999-6 (stock Or mutual rand Sales and cer(ain oeter lraosaclims ro brokers) • Form 1o99-S fp'ocseds from real estate iransactiv,s� • Form 101!9-K (merchant card and third party efework transactiars • For, 109 g:onm mwf rics interestl, 109E-E (student loan Interest, 1098-T ibntiun) • Fam 1D99-C [cmxo ed dent{ • pone ;009-A iacguis(hon c• .Iomdonuirtm of secured Iaropady) LISP. Fnrr,, fV-9 rntly II you !(*.I ILLS. pee ore (nrluUirtg a resident allen). to prrvidr- vocr Causer -fIN. if ynv do nr.I retum Fnno ".'.e r i'.!to requester wile a TIN you III be sttbjecl to VvItup +vl[htroruTnp. See W vt o:zn:#u:; wifntfola9yi2 on page 2. (y ageing file flle d so: orm. you .•r t) that tili,, Tltl Su : ar:: ( r 1n,norrect (ar:ou ate.:0,Ig for a nurnher u. losrrrat, -rend, alhf y u Sle.+ f ,upie: l to backrp wnbholdinp, er 3. Horn, exon,ptron from dachup withholding if •mu are a U.S. exampi payee. 1=, jpnfiratsii. ". are al,, oen ly •p Oat " U.S. ca a r, yurvallocable slwre of any ps lor'd1 p' I.:crne cram a U.& trade oil bvsine;s is art suhJect to the a:Il molding lie on fore on cabnerssi+nre of etieciiveiv connected income, Intl Cendp thcr FMCA aodars, oaleed on U, a form (i1 any) mat --aline met you are eerri I !rpm Ilse FATCA reroding, a cornea. Soo Whar is FATCA rvnr flingP un Va`iei FJrhJrlllyil,tor r.son. CI!, Fin. , 0731 X Form W-S (Rev. 12-201,1) Bid Received from Brauntex Materials Inc. Marked as Non -Responsive • Disclosure of Lobbying Activities page not marked N/A • W-9 was returned but left blank W'f*l►SW -64 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ROAD MATERIALS Bid Number: 2025.02 January 1, 2025 through December 31, 2025 Vendor's Name & Address • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT ROADS ERI%/fi �B term aREqul Bid IteniJ#ji Lim ich Tor ust oi' L juivalent F Price perton / delivery price to County Stockpile and/or Jol site MINIMUM LOCATION UNIT MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton Precinct 2 Ton Precinct Ton ' i S Precinct 4-PTon 1 i I Precinct 4-5 ; Ton Remarks: bid Btd ItEs`m #2 esto �4 In kli o bus, =v qulii t r 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 j I i Precinct Ton ' I { Precinct 4-P I Ton ; ' Precinct 4-S Ton I I Remarks: 01A Page 31 of 63 Bld'Item #3 Item 247, Type A Ll/4t1ncl]lp Eg4JJralent Price per ton / delivery price to County Stockpile and/or Jobsite TMATERIAL MINIMUM LOCATION Unit DELIVERY TOTAL LOAD/ORDER Precinct 1 Ton I Precinct ;. Ton ; Precinct Ton I Precinct 4-P I Ton ! i i i Precinct 4-S I Ton ' I Remarks: no Id Bld Item4 (tefh 247, Wes one, C#,Cade [13/41nch],mor Equivalent f; Price per ton / delivery price to County Stockpile and/orJobsite z MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i i Precinct 1 I Ton II J Precinct Ton i I Precinct Ton I I Precinct 4-P; Ton ' I Precinct 4-S I Ton I I I I Remarks: Bad Mein,#5r Item 265 2,:2 Fly Ash or Equivalent °.'. See Specifications, Bid Item NS for more information an this material Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER ' 1 Precinct 1 Ton I ' i I Precinct 2 I Ton I 1 Precinct I Ton I Precinct 4-P I Ton i Precinct 4-5 ; Ton I Remarks: Page 32 of 63 #63 35, Ce7ent Or EqutNal 2* 5 �, Hydra aGc Cement Type 1, 6 Ik (P atw er e ed) " 275-.1, Hydrauilc Ceme tT n Pefri,GIbB LLCdsO„x #of'gsona.Pallo" Y _ Price per unit/delivery priceto County Stockpile and/or Jobsite _... ..._ _ -vh MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 I Ton I I 1 of 476 i I Bags on Pallet I Precinct 1 Ton I I 1 I I of 47 lb 1 Bags on Pallet 1 1 1 I i Precinct 3 1 Ton 1 1 1 i 1 _of47lb1 I ' Bags on Pallet ; 1 Precinct 4-PTon of 47 lb ' I Bags on Pallet Precinct 4-S 1 Ton 1 I1 1 of 47 lb 1 1 Bags on Pallet Remarks: bid BIdIteA. #7 fe;0 Gra Pre C Nted Rock) or equivalent ' Price per ton / delivery priceto County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 1 Ton 1 �•� ' 3�I •� . W I -LS tV( I 1 S13q .00 1 •Of� 1 2S l Precinct 2 I Ton I I /� q Precinct 3 I Ton (J •/60 I zq • 0 ri�Y� )l ' w ' Precinct 4-P; Ton 1 6•W 1'��C ' C6(4•GL^) IZ�J IL71�U(` I i �S .OD i .W �.W ' IS VIE Preclnct 4-S � Ton J� Remarks: Page 33 of 63 A'x:.K j if .r '. �1 4i Bid Itcrq #8 Iteem 2, Tr , e PB, Grady 4 (?r� eil'Rock --"Ec(uiyaleq- _ Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER KS'c� 3� gN.ao 2S-totf Precinct 1 Ton .ca (' �-'n Precinct ' Ton I S•�o '� 1 7'11 u -CO I ICED Precinct I Ton I ry .co/'� I Precinct 4-P I Ton I� 1 ��' ��.� -W�• N� I Precinct 4-S j Ton ` —4J'"" ' ; 39. W ' [""1 "Qo IS It-'1.> Remarks: item 302, Type PE, Grade 3 (Pre -Coat igckj e s= Bad ITernz#9: Waterial Source out of ;. * or EqulvaleriY 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 i I 1 I Precinct 2 Ton ; 1 Precinct 3 I Ton I i I Precinct 4-P 1 Ton I I I I i Precinct 4-S ; Ton I 1 Remarks: no Bid Item O Itirfv 301 T e R ,Grade 4 (Pre Cued RockY r �Yp . *nl'IMaterial;Source Egwvalerit ou`E:of pt 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 Precinct 2 1 Ton I i I Precinct 3 I Ton I Precinct 4-P 1 Ton I I Precinct 4-S ; Ton 1 1 1 Remarks: bid Page 34 of 63 Id It } jy.Oe E, Grade �; icffon dyLlm jAh,... ;n'e .yCi'ClILc"I,�,en iv..w"r Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER i Precinct 1 Ton I I i i i Precinct 2 - Ton I I i I Precinct Ton I I Precinct 4-P ' Ton I I ' i i Precinct 4-S ; Ton i Remarks: t m �l r, Fite Z 3 0 ype f?r, �c L' stone) or. � trivalent r �1. W, . j _ _.., Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER j I Precinct 1 Ton I I { I Precinct Ton 1 I I Precinct 3 Ton I I I I Precinct 4-P ' TOn I i i Precinct 4-S ;. Ton Remarks: 1 Intentionally Left Blank Page 35 of 63 See Specifications, Bid Item #13 for more information on this material Price per unit / delivery price to County Stockpile and/orJobsite lion and/or 50Ib Bag) MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ; Ton I' 50 lb Bag Precinct I Ton I i So lb Bag I i 1 Precinct 1 Ton I I I I 1 I 50 lb Bag ' i Precinct4-P I Ton 50 lb Bag Precinct4-S I Ton I I I _ 50 lb Bag I I m #14i item 334, Type D Hot Mix Cold Laid Asphalt Pr Equivalent See Specifications, Bid Item #14 for more information on this materia. Price per ton / delivery price to County Stockpile and/or Jobsite LOCATION Unit MATERIAL I DELIVERY Precinct 1 I Ton7J • fi0 I 3 .QO Precinct i Ton I �n Precinct 3 I Ton Precinct 4-P 1 Ton I zo I Y%> r^ Precinct4-S 1 Ton I I ?J� Remarks: Price per ton / delivery price to County Stockpile and/or Jobsite TOTAL .06 MINIMUM MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER Precinct 1 ' Ton I I i I Precinct 2 I Ton I I Precinct 3 Ton I I I Precinct4-P I Ton i I I i Precinct4-5 ! Ton ! Page 36 of 63 11 i�j m 49rap,Sectlon 2r3stone'�f{Ipr" �" in f L.sto� r" E FGL ilr r Price per ton / delivery price to County Stockpile and/or Jobsite MINIMUM LOCATION Unit MATERIAL DELIVERY TOTAL LOAD/ORDER I Precinct 1 Ton I I I I Precinct 2 ' Ton I I Precinct ' Ton i Precinct 4-P I Ton } i Precinct 4-5 I Ton i 1 I Remarks: no �jq 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 vendor, 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 all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID Date: 40w�! _ J Authorized Signature & Title: Type Name &Titleppof Authorized Signature: Wk1 02har I 0Ad6V) Phone Number: Email: Sit.,*{ (q)jorwwxiYmc Ia1S'Cqsi Exceptions and or Variations from Specifications and/or additional Notes: Page 37 of 63 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: RrauotX (bi"eriais', T-r)c.. Address: P-O- eo) 312t021 New Erowmu els ,-Tx Remittance Address: Telephone: �3D" taJ bZ�Lo Fax: (?Z0 -y2b -I995 Email: $U.1C� 9 bra.LA'�-IeXrYA-. jCL(S•Carm Signature of Authorized Representative: Lb&�/,r�(h Printed name of Authorized Rep: ORDER — CONTACT INFORMATION Order Contact Name & Title: 4ialeq LU2 Con uc--r Spec( Order Contact Telephone: qb & bzS Order Contact Fax: QaO— lo,•1 — 10I0IS Order Contact Email: SC1 6Ccbb( Ui1WVWa+eG1GUS•CaM INVOICES - CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: +Iellp,h Cfi Sa r7, I/ ou� aec-elVabic r-. Contact Telephone: Contact Fax: (�Zp' L z- Contact Email: Wm� lor"n-Kxmatr.rlaS.Com Page 38 of 63 STATE OF TEXAS {} AFFIDAVIT COUNTY OF {} IYllu o, being first duly sworn, deposes and says: that he or she is �/ (Type or Print Name) the _ 6:34r� of irA !/t 4 (� /✓tC having its (Type or Print'1 itle) (Type or Print Name ofCompany/Firm) principal address at /Sd xf d, G"f 16(- A Atdwit' 79/4 Z (Type or Print Physical and who submits herewith to Calhoun County the attached bid/proposal; that he orshe is the person whosename is signed to the attached bid/proposal; that said bid/proposal Is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or Indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, orto raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the condit'6ns and re vire ents contained in the bid/proposal. Signa��J� ._. Printed Name and Title of Affiant SWORN TO AND SUBSCRIBED BEFORE1 ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this aO n�day of October. 20�. �. SARAH KADERLI BORES NOTARY PUBLIC .N. .z: IDk 10648187 ;..'? Slate of Texas Comm. Exp. 11.18.2024 Notary Stamp/Seal I UA4014 la Signature of Notary Public Page 39 of 63 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity A complete copy of Chapter 176 of the Local Government Cede maybe found at http://www.statutes.legis.state.tx.us/ Does/LG/him/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code § 176.0010-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government off icerora family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (if) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code § 176.006(a) and (a-1) (a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 40 of 63 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, a4th Leg., Regular Session. OFFICELISEONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has abusiness 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- 1 Name of vendor who has ayb�usiness relationship with local governmental entity. (/ECG �c aLly !�✓ y(/1C. 2 III ------III ��/ Check this box If you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4j Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yes FlNo B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? Yes FIND 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 ElCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 i L /0 2z Zo2 Sig na ure of ventl r �d ing usmess with the governmental entity ate Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 41 of 63 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section 1(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 42 of 63 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec, 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken tinder 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 43 of 63 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS [n accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his / her knowledge and belief, that its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction or records, making false statements, or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification. d. Have not within a three-year period preceding this application / proposal had one or more public transactions (federal, state, or local) terminated for cause of default. e. Acknowledge that all sub -contractors selected for this project must be in compliance with paragraphs (1) (a — d) of this certification. Name and Title of Authorized Agent Date' Sigr a i e of uthorized Agent I am unable to certify to the above statements. My explanation is attached. Page 44 of 63 Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) The undersigned certifies, to the best of his or her knowledge and belief, that (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti -lobbying certification be Included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). The Contractor, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 at seq., apply to this certification and disclosure, if any. Signaature of 0 r tractor's Authorized Official �fl/�%rZrr r L% �%y..(,ti Printed Name and Title of Contractor's Authorized Official �d/2 L/%4L-li Date Page 45 of 63 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The fling of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to Influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enterlhe full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5, If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments, 8. Enter the most appropriate Federal identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity Identified In item 4 or 5. 10. (a) Enter the full name, address, city. State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and Include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB. control number for this information collection is OMB No.0348- 0046, Public reporting burden for this collection of information Is estimated to average 10 minutes per response, including time for reviewing inslructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0340-0046). Washington, DC 20503 Approved by OMB 0348-0046 Page 46 of 63 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 L Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b.. grant _ b. initial award b. material change c. cooperative agreement c. post -award d. loan For material change only:. e. loan guarantee Year_ quarter_ I. loan insurance Date of last report 4. Name and Address of Reporting Entity: S. If Reporting Entity in No. 4 is Submvardee, Enter Prime _ Subawardee Name and Address of prime: Tier if Known: Con ressioual District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description CFDA Number, if applicable: S. Federal Action Number, iflnown: 9. Award Amount, iflnown: S 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (includingnehh-ess if Cfindividual, lase name, first name, MI): diferentfran Na. 10a) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: by the tier abovewhen 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) Page 47 of 63 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 8511 Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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. [,(authorized official) �n/!'�%a . 6.. do herebyverify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.php 6,4,4r4- Ncrmlinc Signature of Authorized Official Printed Name of Authorized Official Title of Authorized Official Date Page 48 of 63 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 /P&4kpc `4&41164 is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Idol.0. Printed Name and Title of Authorized Agent a,4 224 y. Date Page 49 of 63 Request for Taxpayer Give Form to the F°°n Identification Number and Certification requester. Do not (Rev.Odober2013) Oepatlrnera of the Treasury Send to the IRS. Intemal Revenue SeNico ►Go to www.imgov/FprrnW9for instructions and the latest infortna0om 1 Name (as sham on your incometex return). Name is required cattle line. do not leave this line blank 2 Business nomu/diaregmded entity name, if offered from ebova w 3Check appropriate boxfarfedera act ciassPocztim of the person whose home is entered online 1. Check only one of the 4 Fxomptions imms, apply onlyto following seven boxes. certain entities, not Individuals; see n p ❑ indMiclueusole pespdotor at ❑. CCoryoalian ❑SCorporation ❑partnership ❑Tnnewedum instructions, an page 3): m e singla-member LLC Exemptpaysemde(geny) j^ ❑ Unshod liability company. Enter the tax classification(C=C corporation, 8-3 massacres. P=Pammuship)* `o Note: Check the appropriate box in the lino above for the lax classification of the single -member owner. Conolcheck ExemplionfronFATCArapading �2 LLC 9the MCis classified esaeinglamambar LLD that is dleregerdedfmn the owner unless lheawnaraf the LLC is code fit my) e another LLC Mat is nsteisr°gardedfrom the emerfar U.S. federal lax purposes. Ctherviise, asingle-member LLC that LL ° is chmeriardetl lame the owner should checkihe appropriate box for the tax classification of its owner. YNa®unL ❑ Ciher(sae insbucgens)� t� mwwwewkb x.usJ S y 5Address (number, sueot, and ml. or suite rw.) Sea insbualiens. Requesters name and mdress(optuna9 a CALHOUN COUNTY 41 402 5 ANN ST, PORT LAVACA TX 77979 a City, state, and ZIP coda 361.653-4610 FAX: 361-553-4614 7 Ust account numbeds) here (oplionag Taxpayer Identification Number (FIN) Enter your TIN In the appropriate box. The TIN provlded must match the name given online 1 to avoid I S°ciai mou fly number ls,die, this Isentity, your social security number (Sater.F ever, fora backup witen,san&For generally ciaWctions ietor, or rsee the for Pert I,Sete).Forother resident alien, sale proprietor, or disregarded _m -� entitles, it is your employer Identification number (EIM• If you do not have a number, see How toget a TIN, later. or Note: Ifthe account is In more than one name, amthe Instructions for line 1. Also see What Name and I Employer Identification number Number To Give the Aequesterforguidelines on whose numberto enter. F-i-1 (—i-T i i i i i 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. ciazen or other U.S. person (defined below); and 4. The FATCA codes) entered on this form (deny) 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 oto reohmenall tInternet of seeured d8nds, on your tax return. For real estate trommi llons, item 2 does not apply. For mortgage Interest paid, q property, cancellation of debt, contributions to an individual retirement arrangement(ifflQ, and genealty, payments other than Interest and dividends, you am not required to sign the certificatlon, but you must provide your coned TIN, Sao the Instructions for Part 11, later. Sign Signature of Her, u.s. pereon. am.V, General Instructions - Form 1099-DIV (dividends, including those from stocks or mutual funds) Section references are to the Internal Revenue Coda unless otherwise • Form 1099-MISO (various types of Income, prizes, awards, or gross noted. proceeds) Future developments. For the latest Information about developments • Form 1099-5 (stock or mutual fund sales and certain other related to Form W-9 and its instructions, such as legislation enacted transactions by brokers) attar they were published, go to www.frsgov(FormW9. • Form 1099-5 (proceeds from real estate transactions) Purpose of Form • Form 1099-K (merchant card and third party network transactions) An individual or entity (Fare W-9 requester) who Is required to file an • Forth 1098 (home mortgage Interest), 1090-E (student loan Interest), Information return with the IRS must obtain your coned taxpayer 1098-T lattice) Idant9lcatlon number MM which may be your social security number • Forth 1099-0 (canceled debt) (SSM, Individual taxpayer identification number (TIN), adoption taxpayer Identification number f(tTIM, or employer identification number 'Form 1099-A(acquisition or abandonment of secured property] (EIM• to report on an Information return the amount paid to you, or other Use Forth W-9 only if you we 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 Forth W9 to the requester with a TIN, you might • Form 1099-INTthousand earned or pald) be subject to backup withholding. See What Is backup withholding, later. Cat N. 10MIX Farm W-9 (Rev. 10.2018) Page 50 of 63 NOTICE OF= MEETING — 11/13/2024 12. Consider and take necessary action to award the bids for Asphalts, Oils & Emulsions, Bid Number 2025.03, for the period January 1, 2025 through December 31, 2025. (RHM) Page 9 of 16 Debbie Vickery From: demi.cabrera@calhouncotx.org (demi.cabrera) <demi.cabrera@calhouncotx.org> Sent: Thursday, November 7, 2024 9:32 AM To: Debbie.Vickery@calhouncotx.org Subject: Agenda Items Good Morning, Can you please place the following items on the agenda for Commissioners Court on Wednesday, November 13, 2024: • Consider and take necessary action to award the bids for Insecticides for Mosquito Control, Bid Number 2025.01, for the period January 1, 2025 through December 31, 2025. Consider and take necessary action to award the bids for Road Materials, Bid Number 2025.02, for the period January 1, 2025 through December 31, 2025. I will have the back up and copies to you by the end of the day. Thank you, Q¢mi Cabran Calhoun County ,�,56i.stant auditor 361-553-4613 361-5534614 (fax) Calhoun County Texas CALHOUN COUNTY, TEXAS BID TABULATION ASPHALTS, OILS AND EMULSIONS ANNUAL SUPPLY CONTRACT, BID NUMBER: 2025.03 For the Period Beginning January 1, 2025 and Ending December 31, 2025 3,gQ BASELINE PRICE ON OCTOBER 28, 2024 FOR DIESEL FUEL ADJUSTMENT ON DELIVERY PRICE (www.ela.gov/petroleum/gasdiesel) (Gulf Coast Area) Bids that met specs 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). ASPHALTS, OILS AND EMULSIONS Item 300, Asphalts, Oils and Emulsions PRODUCT/ BIDDER LOCATION Unit DELIVERY TOTAL DEMURRAGE MATERIAL AND REMARKS, IF ANY $80 per hour after 2 Precinct 1 Gallon $2.95 $0.20 $3.15 free hours. CLEVELAND ASPHALT PRODUCTS, INC. $80 per hour after 2 Precinct 2 Gallon $2.95 $0.20 $3.15 free hours. REMARKS: PRICES BASED ON MINIMUM 5000 GALLON $80 per hour after 2 Precinct 3 Gallon $2.95 $0.20 $3.15 free hours. LOAD, FOR SMALLER QUANTITIES PLEASE CALL 800-334-0177. DILUTED MATERIAL CANNOT BE RETURNED $80 per hour after 2 Precinct 4-P Gallon $2.95 $0.20 1 3.15 free hours. FOR CREDIT; RETURNS ARE FOR MATERIAL ONLY, NOT FREIGHT. $80 per hour after 2 Precinct 4-S Gallon $2.95 $0.20 $3.15 Ifree hours. $95 per hour after 2 Precinct 1 Gallon $3.75 $0.31 $4.06 free hours $95 per hour after 2 Precinct 2 Gallon $3.75 $0.31 $4.06 free hours MARTIN ASPHALT COMPANY $95 per hour after 2 Precinct 3 Gallon $3.75 $0.31 $4.06 free hours REMARKS: 5000 GALLON MINIMUM $95 per hour after 2 Precinct 4-P Gallon $3.75 1 $0.31 1 $4.06 lfree hours $95 per hour after 2 Precinct 4-S Gallon $3.75 $0.31 $4.06 free hours Page 1 of 3 PRODUCT/ BIDDER LOCATION Unit DELIVERY TOTAL DEMURRAGE MATERIAL I I I I AND REMARKS, IF ANY Precinct 1, 2, Gallon 3, 4-P, 4-S NO BIDS RECEIVED PRODUCT/ BIDDER LOCATION Unit MATERIAL DELIVERY TOTAL DEMURRAGE AND REMARKS, IF ANY $95 per hour after 2 Precinct 1 Gallon $3.65 $0.31 $3.96 free hours $95 per hour after 2 Precinct 2 Gallon $3.65 $0.31 $3.96 free hours MARTIN ASPHALT COMPANY $95 per hour after 2 Precinct 3 Gallon $3.65 $0.31 $3.96 free hours REMARKS: 5000 GALLON MINIMUM $95 per hour after 2 Precinct 4-P Gallon $3.65 $0.31 $3.96 Ifree hours $95 per hour after 2 Precinct 4-S Gallon $3.65 $0.31 $3.96 Ifree hours $80 per hour after 2 Precinct 1 Gallon $3.90 $0.20 $4.10 free hours CLEVELAND ASPHALT PRODUCTS, INC. $80 per hour after 2 Precinct 2 Gallon $3.90 $0.20 $4.10 free hours REMARKS: PRICES BASED ON MINIMUM 5000 GALLON $80 per hour after 2 Precinct 3 Gallon $3.90 $0.20 $4.10 free hours LOAD, FOR SMALLER QUANTITIES PLEASE CALL 800-334-0177. DILUTED MATERIAL CANNOT BE RETURNED $80 per hour after 2 Precinct 4-13 Gallon $3.90 $0.20 $4.10 free hours FOR CREDIT; RETURNS ARE FOR MATERIAL ONLY, NOT FREIGHT. $80 per hour after 2 Precinct 4-S Gallon $3.90 $0.20 $4.10 free hours Intentionally Leff Blank Page 2 of 3 PRODUCT/ LOCATION Unit DELIVERY TOTAL DEMURRAGE MATERIAL $80 per hour after 2 Precinct 1 Gallon $2.55 $0.20 $2.75 free hours $80 per hour after 2 Precinct 2 Gallon $2.55 $0.20 $2.75 free hours $80 per hour after 2 Precinct 3 Gallon $2.55 $0.20 $2.75 free hours $80 per hour after 2 Precinct 4-13 Gallon $2.55 $0.20 $2.75 free hours $80 per hour after 2 Precinct 4-S Gallon $2.55 $0.20 $2.75 free hours $95 per hour after 2 Precinct 1 Gallon $2.70 $0.31 $3.01 free hours $95 per hour after 2 Precinct 2 Gallon $2.70 $0.31 $3.01 free hours $95 per hour after 2 Precinct 3 Gallon $2.70 $0.31 $3.01 free hours $95 per hour after 2 Precinct 4-P Gallon $2.70 $0.31 $3.01 1free hours $95 per hour after 2 Precinct 4-S Gallon $2.70 $0.31 $3.01 free hours LOCATION I Unit PRODUCT/ I DELIVERY TOTAL MATERIAL Precinct 1, 21 Gallon 3, 4-P, 4-S DEMURRAGE NO BIDS RECEIVED Intentionally Left Blank BIDDER AND REMARKS, IF ANY CLEVELAND ASPHALT PRODUCTS, INC. REMARKS: PRICES BASED ON MINIMUM 5000 GALLON LOAD, FOR SMALLER QUANTITIES PLEASE CALL 800-334-0177. DILUTED MATERIAL CANNOT BE RETURNED FOR CREDIT; RETURNS ARE FOR MATERIAL ONLY, NOT FREIGHT. MARTIN ASPHALT COMPANY REMARKS: 5000 GALLON MINIMUM BIDDER AND REMARKS, IF ANY Page 3 of 3 Demi Cabrera From: eia_elists@eia.gov (U.S. Energy Information Administration) <eia_elists@eia.gov> Sent: Monday, October 28, 2024 3:32 PM To: peggy.hall@calhouncotx.org Subject: Today's Diesel Prices 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. bul.pandrnr Swfv," antiAnalysls g• U.S. (Energy Information ® Administration On -highway diesel prices, by week and PADD (Self service cash price in dollars per gallon, including taxes) Date 10/14/24 10/21/24 10/28/24 U.S. 3.631 3.553 3.573 PADD 1 - East Coast 3.586 3.590 3.605 PADD 1 a - New England 3.766 3.760 3.753 PADD 1 b - Central Atlantic 3.861 3.816 3.804 PADD 1 c - Lower Atlantic 3.464 3.489 3.516 PADD 2 - Midwest 3.651 3.543 3.569 PADD 3 - Gulf Coast 3.337 3.199 3.230 PADD 4 - Rocky Mountain 3.635 3.636 3.655 PADD 5 - West Coast 4.274 4.210 4.206 PADD 5b - West Coast less CA 3.874 3.785 3.791 California 4.734 4.698 4.682 Data source: Gasoline and Diesel Fuel Update PADD=Petroleum Administration for Defense District 1 Like EIA on Facebook ORFollow us on Twitter Watch EIA on YouTube Follow EIA on Linkedln Got this as a forward? Sign up to receive our future emails. U.S. Energy Information Administration 1 1000 Independence Avenue, SW, Washington, DC 20585 1 CALHOUN COUNTY, TEXAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ASPHALTS, OILS AND EMULSIONS Bid Number: 2025.03 January 1, 2025 through December 31, 2025 Vendor's Name & Address �7Z 057 • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • PRODUCTS/MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT ASPHALTS, OILS AND EMULSIONS Item 3jOQ;'Flsohalts0ils and Emulsions (BId Item,Lasted or Equivalent) BitlUhem #1 Primer Oil or EquivalehtC`�' Price per gallon / delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY I 1 1 J I i qr O o I$�Per Hour After Precinct 1 Gallon , Free Hours 1 ' • l� Per Hour After Precinct 2 I Gallon 1 Free Hours i 3.�S 1 L)(/r l.Y 1$A.Per Hour After Precinct 3 Gallon 2 Free Hours ' ' 3. l5 3I ' ��// i$�Per Hour After 1 V Precinct 4-P I Gallon 1 I r `r' I—Free Hours r 1 'O$ � ' 3 1 T 93 IPer Hour Aker Precinct 4-5 II Gallon I __2- Free Hours Remarks: 3�xv p{ calp' Page 30 of 53 j. id Item #2: P2 Prime C¢ncer Price per gallon / delive LOCATION I Unit Precinct 1 1 Gallon 1 Precinct 2 ! Gallon i i Precinct 1 Gallon i Precinct 4-P 1 Gallon Precinct 4-5 1 Gallon arks: or Equivalent e to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, MATERIAL DELIVERY TOTAL IFANY I 1 jr'//>, I :$ Per Hour After I Iv / y Free Hours i$_ Per Hour After i— Free Hours ' I �$_ Per Hour After i _ Free Hours pp i 1 Per Hour After _ Per Hour After I Free Hours dm #3 RC-250 or Equivalent ' Temperature must be no lower than 1400 Price per gallon / delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IF ANY 1 I 1 i J. 1 �//�yr `` I$ 1 J Per Hour After 1 Precinct 1 ; Gallon "' I ' " 1 `d'/�Frreee Hours 3/ 1 �� is Per Hour After Precinct 2 1 Gallon l v 1..e I I 4 6 Ili Free Hours I 1 i I � I r I "` 1 a i i 13.�� ' I $ Per Hour After Precinct 3 1 Gallon i I �� Free Hours I I I I 1$ Per Hour After Precinct 4-P I GallonI&9�'/1Fr(ee Hours I I UG f n� ; ` 1 t �q `C 1$ Per Hour After Precinct 4-S 1 Gallon 1 ,} , ;�i Free Hours Remarks: Page 31 of 53 CRS-2 or Equivalent Temperature must be no lower than 150. and no higher than 1800 Price per gallon / delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY 1 I 1 1 f� •ri..r% '� V i 2' / 1 I 2 C � i$ Per Hour After Precinct 1 Gallon a I ✓ 4, Free Hours i I �I l 1 I 1 01 1$� Per Hour After Gallon Precinct 2 1 • i ,/ !__I, Free Hours 1 �, '(V 1 0' 2s I$J v Per Hour After Precinct 3 1 Gallon i J 1 2 Free Hours f 3-, j5.0 Per Hour After Precinct 4-P Gallon 121 Free Hours ' 1 ' 1$� Per Hour After Precinct 4-S i Gallon V 3.01 12 Free Hours 02 CWE 2 or4Equivalenf Price per gallon/ delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY 1 1 1 ' �//1' $ Per Hour After 1 Gallon j / /'r _ Free Hours 1 � i$ Per Hour After 2 j Gallon Free Hours 1 1 ' ' ' 1 Per Hour After 3 Gallon j Free Hours 1 1 f i Per Hour After 4-P i Gallon _Free Hours i Per Hour After 4-S Gallon ; Free Hours /in m cncnwm o Be sure to read, complete, sign and date the next page Page 32 of 53 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 vendor, 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: ! I Authorized Signature & Title: Type Name & Title of Authori Phone Number: 71' �—%()L03,50-Q Email:V16h44, ESQINo LMGiANf/IIP•COM Exceptions and or Variations from Specifications and/or additional Notes: Page 33 of 53 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: IBC ARih/1% �)M Address: Remittance Address: y 5 80 / 9J` 3Ld7 Telephone: 7l'J J_Ej b (p96-0-J Fax: a' q ,01 Email: Signature of Authorized Representative: Printed name of Authorized Rep: 00 ORDER — CONTACT INFORMATION Order Contact Name & Title: a//a V ll m,Q - Order Contact Telephone: 712j 35 (0 `JJ 53 Order Contact Fax: Order Contact Email: INVOICES — CONTACT INFORMATION For Invoice Inquiries: / Contact Name & Title: /f�j n - V /�C CGCI�/ Contact Telephone: 7i 3 3,5-0 6�359 Contact Fax: Contact Ema - '?733 Page 34 of 53 STATE OF TEXAS {} AFFIDAVIT COUNTY OF „� {} eJ'q �4i01n. o being first duly sworn, deposes and says: that he or she is (Type or Print N mel I _ , the _ JIa L114 KLQ Q• of (Type or Print itle) principal address at ^.� L a{r"641, S having its V (Type or Print Physical and Mailing Address) who submits herewith to Calhoun Countythe attached bid/proposal; that he orshe is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation notherein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal orwithdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid prices) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the c ditions nd re uirements contained in the bid/proposal. UbiZ7 Signature of ffiant ' /r / K11)q- ,n Printed Name and Title of Affiant S�NAYLrih 1//�uyn 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 , 20_ %:Arn&o LESLIE MICHELLE MURRAY i ature of Notary u lic Si Public, State of Texas N ap j yr romm. Expires 03-27.2028 ''n°ota` Notary ID 11919132 Page 35 of 53 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 pate 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. A-- / // 2 Check this box it 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 is being disclosed. /V z y 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 focal government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income. other than investment income, from the vendor? F1 Yes 71 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 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 ElCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(8). excluding gifts described in Section 176.003(a-1). 7 I Signature of ender ingbusiness with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 37 of 53 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1956, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as president by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability. and ensure consistency among agency regulations• concerning debarment and suspension ofparticipants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I (c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal Financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance; loans, and loan guarantees. (c) This Order does not cover procurement prograrins and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign goverrunents or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agenev designated pursuant to Section 5 identifying infonnation concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in all affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However. I intend that exceptions to this policy should be granted only infrequently. See. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations sliall be published within twelve months of the date of the guidelines. Page 38 of 53 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. s. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from programparticipation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. See. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall male recommendations as are appropriate further to curb fraud, waste. and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into anv transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 39 of 53 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. dJj /' 1i1,+o Nat e and Tit e o Authorized Agent V u.T1�VU a !�/� 12 f NO Signature off Authorized Agent /oly Datef f am unable to certify to the above statements. My explanation is attached. Page 40 of 53 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/"f , certifies or affirms the truthfulness and accuracy of each statement of its certification anq 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. Printed Name and Title'of Contracfor's Authorized N�la�Date G01 Page 41 of 53 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous fling, pursuant to title 31 U.S.C. section 1352. The fling of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial fling and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime orsubaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is theist tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number, Invitations for Bid (IFB) number, grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5, 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to Influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348. 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 Page 42 of 53 Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for mblic. burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offerlapplication 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, linter _ Prime Subawardee Name and Address of Prime: Tier_, if Mown: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ffopplicable: 8. Federal Action Number, ifknonn: 9. Award Amount, ifknovn: S 10. a. Name and Address of Lobbying Registrant b. individuals Performing. Services (including address if' (iindividual, Iasi nama,first name, Ml): dieren(fi-om No. 10a) (last name. first name, rYll): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature: /iti•" disclosure of lobbying activities is a material b 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 3I Title: U.S.C. 1352. This information will he reported to the Congress semi-annually and will be available for public a �� Telephone No.9 �3 �.� (OW o ate•.:O �r a inspection. Any person who fails to file the required disclosure shall be subject ton civil penalty of not less than 510,000 and not more than 5100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL(Rev. 7-97) Page 43 of 53 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85`h Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 2270.001, Texas Government Code: "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. 1,(authorized official)_cd-,-)a//t/0 , do hereby verify the truthfulness and accuracy of the contents of the statements sulinitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller..tt`exaass.gov/purchasing/publications/divestment.php I9mkil a4� aJ,7 Qwfaol of Authorized Official Printed Name of Authorized Official Title of Authorized 1011 Date Page 44 of 53 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. 0 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) Ca/ I certify that i"'( Ar-h'A A4J is a "Resident Bidder" of Texas as (Company N e) defined in Government Code §2252.001. of Authgri�ed Agent V-�l Printed Name and Title of Authoriz Agent te Da/ Page 45 of 53 Farm W-13 Request for Taxpayer (Rev. March 2024) Identification Number and Certification Give farm to the requester. Do not Department of the Treasury Internal Revenue Service Go to www.ils.gov/Forni for instructions and the latest information. Send t0 the IRS. Before you begin. For guidance related to the purpose of Form W9. see Pumose of Fn m. hah,w I Name of entity/Individual. An entry Is required. (For a sole proprietor at disregarded entity, enter the owner's name an line 1, and enter the business/disregarded entity's name on line 2.) MARTIN ASPHALT DBA OF MARTIN PRODUCT SALES, LLC -2 Business more/disregarded entity name, it different from above. m1so Check the appropriate box for federal tax classification of the entily4nrlividual whose name Is entered on line 1. Check 4 Exemptions (codes apply only to Doty one of the following seven boxes, certain entities, not individuals; o' o ❑ Individualsole proprietor ❑ Ccorporation ❑ Scorporation ❑ Partnership ❑ Trust/estate see instructions on page 3): d ❑✓ LLC. Enter the tax classification (C = C corporation. S = S corporation, P = Partnership) . . S Exempt payee code (if any) n o u Note: Check the "LLC" box above and, in fhe entry space, enter the appropriate code (C, S. or P) for the lax `o classification of the LLC, unless it is a disregarded entity. A disregarded entity should Instead check the appropriate for Exemption from Foreign = Account Tax box the tax classification of its owner. Compliance Act(FATCA) reaming e $ ❑ Other (see instructions) code (if any) a`a !t !31, If on line 3e you checked "Partnership" or "Trusilestate," or chocked "LLC" and entered "P- as its lax classification, y you are providing this tone to a partnership, trust, or estate in which you have an ownership Interest, check (Applies to accounts maintained y❑ .and this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . , outside the United Stales) o 15 Address (number, street, and apt. or suite no.). See instructions. Requester's name and address (aptionaq 3 RIVERWAY SUITE 400 'f.6 City, state, and ZIP code HOUSTON, TX 77056 '7 List account numberls) 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 (Sate). However, fora resident alien,ien, sole proprietor, or disregarded entity, sea the instructions for Part I, later, For other entitles, it is your employer identification number (EIN). It you do not have a number, see Now to get a or TIN, later. Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. Untleripenalties of perjury, I certify that: 1. Thonumber 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. TbeFATCA 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 estatetransactions, 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 IU.S. personf VIA y./ AVddjt cJ Data i rod Y era( insLCUCLIons references are to the Internal Revenue Code unless otherwise 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,9ov/FormIN9. What's New Une 3a has been modified to clarify haw a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the "LLC" box and enter its appropriate tax classification. New line 3b has been added to this form. A flow -through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when It provides the Form W-9 to another flow -through entity in which it has an ownership interest. This change is intended to provide a flow -through entity with information regarding the status of Its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat. No. 10231x Form W-9 (Rev. 3.2024) CALHOUN COUNTY TEXAS INVITATION TO RID FORM ANNUAL SUPPLY CONTRACT FOR ASPHALTS, OILS AND EMULSIONS Bid Number: 2025.03 January 1, 2025 through December 31, 2025 Vendor's Name & Address Cleveland Asphalt Products, INC. PO Box 1449, Shepherd, TX 7731 • Please Type. If handwritten, must be in ink and legible. White out is not acceptable. • SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • PRODUCTS/MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT SIPHALTS. AILS AID EMULSIONS , Item 300 Asphalts, O,IIs and�Emulsions �s ( I tem Listed or Equ1val60) •. tr+' Bid Item ^ 1 Prime II or E ulvale # q!,_ ., Price per gallon / delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY 1 $2.95 $0.20 $3.15 1$ 8000 Per Hour After Precinct 1 1 Gallon 1 , 2 Free Hours 1 $2.95 1 $0.20 1 $3.15 1$ 80600 Per Hour After Precinct 2 I Gallon 1 1 1 2 Free Hours 1 $2.95 1 $0.20 1 $3.15 is 8000 Per Hour After Precinct 1 Gallon 1 1 12 Free Hours + 1 I $2.95 1 $0.20 1 $3.15 I ;$ 8000 Per Hour After Precinct 4-P Gallon 1 1 1 2 Free Hours 1 1 $2.95 1 $0.20 1 $3.15 I 1$ 8000 per Hour After Precinct4-S Gallon 1 1 1 I Free Hours Remarks:AE-P: All prices based on minimum full load of 5000 gallon load for smaller quantities please call 800-334-0177 Diluted material can not be returned for credit; Returns are for material only, not freight. Page 30 of 53 n #2 tP2 Prime Concentrate or Equivalent Price per gallon / delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY 1 '$ Per Hour After Precinct 1 I Gallon NA NA NA �_ Free Hours 1 1 1 1 ,$ Per Hour After 1 Precinct2 Gallon I NA I NA NA Free Hours 1 { I I I 1 NA 1 NA 1 1 NA 1 1 1$ Per Hour After Precinct 3 1 Gallon 1 1 1 :—Free Hours ' I NA NA NA 1$ Per Hour After Precinct 4-1)1 Gallon i i �_ Free Hours I i 1 NA 1 NA 1 1 NA 1$ Per Hour After Precinct 4-S Gallon 1 I Free Hours n 3 R�'25O or Equivalent ;:, ..41 Temperature must be no lower than 1401 Price per gallon / delivery price to County Stockpile and/orJobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IF ANY I ' 1 1$ 80.00 Per Hour After ' Precinct 1 ; Gallon 53.90 $0.20 $4.10 1 ; 12 Free Hours = I $3.90 1 $0.20 $4.10 1$80,00 Per Hour After Precinct 2 1 Gallon 1 I 2 ;_ Free Hours 1 1 $3.90 $0.20 1 $4.10 80.00 1 Per Hour After Precinct 3 1 Gallon 1 1 Free Hours 1 1 $3.90 1 $0.20 ` $4.10 1$ 80.00 Per Hour After Precinct 4-P I Gallon 1 1 1 2 Free Hours i i i 1 1 $3.90 1 $0.20 1 $4.10 1$80.00 per Hour After Precinct 4-S 1 Gallon 1 1 1 1 2 Free Hours All prices based on minimum full load of 5000 gallon load for smaller quantities please call 800-334-0177 Diluted material can not be returned for credit; Returns are for material only, not freight. Page 31 of 53 CRS-2 or €givalent Temperature must be no lower than 1500 and no higher than 1801 Price per gallon / delivery price to County Stockpile and/orJobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IF ANY l 1 $2.55 $0.20 1 $2.75 l$ 80_00 Per Hour After Precinct 1 ; Gallon 1 1 2 Free Hours 1 1 80.00 $_Per Hour After Precinct 2 1 Gallon I 52.55 l $0.20 1 $2.75 1 2 Free Hours I 1 I 1$ 8000 Per Hour After Precinct 3 1 Gallon I $2.35 1 $0.20 I $2.75 ; 2 Free Hours ' ' I I ' $80_00 Per Hour After Precinct 4-P ` Gallon 1 $2.55 $0.201 $2.75 2 Free Hours ' 1 1 $2.55 1 $0.20 1 $2.75 l$80_00 Per Hour After Precinct 4-S 1 Gallon 1 I , 1 1 2 Free Hours d material can not be returned for credit; Returns are for material only, not freight. "0 .{. � � P2ME 2dit,Equivalent� N' Price per gallon / delivery price to County Stockpile and/orJobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY 1 Precinct 1 I Gallon 1 NA NA I 1 NA 1$-Per 1 Hour After Free Hours 1 1 I I 1 1 1$Per Hour Alter Precinct 2 I Gallon l NA I NA I NA 1 Free Hours 1 1 1 ' i 1 1 $_Per Hour After Precinct 3 1 Gallon NA I NA I NA I Free Hours 1 l 1 l I 1 Per Hour After Precinct-P I Gallon I NA 1 NA 1 NA 1 Free Hours I 1 1 l ' ' ' l$Per Hour After Precinct 4-S l.. Gallon l NA I NA NA I_ Free Hours Be sure to read, complete, sign and date the next page Page 32 of 53 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 vendor, 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: 10/7/2024 Authorized Signature & Title: �// , Sales Rep. Type Name & Title of Authorized Signature: Clayton Moore, Sales 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 full load of 5000 gallon load for smaller quantities please call 800-334-0177 Diluted material can not be returned for credit: Returns are for material only, not freight. Page 33 of 53 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name: Cleveland Asphalt Products, INC. Address: PO Box 1449 Shepherd, TX 77371 Remittance Address: PO Box4652 Department #936 Houston, TX 77210-4652 Telephone: 800-334-0177 Fax: Email: office@clevelandasphaltproducts.com Signature of Authorized Representative: �,�%`� c--s Printed name of Authorized Rep: Clayton Moore ORDER — CONTACT INFORMATION Order Contact Name & Title: LeeAnn Ails, Office Manager Order Contact Telephone: Order Contact Fax: 800-334-0177 Order Contact Email: office@clevelandasphaltproducts.com INVOICES — CONTACT INFORMATION For Invoice Inquiries: Contact Name &Title: LeeAnn Ails, Office Manager Contact Telephone: 800-334-0177 Contact Fax: Contact Email: office@clevelandasphaltproducts.com Page 34 of 53 STATE OF TEXAS {} AFFIDAVIT COUNTY OF San Jacinto {} Clayton Moore being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Sales Rep. of Cleveland Asphalt Products, INC. . having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 100 Asphalt Lane, Shepherd, TX 77371 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal orwithdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement; communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. Signature of Affiant - Clayton Moore, Sales Rep. Printed Name and Title of Afflant SWORN TO AND SUBSCRIBED BEFOREME by the above Affiant, who, on oath, states that the. facts contained 1n the ��4 , above are true and correct, this day of October . 20 24 DESTINY YOUNG ®fi Notary ID #133791495 ,$ aA{ySQmmmission Expires o R° June 2, 2026 q li q2f Signature of of ry Pu I c Page 35 of 53 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity Acomplete copy of Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code 6176.001(1-a):"Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal,state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code fA 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor, (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (1) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code S 176.006(a) and (a-11 (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.elhics.state.tx.us Revised 11/30/2015 Page 36 of 53 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, 64th 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 data the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. Clayton Moore for Cleveland Asphalt 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.) 3 Name of local government officer about whom the information is being disclosed. NA Name of Officer IJ Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? FlYes 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? F7Yes Fx--1 No 5 Describe each employment or business relationship that the vendor named in Section l 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. NA 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 �.� ���� 10/7/2024 Sigfiature of vendor domgTiL ess with the govarnmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Page 37 of 53 DEBARMENT & SUSPENSION Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that party from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. Page 38 of 53 Sec. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. Sec. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. Sec. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. Sec. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SRF Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, or voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. Page 39 of 53 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. 10/7/2024 Name and Title of Authorized Agent Date Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. Page 40 of 53 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 ContractorlevelandAsphalt 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 at seq., apply to this certification and disclosure, if any. 7 igliature of Contractor's Authorized Official Clayton Moore, Sales Rep. Printed Name and Title of Contractor's Authorized Official 10/7/2024 Date Page 41 of 53 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all Items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enterthe full name, address,city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the fler of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards Include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the applicaflon/proposal control number assigned by the Federal agency). Included prefixes, e.g., "RFP-DE-90-001." 9. Fora covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name; and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless It displays a valid OMB control Number. The valid OMB control numberfor this Information collection is OMB No.0348- 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instmctlons, searching existing data sources; gathering and maintaining the data needed, and cimplefing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503 Approved by OMB 0348.0046 Page 42 of 53 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 disclosnml 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 e. 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, )rappllcable: S. Federal Action Number, ifknown: 9. Award Amount, ifknown: S 10. a.Name and Address of Lobbying Registrant Is. individuals Performing Services(including address if (iffndividua1,, lot naate,fitwt name, Ml): dierentfrom No. 10a) (last tare, first tame, 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: 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 he reported to the Congress semi-annually and will be available for public Telephone No.: 800-334-0177 Date: 10/7/2024 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) Page 43 of 53 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.002 The 85" Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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,(authorized official) Clayton Moore do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https:Hcomptroller texas gov/purchasing/publications/divestment ohp Cleveland Asphalt Products, INC. Company Name Signature of Authorized Official Printed Name of Authorized Official Sales Rep. 10/7/2024 Title of Authorized Official Date Page 44 of 53 RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 etseq. 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 certifythat (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 1City and State) M 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 10/7/2024 Date Page 45 of 53 W-9 Request for Taxpayer Give Form to the Form (Rm Octobar9ote) Identification Number and Certification I requester. Do not OePUVn.ntclthaTmmuy send to the IRS. mtemd RwasuaSewica 01Go to Www.1rsgav/FbmrW9 for instructions and the beast information, 1 Nama(ae anawn an yourincamatax mtum). Nemeis re queen on this line; do not leave this tine blank 2 Business name/divaearded entity name, If different from shows 0 3 Check appropdateboxforfedeml tudwiNcationd the person whose name isentered on line 1. Check Onlyone of the 4 Exemptiom(cudes apply only to r� foltovdn9 seven tines. cmealn entities, not ledhiduds; see a. a ❑ IntllNduaVwle propnalorar ❑ CComoregon ❑ SComoratlon ❑ partnership ❑ TrusVeslate instructions an page P3 $c .Inglarmember LLC FxMixfoyeaocda(dany)_ ¢� ❑ linked liability company. Enter Me tau Classification(C_C corporation,S=S corporation, F-PaMeshlp)► `o NOW:Ched(tha appropriate bexin the line above forth. taxclessitication ofthe sinsmmemberow er. Oonotcheck Fxemptionfmm FATCAmp riag E U.CI he LLC iselamiged se, a dnglememberLLC that is cluagardedfrom the owneruNess the owns of the LLC is another LLC Nat Is not disregarded from the Owner for U.S. federal tax purposes. ONuwise, a aingla-member LLC that wtle Of any) �2 is disregarded from the owner should chock the appropriate box forms tax desswoaden of its owner. ❑ Olher(seaireaucgana)> Pa"ammacumamaWweadt na uss 5 Add. (ru nbar. street' and apt or suite no.) See lnstrudium. Requester's name and address (opfiona9 H CALHOUN COUNTY s City, seats, and ZIP coda 202 S ANN ST, PORT LAVACA TX 77979 361.553.4610 FAX: 361.563.4614 7 Ust account numbers) hem(optionag Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on line l to avoid I Social securltynumber I reckupsident withholding.Individuals, disregarded this Is generally socudry numher(SSter. However, tore -m-� resident alien, sole propdmag or disregarded eery, see the Instructions for numbs I, later. For other entities,.it Is your employer ldentifimdon number (EIM- If you do not have a number, see How to gets LM TIN, later. or Note: Ifthe account is in more than one name, see the Instructions for line 1. Also sea WhatNemeantl I Employer tdon0n—number Number TO Give the Requester for guidelines on whose number to enter. F-T1 F-1 1. The number shown an this form Is my correct taxpayer identification number Ow 1 am waiting fora number to be Issued tome); 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 any subject to backup withholding as a mutt of a failure to report all Internet 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 (definad below); and 4. The FATCA code(s) entered on this form (d any) Indicating that I am exempt from FATCA reporting Is coned. Certification Instructions You must cross out Item 2above I you have been notified by the IRS that you are currently subject to backup withholding bemuse you have felled 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 retirementanangemam ORA), and generally. payments other than Interest and dMdends, you ere not required to sign the CeAfication. but you must provide you wheat TIN. See the Instructions for Part II, later. Sign 'U"' rest Hare U.S. paean► pate► General Instructions Section references are to the trained Revenue Code unless othensin, noted. Future developments. For the latest Information about developments related to Form W-9 antl its instructions, such as legislation enacted after they were published, go to wMetmyov/ForroM. Purpose of Form An Individual or Natty, (Form W-9 requester) who Is required to file an Information return with the IRS must obtain your cowed taxpayer Identification number RIM which may be your social security number (SSM. Individual taxpayer Identification number QMM, adoption taxpayer Identification number (ATIM, or employer Identification number (EIM, to report an an Information return the amount paid to you, or other amount reportable on an Information return. Examples of information returns Include, but are not limited to, the following: • Fore 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-14ISC (various types of [name, prizes, awards, or Seems proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Fenn 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party networktransactiotts) • Fenn 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tNgon) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured properly) Use Form W-9 only it you ere a U.S. parson (including a resident alien), to provide your correct TIN. Ifyou 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. 102SIX Fdn W-9 (Rev. 10-2018) Page 46 of 53 Form ■ e =M I Request for Taxpayer I Give form to the (Rev. March 2024) I Identification Number and Certification I regUester. Do not Department of the Treasury send to the IRS. Internal Revenue Service Go to ww4r.frsgov/FormW9 for instructions and the latest information. Before you begin. For oUldance related to the purpose of Form W-9. see Pumose of Prvm below. Name of entilpiindlvidual. An entry is required, (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded entity's name on line 2.) Cleveland Asphalt Products, INC. 2 Business name/disregarded entity name, if different from above. yas Check the appropriate box for federal tax classification of the entity/individual whose name is entered on lined. Check 4 Exemptions (codes apply only to only one of the following seven bones. certain entities, not Individuals; p' cc ❑ Indivldualysofe proprietor [Z C corporation ❑ S corporation ❑ Partnership ❑ Trust/estate see Insinuations on page 3): 6 c ❑ LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . . Exempt payee code (f any) Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate Exemption from Foreign Account Tax o` box for the tax classification of its owner. Compliance Act (FATCA) reporting E� ❑ Other (see instructions) code Ql any) 3b It on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P' as Its tax classification, d (Applies to accounts maintained y and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if have outside the United you any foreign partners, owners, or beneficiaries. See instructions . . . . . . , ❑ A6 Address (number, street, and apt. or suite no.). See instructions. Requester's name and address (Optional) PO Box 1449 6 City, state, and ZIP code Shepherd, Texas 77371 7 Lst account numbers) here (optional) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid II backup withholding. For individuals, this is generally your social security number (SSN). However, for a L resident afen, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entries, it is your employer identification number (EIN). If you do not have a number, see How to get a or TIN. later. ._ Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. 7 F61 — 0 2 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 afailure 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 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-. i.am nntnequired to sign the certification, but you must provide your correct TIN. See the instructions for Part If. later, Sign 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.;a.gov/FormWg. What's New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that Is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the "LLC" box and enter its appropriate tax classification. Date New line 3b has been added to this form. A flow -through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow -through entity in which it has an ownership interest. This change is intended to provide a flow -through entity with information regarding the status of Its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). Purpose of Form An individual or entity (Forth W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat No. 10231X Form w-9 (Rev. 3-2024) Jan kps-pom) ue, CALHOUN COUNTY, 7DAS INVITATION TO BID FORM ANNUAL SUPPLY CONTRACT FOR ASPHALTS, OILS AND EMULSIONS Bid Number: 2025.03 January 1 2025 through December 31, 2025 Vendor'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. *SEE SPECIFICATIONS AND GENERAL CONDITIONS FOR COMPLETE REQUIREMENTS • PRODUCTS/MATERIALS BID MUST BE BROKEN DOWN INTO PRICE PER UNIT AND DELIVERY PRICE PER UNIT HAL OI D E ULSIO ,�� r Bldk Items Iste qu► en�,� ,r t� £ Bid Item A: Primer Oil or Equiyaler " �� Wi,_; Price per gallon/ delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL If ANY ! I I IS Per Hour After Precinct i 1 Gallon i'1 Free Hours I :S__ Per Hour After Precinct 2 Gallon Free Hours Per Hour After Precinct 3 Gallon Free Hours ! ' is _ Per Hour After Precinct 4-P Gallon j Free Hours is _ Per Hour After Precinet 4-S I Gallon j Free Hours Remarks: Page 3D of Si ff Bid Item #2 P2Il t fte Concentrate or Ecivalent Price per gallon/ delivery price to County Stockpile and/orlobsite PRODUCT/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY j I j I $2.24 ! Included $2.24 8o ao $--- Pet Hour After Precinct 1 Gallon I I Z Free Hours i 1 1 Precinct 2 ; Gallon $2.24 Included 1 $2,24 $$f)- as Per Hour After 1_2 Free Hours I I 1 $2.24 included; $2.24 $�-00 Per Hour After Precinct 3 Gallon I.2 Free Hours j 1 80.00 Per Hour After Precinct 4P Gallon $2.24 i Included 1 $2.24 $--- Free Hours 1 i i i i Precinct 4-S 1 Gallon i $2.24 ; Included i $2.24 '1580.00 Per Hour After i-2 Free Hours "Please see Itlached equivalent and/or superior probuct ir1nr,.Lon and Sole Source Alfidavil. Remarks: •'P Squared is proudly recognized and accapted by Tarrant County Co-op. Bid Item #3 Rat 250` or Equivalent. Temperature must be no lowerthan 140' Price per gallon/ delivery price to County Stockpile and/orlobsite PRODUCE/ DEMURRAGE, LOCATION Unit MATERIAL DELIVERY TOTAL IFANY I 1 ' i is Per Hour After Precinct 1 i Gallon i Free Hours ' I I I ; I 5 Per Hour After Precinct 2 1 Gallon I I Free Hours 1 i 1 i 1 i IS--_ Per Hour After Precinct 3 1 Gallon I I Free Hours ' I 1 Per Hour After Fred net 4-P 1 Gallon 1 Free Hours I I ' E I ,-- Is Per Hour After Precinct 45 1 Gallon I _ Free Hours Remarks: Page 31 of 53 Bid Item #4: CRS-2ror Equivalent ?Sc, r� . Temperature must be no lower than 150and no higher than 180' Price per gallon/ delivery price to County Stockpile and/or Jobsite 1 PRODUCT/ 1 DEMURRAGE, LOCATION t Unit MATERIAL I DELIVERY I TOTAL IFANY I i I I I !$ Per Hour After Precinct 1 Gallon Free Hours I I I I ,Ta__ Par Hour After Precinct 2 Gallon I 1 Free Hours I Rx Hour After Precinct 3 Gallon I 1 1 I Free Hours i 1 Par Hour After Precinct 4? Gallon Free Hours I I I per Hour After Precinct 4-5I Gallon 1 Free Hours Remarks: Bid Item #5: 1?2 C, _'2 or Equivalent x . Price per gallon/ delivery price to County Stockpile and/or Jobsite PRODUCT/ DEMURRAGE, LOCATION I Unit MATERIAL DELIVERY TOTAL IFANY $3.29 Included ; $3.2912 6000 far Hour After -- Precinct 1 Gallon : I Free Hours @@4 Included , $3.29 S ea.00 Par Hour After 12 '... Precinct 2 Gallon y�3.29 Free Hours 1 G 0000 Pa Hour After --- ' Precinct Gallon ' $3.29 I 1Included $3.29 12 Free Hours ' 3.29 Included ! 3.29 I_= Is co Per Hour After Hours Precinct,I-P Gallon Free f Preci net 4-S Gallon $3-2c Included! q;'.1 7Q I_3 I$ 80.00 Per Hour After Free Hours 'Please see attached equivalent and/or superior product information and Sole $ounce Affidavit Remarks: "P Squaretl is proudiv recoeniZed and accepted by T shad County CO -Op. Be sure to read, complete, sign and date the next page Page 32 of 53 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 vendor, 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 andfully understands and hosfollowed all requirements. FAILURE TO SIGN BELOW SHALL DISQUALIFY THE BID 24 October 2024 Date: -- 24— — — — — — — — — — — — Authorized Signature & Title: Dane McGinnis PannerlCFO — — Type Name &Title of Authorized Signature --------- Phone Number: 254.829-0320 Email: ofr"@p2emu1s1ons.win ----------- — ----------------- Exceptions and or Variations from Specifications and/or additional Notes: **Please see attached a uivalent and/or su er' Squared is proudly recognized and accepted by Tarrant County Co -Op. Page 33 of 53 VENDOR AND ORDER INFORMATION FORM Please Type. If handwritten, must be in ink and legible Vendor's Name:_P Squared Emulsion Plants LLC _____ Address:- 516 South McLennan Loop, Elm Mott, Texas 76640 ------------------------- Remittance Address: 516 South McLennan Loop. Elm Mott, Texas 76640 Telephone:254-829_0330--- - - -- - - - - - -- 2 Fax:--54 82933 -07 ------ ------ -------- - - - - -- Email: ofice@p2emulsions.com / Signature of Authorized Representative:— — Printed name of Authorized Rep: Dane Mc_innis --- — ORDER -CONTACT INFORMATION Order Contact Name & Title: David Williams ------------------ Order Contact Telephone: 361-877-2584 ------------------- Order Contact Fax: NIA Order Contact Email: david@p2emulsions.com -------------------- INVOICES - CONTACT INFORMATION For Invoice Inquiries: Contact Name & Title: Amber Young -------------------- - Contact Telephone: _254-_829-0330 ---------------- - Contact Fax: __ 254-829-0337______________ Contact Email: admin@p2emulsions.com ----------------------- Page 34 of 53 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by R.B. 2i 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire 6 being filed h accordance with Chapter 176, Loral Government Code, by a vendor who Date Recewed has a business relationship a; defined b7 Section 176.001 (1a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). B' law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 71h business day after the dale 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 it the vendor knowingly violates Section 176.006, Local Government Code. Pn offense under this section is a misdemeanor. I J Name of vendor who has a business relationship with local governmental entity. OCheck this box if you are filing an update to a previously filed questionnaire. (The law requires that you fle 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 fled questionnaire was incomplete or inaccurate.) 1_I Name of local government officer about whom the information is being disclosed. Name of Officer Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described IN Section 176.003(a)(2)(A). Also describe arty family relationship with the local government officer. Complete subparts Aand Bfor each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A s 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? Dves ❑ 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? Dves No J Describe each employment or business relationship that the vendor named it Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. ❑ Check this box I 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). gnature of vendor doing business with governmental entity Dale Form provided by Texas Ethics Commission www.ethics.state.N.us Revised 11/?6201 5 Page 37 of 53 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 Cede. An offense under this section is a misdemeanor. !J Name of vendor who has a business relationship with local governmental entity. P Squared Emulsion Plants, LLC 2 Check thisbozifyouarefilinganupdatetoapreviouslyfiledquestionnaire.(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.) 3J Name of local government. officer about whom the information is being disclosed. N/A Name of Officer .4J Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable Income, other than investment income, from the vendor? Yes FX I 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 Fx—]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. NIA 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)(6), excluding gifts described in Section 176.003(a-1).. 7 �%��- X. 1g�� 10-24-2024 Signature of vendor doing buss s with t governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11130/2015 CERTIFICATION REGARDING DEBARMENT & SUSPENSION AND OTHER RESPONSIBILITY MATTERS In accordance with the Executive Order 12549, the prospective primary participant certifies to the best of his/ her knowledge and belief, that its principals: a Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded firm 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 it connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract Linder 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 ofany ofthe offenses enumerated it paragraph ([) (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 it compliance with paragraphs (1) (a -d) ofthis certification. Dane McGinnis Partner/CFO Name and Title of Authorized Agent 24 October 2024 I an unable to certify to the above statements. My explanations attached. Date Page 40 of 53 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 h 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 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," n accordance with its instructions. (c) The undersigned shall require that the language paragraph 1 and 2 of this anti4obbying 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). P Squared Emulsion Plats LLC The Contractor, _________ , ce i es or affirms the truthfulness and accuracy of each statement of its certiGtion and disclosure, if any. In addition, the Contractor understands and agrees that. the provisions o�1 U.S.C. § �801 at seq., apply to this certification and disclosure, if any. Dane McGinnis Of October2024 Page 41 of 53 Approved by OMB Disclosure of Lobbying Activities (bmplete this firm In disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse to, nohlic Nall", disrinsnref 0348-0046 1. Type of Federal Action: 2 Status of Federal Action: 3. Report Type: a contract a bid/offer/application a inital filing _ _ It grant _ _ h initial award - - Ir material change e cooperative agreement. c post -award d loan For material change only: e, loan bnmrnnfce Year___ quarter___ f loath insurance Date of last report A Name and Address of Reporting Entity: 5. if Reporting Entity in No. 4 Is Subawardee, Enter Prime _ _ Subawwricsc Mane and Address of Prune Tier_ _ _ , f f Known: / Conifressional District, ifknown:.. ' oneressional District, ifknown: 6. Federal Department/Agency: 7. Federal Program Name/Description: 7 CPDA Number, ifapplicable: 3 Federal Action Number, ifnown: 9. Award Amount, ifnounr S 10 a Name and Address of Lobbying Registrant b. Individuals Performing Services (inchelingaddress if (ifiorlividrml. Iasi newre, first twine, ,Lip: el((ferentfi our Ab. J(Jal (lnsi naeq Jiisr name. All): 1,02 IL Information requested through this form Is authorized by life 31 U.S.C. section 1352 This Signature: disclosure of lobbying activiffes Is a material Dane M IMIS representation of fact upon which reliance was placed Print Name: by the tier above when this transaction was made or paftnel'/CF 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.:254-829-0330 DAa24.Qc2ober 2024 inspection. Any person who fails to file the required disclosure shall he 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) Page 43 of 53 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85`h Texas Legislature approved new legislation, effective September 1 2017, which amends Texas Local Government Code Section I Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: I Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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 h 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. - _ y (authorized official) Dane McGinnis _ _____ do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https•//comptroller texas gov/purchasing/publications/divestment php P Squared Emulsion Plants LLC Company Name Signature Partner/CFO Title of Authorized Official Dane McGinnis Printed Name of Authorized Official 24 October 2024 Date Page 44 of 53 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. ❑ Icertify 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) X I certify that P Squared Emulsion Plants LLC is a "Resident Bidder" of Texas as -------------- (Company Name) defined in Government Code §2252.001. Printed Name and Title of Authorized Agent 24 October 2024 Date Page 45 of 53 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: 2024-1230633 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 Date Filed: 10/24/2024 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 description of the services, goods, or other property to be provided under the contract. 2025.03 Annual Supply Contract for Asphalts, Oils and Emulsions 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 fit(/ My name is r t �.i.�% and my date of birth is13'l'j nn 1n� �/�i.. My address is V . f rr ( r qj �, -10O , 1JS. (street) I (city) (state) (zip code) (country) I declare under penaltyofperjurythat theloregoing is true and correct. Executed in ! r r. K/oy ® µ'"/ H County, State of -40i, on /n� ryr�� the of Od ph l , 20-. (month) (year) gnatur f Tuthorize6 ag t`o�ontracting (Declarant) business entity Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V4.1.0.48da51f7 P2 Emulsions LpdService. Performance, Commihneut. 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 like Calhoun County asserts 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 24th day of October 2024. o r, 0 •. :2 L C N Seth McGinnis, C.E.O. :olEOF�ao (Signature) (Printed Name) (Title) SWORN TO AND SUBSCRIBED before me on October 24, 2024, Seth McGinnis. Notary Public, St e f Te s My Commission expires on jams 5, 2027, , P2Emulsions.com 516 South McLennan Loop Elm Mott, Texas 76640 254-829-0330 P2 Emulsions Service. Performance. Commitment. Date: October 24, 2024 To: Calhoun County Subiect: 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" Oil]' 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. "C W P — 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 "P 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. -AlI P Squacd Emulsion Plants LLC pmariemry produos fulfill the formal requimmnma round in Texas I. Deal Gavernmmm Codes teyardiny "man purchasing Section 263.024,7.A. (AvailaW upon requesp ..All P Squared Enndfion Plants LLC Proprieta,y pmdums arc 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 P2 Emulsions Service. Performance. Cornmitn:enL Pricing Effective As Of October 1, 2024 Pricing subject to change with written notice. P2 Salesman: David Williams Contact Number: 361-877-2584 Product Tanker FOB Plant Tanker FOB County Drum/Tote Plant P2 Stabilizer $2.68 $2.96 $2.90 P2S1 $2.68 $2.96 $2.90 CWE-2 JP2 ROC $2.83 $3.10 $3 05 (Road Over Coat) P2 Rejuvenator $2.68 $2.96 $2.90 P2 Prime Concentrate $1.97 $2.24 $2.19 P2RTU $1.93 $2.20 $2.15 **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 $35.00 per drum Containers are re -usable and can be rinsed out, brought back and re -tilled at customer discretion Containers priced individually and sold only with orders for material Thank you and we look forward to serving all your emulsion needs! P2Emulsions.com 516 South McLennan Loop Elm Mott, Texas 76640 254-829-0330 #13 NOTICE OF MEETING - 11/13/2024 13. Consider and take necessary action to award the qualified bidder for Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County, Texas. (RHM) •ecommen UST: APPROVED;[UNANIMOU IR: David Hall, Commissioner P ONDER: Gary Reese; Commissioner; Judge Meyer, Commissione Behrens, Reese Page 10 of 16 CONTRACT DOCUMENTS FOR THE BID NUMBER 2024.10 ANNEX BUILDING ROOF IMPROVEMENTS PROJECT FOR CALHOUN COUNTY, TEXAS SEPTEMBER 2024 G&W ENG INEERS, INC. 205 W. Live Oak • Port Lavaca, TX 77979 • 361-552-4509 1 (R�vired NetAdd mdum No. I - 4 2.rd5.24) 1 "I 6 i Si Number 1!Y rs .it i ewarJl t„ Sid iei6 !9 i*u °t`�, r. ��e Arn@" ain81&3ils'�`v' !"as4b$ Ira➢p4oJ'e-i¢naN-.a i��Uic3n`� for ° ail" oun U: 3 aaesda ;dt�a�saxher b,024 befsa0ai3.4n. NA P-5ar—Kiel-96 BASE WORK SCOPE is: Approximately 4,435 SF of roof tear down to lightweight concrete deck there replace with new insulation and system to meet windstorm requirements, penetration updates, new roof hatch with fall prrstecti+on all completo in place per plans and specifications. Item Quantity Unit Unit Price Total Bid Price B, 1) Furnishing all necessary equiprr2nt, mate(ials, 1 L.S and labor for Mobilization, demobilization, barricades, insurance, and bonds as per plans and specifications £� pU0 2J Z 000 l B.2) Furnish all necessary equipment, materials, and 9 LS labor for the roof replacement scope of work for the .' /` A entire building in accordance with drawings aid specifications, Includes, but not limited to all flastungs, sheet metal, trirn, roof systems (i'nernbranes and boards), two layers of tapered insulation (R25), wood nailers for parapet extension, fasteners, sealants and other items necessary to fully complete the work B.3) Furnish all necessary equipment, materials, and LS labor for ti a roof top peneiraiort rnod,fications in boaids,f_�*�.n FaI@n and �!" r,r& n� to frilly omple r in work (r Yc �.I(� � Mec.haii!Cal fIVAC fv uds). (� B,4) 3% Ovlhers Contingenicw To be us-c! only as :i 3% of Base aid dil'2�t r y n nc r I r t,J/ ''0 p 4 a -_ am Ij, ✓ (7.03 X Sun. Of / change orders thal inCllcate 3rnount> to b charged to Cease Bid Lines the O,Ar r5s Cunt ngercy 1-3 above) .i SE& (Ded Curb aid '1 w w to new f0ofclecklfig i tno a � 7 12 DO 7 requi ,i , tn„ a -pa to adequatei7 spne ,�,ac ;ci accept new roof sysTern. Work after hotir s ,and or weekend required and coordinating with Owner's "-IVAC Contractor. Item Quantity Unit Unit Price Total Bid Price ALTERNATE BID ITEM(S) Iterri {?uantity ;tit Unit Price Total Bid !'rice AA) Furnish all necessaiy equipment, materials, and labor for a RT Roof System in lieu of a tapered insulation roof system. Includes all of the necessary mater als as in tl ea base bid LS) C� Ai ,'I ER�� C, ,� � �i<� ��0 O (n A m O O n J.. 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Please try another search or go back to previous results. Go Back Feedback Our Website Our Partners About This Sit- AI,gl isltlon.gov Our Community USASpending.gov Release Notes Grants.gov System Alerts More Partners Policies Customer Service Terms of Use Help Privacy Policy Check Entity Status Restricted Data Use Federal Service Desk Freedom of Information Act External Resources Accessibility Contact 0 WARNING This is a U.S. General Services Administration Federal Government computer system that is "FOR OFFICIAL USE ONLY." This system is subject to monitoring. Individuals found performing unauthorized activities are subject to disciplinary action including criminal prosecution. This system contains Controlled Unclassified Information ICU I). All individuals viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part 2002 and GSA Order CIO 2103.2 CUI Policy. -,Port Enterprises, Ltd. i P.O. Box 1299 11303 Conroy Lane Manchaca, TX 78652 (512)280-1030 Fax # (512) 280-1032 P.O. Box 271482 Corpus Christi, TX 78427 1955 Saratoga Corpus Christi, TX 78417 (361)289-2944 Fax # (361) 289-7163 1166 Pieper Road New Braunfels, TX 78130 (830)327-1214 Fax # (830) 327-1216 www.portroofing.com INSIST ON A PROFESSIONAL ROOFING CONTRACTOR • I. I I I. N •.. /`; BuildingAnnex Roof • Copy Port Enterprises, Ltd. 1955 Saratoga Blvd. Corpus Christi, TX 78417 (361) 289-2944 BI (Revised per Addendum No.1-19.29.24) �\ PROJECT NAME: Bid Dumber 2024.10 —Annex Buildino Roof Improvements Project for Calhoun County, Texas DUE DATE: Tuesday, November 5. 2024 before 2.00.00 p m DAME: Port Enterprises, Lid. BASE NVORK SCOPE is: Approximately 8,435 SF of roof tear down to lightweight concrete deck then replace with new insulation and system to meet windstorm requirements, penetration updates, new roof hatch with fall protection all complete in place per plans and specifications. (tgm Quantity Unit UujttP.r,"ice' Total;Bid Price B.1) Furnishing all necessary equipment, materials, 1 LS 20,440.00 0,440.00 and labor for Mobilization, demobilization, barricades, insurance, and bonds as per plans and specifications 8.2) Furnish all necessary equipment, materials, and 1 LS 321,831.00 321,831.00 labor for the roof replacement scope of work for the entire building in accordance with drawings and specifications. Includes, but not limited to all flashings, sheet metal, trim, roof systems (membranes and boards), two layers of tapered insulation (R25), wood nailers for parapet extension, fasteners, sealants and other items necessary to fully complete the work. 8.3) Furnish all necessary equipment, materials, and 1 LS 31,718.00 31,718.00 labor for the roof top penetration modifications in accordance with drawings and specifications. Includes, but not limited to all flashings, sheet metal, trim, boards, fasteners, sealants and other items necessary to fully complete the work. (Excludes Mechanical HVAC Mods). B.4) 3% Owners Contingency: To be used only as 1 LS 3% of Base Bid 11,219.00 directed by Engineer for Owner's purposes and only by (0.03 X Sum of change orders that indicate amounts to be charged to Base Bid Lines the Owner's Contingency. 1-3 above) 385,208.00 TOTAL BASE BID $ OWNER'S OPTION(S) Quantity Unit Unit Price Total Bid Price rnish all necessary equipment, materials, and 1 LS 7,500.00 7,500.00 the roofing support of modification of HVACich includes closing of the space between the :Furnish and new with new roof decking, demo as in the area to adequately seal the space andew roof system. Work after hours and ord required and coordinating with Owner'sontractor. Item --"v I � u: � I� s`i€s—N A� S Qu ni)ty f U Alt Y YFy U1ji� Price Total Bid Prue a 4. �. � •^��..i�. .. ALTERNATE BID ITEM(S) Item Quantity Unit Unit Price Total Bid Price A.1) Furnish all necessary equipment, materials, and 1 LS 315,212.00 315,212,00 labor for a RT Roof System in lieu of a tapered insulation roof system. Includes all of the necessary materials as in the base bid. TOTAL ALTERNATE BID (Bid Items B1,A1,B3 & B4) 378,589.00 SPEC[ FICATION NOTES Calhoun County is receiving Bids for items and quantities of work generally as follows: Bids are invited for items and quantities of work generally as follows: Approximately 8,435 SF of roof tear down to lightweight concrete deck then replace with new insulation and system to meet windstorm requirements, penetration updates, new roof hatch with fall protection all complete in place per plans and specifications. County to provide: 1. Unsecured place to store contractor equipment and vehicles 2. Unsecured area to store excess materials required for construction. The BIDDER, in compliance with the invitation for bids for Bid Number 2024.10 —,Annex Building Roof Improvements Project for Calhoun Cg2Et Texas, having examined the plans and specifications with related documents and the site of the proposed work, and being familiar with all of the conditions surrounding the construction of the proposed project, including the availability of materials and labor, hereby proposes to furnish all labor, materials and supplies in accordance with the contract documents, within the time set forth herein. These price(s) are to cover all expenses incurred in performing the work required under the contract documents, of which this proposal is a part. These price(s) are firm and shall not be subject to adjustment provided this Proposal is accepted within thirty (30) days after the time set for receipt of proposals. BIDDER hereby agrees to commence work under this contract on or before a date to be specified in a written "Notice to Proceed" to be issued by the County and to substantially complete within 90 consecutive calendar days as stipulated in the specifications. BIDDER further agrees to pay as liquidated damages, the sum of $300.00 for each consecutive calendar day. I hereby acknowledge the receipt of the following addenda: SUBCONTRACTORS. The undersigned BIDDER proposes that he will be responsible to perform major portions of the work at the project site with his own forces and that specific portions of the work not performed by the undersigned will be subcontracted and performed by the following subcontractors. Type of (Mork Subcontracted Name of Subcontractor Lightweight Insulating Concrete Drury South The undersigned hereby declares that he has visited the site and has carefully examined the contract documents relative to the work covered by the above bid. Bidder Name: Port Enterprises, Ltd. Address: 1955 Saratoga Blvd., Corpus Christi, TX 78417 Phone: (361) 289-2944 EIN or Tax ID No.: 74-1975498 Signature: Name and Title: Cody Comstock, Vice President for General Partner, Port Enterprises Roofing Inc. Email Address: codyQportroofing.com BID BOND TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA Hartford, Connecticut 06183 KNOW ALL MEN BY THESE PRESENTS, that we Port Enterprises LTD as Principal, hereinafter called the Principal, and Travelers Casualty and Surety Company of America a corporation duly organized under the laws of the State of Connecticut as Surety, hereinafter called the Surety, are held and firmly bound unto Calhoun County as Obligee, hereinafter called the Obligee, in the sum of Five Percent of Amount Bid Dollars ($ 5% ), for the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, the Principal has submitted a bid for Annex Building Roof Improvements Project for Calhoun County NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding or Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter such Contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the penalty hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith contract with another party to perform the Work covered by said bid, then this obligation shall be null and void, otherwise to remain in full force and effect. Signed and sealed this 5th day of November , 2024 Port Enterprises, LTD (Principal) _ �( (witty ss) BY C;� (Title) a Cody Comstock. vice President for General Partner, Port Enterprises Hoofing Inc fl�.�✓fir _ .-r-r�� r—' (W(ness) Kaitiyn Tarango Travelers Casjualo and Surety Company of America (Title) The Company executing this bond vouches that this document conforms to American Institute of Architects Document A310, February 1970 Edition State of Texas } SS: County of Tarrant } SURETY ACKNOWLEDGEMENT (ATTORNEY -IN -FACT) On this 5th day of November In the year 2024 before me, Bailee Marie Islas a Notary Public in and for said County and State, residing therein, duly commissioned and sworn, personally appeared Jennifer Upton known to me to be the duly authorized Attomey-In-Fact of the Travelers Casualty and Surety Company and the same person whose name is subscribed to the within instrument as the Attomey-in-Fact, of sold Company and the said Jennifer Upton duly acknowledged to me that he subscribed the of the Travelers Casualty and Surety Company thereto as Surety and his own name as Attorney -in -Fact. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year in this certificate first above written. Notary Public in and for Tarrant State of Texas My Commission expires: June 27, 2028 AlBAILEE MARIE ISLAS a• • o � MY COMMISSION EXPIRES ao-wlaED.sn6 * 4 06127/2028 NOTARY ID: 134968711 County Travelers Casualty and Surety Company of America Travelers Casualty and Surety Company T AVELE PI St. Paul Fire and Marine Insurance Company POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That Travelers Casualty and Surety Company of America, Travelers Casualty and Surety Company, and St. Paul Fire and Marine Insurance Company are corporations duly organized under the laws of the State of Connecticut (herein collectively called the "Companies"), and that the Companies do hereby make, constitute and appoint Jennifer Upton of FORT WORTH . Texas , their true and lawful Attorney(s)-in-Fact to sign, execute, seal and acknowledge any and all bonds, recognizances, conditional undertakings and other writings obligatory in the nature thereof on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. IN WITNESS WHEREOF, the Companies have caused this instrument to be signed, and their corporate seals to be hereto affixed, this 21st day of April, 2021. �11Wp„Y 9a�GSY fiK0 Q, MO 464�0'A^ State of Connecticut Vf' Y' By: City of Hartford ss. Robert L. Raney` enior Vice President On this the 21st day of April, 2021, before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior Vice President of each of the Companies, and that he, as such, being authorized so to do, executed the foregoing instrument for the purposes therein contained by signing on behalf of said Companies by himself as a duly authorized officer. IN WITNESS WHEREOF, I hereunto set my hand and official seal. wonnm My Commission expires the 30th day of June, 2026 �4� Ms r usuo . 4 Anna P. Nowik, Notary Public This Power of Attorney is granted under and by the authority of the following resolutions adopted by the Boards of Directors of each of _ the Companies, which resolutions are now in full force and effect, reading as follows: RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice - President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint Attorneys -in -Fact and Agents to act for and on behalf of the Company and may give such appointee such authority as his or her certificate of authority may prescribe to sign with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional undertaking, and any of said officers or the Board of Directors at any time may remove any such appointee and revoke the power given him or her; and it is FURTHER RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice President may delegate all or any part of the foregoing authority to one or more officers or employees of this Company, provided that each such delegation is in writing and a copy thereof is filed in the office of the Secretary; and it is FURTHER RESOLVED, that any bond, recognizance, contract of indemnity, or writing obligatory in the nature of a bond, recognizance, or conditional undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary and duly attested and sealed with the Company's seal by. a Secretary or Assistant Secretary; or (b) duly executed (under seal, if required) by one or more Attorneys -in -Fact and Agents pursuant to the power prescribed in his or her certificate or their certificates of authority or by one or more Company officers pursuant to a written delegation of authority; and it is FURTHER RESOLVED, that the signature of each of the following officers: President, any Executive Vice President, any Senior Vice President, any Vice President, any Assistant Vice President, any Secretary, any Assistant Secretary, and the seal of the Company may be affixed by facsimile to any Power of Attorney or to any certificate relating thereto appointing Resident Vice Presidents, Resident Assistant Secretaries or Attorneys -in - Fact for purposes only of executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such Power of Attorney or certificate bearing such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding on the Company in the future with respect to any bond or understanding to which it is attached. I, Kevin E. Hughes, the undersigned, Assistant Secretary of each of the Companies, do hereby certify that the above and foregoing is a true and correct copy of the Power of Attorney executed by said Companies, which remains in full force and effect. Dated this 5th day of November , 2024 pwyrgnN(� n pwiv axon i � fly�CAYN�R c HPCONNfl�, n toTt ( GGG! Kevin E. Hughes, Assi tant Secretary �./ To verify the authenticity of this Power of Attorney, please call as at 1-800-421-3880. Please refer to the above-namedA ttorney(s)-in-Factand the details of the bond to which this Power of Attorney is attached. I M'00 VI, -NZIr11C41 To obtain information or make a complaint: You may call Travelers Casualty and Surety Company of America and its affiliates' toll - free telephone number for information or to make a complaint at: 1-800-328-2189 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 You may write the Texas Department of Insurance: P. O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: http://www.tdi.state.tx.us E-mail: ConsumerProtectionatdi.state.tx.us PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact your Agent or Travelers first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR BOND: This notice is for information only and does not become a part or condition of the attached document and is given to comply with Texas legal and regulatory requirements. (PN-042-B) Ed. 10.18.07 STATEMENT OF BIDDER'S QUALIFICATIONS All questions must be answered and the data given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he/she desires. Name of Bidder: Port Enterprises Ltd. Date Organized: 1963 Address: 1955 Saratoga Blvd Date Incorporated: N/A Corpus Christi, TX 78417 Number of Years in contracting business under current name: 46 CONTRACTS ON HAND: Contracts Dollar Amount Completion Date Chisholm Trail Middle School $3,699,257.00 12/2024 Mathis ISD Roofing Improvements $1 699 990.00 1/2025 Driscoll and Akins Middle School $388,157.00 12/2024 Port A Public Safety Center $466 892 00 12/2024 Type of work performed by your company: Have you ever failed to complete any work awarded to you Have you ever defaulted on a contract? No List the projects most recently completed by your firm (include project of similar importance): i Project Dollar Amount Mo/Yr Completed (\ Palacios High School $1,521,347.00 7/2024 Palacios Pre K - 5th Campus $845,664.00 7/2024 Del Mar Memorial Classroom $480,000.00 9/2024 Leon Taylor Middle School $910 014.00 8/2023 Major equipment available for this contract: Skytrack, Manlift, Storage Rental Dump Trailer Attach resume(s) for the principal member(s) of your organization, including the officers as well as the proposed superintendent for the project. Credit $ Bank available: Attached reference: Cailtin Reeves (361) 844-1147 The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by the Calhoun County in verification of the recitals comprising this Statement of Bidder's Qualifications. Executed this 5 day of November 2024. by:�i Vice President for General Partner, Port Enterprises Roofing, Inc. (Signature) (Title) Post Office Drawer 749 Corpus Christi, Texas 78403-0749 March 12, 2024 RE: Port Enterprises, Ltd, To Whom It May Concern; Port Enterprises, Ltd. has been a Frost Bank customer since 2009. The company currently has a line of credit, checking accounts and treasury management services with our bank. The company's checking accounts and line of credit are in the low seven figure range with a current balance of zero on the line of credit, Port Enterprises, Ltd. is a very valued customer of Frost Bank. All loans and accounts have been handled as agreed. If you have any questions call me at 361-844-1147. Sincerely, ll 1U�- -12a� Caitlin Reeves Vice President CR/d1 Frost Bank is a subsidiary of Cullen/Frost Bankers, Inc. NYSE Symhol: CFR, a Texas financial services company offering banking, investments and insurance, Present Firm Owners — List of Partners RESUME: Board of Directors: Jennifer McCauley, Partner (President for General Partner, Port Enterprises Roofing, Inc.) Project Manager and Estimator of Manchaca Operations — 30 Years Experience in estimating and supervision Certified Roofing Contractor Cody Comstock, Partner (Vice President for General Partner, Port Enterprises Roofing, Inc.) Project Manager and Estimator of Corpus Cliristi Operations — 31 Years Experience in application, supervision, management, and estimating Certified Roofing Contractor Jake Comstock, Partner (Vice President for General Partner, Port Enterprises Roofing, Inc.) Project Manager and Estimator of New Braunfels Operations — 31 Years Experience in application, supervision, management, and estimating Certified Roofing Contractor Stephen McCauley, Partner (Vice President for General Partner, Port Enterprises Roofing, Inc.) Production Manager of Manchaca Operations — 27 Years Experience in application, supervision, and management J"UAATIVIUNO PORT ENTERPRISES, LTD. P.O. BOX 271482 CORPUS CHRISTI, TX 78427 Title: Project Superintendent Port Enterprises, Ltd. 2009 to Present Certifications: OSHA 30 Hour Safety Course Certified Torch Applicator Aerial Lift Safety Course Rough Terrain Forklift Course Miscellaneous Safety Courses JOB SUMMARY: Performs all duties normally required in the trade of roofer following recognized procedures and techniques of such work. Assigns, inspects and directs the work of other employees and keeps the time sheets. Conducts on site safety meetings with crew. Monitors work efficiency, quality and performance of crew. Has sound knowledge of safety procedures applied during roof replacement. Has sound knowledge of operation of various manual & electrical tools (e.g. scraper, sawzall, grinder, sander, kettle, single phase & three (3) phase equipment, generator, LPG torch, spray gun, foam application unit, coil nailer, etc). Has certification to operate machinery needed on site. Orders material. Responsible for seeing that all work meets job specifications and that project is maintaining critical path points. Communicates on a regular basis with the Project Manager regarding the status of the project. Has supervised commercial projects in reroofing and new construction. Job sites that he has performed on include School Districts, Government Projects, Institutional Projects and Retail Projects. He is a key employee who is relied upon to represent Port Enterprises, Ltd. on a project. Safi Reference (Served as Project Superfutendent) Riviera Church Owner: Riviera Chapel General Contractor: Beecroft Construction 361 / 882-6791 Contract Amount: $110,935.00 Mathis High School Additions & Renovations Bond Owner: Mathis ISD General Contractor: Summit Building & Design 956/727-6601 Contact: Richard Rivera Contract Amount: $1,014,487.00 Port of Corpus Christi New Office Facility Owner: Port of Corpus Christi Authority General Contractor: Bartlett CockeBeecroft 210/655-1031 Contact: Htmter Mueller Contract Amount: $527,793.00 Refugio Auditorium Owner: Refugio Independent School District General Contractor: Weaver and Jacobs Constructors 361/277-9300 Contact: Gary Hefernick Contract Amount: 4483,661.00 Northside Sports Gymnasium - Owner: Northside I.S.D General Contractor: Bartlett Cocke General Contractors 210/655-1031 Contact: Tim Martin Contract Amount: $745,363.00 Boerne Middle School North Owner: Boerne I.S.D General Contractor: Bartlett Cocke General Contractors 210-655-1031 Contact: Ryan Zwicke Contract Amount: $861,239.00 Currington Elementary School Owner: Boerne I.S.D General Contractor: Bartlett Cocke General Contractors 210/655-1031 Contact: Craig Jendrush Contract Amount: $1,025,016.00 LaGrange ISD Hermes Elementary School Owner: LaGrange ISD General Contractor: Weaver and Jacobs Constructors, Inc. Contact: Brent Cohmert 361/277-9300 Contract Amount: $1,696,085.00 STATE OF TEXAS {} AFFIDAVIT COUNTY OF Nueces Comstock being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Vice President for General Partnerof Port Enterprises having its (Type or Print Title) (Type or Print Na me of Company/Firm) principal address at 1955 Saratoga Blvd Corpus Christi TX 78417 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; thatthe same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal orwithdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, orto raise orfix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offerto give, nor intends to give at anytime 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, orthe contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, orto any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the conditions and requirements contained in the bid/proposal. Signature of Afriant Cody Comstock Vice President for General Partner Port Enterprises Roofing Inc. Printed Name and Title of Affiant 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 5 day of November , 2o24 a tLI amp.AHARVILLARY PUBLICSTATE OF TEXASMY COMM, EXP.05/03/25 NOTARY ID 611294,9 CONTRACTOR CERTIFICATIONS CERTIFICATION OF BIDDER REGARDING CIVIL RIGHTS LAWS AND REGULATIONS INSTRUCTIONS CERTIFICATION OF BIDDER REGARDING Executive Order 11246 and Federal Laws Requiring Federal Contractor to adopt and abide by equal employment opportunity and affirmative action in their hiring, firing, and promotion practices. This includes practices related to race, color, gender, religion, national origin, disability, and veterans' rights. NAME AND ADDRESS OF BIDDER (include ZIP Code) Port Enterprises, Ltd. 1955 Saratoga Blvd, Corpus Christi, TX 78417 CERTIFICATION BY BIDDER Bidder has participated in a previous contract or subcontract subject to Civil Rights Laws and Regulations. ❑ Yes O No The undersigned hereby certifies that: ❑ The Non -Segregated Facilities clause (Section 109 provision) is included in the Contract. No segregated facilities will be maintained as required by Title VI of the Civil Rights Act of 1964. ❑ The Equal Employment Opportunity clause is included in the Contract (if bid equals or exceeds $10,000). ❑ The Affirmative Action for Handicapped Workers clause is included in the contract. ❑ The Exhibit B — Assurances for Construction Programs is included in the Contract. ❑ The Exhibit D — State of Texas Assurance is included in the Contract. Have you ever been or are you being considered for sanction due to violation of Executive Order 11246- Equal Employment Opportunity, as amended? ❑ Yes E? No Cody Comstock, Vice President for General Partner, Port Enterprises Roofing Inc. NAME AND TITLE OF SIGNER (Please type) 11 /5/2024 S I G NATU R DATE 8/03/2011 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 1491, 80th OFFICE USE ONLY Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Date Received Government Code by a person who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person meets requirements under Section 176.004(a). By law this questionnaire must be filed with the records administrator of the I local governmental entity not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.004, Local Government Code. A person commits an offense if the person knowingly violates Section 176.004, Local Government Code. An offense under this section is a Class C misdemeanor. 1. Name of person doing business with cal governmental entity. RFB / RFP / Contract 2. ❑ Check this box if ou are filin an update to a previously filed questionnaire. (The law requires that y)file an ated completed questionnaire with the appropriate filing authority not later than th 7`h busin ss day the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Name of local governme officer with whom filer has employment or business relationship. Name of Officer This secti n it including s bparts A, B, C & D) must be completed for each officer with whom the filer has a e ploy ant or othe business relationship as defined by Section 176.001(1-a), Local Governm nt ode. ttach additio al pages to this Form CIQ as necessary A. Is the to al g vern ant officer na ed in this section receiving or likely to receive taxable income, other than i vest eni come, from the filer of the questionnaire? ❑ Yes ❑ No B. Is the filer f the es ionnaire receiving or likely to receive taxable income, other than investment income, from r at the it ction of the local government officer named in this section AND the taxable income is not eceived the local governmental entity? ❑ Yes ❑ No C. Is the filer of his questionnaire employed by a corporation or other business entity with respect to which the local g vernment officer serves as an officer or director, or holds an ownership of 10 percent or more? ❑ Yes ❑ No D. Describe each employment or business relationship with the local government officer named in this section. 4. Signature of person doing business with governmental entity Date Signed IIAA11JI► iMIN '1831 Executive Order 12549--Debarment and Suspension Source: The provisions of Executive Order 12549 of Feb. 18, 1986, appear at 51 FR 6370, 3 CFR, 1986 Comp., p. 189, unless otherwise noted. By the authority vested in me as President by the Constitution and laws of the United States of America, and in order to curb fraud, waste, and abuse in Federal programs, increase agency accountability, and ensure consistency among agency regulations concerning debarment and suspension of participants in Federal programs, it is hereby ordered that: Section 1. (a) To the extent permitted by law and subject to the limitations in Section I(c), Executive departments and agencies shall participate in a system for debarment and suspension from programs and activities involving Federal financial and nonfinancial assistance and benefits. Debarment or suspension of a participant in a program by one agency shall have government -wide effect. (b) Activities covered by this Order include but are not limited to: grants, cooperative agreements, contracts of assistance, loans, and loan guarantees. (c) This Order does not cover procurement programs and activities, direct Federal statutory entitlements or mandatory awards, direct awards to foreign governments or public international organizations, benefits to an individual as a personal entitlement, or Federal employment. Sec. 2. To the extent permitted by law, Executive departments and agencies shall: (a) Follow government -wide criteria and government -wide minimum due process procedures when they act to debar or suspend participants in affected programs. (b) Send to the agency designated pursuant to Section 5 identifying information concerning debarred and suspended participants in affected programs, participants who have agreed to exclusion from participation, and participants declared ineligible under applicable law, including Executive Orders. This information shall be included in the list to be maintained pursuant to Section 5. (c) Not allow a party to participate in any affected program if any Executive department or agency has debarred, suspended, or otherwise excluded (to the extent specified in the exclusion agreement) that parry from participation in an affected program. An agency may grant an exception permitting a debarred, suspended, or excluded party to participate in a particular transaction upon a written determination by the agency head or authorized designee stating the reason(s) for deviating from this Presidential policy. However, I intend that exceptions to this policy should be granted only infrequently. Sec. 3. Executive departments and agencies shall issue regulations governing their implementation of this Order that shall be consistent with the guidelines issued under Section 6. Proposed regulations shall be submitted to the Office of Management and Budget for review within four months of the date of the guidelines issued under Section 6. The Director of the Office of Management and Budget may return for reconsideration proposed regulations that the Director believes are inconsistent with the guidelines. Final regulations shall be published within twelve months of the date of the guidelines. See. 4. There is hereby constituted the Interagency Committee on Debarment and Suspension, which shall monitor implementation of this Order. The Committee shall consist of representatives of agencies designated by the Director of the Office of Management and Budget. See. 5. The Director of the Office of Management and Budget shall designate a Federal agency to perform the following functions: maintain a current list of all individuals and organizations excluded from program participation under this Order, periodically distribute the list to Federal agencies, and study the feasibility of automating the list; coordinate with the lead agency responsible for government -wide debarment and suspension of contractors; chair the Interagency Committee established by Section 4; and report periodically to the Director on implementation of this Order, with the first report due within two years of the date of the Order. See. 6. The Director of the Office of Management and Budget is authorized to issue guidelines to Executive departments and agencies that govern which programs and activities are covered by this Order, prescribe government -wide criteria and government -wide minimum due process procedures, and set forth other related details for the effective administration of the guidelines. See. 7. The Director of the Office of Management and Budget shall report to the President within three years of the date of this Order on Federal agency compliance with the Order, including the number of exceptions made under Section 2(c), and shall make recommendations as are appropriate further to curb fraud, waste, and abuse. Implementation in the SIFT+ Programs A company or individual who is debarred or suspended cannot participate in primary and lower -tiered covered transactions. These transactions include SRF loans and contracts and subcontracts awarded with SRF loan funds. Under 40 C.F.R. 32.510, the SRF agency must submit a certification stating that it shall not knowingly enter into any transaction with a person who is proposed for debarment, suspended, declared ineligible, of voluntarily excluded from participation in the SRF program. This certification is reviewed by the EPA regional office before the capitalization grant is awarded. A recipient of SRF assistance directly made available by capitalization grants must provide a certification that it will not knowingly enter into a contract with anyone who is ineligible under the regulations to participate in the project. Contractors on the project have to provide a similar certification prior to the award of a contract and subcontractors on the project have to provide the general contractor with the certification prior to the award of any subcontract. In addition to actions taken under 40 C.F.R. Part 32, there are a wide range of other sanctions that can render a party ineligible to participate in the SRF program. Lists of debarred, suspended and otherwise ineligible parties are maintained by the General Services Administration and should be checked by the SRF agency and all recipients of funds directly made available by capitalization grants to ensure the accuracy of certifications. Additional References C 40 C.F.R. Part 32: EPA Regulations on Debarment and Suspension. 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. Cody Comstock Vice President for General Partner, Port Enterprises Roofing Inc. 11/5/2024 Name and Title of Authorized Agent Date Si ture of Authorized Agent I am unable to certify to the above statements. My explanation is attached. CERTIFICATION REGARDING LOBBYING (To be submitted if the bid or offer exceeds $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, Port Enterprises, Ltd. , 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 06tractor's Authorized Official CodV Comstock, Vice President for General Partner, Port Enterprises Roofing Inc. Printed Name and Title of Contractor's Authorized Official 11 /512024 Date 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 3. Report Type: a. contract Action: a. initial filing b. grant a. b. material change c. cooperative bid/offer/application agreement b. initial award d. loan c. post -award e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: 6. if Reporting Entity in No. 4 is Subawardee, _ Prime Subawardee Enter 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: 7. Federal Action Nu ber, if k n: 9. Award Amount, if known: 10. a. Name and A e s of Lobbying b. Individuals Performing Services (including Registrant address if different from No. 10a) (if individual, last am st name, MI): (last name, first name, MI): 11. Information request thro h this form is authorized by title 31 U.S. . section 1352.This Signazm,� mate disclosure of lobbying act! 'ties is a material �� —e�l �— representation of fact upon ich reliance was placed by the tier above when his transaction Print Name: Cody Comstock was made or entered into. This disclosure is Vice President for General Partner, required pursuant to 31 U.S.C. 1362. This Title: Port Enterprises Roofing Inc. information will be reported to the Congress semi-annually and will be available for public Telephone No.:(361) 289-2944Date: 11 /5/2024 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. Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) r, HOUSE BILL 99 VERIFICATION FORM U Certification Required by Texas Government Code Section 2270.001 The 85"' Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Cody Comstock , do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texa5.gov/purchasing/publications/d ivestment. php Port Enterprises, Ltd. Company Name Signature of Authorized Official Comstock Printed Name of Authorized Official Vice President for General Partner, Port Enterprises Roofing Inc. 11/5/2024 Title of Authorized Official Date RESIDENCE 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. (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. D I certify that (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) D I certify that Port Enterprises, Ltd. is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized A brit Cody Comstock, Vice President for General Partner, Port Enterprises Roofing, Inc. Printed Name and Title of Authorized Agent Date U 11 /5/2024 SECTION 504 CERTIFICATION POLICY OF NONDISCRIMINATION ON THE BASIS OF DISABILITY The Port Enterprises, Ltd. does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs or activities. (Name) Cody Comstock (Address) 1955 Saratoga Blvd Nueces Texas 78413 County State Zip Telephone Number (361 ) 289 - 2944 Voice TDD 1�� Vz CO, 5 ¢ � has been designated to coordinate compliance all Federal statutes relating to nondiscrimination. m � . q �{ �$ r PROJECT IDENT IFIER: 2024.10 Annex Roof Improvements Project for Calhoun County Competitive Sealed Proposal November 5, 2024 Honorable Richard H. Meyer Calhoun County Courthouse 211 South Ann Street 3rd Floor, Suite 301 Port Lavaca, Texas 77979 L Respondent Rain Seal Master Roofing & Sheet Metal, Inc. 2306 Port Lavaca Drive Victoria, Texas 77901 ramonir@rsmincl.com I I, 2024.10 Annex Roof Improvements Proiect for Calhoun County Bid Forms & Request for CSP Table of Contents Cover Sheet Table of Contents BidForm.................................................................................................................................................................Pg. 1-2 SpecificationNotes................................................................................................................................................. Pg. 3 BidBond.................................................................................................................................................................Pg.4-7 Statement of Qualifications...........................................................................................................................Pg. 8-20 Affidavit..................................................................................................................................................................... Pg. 21 Certification Regarding Civil Rights Laws and Regulations...................................................................Pg. 22 Conflictsof Interest..............................................................................................................................................Pg. 23 Certification Re: Debarment & Suspension.................................................................................................Pg. 24 Certification Re: Lobbying and Disclosure of Lobbying Activities ............................................... Pg. 25-26 House Bill 89 Verification Form...........................................................................................................Pg. 27 ResidenceCertificate.............................................................................................................................Pg. 28 Section504 Certificate........................................................................................................................................Pg. 29 SAM....................................................................................................................................................Pg. 30-39 L BID (Revised per Addendum No. 1 -10.29.24) PROJECT NAME: Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County, Texas i DUE DATE: Tuesday, November 5, 2024 before 2:00:00 p.m1 NAME: Rain Seal Master Roofing & Sheet Metal, Inc. r BASE WORK SCOPE is: Approximately 8,435 SF of roof tear down to lightweight concrete deck then l replace with new insulation and system to meet windstorm requirements, penetration updates, new roof hatch with fall protection all complete in place per plans and specifications. t; L, Item Quantity Unit Unit Price Total Bid Price B.1) Furnishing all necessary equipment, materials, 1 LS and labor for Mobilization, demobilization, barricades, insurance, and bonds as per plans and specifications $13,520.00 $13,520.00 B.2) Furnish all necessary equipment, materials, and 1 LS labor for the roof replacement scope of work for the entire building in accordance with drawings and specifications. Includes, but not limited to all flashings, sheet metal, trim, roof systems (membranes and $209,760.00 $209,760.00 boards), two layers of tapered insulation (R25), wood nailers for parapet extension, fasteners, sealants and other items necessary to fully complete the work. B.3) Furnish all necessary equipment, materials, and 1 LS labor for the roof top penetration modifications in accordance with drawings and specifications. Includes, but not limited to all flashings, sheet metal, trim, $2,400.00 $2,400.00 boards, fasteners, sealants and other items necessary to fully complete the work. (Excludes Mechanical HVAC Mods). B.4) 3% Owners Contingency: To be used only as 1 LS 3% of Base Bid directed by Engineer for Owner's purposes and only by (0.03 X Sum of change orders that indicate amounts to be charged to Base Bid Lines $6,771.00 the Owner's Contingency. 1-3 above) TOTAL BASE BID $ $232,451.00 OWNER'S OPTION(S) Item Quantity Unit Unit Price Total Bid Price 0.1) Furnish all necessary equipment, materials, and 1 LS labor for the roofing support of modification of HVAC curb, which includes closing of the space between the old curb and new with new roof decking, demo as $8,500.00 $8,500.00 required in the area to adequately seal the space and accept new roof system. Work after hours and or weekend required and coordinating with Owner's HVAC contractor. 1 L L Item Quantity Unit Unit Price Total Bid Price ALTERNATE BID ITEM(S) Item Quantity Unit Unit Price Total Bid Price A.1) Furnish all necessary equipment, materials, and labor for a RT Roof System in lieu of a tapered insulation roof system. Includes all of the necessary materials as in the base bid. 1 LS $306,178.00 $306,178.00 TOTAL ALTERNATE BID (Bid Items B1,A1,B3 & B4) $306,178.00 2 SPECIFICATION NOTES Calhoun County is receiving Bids for items and quantities of work generally as follows: Bids are invited for items and quantities of work generally as follows: Approximately 8,435 SF of roof tear down to lightweight concrete deck then replace with new insulation and system to meet windstorm requirements, penetration updates, new roof hatch with fall protection all complete in place per plans and specifications. County to provide: 1. Unsecured place to store contractor equipment and vehicles 2. Unsecured area to store excess materials required for construction. The BIDDER, in compliance with the invitation for bids for Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County. Texas, having examined the plans and specifications with related documents and the site of the proposed work, and being familiar with all of the conditions surrounding the construction of the proposed project, including the availability of materials and labor, hereby proposes to furnish all labor, materials and supplies in accordance with the contract documents, within the time set forth herein. ` These price(s) are to cover all expenses incurred in performing the work required under the contract documents, t of which this proposal is a part. These price(s) are firm and shall not be subject to adjustment provided this Proposal is accepted within thirty (30) days after the time set for receipt of proposals. BIDDER hereby agrees to commence work under this contract on or before a date to be specified in a written "Notice to Proceed" to be issued by the County and to substantially complete within 75 consecutive calendar days as stipulated in the specifications. BIDDER further agrees to pay as liquidated !, damages, the sum of $300.00 for each consecutive calendar day. I hereby acknowledge the receipt of the following addenda: 1. Addendum 1 2. SUBCONTRACTORS. The undersigned BIDDER proposes that he will be responsible to perform major portions of the work at the project site with his own forces and that specific portions of the work not performed by the undersigned will be subcontracted and performed by the following subcontractors. TVpe of Work Subcontracted Name of Subcontractor NIA N/A The undersigned hereby declares that he has visited the site and has carefully examined the contract documents relative to the work covered by the above bid. Bidder Name: Rain Seal Master Roofing & Sheet Metal, Inc. Address: 2306 Port Lavaca Dr, Victoria, Texas 77901 Phone: 361-576-0926 EIN or Tax Signature: Name and Title: Juan Ramon Lozano, Sr. - President Email Address: ramon@rsmincl.com _i L 3 KNOW ALL MEN BY THESE PRESENTS, that we the undersigned, Rain Seal Master Roofing & Sheet Metal Inc. as PRINCIPAL, and Merchants Bonding Company (Mutual) , as SURETY are held and firmly bound unto CALHOUN COUNTY, TEXAS hereinafter called the "Owner', in the penal sum of Five Percent of the Greatest Amount Bid Dollars, ($ 5% G.A.B. ), lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that whereas the Principal has submitted the Accompanying Bid, dated November5th, 2024 , Bid Number 2024.10 — Annex Building Roof Improvements Project for Calhoun County, Texas. NOW, THEREFOR, if the Principal shall not withdraw said Bid within the period specified therein after the opening of the same, or, if no period be specified, within thirty (30) days after the said opening, and shall within the period specified therefore, or if no period be specified, within ten (10) days after the prescribed forms are presented to him for signature, enter into a written contract with the Owner in accordance with the Bid as accepted, and give bond with good and sufficient surety or sureties, as may be required, for the faithful performance and proper fulfillment of such contract; or in the event of the withdrawal of said Bid within the period specified, or the failure to enter into such Contract and give such bond within the time specified, if the Principal shall pay the Owner the difference between the amount specified in said Bid and the amount for which the local Public Agency may procure the required work or supplies or both, if the latter be in excess of the former, then the above obligation shall be void and of no effect, otherwise to remain in full force and virtue. IN WITNESS THEREOF, the above -bounded parties have executed this instrument under their several seals this 5th day of November, 2024 , the name and corporate seal of each corporate party being hereto affixed and these present signed by its undersigned representative, pursuant to authority of its governing body. Rain Seal Master Roofing & Sheet Metal InCSEAL) (SEAL) Attest: By: Affix Corporate Seal Attest: By Affix Corporate Seal Attest: By: LCountersiped Merchants Bonding Company (Mutual) m Attorney -in -Fact, State of Texas I it Christina Dale CERTIFICATE AS TO CORPORATE PRINCIPAL I, certify that I am the current I ,Secretary of the Corporation named as Principal in the within bond; that Juan Ramon Lozano. Sr. who signed the said bond on behalf of the Principal was then President of said corporation; that I know his signature, and f his signature thereto is genuine; and that said bond was duly signed, sealed, and attested to, for and in behalf of said corporation by authority of this governing body. 1-1 Corporate Seal Title: President " Power -of -attorney for person signing for Surety Company must be attached to bond. 5 MERCHANTS�+� I- BONDING COMPANY, MERCHANTS BONDING COMPANY (MUTUAL) • P.O. BOX 14498 • DES MOINES, IOWA 50306-3498 PHONE: (800) 678-8171 • FAX: (515) 243-3854 ADDENDUM TO BOND This Addendum is in reference to the bond(s) to which it is attached. Merchants Bonding Company (Mutual) ("Merchants") deems the digital or electronic image of Merchants' corporate seal below affixed to the bond(s) to the same extent as if a raised corporate seal was physically stamped or impressed upon the bond(s). The digital or electronic seal below shall have the same force and effect as though manually fixed to the bond(s). All terms of the bond(s) remain the same. Signed and effective March 23, 2020. MERCHANTS BONDING COMPANY (MUTUAL) •z: 1933 By. ...�� Larry Taylor, President, L, MERCHANTS�+�� BONDING COMPANYr, POWER OF ATTORNEY Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., both being corporations of the State of Iowa, d/b/a Merchants National Indemnity Company (in California only) (herein collectively called the "Companies") do hereby make, constitute and appoint, individually, Aaron Endris; Ben D Smith; Brian E Lewis; Jeffrey P Pratt; Norma Camarillo; Theresa Miller; Tricia Balolong their true and lawful Attorney(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof, an behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and April 27, 2024 and adopted by the Board of Directors of Merchants National Banding, Inc., on October 16, 2015 and amended on April 27, 2024, - "The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute an behalf of the Company, and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof." "The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company, and such signature and seal when so used shall have the same force and effect as though manually fixed." In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and aut hority, hereby given to the Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety. company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner - Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 29th day of July 2024 ......., •..•" ° • MERCHANTS BONDING COMPANY MUTUAL •�QCo S'PO A� '. �`%..G .. MERCHANTS NATIONAL BONDING, INC. ) g:Gp(L Rgr;oy: �•�.�oPPoy9.�9?,. d/b/aMERCHANTSSNATIIONNJALINDEM!NNIITTYYCOMPANY Gi? -0 G'.�: -o- o �`:• Z. 2003 ; �; : y; 1933 c: By sd . �. ........... STATE OF IOWA �' * ••• '• � it President °•. COUNTY OF DALLAS ss. •••.....u••••' ..... On this 29th day of July 2024 , before me appeared Larry Taylor, to me personally known, who being by me duly sworn did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors. APRIA4S Penni Miller Z `r Commission Number 787952 .. • • My Commission Expires IOWPI January 20, 2027 "`••••. (Expiration of notary's commission does not invalidate this instrument) Notary Public I, Elisabeth Sandersfeld, Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do hereby certify that the above and foregoing is a true and correct copy of the POWER -OF -ATTORNEY executed by said Companies, which is still in full force and effect and has not been amended or revoked. In Witness Whereof, I have hereunto set my hand and affixed the seal of the Companies on this ° ION •. .•...... ° NGC 5th day of November , 2024 . '~y�o�POR,'�y% ' 0o�co`PP09�'o9ys.•• `//'L/ —"_ `�'��/L"'vv —L :3 2003 ;��f :y; 1933 .. '} •. POA 00 18 (6124).............°°•' Secretary See Attached Certifications STATEMENT OF BIDDER'S QUALIFICATIONS More upon Request All questions must be answered and the data given must be clear and comprehensive. This statement must be notarized. If necessary, questions may be answered on separate attached sheets. The Bidder may submit any additional information he/she desires. Name of Bidder: Rain Seal Master Roofing & Sheet Metal Inc. Date Organized: 1999 Address: 2306 Port Lavaca Drive, Victoria, Texas 77901 Date Incorporated: 10/9/2002 Number of Years in contracting business undercurrent name: 241-Years CONTRACTS ON HAND: Contracts DollarAmount Completion Date Hondo Readiness Center $415,000.00 2nd Qtr 2025 Victoria County $295,800.00 Dec 2024 Type of work performed by your company: Commercial Roofing/Contracting Have you ever failed to complete any work awarded to you? No Have you ever defaulted on a contract? No List the projects most recently completed by your firm (include project of similar importance): Project Dollar Amount Mo/Yr Completed VISD $2,395,717.00 October 2024 f Victoria College $365 500 00 February 2024 Corpus Christi ISD $3 014 000 00 March 2024 Coastal Bend College $226 549.00 March 2023 Major equipment available for this contract: See Attached List Attach resume(s) for the principal member(s) of your organization, including the officers as well as the proposed superintendent for the project. Attached Credit $ available: See Attached Bank reference: Prosperity Bank The undersigned hereby authorizes and requests any person, firm, or corporation to furnish any information requested by the Calhoun County Project Management Team in verification of the recitals comprising this Statement of Bidder's Qualifications. Executed this 4th __.day of November 2024. by: _ President '(Signature) (Title) S X V s O O r t0 m y m M M O Y m m O O O LL Y U N O F U (l N O O �F.�gl-F� o o A m asi N m rn rn r o o m m m o E o N - m — rn m o N (7 N C v N O z O l o E U m O ti N N N m O— N O N❑ O D_ m y w a 1 _ m Q m C7»>'_ao c l-m c LL m � E:m E o E - N m rn O O ornm�rcormvu�orm a7 rn m m OJ O S t0 LL O U 6 m `"''`�'-�arnrnornmoOorn rn rn o rn rn o o O rn �- Y O Y U Y U O Y Y YYYY � 9 9 r w, 'a m YY U a co a U U a d °' m m m R F a E c $ c m W.000 c c c m o m c c O c o L 3 m m C m C (0 C (0 C>>>>> 0 0 0 0 0 0 .O F- N 9 N 9— .0 N C N c O 3 m O N d m L L L L t E m m m E m D N O C C _C_ U U UUU O E LLL�. - LL LL.S cYH N O OJ 0 0 0 0 0 0 0 0 O O W 0 0 0 0 0 0 0 0 N 0 O 0 O 0 0 0 O 0 0 ON Z O O O V r N N N N N N N W Y Y Y Y Y Y Y F- m N N N N N N N Y N N N N N N N 0 o m rn m m o o rn o rn o w rn o Y t0 m m C m C C N L U N m _ W � E � S ma 2 � m L o tO a l0 m � a O mN m 3 O N .p �` C C N U E E N D_ O m m w m;9 m= o o m d mmm m m a E w-- w m C-o m `m fq Lam. NC m N L ma N C t-o UJ (7 J E E 0 -- W � Y m o 'O E O t0 N 3 O U'o U L w m 2 N m O m'c N m an m m m O O 9 a c U U m m n U) m o O s m d y w m a a m m) R>>> E dg.�v U O� O m N m N N L m U E o �w,.L.vw�w ami o o.`r no - m wr 3 3U U N �Eq N E N N tq N UEi N N N N (L N N a m S a m L j ro 0 3 0 :c m aci aci aci m m aci aci aci aci .mc o 0 0 0. o o r o 3 m c r UZF-f-�--Z�--F-F'r F-(nNNNmNNYUN�O=1 d'MfL �ON�U 9 Juan R. Lozano S r. Years in the Roofing Business! � Co Roofing: Commercial Roofing: Built -Up, Metal President Fabrication, Sheet Metal, Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and C Installation. CCovering: Homes, Businesses, Schools, Government Entities, Churches, Plants, j County/City Facilities, Ports of Entry, and Pf More! f r f [ , Experience Experience t. 1998 - Current Bidding Jobs Upwards of $2.5 Million ` President Rain Seal Master Roofing & Sheet Metal, Inc. Dollars. l Key Responsibilities (Include but Not Limited to): Working With Architectural Firms as well -Attending Pre-B!d.Construction Meetings for Robf/Site Inspections as Engineers. Working With Construction Companies. -Bidding Projects (Government, Schools, Comrn6 c!al) Working With the Community. r Purchasing and Co-ordinating Material Orders Skills Scheduling Material Deliveries / Storing Material r Supervisor pubes on the Job to Check Progress and Check that • Inventory Control RemovournstOi tion Process isi Running According to Schedule Problem Solving {{ Keeping Necessary People Updated on Job Progress • Metal Work f Teamwork Qualifications include but not limited to: Employee Management, . Leadership t Equipment Management, Inventory Management; Software . Communication (Quantum,Contraet, Microsoft Excel/Office, On screen Takeoff, Outlook, end Morel Valid.DL, Extensive knowledge in Rdofing and Creativity Roofing Materials/Installation, Comprehension of basic shop t math/measurements: Technical Drawing/Drafting: Contact 1987 - 199.8 Supervisor/Foreman Easley Roofing & Sheet Metal, Inc:: Juan Ramon Lozano, Sr. Experience with both construction companies ani overseeing 2306 Port Lavaca Drive employees on thejob site. Putting Project together. Victoria, Texas 77901 361-576-0926 L, ramon@rsminc1.com t0 Juan R. Lozano, Jr® Estimator/Project Manager/ Superintendent r' �l Experience r 2005- Current Superintendent/Foreman Rain Seal Master& Sheet Metal, ! Inc. Key Responsibilities (Include but Are Not Limited to): -Handles Field Activities such as Job Progress -Delivers Job Reports to Project Manager Communicates with General Contractor Representative, Owner Rep, Architect Reps Keeping Them Up to Date Supervises Employee Progress and Production Enforces Job Safety/Fall Protection Conducts Weekly Safety Meetings ( Schedules Crews to Various Job Duties -Supervises Shop Fabrication Duties 111 -Progress Reports of New Construction, Renovations, and Various Projects. Supervising all Trades, Contractors, and Inventory of Supplies Throughout Duration of Project at Hand. L-Handles Pre -Bid Meetings and Bid Prepping. L 18+ Years in the Roofing Business! Commercial Roofing: Built -Up, Metal, Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and Installation. Covering: Businesses, Schools, Government Entities, Churches, Plants, County/City Facilities, Ports of Entry, and More! Education 2005 High School Graduate Skills • Metal Work • Inventory Control • Leadership • Safety Protocol • Communication • Teamwork Contact Juan Ramon Lozano, Sr. 2306 Port Lavaca Drive Victoria, Texas 77901 361-576-0926 ramon@rsmincl.com e j a n d ro Torres years in the Roofing Business! Co Commercial Roofing: Built -Up, Metal, Foreman/Sheet Metal Shop Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and Foreman Installation. Covering: Schools, Government Entities, Churches, Plants, County/City Facilities, Ports of Entry, and More! Experience Education 1999 - Current 1996 - Foreman Rain Seal Master Roofing & Sheet Metal, Inca High School Graduate ' Key Responsibilities (Include but Not Limited to): Mexico -Overseeing Job Site Progress Ensuring that Job Site Checklist is Correct and Everything is in Place for Daily Production Skills Updating/Reporting to Superintendent on Progress or Issues Enforcing Job Safety/Fall Protections Invento Inventory Control • Problem Solving -Overseeing Sheet Metal Fabrication in the Shop Metal Work • Teamwork Keeping Necessary People Updated on Job Progresg Leadership 1997 - 1999 Superintendent Easley Roofing & Sheet Il9etal,. Inc. Key Responsibilities: Contact -Oversaw Job Progress Juan Ramon Lozano, Sr. -Ensured Everything Needed for Daily Production is Available 2306 Port Lavaca Drive -Enforced Job Safety Victoria, Texas 77901 361-576-0926 -Kept Necessary People Updated on Job Progress L� ramon@rsmincl.com 12 \ a' as B e n 44+ Years i the Roofing Business! ■ M V �✓ y Commercial Roofing: Built -Up, Metal, Superintendent/Roof Foreman Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and Installation. Covering: Businesses, Schools, Government Entities, Churches, Plants, County/City Facilities, Ports of Entry, and r , More! t Experience Education Oct 2007 -Current 1980 Superintendent/Roof Foreman Rain Seal Master& Sheet High School Graduate Metal, Inc, �. Mexico Key Responsibilities (Include but Are Not Limited to): -Handles Field Activities (Job Progress, Equipment/Tools, Job Site Safety) -Delivers Job Reports to Project Manager -Communicates with General Contractor Representative, Owner Skills Rep, Architect Reps, Etc. Keeping them Up to Date -Supervises Employee Progress and Production . Problem Solving -Enforces Job Safety/Fall Protection • Leadership -Conducts Weekly Safety Meeting ` • Safety Protocol r • Communication 11 -Schedules Crews to Various Job Duties . Teamwork Supervises Shop Fabrication Deities L 1980 - 1996 Superintendent Easley Roofing & Sheet Metal, Inc. Contact Responsibilities: Oversaw Job Progress Juan Ramon Lozano, Sr. -Ensured Everything Needed for Daily Production is Available 2306 Port Lavaca Drive -Enforced Job Safety Victoria, Texas 77901 -Kept Necessary People Updated on Job Progress 361-576-0926 ramon@rsminc1.com 13 Martin (Rob) Years in the Construction &Roofing Bus Business! l Villarreal Commercial Roofing: Built-Up,Metal, Composite, Modified, Coal)Tar, Single Ply, Sheet Metal and Gutter Fabrication and Superintendent/Safety Installation. Coordinator Covering: Schools, Government Entities, Churches, Plants, County/City Facilities, Ports of Entry, and More! Experience Education ! € 2016 - Current 1982 Superintendent Rain Seal Master Roofing & Sheet Metal, High School Graduate Inc. Key Responsibilities: Field Activities Such as Job Project Progression Equipment Management Skills -Safety Management &Training Communications with Contractors, Owners, and Reps • Inventory Management Problem Solving -Scheduling, and Organizing Crew Duties . Teamwork . Safety Management -Reporting all Progress and Issues to Project Manager . Leadership ` 2001 - 2016 L Superintendent Kuntz Contracting Corp. Same Basic Duties as Above Contact 1992 -199$ Supervisor Baum Construction Juan Ramon Lozano, Sr. Same General Duties as Above 2306 Port Lavaca Drive Victoria, Texas 77901 361-576-0926 ramon@rsmincl.com (, a ry i n Ramon !l Years in the Construction and Roo Roofing Business!. Commercial Roofing: Built -Up, Metal, T u rci os Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and Roof Mechanic/Laborer Installation. Covering: Schools, Government Entities, Churches, Plants, County/City Facilities, ` t. Ports of Entry, and More! F' Experience Education `( t 2023 - Current 2013 Roof Mechanic Rain Seal Master Roofing $ Sheet Metal, Inc, High School Graduate Key Responsibilities (Include but Not. Limited to): Mexico -Removing Roofing and Depris -Minor Construction and Roof Repairs -Ensuring that Everything is in Place for Daily Production Skills -Updating/Reporting to Foreman on progress or Issues Cleanup -Awareness of Job Safety/Fall, Protection Problem Solving • Time Management Installing New Roofing System Per Instructions/Plans . Strong Work Ethic • Teamwork -Keeping All Necessary People Updated on Job Progress Leadership 2013 - 2023 construction and Roof Laborer' Key Responsibilities Contact I( -Building and Installations Juan Ramon Lozano, Sr. -Ensured Everything Needed for Daily Production is Available 2306 Port Lavaca Drive Victoria, Texas 77901 -Job Safety Awareness 361-576-0926 " ramon@rsmincl.com L -Kept Necessary People Updated on Job Progress 15 1 Gerardo Sanchez 44+ Years i the Roofing Business! Commercial Roofing: Built -Up, Metal, Roof Mechanic/Laborer Composite, Modified, Coal Tar, Single Ply, Sheet Metal and Gutter Fabrication and Installation. -, Covering: Businesses, Schools, Government Entities, Churches, Plants, County/City Facilities, Ports of Entry, and C. More! �1 Experience Education - Oct 2007 - Current 1980 Superintendent/Roof Foreman Rain Seal Master & Sheet High School Graduate f( Metal, Inc. Mexico t , Key Responsibilities (Include but Are Not Limited to): -Minor Construction/Roof Repairs -Ensuring Everything is in Place for Daily Production -Communicates with Foreman and Superintendent Skills -Awareness of Job Safety/Fall Protection -Removal of Existing Roofing Systems € . Problem Solving -Installation of New Roofing Systems . Roof Prep/Cleanup 1980 - 1996 • Safety Protocol E Superintendent Easley Roofing & Sheet Metal, Inc. • Communication Responsibilities: • Teamwork - Oversaw Job Progress C-Ensured Everything Needed for Daily Production is Available -Enforced Job Safety Contact { L-Kept Necessary People Updated on Job Progress Juan Ramon Lozano, Sr. 2306 Port Lavaca Drive Victoria, Texas 77901 361-576-0926 L; ramon@rsminc1.com PROSPERITY BAN-4 February 26, 2024 To Whom It May Concern Greetings: The Following is a brief summary of our relationship with Juan Ramon Lozano, Sr. and Rain Master Roofing and Sheet Metal, Inc. Mr. Lozano and Rain Seal Master have been valued customers since March 2003. For many years we have extended the company a $500,000 Revolving Credit Line used to finance working capital. The line. is secured by accounts receivable, inventory, equipment and general intangibles. This credit facility has always been handled as agreed and its j next maturity date will be 11/03/2024. In addition the company and Mr. Lozano have liquid funds comprised of multiple checking accounts, investment accounts and certificates of deposit, which currently total $530,853.65. We consider Mr. Lozano and Rain Seal valued customers of the bank and in our opinion, they are financially sound. Feel free to contact the undersigned if you have a questions. Sincerely, J.R. Amaya Banking Center President 1206 North John Stockbauer Dr Victoria, TX 77901 NMLS #1192879 11 r .m Z W Q W 0 L W •; LO o LO cm cV CDi a 3 n 0 N O N 0 7 042 Q) U N O N J 9 106 L N 0 Ln ® �> bo v ��--DH)aiE >mr, m 0-0 -0 i � Q O N o O N Q O U o B U O u R N C ® .0 � -h � m m m O17, + I E n T � � L u � C O z L L O O ❑ ai d- O U M bjD j D � ( � Q C �qq�� p�4 m �p X OJ N ❑. u �d � L v� u H (U U Q [n mil. � B L m N d R g- m a O rL6 C= I o N E � a)O 61J ;h '- � � � m ro O o`N � u ra 4L O I u§d V1 4- O' .V '� u o C w o p ® qa t;� i O O m v w j O I E u�Vza�CaJ i� gad cu 4[m O [n QJ -0 V) ul a $ m m .0 ® ,� S ..0 O +-+ ram^ I � n ® c� ao �a v R N E :L:LE a��—_ B o ">_ a C Ql I .">_ FO t� ® ra g w .W to tn � C6 .- O k-- U v- _ L ® O L in O �O > v O v w bLo o mT O p � v C I s m .� u .O n A u .L N � U7 M o v w c m '� N L E uuw ® (6 bfl L 0- tD N O p� -Lf) O .Q :3 Q Y ._ N V CU V1 E O n 3 i !f7 ru QJ Ln r Q w E F- O a)D -`- M �� 1 iJ O o 9J O v O m m R -� ^ -0 > R;E CO Q% �O4 V CD I ® C V � m O L V N N u r6 .� - u N Lu 0m V f6 `o o R 2 Lip ape m to L 4� N Q ui E E no Ln bO w V 0M Zaua` B o E v L � +5.+ Vl 19 ilq W G��SPACTpgSe U V � W w � c's Q ��'Oosaa�1p e O O w A♦ (0rA / m 2 14 O N qJp W Z L W 19 i z a�. 11 1, STATE OF TEXAS {} AFFIDAVIT COUINTYOF Victoria {} Juan Ramon Lozano, Sr. being first duly sworn, deposes and says: that he or she is 111 (Type or Print Name) the President of Rain Seal Master Roofing & Sheet Metal, Inc, havingIts (Type or PrintTitle) (Type or Print Name of Company/Firm) principal address at 2306 Port Lavaca Dr, Victoria, Texas 77901 (f (Type or Print Physical and Mailing Address) t who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed ttt to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, orto raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offerto give, nor intendsto 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/proposal; and L e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or I{ proposed fees are awarded and upon the conditions and requir contained in the bid/proposal. L- Signature of Affiant Juan Ramon Lozano, Sr - President Printed Name and Title of Affiant 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 12024 L, Notary Stamp/Seal Signature of Notary Christina M Dale My Commission Expires 6/27/2028 •6 Notary ID134969417 V CONTRACTOR CERTIFICATIONS CERTIFICATION OF BIDDER REGARDING CIVIL RIGHTS LAWS AND REGULATIONS INSTRUCTIONS CERTIFICATION OF BIDDER REGARDING Executive Order 11246 and Federal Laws Requiring Federal Contractor to adopt and abide by equal employment opportunity and affirmative action in their hiring, firing, and promotion practices. This includes practices related to race, color, gender, religion, national origin, disability, and veterans' rights. NAME AND ADDRESS OF BIDDER (include ZIP Code) Rain Seal Master Roofing & Sheet Metal, Inc. 2306 Port Lavaca Drive Victoria, Texas 77901 CERTIFICATION BY BIDDER Bidder has participated in a previous contract or subcontract subject to Civil Rights Laws and Regulations. gr Yes ❑ No The undersigned hereby certifies that: 9 The Non -Segregated Facilities clause (Section 109 provision) is included in the Contract. No segregated facilities will be maintained as required by Title VI of the Civil Rights Act of 1964. Ed The Equal Employment Opportunity clause is included in the Contract (if bid equals or exceeds $10,000). Rr The Affirmative Action for Handicapped Workers clause is included in the contract. 9 The Exhibit B — Assurances for Construction Programs is included in the Contract. Rr The Exhibit D — State of Texas Assurance is included in the Contract. Have you ever been or are you being considered for sanction due to violation of Executive Order 11246- Equal Employment Opportunity, as amended? ❑ Yes 9 No NAME AND TITLE OF SIGNER (Please type) Juan Ramon Lozano, Sr. - President 11/1 /2024 SIGNAT DATE L 22. 8/03/2011 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being fled in accordance with Chapter 176, Local Date Received Government Code by a person who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person meets requirements under Section 176.004(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 person becomes aware of facts that require the statement to be filed. See Section 176.004, Local Government Code. A person commits an offense if the person knowingly violates Section 176.004, Local Government Code. An offense under this section is a Class C misdemeanor. 1. Name of person doing business with local governmental entity. RFB / RFP / Contract Rain Seal Master Roofing &Sheet Metal, 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 7t" business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Name of local government officer with whom filer has employment or business relationship. N/A Name of Officer This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other business relationship as defined by Section 176.001 (1 -a), Local Government Code. Attach additional pages to this Form CIQ as necessary A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the filer of the questionnaire? ❑ Yes ❑ No B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? ❑ Yes ❑ No C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? ❑ Yes ❑ No D. Describe each employment or business relationship with the local government officer named in this section. 4. Signature of person doing business with governmental entity Z Date Signed 11/1/2024 I Z3 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. 7uan Ra+�ori Lo4ano,5r. 7ires�c�en� Name and Title of Authorized Agent SigratLAVMAuthorized Agent I am unable to certify to the above statements. My explanation is attached. 20ZL4 ate 7-4 r, CERTIFICATION REGARDING LOBBYING (To be submitted if the bid or offer exceeds $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 f 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, I "Disclosure Form to Report Lobbying," p y g," in accordance with its instructions. f (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. f 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 (1 imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). i Rain Seal Master Roofing The Contractor, & Sheet Metal, Inc. , certifies or affirms the truthfulness and accuracy of each statement of r , its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of IL 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. LJ Signature of Contractor's Authorized Official i Juan Ramon Lozano, Sr. - President Printed Name and Title of Contractor's Authorized Official 1111 /2024 2.5 I—, f Disclosure of Lobbying Activities 0348-0046 1 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclnsura) 1. Type of Federal Action: 2. Status of Federal 3. Report Type: a. contract Action: a. initial filing N/A b. grant a. N/A b. material change c. cooperative bid/offer/application agreement N/A b. initial award d. loan c. post -award e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Prime Subawardee Enter 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: 7. Federal Action Number, if known: 9. Award Amount, if known: N/A N/A 10. a. Name and Address of Lobbying b. Individuals Performing Services (including Registrant address if different from No. 10a) (if individual, last name, first name, MI): (last name, first name, MI): 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 by the tier above when this transaction Print Name: Juan Ramon Lozano, Sr. was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This Title: President information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the Telephone No.: 361-576-0926 Date: 11/1/2024 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 FORM Certification Required by Texas Government Code Section 2270.001 The 85'h Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Juan Ramon Lozano, Sr. , do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://com ptrol ler.texas.gov/purchasing/publications/divestment. nho Rain Seal Master Roofing & Sheet Metal, Inc L Company Name Signature of Authorized Official L President Title of Authorized Official Juan Ramon Lozano, Sr. Printed Name of Authorized Official 11/1 /2024 Date 2� Pursuant to Texas Government Code §2252.001 etseq., as amended, Calhoun County requests Residence t Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of t 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. D I certify that (Company Name) N/A is a "Nonresident Bidder" of Texas as defined in Government Code §2252.001 and our principal place of business is (City and &m) D I certify that Rain Seal Master Roofing & Sheet Metal, Inc. is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Juan Ramon Lozano, Sr. - President Printed Name and Title of Authorized Agent 11/1/2024 Date k Zg SECTION 504 CERTIFICATION POLICY OF NONDISCRIMINATION ON THE BASIS OF DISABILITY The business - Rain Sea[ &Sh etMetal.ter lnci2oofing does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs or activities. (Name) Rain Seal Master Roofing & Sheet Metal, Inc. (Address) 2306 Port Lavaca Dr Victoria Texas 77901 County State Zip Telephone Number ( 361 ) 576 - 0926 Voice ( ) TDD Juan Ramon Lozano, Sr. has been designated to coordinate compliance all Federal statutes relating to nondiscrimination. a a 11/4/24, 8:38 AM M An official website of the United States government Here's how you know E, SAM*oova rHome Search Data Bank Data Services Help t' l < Responsibility And Qualification 0 , Entity Registration Exclusions Responsibility/ Qualification Exclusions Proceedings Other Responsibility & Integrity l ' Information Corporate Relationships RAIN SEAL MASTER ROOFING AND SHEET METAL, INC Unique Entity ID CAGE/NCAGE VJ5JENFES4D7 (blank) Physical Address 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States Purpose of Registration All Awards SAM.gov c 00 0 Submitted Registration Mailing Address 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States Entity/ Information Expiration Date N/A I' 1114/24,8:38AM SAM.gov I" EXCLUSIONS There may be instances when an individual or firm has the same or similar name as your search criteria, but is actually a different party. 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I,' CORPORATE RELATIONSHIF1 Legal Business Name CAGE Responsibility & Integrity Record Highest Owner (none) Immediate Owner (none) N/A (none) (none) N/A Predecessors 1; (none) (none) N/A 31 € 11/4/24, 8:38 AM IN An officialwebsiteofthe United States government Here'showyouknoSAKow Home Search Data Bank Data Services Help < Core Data i 1. fp f Entity Registration ' Core Data i, Business Information r Entity Types ( Financial Information Taxpayer Information (f(' l ; Points of Contact Assertions Reps and Certs (FAR/DFARS) _ Reps and Certs (Financial Assistance) Exclusions Responsibility / Qualification Entity Reporting L RAIN SEAL MASTER ROOFING [_ AND SHEET METAL, INC Unique Entity ID CAGE/NCAGE VJ5JFNFFS4D7 (blank) L. 32. SAM.gov Submitted Registration n oo Entity Information Expiration Date N/A 0 s 11/4/24, 8:38 AM Physical Address 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States Purpose of Registration All Awards Version Submitted Registration BUS11NESS W®RMATION l , Doing Business As RAIN SEAL MASTER l ROOFING AND SHEET METAL INC Division Name (blank) Congressional District Texas 27 URL (blank) Division Number (blank) State/Country of Incorporation Texas, United States Owner CAGE Legal Business Name Immediate Owner (blank) (blank) Highest Level Owner (blank) (blank) Executive Compensation SAM.gov Mailing Address 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States Registration Dates Activation Date Initial Registration Date (blank) Nov 1, 2024 Submission Date Nov 1, 2024 Entity Dates Entity Start Date Fiscal Year End Close Date Oct 9, 2002 Dec 31 Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). 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In your business or organization's preceding completed fiscal year, did your business or organization (the legal entityto which this specific SAM record, represented by a Unique Entity ID, belongs) receive both of the following: 1.80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements and 2. $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? 33 { 11/4/24, 8:38 AM SAM.gov [ No Does the public have access to information about the compensation of the senior executives in your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Not Selected SAM SEARCH AUTHORIZATION I authorize my entity's non -sensitive information to be displayed in SAM public search results: Yes C NTffy TYPES Business Types Entity Structure Corporate Entity (Not Tax Exempt) Entity Type Business or Organization Profit Structure For Profit Organization Organization (blank) Factors LPayments LAccepts Credit Card Payments L No Sc�cio-Eco �c� is T Minority-Owned Business, Self Certified Small Disadvantaged Business, Hispanic American Owned Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA -certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration. Debt Subject To Offset No L 34 11/4/24, 8:38 AM , ACCOUNT DETAILS 11, EFT Indicator 0000 CAGE Code (blank) �,' Electronic (Funds Transfer Account Type Checking ' Account Number *******56 Routing Number ***""*55 Lockbox Number (blank) E Financial Institution PROSPERITY BANK �ll u �J TAXPAYER INFORMATION SAM.gov Automated Clearing Douse Phone (U.S.) 3615760926 Phone (non-U.S.) (blank) Email (blank) Fax (blank) mitts CCU ATI ca t_ . Juan Ramon Lozano, Sr. 2306 Port Lavaca Drive Victoria, Texas 77901 United States J Taxpayer Name Name/Title of Individual Executing Rain Seal Master Rooting Consent and Sheet Metal Inc President Address Signature 2306 Port Lavaca Drive, Juan Ramon Lozano Sr Victoria, Tx 77901 United States EIN °****5344 L POINTS OF CONTACT L Accounts Receivable ROC l_ Primary Point of contact L Juan R Lozano, Sr,, President L Email Phone Fax 315 Type of Tax Applicable Federal Tax Tax Year (Most Recent Tax Year) 2023 TIN Consent Date Nov 1, 2024 Address 11/4/24, 8:38 AM f ramon@rsmincl.com Eectronic Business fPrimary Point of Contact 361576-0926 Juan R (L®nano, Sr., President Email Phone ramon@rsminci.com 361576-0926 Alternate Point of Contact Christina R Dade, Adman Email Phone cdaie@rsminci.com 361576-0926 Government Business f Primary Point of Contact Juan R Lozano, Sr., President Email Phone ramon@rsmincl.com 361576-0926 L L Alternate Point of Contact Christina P Dade, Admin Finatl Phone SAM.gov 3614859393 (blank) Fax Address 3614859393 2306 Port Lavaca Drive Victoria, Texas 77901 United States Fax Address 3614859393 2306 Port Lavaca Drive Victoria, Texas 77901 United States Fax Address 3614859393 2306 Port Lavaca Drive Victoria, Texas 77901 United States Fax Address 3to 11/4/24, 8:38 AM cdale@rsminci.com f, i Past Performance Primary Point of contact Christina fP Dade, Admin Email cdale@rsmincl.com f' Alternate Point of Contact 361576-0926 Phone 361576-0926 tl i Christina R Dale, Admin (1 l j Email Phone cdale@rsminci.com 361576-0926 l _1 1 -' Our Website About This Site Our Community Release Notes System Alerts Policies Terms of Use L� SAM.gov 3614859393 Fax 3614859393 Fax 3614859393 Feedback Our Partners Acquisition.gov USASpending.gov Grants.gov More Partners Customer Service Help 2306 Port (Lavaca Drive Victoria, Texas 77901 United States Ad d ress 2306 Port Lavaca Drive Victoria, Texas 77901 United States Ad d ress 2306 Port Lavaca Drive Victoria, Texas 77901 United States 31 1114/24, 8:43 AM SAM.gov I Entity 0 An official website of the United States government Here's how you know SPAN*oov,, i Home Search Data Bank Data Services Help _ Entity Registration Responsibility/ Qua Iificatia 1 Entity Reporting ( Service Contract Reports BioPreferred Reports < Back to Workspace 1v:1211011K]W_[>wU% 71a:4':4.91U,7JP[47L1lIkPCI•:1aa0177 Unique Entity ID VJ5JENFES4D7 CAGE/NCAGE (blank) Registration Status Expiration Date Submitted Registration N/A Purpose of Registration All Awards Physical Address . 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States Mailing Address 2306 Port Lavaca DR Victoria, Texas 77901-8609, United States R00 z 10 oo Download 148 11/4/24, 8:43 AM SAM.gov I Entity l Version Submitted Registration No Reports Required. 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All individuals viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part2002 and GSA Order CIO 2103.2 CUI Policy. -69 #14 NOTICE OF MEETING — 11/13/2024 14. Consider and take necessary action to award the Request for Qualifications for Engineering, Architectural and Surveying Services for the CMP Cycle 29 Grant, GLO Contract No. 25-003- 009-E702 — New Amenities at Bill Sanders County Park, RFQ 2024.11. (RHM) Page 11 of 16 Calhoun County, Texas RATING SHEET SCORES RFQ 2024.11 Engineering, Architectural and Surveying Services for CMP Cycle 29 Grant, GLO Contract NO. 25-003-009-E702 - New Amenities at Bill Sanders County Park RFQs were opened at 2:00:00 PM, Monday, November 4, 2024 in the County Judge's Office. 4 RFQs were received G & W Engineers, Inc. (Port Lavaca) Civil Corp Engineers (Victoria) Urban Engineering (Victoria) moffatt & nichol (Corpus Christi) The 3 RFQs were rated by a committee consisting of: Gary Reese, Commissioner Precinct 4 Richard H. Meyer, County Judge Candice Villarreal, County Auditor Vendor Rating Score Average of Total Points Urban Engineering 97.67 G&W Engineering, Inc. 94.67 Civil Corp Engineers 90.00 moffatt & nichol 83.67 CALHOUN COUNTY, TEXAS RATING TOTALS FOR EACH COMMITTEE MEMBER RFQ 2024.11 Engineering, Architectural and Surveying Services for CMP Cycle 29 Grant, GLO Contract NO. 25-003-009-E702 - New Amenities at Bill Sanders County Park URBAN ENGINEERING Experience Work Performance Capacity to Perform Total Points GARY REESE 59 24 15 98 RICHARD H. MEYER 59 24 15 98 CANDICE VILLARREAL 59 23 15 97 TOTAL AVERAGE 293 M G & W ENGINEERS, INC. Experience Work Performance Capacity to Perform Total Points GARY REESE 58 24 15 97 RICHARD H. MEYER 56 23 15 94 CANDICE VILLARREAL 55 23 15 93 TOTAL AVERAGE 284 =3 94.67 CIVIL CORP ENGINEERS Experience Work Capacity to Perform TotalPerformance Points GARY REESE 49 24 15 88 RICHARD H. MEYER 54 23 15 92 CANDICE VILLARREAL 54 21 15 90 TOTAL AVERAGE 270 =3 90.00 MOFFATT & NICHOL Experience Work Performance Capacity to Perform Total Points GARY REESE 40 23 15 78 RICHARD H. MEYER 53 21 15 89 CANDICE VILLARREAL 48 21 15 84 TOTAL AVERAGE 251 =3 83.67 r r 0 L' Request for Qualifications: Calhoun County Prepared by: r14 Ci A C o r ENGINEERS • SURVEYORS 4611 E. Airline Rd. Ste: 300 Victoria, TX 77904 Randy Janak, PE, CFM rjanak@civilcorp.us (361)570-7500 Texas PE Firm Cert # 10283 L rio'CivilCorp an ESP COMPANY November 4, 2024 Honorable Richard H. Meyer — Calhoun County Judge Calhoun County Courthouse 211 South Ann Street 3ro Floor Ste: 301 Port Lavaca, TX 77979 Re: Calhoun County: RFQ for Engineering, Architectural, & Surveying Services For CMP Cycle 29 Grant, GLO Contract No. 25-003-009-E702 - New Amenities at Bill Sanders County Park Judge Meyer: CivilCorp, LLC, has been successful in providing civil engineering, land surveying, and construction management services throughout the State of Texas for over 15 years. By staying committed to providing practical and economical design services, we assist growing communities with maintaining and improving infrastructure systems. We offer high quality, efficient, and aesthetically pleasing designs that provide for future growth and expansion. We consistently review local regulations, applicable codes, and various geometric design criteria and standard methods for designing and developing plans and specifications. We also participate in regional mobility committees and professional organizations to stay abreast of current planning goals. CivilCorp is pleased to submit our Statement of Qualifications for the new amenities at Bill Sanders County Park By utilizing the latest technology, and blending it with experienced and skilled professionals, we are able to provide the level of commitment necessary to realize regional developmental goals. CivilCorp performs in-depth research to assess the project requirements and devise a plan and design that is structured to incorporate issues relating to public access, (j environmental concerns, drainage issues and utility requirements. CivilCorp has a solid history of working with L municipalities on these types of projects and the issues typically associated with project development. CivilCorp's professional talents are combined to present a depth of experience and local knowledge to realize the goals set forth by Calhoun County. CivilCorp's clients include city, county and state governments. We have worked with Calhoun County, Victoria County, Jackson County, City of Edna, City of Bay City, City of Port Lavaca, City of Victoria, City of Wharton, City of Ganado, City of El Campo, City of Seadrift, City of East Bernard, Dewitt County Drainage District, and have been awarded TxDOT contracts in all regions of the state of Texas. CivilCorp is also the engineer for the Port of Victoria. Our comprehensive experience includes field surveying, utility engineering, drainage analysis and design, roadway and parking lot design, specifications, and cost estimates. We recently added unmanned aerial vehicle (drone) and GIS capabilities. In addition, through ourwork for the Port of Victoria, we have experience coordinating with and obtaining permits with the U.S. Army Corps of Engineers — Galveston District. If selected, we have the resources, experience, commitment, and available personnel to complete the tasks needed to satisfy this contract. CivilCorp has the resources and manpower available on all levels to complete this project on time and within budget. CivilCorp has worked on similar projects and can begin work immediately upon notice to proceed. 4611 E. Airline Rd. Ste: 300 •Victoria, Texas 77904 • Tel: (361) 3715380 Victoria a Houston • Austin • Corpus Christi I CivilCorp brings every aspect of the design requirements for this project with similar design experience. Our team has the following unique characteristics: • Experience working with several cities and counties on municipal construction including multiple grant projects • 20 Professional Engineers with overlapping capabilities Experienced Project Manager with a proven track record for on -time and within budget project delivery. • Staff with pertinent project experience in all aspects of project design from analyzing alternative options, ADA compliance, drainage, surveying, utilities, SW3P, and traffic control to construction phase services • Written QAIQC Program — Applied on past projects • Located 30 minutes from the County's office. CivilCorp confirms the following: • Our firm meets the appropriate state licensing requirements to practice as an Engineer in the state of Texas • Our firm has not engaged in any unethical practices within the 15 years we have been in business ' CivilCorp would like to be considered for the Texas Community Development Block Grant project as described in this RFQ. We appreciate this opportunity to submit our Letter of Interest and look forward to continuing a working relationship with Calhoun County. Sincerely, Randy P. Janak, PE, CFM Vice President —Victoria 1, ril Q A I C o r p ` ENGINEERS • SURVEYORS Request for Qualifications: Engineering/Architecture/Surveying Services: Calhoun County for New. Amenities at Bill Sanders County Park CivflCorn, LLC 4611 E. Airline Rd., Suite 300 Victoria, Texas 77904 Voice: (361) 570-7500 Fax: (361) 570-7501 Houston Office: P.O. Box 1029 Fulshear, TX 77441 Voice: (832) 252-8100 Fax: (832) 252-8103 Round Rock Office: 2300 Greenhifl Dr. Suite 400 Round Rock, TX 78664 Voice: (512)-828-0406 Corpus Christi Office: 801 Lipan St. Corpus Christi TX 78401 Voice: (361)-371-5380 Ben Galvan, PE, RPLS President Services: Civil Engineering Land Surveying Construction Inspection Founded: 2008 (CivilCorp, LLC) CivilCorp, LLC is registered with the Texas Board of Professional Engineers to provide engineering services in the State of Texas. Registration #10283 L COMPANY NARRATIVE: CivilCorp has successfully completed many engineering and surveying projects in and around Calhoun County and various state, local, and private establishments throughout the state. Our resume includes drainage studies, public works, utility projects, city residential streets, hydrology and hydraulics, stormwater management, rural farm -to -market roadways, highways, and industrial paving projects each with varying terrain conditions, environmental issues, agency coordination and public involvement. We have worked on numerous roadway design projects in the South Texas region. Our comprehensive experience includes drainage analysis and design, field surveying, utility engineering, roadway design, specifications, and cost estimates. We have completed numerous CDBG, CDBG DISASTER RECOVERY, AND FEMA projects throughout our region. We have also completed numerous designs for roadway, drainage, water and sewer facilities for south Texas and surrounding communities. CivilCorp, LLC, has been successful in providing civil engineering, land surveying, and construction management services with our key staff throughout the State of Texas for over 15 years. CivilCorp merged with ESP Associates, Inc. in August 2023. ESP is a multi- disciplinary engineering design and consulting firm serving all phases of project development with civil engineering, surveying, planning, landscape architecture and construction -phase services, with corporate headquarters in Fort Mill, South Carolina. ESP is ranked #194 on ENR's Top 500 Design Firms for 2024. Our combined resources exceed 750 full time employees in 35 offices across the United States in the ESP family. We offer high quality, efficient, and aesthetically pleasing designs that provide for future growth and expansion. We consistently review local regulations, applicable codes, and various geometric design criteria and standard methods for designing and developing plans and specifications. We also participate in regional mobility committees and professional organizations to stay up to date on current planning goals. Together with our teaming partners, we have the resources, experience, commitment, and available personnel to complete the tasks needed to satisfy this contract. LCalhoun County: New Amenities at Bill Sanders County Park Page 1 r Entity Justification Civil Engineering CivilCorp's Civil Engineering expertise include: • Roadway and Transportation Planning and Design • Bridges and Roadway Support Structures • Water Distribution Systems • Wastewater Collection Systems • CDBG and FEMA Projects • Drainage design and analysis • Transportation Signals and Illumination • Project Management and Coordination • Construction Inspection Services • Construction Administration • Storm Water Conveyance and Detention Systems • Watershed and Hydraulic Analysis • Land Development Planning and Feasibility Studies • Commercial and Residential Subdivision Design • Commercial and Industrial Developments • Research and Development • Apartment and Condominium Projects Surveying CivilCorp's Surveying expertise includes: • GPS Surveys, • UAV and Terrestrial LiDAR Surveys, • Right -of -Way and Route Surveys, • Topographic and Design Surveys, • Horizontal and Vertical Control Networks, • Boundary Surveys, • Channel Cross Sections and Profiles, • Hydrographic Surveys, • Record Abstracting, • Construction Staking and Progress Reports, • As -Built Surveys Drone Surveying: CivilCorp's two Unmanned Aerial Vehicles (UAV), perform surveys efficiently, safely and at a fraction of the cost of traditional surveys. UAV applications include: topographic surveys, collection of up- to -date LiDAR and aerial imagery, 3D modeling, volumetric surveys for stock piles and cut/fill calculations, and monitoring and infrastructure inspections. Our FAA certified pilot works closely with our GIS and engineering teams to maximize data viability and use. L Bathymetric Surveys: CivilCorp's surveying technology includes the portable echo sounder, which gathers positional data of the bottom of [ waterbodies where it is impossible or unsafe to gather data using ICalhoun County: New Amenities at Bill Sanders County Park Page 2 conventional methods. The echo sounder connects to a GNSS RTK rover and can be mounted: on a manned boat; or on a remote -control platform to fit a variety of applications. Below surface survey grade data can be collected in saltwater, freshwater, still or swift moving water. The portable nature of the remote -control setup gives us the ability to conduct operations where access is limited and prevents the use of a full-sized motor operated boat. Construction Engineering Inspection CivilCorp provides construction management services with the focus of meeting every client's needs. We develop a plan that incorporates budgetary constraints and funding issues as well as community and environmental needs. A continuous flow of communication is maintained throughout the construction process between the owners, designers, consultants, and agencies through regularly scheduled progress meetings and site visits. We complete projects involving analysis of plans and specifications in both urban and rural areas. Successful (' assignments have required wide-ranging (, knowledge of construction & maintenance procedures, traffic control, disputes, and shop drawings. We assisted in the oversight of contracts, issued work orders, construction schedules and job progress on various construction projects. I i By outlining, organizing, and developing practical and economical solutions to ( detailed design and construction issues, we ( deliver the level of commitment essential to construction management. Utility Engineering CivilCorp provides timelv and efficient ui 1, ng, design, and management. We are adept at utility coordination (UC) and utility conflict management (UCM). We coordinate with design engineers, surveyors, and utility companies to determine critical areas or conflicts requiring utility investigation, mitigation, relocation, depth of lines and collecting data in the field. CivilCorp provides SUE quality Level A, B, C, and D investigations. Field data is transmitted in real-time to our GIS team for assessment and QAIQC to maximize accurate data acquisition, minimize field trips, and mitigate errors and time. Our team provides UC and develops/updates UCM databases to document utility information including utility owner, contact information, facilities, potential conflicts, and resolutions. We successfully led UC and UCM on major complex transportation projects. We understand the critical and time -sensitive nature of utility management and work to mitigate negative impacts to projects. Its never too early to start utilities work in any project. Calhoun County: New Amenities at Bill Sanders County Park Page 3 GIS Our robust geographic information system team helps organize, visualize and analyze spatial information. Whether ( a local school district or a large oil company, GIS applications are a powerful tool to help track and manage critical ! infrastructure and facilities for any organization. Utilization of GIS helps project managers analyze information for better decision making, and improves communication & coordination by providing a strategic means of sharing information with decision - makers, clients and staff. GIS technology and principles are applied to virtually any field but are particularly valuable for surveying and engineering projects. The CivilCorp GIS staff is adept with GIS tools such as ESRI ArcMap and is forging into new geospatial territory with f, leading- edge technology such as E unmanned aerial vehicles, LiDAR, and photogrammetry. Our wealth of experience and dedication to innovation with advancing technologies ensures CivilCorp has the ability to complete superior projects in a more effective and cost-efficient manner. Materials Testing CivilCorp provides code- or specification -mandated review and testing of materials for projects including soil, aggregate and concrete to meet ASTM, ACI, AASHTO and TxDOT specifications. Our material testing laboratory is located in Victoria, Texas. CivilCorp is committed to being an integral part of the project team that works to move the project from the conceptual plan to the finished product. Calhoun County: New Amenities at Bill Sanders County Park Page 4 I 1 MAJOR SUBCONSULTANT INFORMATION TERRACON CONSULTANTS, INC. r Terracon is a 100 percent employee -owned consulting engineering firm providing quality services to clients. Since t 1965, Terracon has evolved into a successful multidiscipline firm specializing in: • Environmental • Facilities • Geotechnical • Materials Over its history, Terracon has achieved significant expansion through both internal growth and acquisitions. Terracon currently has more than 7,000 employees in more than 180 locations and 42 states nationwide. Terracon has 26 Texas offices, including locations in Freeport, Victoria, and Corpus Christi. With more than 40 projects performed in Calhoun County alone, our engineers have extensive experience in the South Texas region. Terracon provides services on thousands of projects across Texas each year. Our culture, systems, and structure enable us to excel at both small and large projects. By combining our national resources with specific local area expertise, we consistently overcome obstacles and deliver the results our clients expect. Terracon serves a diverse portfolio of private and public clients. By being responsive, resourceful, and reliable, we strive to exceed our clients' expectations for service, solutions, quality, and speed of delivery. Based on a deep understanding of our clients' needs, Terracon's commitment is centered around these key objectives. Calhoun County ISO Pavement Project; Port Lavaca, Texas Terracon performed geotechnical engineering services for proposed developments at existing Calhoun County ISD buildings in Port Lavaca. Terracon's scope of services for the project included the advancement of 27 test borings across 9 locations to a depth of 6 feet below existing grade, coring at 13 boring locations with Dynamic Cone Penetrometer (DCP) tests, laboratory testing, engineering analysis, and preparation of a geotechnical report. Terracon's work served to identify necessary pavement improvements and provide recommendations for improvement techniques. Laboratory testing included tests for moisture content, dry unit weight, unconfined compression, Atterberg limits, and percent finer than No. 200 Sieve. Based on findings, Terracon delivered a geotechnical report that included site condition descriptions, a geotechnical characterization, a geotechnical overview, earthwork recommendations, and pavement recommendations. Compass Environmental Solutions, LLC Compass Environmental Solutions, LLC (COMPASS) is a multi -discipline environmental consulting firm with a permanent core staff of senior level scientists and an experienced support staff, allowing us to work all across the state of Texas. COMPASS's office is located in Rosenberg, Texas and supports an environmental focus on the Texas Gulf Coast Region. This office provides services in ecology, Waters of the U.S./wetlands, vegetation, Clean Water Act permitting, and aquatic/marine biology as they often relate to coastal environmental permitting. COMPASS is led by Mr. Andrew Boswell and Mr. Matthew Chastain, PWS as Principals, Owners, and Senior Scientists. COMPASS is focused on providing environmental support on projects for large and small local governmental bodies, such as Municipal Utility Districts (MUDS), villages, cities, and counties; private entities and developers; engineering firms; oil and gas clients; as well as state and federal agencies. <<; Calhoun County Precinct 4 Green Lake Improvement Project Calhoun County, Texas Calhoun County Precinct 4 received multiple grant awards to assist with public access improvements and restoration activities within County -owned parcels adjacent to Green Lake, near Tivoli, Texas. These improvements included a new boat ramp, park, facilities, trails, parking and roads, entry gate, and associated infrastructure. To support this effort, COMPASS ecologists and project managers were responsible for all environmental fieldwork, reporting, and permitting, including: Calhoun County: New Amenities at Bill Sanders County Park Page 5 I' • Waters of the U.S. delineation • Threatened and endangered species assessments and reporting • Cultural resource desktop and Phase II pedestrian surveys • Texas Historical Commission (THC) concurrence and coordination • USACE Nationwide and/or Individual Permitting packages, including coordination, and approval Compass staff oversaw the permitting process through the USACE, worked with the project team on an avoiding and minimization impacts, and coordinated with the County and project engineer on project design. Due to Compass's and project engineer's teamwork and engagement, we are finding ways to avoid and minimize impacts to wetlands and waters to the greatest extent practicable, reducing and/or eliminating the need to obtain approvals from various agencies and expediting project schedules. RELATED CIVILCORP Brighten Road Bridge Replacement- Calhoun County CivilCorp provided professional services to assist Calhoun County with project development to replace 2 timber bridges on Brighten Road. The work will consist of providing engineering, surveying, environmental coordination, geotech, bidding, and construction management. The proposed bridge replacements consisted of two-26 ft wide x 25 ft long slab span bridges. The low bid was $926,399, but CivilCorp was able value engineer the project with i the contractor to lower the bid to $843,150. The project is 99% complete. Public Safety Headquarters, Victoria, TX CivilCorp prepared the Civil site design for new public safety headquarters to house full police department, municipal court, and fire administration. Project scope consisted of new two-story 70K square foot building, 89- space public parking lot, 236-space secured parking lot, on nine -acre site with significant elevation change. Coordinated extensively with Owner, project Architects (FGMA and RMA Architects), and design team. Managed design and preparation of construction drawings for drainage, utility, paving and grading improvements associated with project. Corpus Christi Liquefaction Administration Building, San Patricio County, TX CivilCorp prepared the Civil site design for new two-story office/admin/training building, 80-space parking lot, and heavy haul access road. Coordinated extensively with Owner, project Architects (PDR+ and Energy Architecture), and design team. Designed and prepared construction drawings for drainage, utility, paving and grading improvements associated with project. Victoria County Downtown Parking Lots Reference: John Johnston, PE, County Engineer CivilCorp prepared topographic surveys of three existing parking lots in downtown Victoria that were in need of rehabilitation/reconstruction. CivilCorp prepared the layouts and design plans for reconstructing two parking lots with concrete pavement and resurfacing/restriping the third parking lot and adding ADA sidewalk improvements. CivilCorp also submitted the projects for TAS accessibility review and assisted during bidding with preparation of bid documents, bidding, and awarding of contract. l Calhoun County: New Amenities at Bill Sanders County Park Page 6 (1 Bonaire and Morningside Additions Water and Sanitary Sewer Improvements, City of Victoria Reference: Ken Gill, PE, Public Works Director, City of Victoria CivilCorp prepared the plans and estimate for water and sanitary sewer improvements for the streets in l Bonaire and Morningside Additions. Water main replacement totaled 16,700 feet and sanitary sewer line replacement by traditional open cut, pipe -bursting, and CIPP lining methods totaled 5,700 feet. The plans also included the replacement of all services, fire hydrants, valves, and manholes. 2021 Bond Project, City of Edna Reference: Gary Broz, City Manager, City of Edna CivilCorp prepared the plans and bid documents for roadway, water, and sanitary sewer improvements for various streets in Edna. Road improvements were based on existing street conditions and included varying combinations of subgrade rehab, base rehab, prime, seal coat, and onyx surface treatments. Streets to be rehabbed also included replacing aging water and sewer lines. Water main replacement totaled over 14,500 feet and sanitary sewer line replacement by both traditional open cut and pipe bursting methods totaled over 10,000 feet. Replacement of all services, fire hydrants, valves, and manholes were also included in the plans. Gilbert Road Drainage Improvement Project, City of Edna Reference: Gary Broz, City Manager, City of Edna CivilCorp prepared the plans and bid documents for drainage improvements for along Gilbert Rd, Dewberry Ln, Alba St, Sunny Ln, and Asbeck Ln. in Edna. Drainage improvements along Gilbert Rd included designing an underground storm sewer pipe system with surface inlets to help alleviate flooding issues along Gilbert Rd. Storm sewer pipe outfalled at Dry Creek. Additional improvements to surrounding roads included ditch excavation and driveway pipe cleaning and replacement when necessary. Independence Drive Street and Drainage Improvements, City of Port Lavaca L Reference: Jody Weaver, PE, City Manager, City of Port Lavaca CivilCorp performed Survey, Design, Bid and Construction Phase Services for the Independence Drive Street and Drainage Improvements. Work included reconstructing and widening from two lane open ditch street to two lanes with continuous left turn lane with curb & gutter, adding new 10' shared use path and new underground storm drainage system. Sam Houston Drive Reconstruction, Victoria, Texas Reference: Ken Gill, PE, Public Works Director, City of Victoria CivilCorp prepared the plans, specifications and bid documents for the reconstruction of Sam Houston Drive in the City of Victoria. This street section is 2 miles in length and consists of 4 lanes of traffic with a continuous left turn lane. The proposed street section will include raised medians and will be reconstructed as a concrete street. The overall project includes street paving, drainage improvements and utility improvements from Laurent Street to U.S. 59 Business. The project was phased into five separate sections to minimize inconvenience to the businesses along the route. The phases included several steps to provide improvements to the intersection traffic flow early in the project along with facilitating the construction of the additional storm sewer trunklines. In addition, the existing storm sewer system was analyzed and redesigned in sections to improve drainage. Geometry improvements were made to all intersecting streets and right-of-way mapping was required for property acquisition of 51 parcels of right of way. Calhoun County: New Amenities at Bill Sanders County Park Page 7 Placido Benavides — Whispering Creek Floodplain Modelling Reference: Ken Gill, PE, Public Works Director, City of Victoria CivilCorp prepared plans and bid documents for the construction of two miles of new two-lane roadway with left turn lanes at the intersections. Overall project design included paving, drainage and utility improvements. A E new 12" water line was designed along the new roadway r, and a new 16" water line was designed along Salem !I Road to connect to an existing water line at Loop 463. New fire hydrants gate valves were spaced in accordance with City requirements. Water main and service stubouts were installed to facilitate serving future developments and to minimize future road crossing bores. The new street was classified as an arterial street and ultimately will include two lanes in each direction separated by a grass median. This first phase was " designed with the two lanes to be constructed with concrete pavement on the west side of the median. The street drainage system was designed for the 25-year storm and consisted of new curb inlets, storm sewer pipe, box culverts, and pipe extensions for the future lanes. A new major culvert crossing of Whispering Creek was designed and modelled through HEC-RAS and a Conditional Letter of Map Revision was submitted and t approved by FEMA. A new 18" sanitary sewer line ranging in depth from 10-20' was designed along the new roadway to serve the adjoining undeveloped tracts. The new 18" line connected to an existing 18" line that L J ended at Phase 1 of the Salem Crossing Subdivision. The new 18" was also designed through a utility easement L along future ROW through Salem Crossing that connects to Placido Benavides. Stubouts were placed along the road to serve future development. Other utility coordination included a major pipeline crossing in which we coordinated with the pipeline company to determine the location and depth of the pipeline as it crossed the new street ROW. We also included in the plans an air bridge over the pipeline to be used during construction and permanent concrete slope paving over the pipeline in the ROW. We also coordinated with the gas distribution company to have an 8" gas main lowered as it crossed the new street ROW to avoid a conflict with the proposed storm sewer. Additional coordination and utility meetings were held with gas, phone, cable, and electric companies during the design stage. In addition, coordination was done with two separate electric providers for the design and installation of street lights due to the project crossing service boundaries for the two providers. Calhoun County: New Amenities at Bill Sanders County Park Page 8 LJ ' PAST CDBG, CDBG DISASTER RECOVERY, AND FEMA EXPERIENCE Victoria County — Street and Drainage • Jackson County — Street and Drainage Port Lavaca — Water, Sanitary Sewer, Street and Drainage • Ganado — Sanitary Sewer, Emergency Generators/ Lift Station Rehab . East Bernard — Street and Drainage City of Bay City — Sanitary Sewer and Sidewalk Texas CDBG No. 7215031 Sewer Improvements, City of Bay City Reference: Herb Blomquist, Public Works Director, City of Bay City CivilCorp coordinated the preparation of the plans, specifications, and estimate for a sanitary sewer improvement project replacing over 8,800 feet of 6"-8" sanitary sewer line by pipe bursting, boring, and open cut construction methods. Texas CDBG No. 7215390 Bonorden System Improvements, City of Port Lavaca Reference: Jody Weaver, PE, City Manager, City of Port Lavaca CivilCorp served as the Project Engineer for preparation of the plans, specifications, and estimate for a sanitary sewer improvement project replacing over 2,500 feet of 6" sanitary sewer line. Road Rehabilitation and Drainage Improvement Projects, Victoria County Reference: Ben Zeller, County Judge, Victoria County, 115 N. Bridge St, Victoria, TX 77901; (361) 575- 4558 CivilCorp has been assisting Victoria County with various surveying, road, parking lot, and drainage improvement projects since 2008. Projects included rehabilitation of County roads with cement treatment and new surface treatments, reconstruction of County roads and parking lots with stabilized subgrade, new base and surface treatments/hot mix, and drainage improvements with culvert replacements and ditch improvements. CivilCorp coordinated preparation of the plans, specifications, and estimates and assisted with the bidding and construction phase services. CivilCorp also completed the materials testing during construction for the projects completed in the last few years. The following is a list of some of the projects completed for Victoria County: • CDBG-DR GLO Contract No. 20.065.094-C262 Various Road and Drainage Improvements in Precincts 1, 2, 3, and 4 (construction estimate $2.9 million) (wrapping up design and starting bidding process) • Rehabilitation of River Rd, Mexico Rd, Tibiletti Rd, and Poui Rd in Precinct 2 (project length 14,700') • Reconstruction of Nursery Rd in Precinct 2 (project length 15800' , I • Reconstruction of Raab Rd in Precinct 2 (project length 5,500') • Reconstruction of Patty Dodson Center and JP3 Building Parking Lots • Adcock Dairy Rd Rehabilitation in Precinct 2 (project length 2,000') • Brentwood Subdivision Street Rehab • Bischoff Rd Drainage Study • Acorn Loop Drainage Study and Improvements Calhoun County: New Amenities at Bill Sanders County Park Page 9 I Road Rehabilitation and Drainage Improvement Projects CDBG-DR GLO Contract No. 20.065.096-C267, Jackson County Reference: Jill Sklar, County Judge, Jackson County,115 W. Main, Edna, TX 77957; (361) 782.2352 CivilCorp performed the topographic survey and prepared the plans, specifications, and estimates for various road rehab and drainage improvement locations in Jackson County. Road rehabilitation included cement treatment of existing pavement, flexbase, and new surface treatments. Drainage improvements included 60" culvert replacement, driveway culvert replacements, and ditch regrading. Plans have been completed and construction is underway. Texas CDBG No. 729621 Water Distribution System Improvements, City of Port Lavaca Reference: Jody Weaver, PE, City Manager, City of Port Lavaca Mr. Janak served as the Project Engineer for preparation of the plans, specifications, and estimate for a water line improvement project replacing over 4,000 feet of water line located in various City streets. Texas CDBG No. 712290 Sewer Collection System Improvements, City of Port Lavaca Reference: Jody Weaver, PE, City Manager, City of Port Lavaca As Project Engineer Mr. Janak coordinated the preparation of the plans, specifications, and estimate for a sanitary sewer improvement project replacing over 2,000 feet of 8" sanitary sewer line. Texas CDBG No. 7220429 Water Improvements (TDA), City of Seadrift Reference: Mayor Elmer DeForest, City of Seadrift, 501 Main St, Seadrift, TX 77983, 361.785-2251. CiviCorp prepared the plans, specifications, and estimate for a water improvement project consisting of 2,600 feet of 6" water main and appurtenances. Calhoun County: New Amenities at Bill Sanders County Park Page 10 SCOPE OF WORK Preliminary and Final Design Plans and Specifications CivilCorp will prepare all preliminary and final design plans and specifications, including all work required with bidding and interim and final inspections of the construction project. This work will include incorporating the work identified and developing plans and specifications for letting. We know the value of quality work and the importance of identifying and field verifying the condition of all existing facilities. The project area will be surveyed and field inspected to ensure an accurate base map. A complete inventory of ( valves, service connections and existing fire hydrants along the proposed project limits will be performed. Survey ` work will also include topography of existing driveway locations and other existing improvements that could impact the project design. Design work will begin once the base map is complete. All work during this phase will be closely coordinated with the County to ensure compliance with the project budget. The estimates will support the plan sheets and include detailed materials and accurate unit prices. CivilCorp has provided detailed accurate estimates for Victoria and in surrounding counties on similar projects. Preparation of Table 2 Budget Justification CivilCorp will coordinate and consult with the County to determine the detailed scope of work for the project. CivilCorp will prepare the Table 2 Budget Justification and required exhibits for the District's grant application. CivilCorp has been successful in TABLE 2 -BUDGET JUSTIFICATION OF RETAIL COSTS Fro)cdTNofargdkea. vswn•<w.nn.bntn.Mn•ueronu anewera ._..-.-"Matedal0adl0aef9ervi[u' W- UM QwINe7 OaubWlon /Wu&km idol jwgaro 0ra4�e$e Fai4mn 5 Fx®rate Dltehn rar PddMoW WFadry S6A0� 11,300 W],&00 y0 $67,800 �flmd and OminaOe FndMes S Emsbn&9adimd4atbnfdntrek 1$2,0w.wjI .. 1 ... $2.000 f0 41,000 faz9 and gaMaga Fa[AMc 5 Tmfflc Cgntrd &Sgrta9e 43,000.001s 1 $3,000 $0 $3,000 Rand and Otabiege FaWNez s CdnaM BOX MUM(Tx try I ;600.O IV 35 $2F,0M $D S23.000 fiootl and palmde PotlMFn 5 Convem (8) $15,000.00 o 2 $301M $0 —$OF no,=fkadwall Mad xd Oraliupe A4[aal. _ s CmMeEma(5x27 UQ.WIV 30 S7,200 $7,200 Mood and DroMnge$aKtYs $ CnndehlWadwali ($') $5,500MIM I, 2 $17p00 $0 $17,000 ftamam Dmr¢9e Ta[irftl S Mg41iud0m -__ ;I,900.W [s 1 3].i00 4].a00 1. [denEfy and esplaln Na annwl,paJe.Ced gperatlgn end mamtere�mstsaaodakd aNN Ne propdsM seNaUeF. eMual malnttMnce gfditchnand MvdtAamow4x3andckadng t nWatAxedinun[MnualcoabartafOnatetlat fi00g 2�Identi(y and expbin airy spa4il eighMabp aclMll¢._. .... --.—. ______— — l$urveVn'g M�lningaNenaM dttd+ibwllnes ..__ i _ assisting the City of Port Lavaca, Bay City, Ganado and Seadrift with the preparation of Table 2 Exhibits on past grant applications. Preparation of Bid Package and Advertising for Bids CivilCorp will assist in obtaining bids for the construction project. We will ensure that all applicable bidding information is required by the grant and is included in the bid documents. We will consult with Calhoun County as to the acceptability of the contractor and will evaluate the bids, as well as assemble and award the project. We are familiar with the local contractors and have a solid history of working with most of them on City of Bay City, City of Port Lavaca, and City of Victoria projects. Administer Construction Oversight L Construction administration and oversight begins with having a good set of construction plans and specifications that everyone understands. Our staff includes former TxDOT employees who are very familiar with construction operations and have been trained to inspect and correct on -going construction problems that may be encountered. We will review the contractor's monthly pay request and submit the approved request for payment. We will ensure that all pay requests have the required retainage withheld and coordinate all payments with the grant administrator. Calhoun County: New Amenities at Bill Sanders County Park Page 11 f } Conducting All Field Testing and Inspections (Interim and Final) CivilCorp will provide the initial staking as required to allow the contractor to construct the project. We will establish horizontal control and will make visits to the site at intervals appropriate to the various stages of the construction. We l will determine if the work is proceeding in accordance with the plans and specifications. Such visits shall be followed by written reports describing the observed progress, and endeavor to protect the County against defects and deficiencies in the work. We will also issue all necessary interpretations and clarifications of the plans and specifications and act as judge of the acceptability of the contractor's work. (' Preparation of Record Drawings After project completion, CivilCorp will provide a final plan set with all field changes marked on the drawing. The record drawing is a valuable resource that will be provided in both a hard copy and digital format. All Other Engineering Services CivilCorp will work with Calhoun County as required to ensure a smooth project schedule. We will assist in obtaining approvals of authorities having jurisdiction over potential environmentally sensitive areas, provide surveying services as required and assist the County as needed for project development. Easement or Other Real Property Survey if Acquisition is Required Right-of-way acquisition is a key element of project development. If a required parcel can only be acquired through eminent domain, then the project schedule may be jeopardized. Therefore, public involvement is essential and will help create community support for this project. The horizontal alignment will be modified during the preliminary schematic design with the intent of minimizing the number of parcels needed and also not creating uneconomic remainders of property. This means that if a property will be severed leaving an extremely small undeveloped remainder on one side, then we would consider either shifting the alignment to create the remainder to only one side or to purchase the uneconomic remainder. Existing property boundary lines will be established and overlaid on our base map to help us determine the most economic alignment that will minimize impacts to both existing structures and the natural environment. Right-of-way determination begin with property research performed by our in-house staff for obtaining right of entry and ownership information. STAFFING PROFILE CivilCorp has a staff that is made up of over 100 full-time employees, including 20 Licensed Professional Engineers and 4 Registered Professional Land Surveyors. We also have 10 full-time survey field crews and 23 CADDISurvey Technicians. Our professional and technical staff has broad and varied cumulative experience in civil engineering, ADA compliance, drainage design, surveying, and construction administration. CivilCorp's proposed project staff will contribute technical expertise to every aspect of project development from meeting with the County to determine project needs to planning, design, and construction management. Our education, registration, and experience combine to present the best possible design services for the County. CivilCorp will ensure that materials meet specifications and that the work is being completed within budget and as designed. We are ready to begin work on this project as soon as we are notified. CivilCorp works on projects all over the state simultaneously, many of which are not in close proximity to where our offices are based. Because of this our company standard practices and procedures are designed to enable us to stay on track with varying schedules, completing work efficiently no matter where the project is located. Each of our office locations have multiple engineers and engineer technicians willing to do what is necessary to meet project deadlines. Office technicians and Field crews alike work extended hours, including nights and weekends, as project deliverable schedules dictate. Furthermore, because all employees are accustomed to working with team f members from other offices, communication is smooth and does not hinder the workflow. Calhoun County; New Amenities at Bill Sanders County Park Page 12 1J I I All office servers are accessible to key personnel to ensure seamless access to all electronic files and data company wide. CivilCorp's standardized project file structure, naming and data collection practices enable staff to easily jump into work on a project with little downtime as there is no guesswork on where to find specific data or project files. In addition, CivilCorp maintains standard work logs and project reports for every project. At any time, personnel can reference these project spreadsheets to find key information on a project. CivilCorp manages and schedules resources through weekly production meetings. All offices are in attendance and all project managers, assistants and key technicians are present to discuss schedules, budgets and receive up to date progress reports on each project. This allows us to look ahead on our schedules and make adjustments to the allocation of resources before any problems arise and ensures that all resources are being used efficiently to maintain the various project schedules. Maintaining close working relationships with all of our team members allows us to all work together to ensure project milestones are met and that the County receives the quality deliverables that they can expect from our firm. CivilCorp will utilize all resources available to ensure that Calhoun County, as a client, is always taken care of, and we will always strive to stay on time, on budget and on task for every project. Ben Galvan, PE, RPLS, is the President of CivilCorp, LLC, and is responsible for overall project development including communication with governing agencies, owners, sub providers, and private companies. Ben will apply his comprehensive knowledge of engineering principles, practices, and applications towards the development of the proposed water system improvements. His experience is well rounded and includes designs of roadway, drainage and utility projects as well as construction administration. As engineer for the Port of Victoria, Ben has experience with the U.S. Army Corps of Engineers — Galveston District. Mr. Galvan has had the opportunity to work on several infrastructure -type projects. He has completed plans for construction of new water and sanitary sewer facilities, relocation of existing facilities, topography, DTMs, preliminary and final plans, specifications, and estimates packages for minor and major roadway and bridge projects. The associated tasks have included developing paving details, utility coordination, and the design for utility replacements or upgrades. His experience includes a wide variety of transportation projects encompassing city, county, farm -to - market, state highway, and complex roadway designs consisting of paving, storm drainage, roadway design and t , alignments, traffic control, signing/pavement marking design, utility coordination, QAIQC, design review and analysis, field coordination, and construction administration. He is well versed in both the engineering and surveying (' requirements for transportation projects. Randy Janak, PE is the Vice President of the Victoria Office. Mr. Janak has been providing civil engineering services for the past 20 years. He has designed and managed public works projects, including water, sewer, street rehabilitation, and drainage infrastructure projects, for various cities and counties. He has designed and managed site development projects for commercial, residential, and industrial facilities. He has prepared schematic and final designs for rural, urban, and highway systems involving new location, rehabilitation, relocation, and widening. He has performed hydrology and hydraulic analysis using HEC-RAS, PondPack, WINSTORM, and HY-8 programs. Additional tasks have included developing the traffic control plans and signing/pavement marking layouts. He has developed Final Plats and Storm Water Pollution Prevention Plans for various commercial and residential projects. CivilCorp has the expertise, experience, and resources to provide engineering design services for the proposed project. We have managed civil design projects through construction management with budgetary constraints ranging from $5,000 to $250,000,000. By offering a wide range of civil design needs from conceptual studies through planning, design and construction management, we have successfully coordinated and managed infrastructure improvement programs for local, regional, and state level agencies. t_ LCalhoun County: New Amenities at Bill Sanders County Park Page 13 I, LITIGATION HISTORY Victoria Electric Cooperative, INC. VS Perkins & Will, INC., ET All filed March 24th, 2023. f CivilCorp was a sub provider on this contract providing the site civil engineering to Perkins and Will, Inc. for a new building for Victoria Electric Coop (VEC). The building has experienced foundation issues and every sub provider was named in the lawsuit, including CivilCorp, who was not involved in the foundation design. This case has been settled with CivilCorp, but is still pending for the other defendants. Admiral Insurance Company VS CivilCorp, LLC filed September 12,th, 2023. CivilCorp was sued by their professional liability insurance company for a coverage claim on the case cited above. The case was settled with both the insurance company and VEC. *Resumes attached to the end of this submittal. Professional Engineer Kee Yean Yang, PE Professional Land Surveyor Wm. Patrick Hohlt, RPLS Environmental/Archeological Support Compass Environmental Solutions L L Engineering Specialist Son Downs Graduate Engineer I Zane Char bula LCalhoun County: New Amenities at Bill Sanders County Park Page 14 I ABILITY TO CARRY OUT SCOPE OF WORK WITHIN THE PROPOSED TIMELINE Our firm is unique in the respect that we offer both surveying and civil engineering services. Our surveyors understand the scheduling needs and level of accuracy needed by design engineers. Our engineers understand the data needed by our surveyors. The efficiency offered by this interaction is a valuable asset for successful project development. CivilCorp is readily available to address our clients' needs. We are not just a service provider, but partners that make your deadlines and budget constraints a top priority. Our commitment to excellence in performance and customer d ^ satisfaction has led to a high repeat customer base. From start to finish, we approach a project with efficient, practical, and innovative problem solving techniques. Our commitment is to provide the highest level of service to ensure the success of every project, finishing in time and within budget. Our clients have been very pleased with our work and dedication. We have completed projects for multiple cities and counties throughout South Texas, all of which we completed on - time and within budget. We have also completed projects for various TxDOT districts including Abilene, Amarillo, Beaumont, Corpus Christi, San Antonio, Pharr, and Yoakum. All of the work authorizations for each of these contracts were completed on time and within budget. Our continued success of receiving TxDOT and municipal Work Authorizations is a good indication of our professional qualifications and ability to undertake high quality work. Providing high quality work is the most effective way to ensure future work with clients. We have met that challenge with TxDOT and with the various cities that we work with and look forward to the opportunity to provide these same quality services to Calhoun County. REFERENCES Ken Gill, PE — City of Victoria Jody Weaver, PE — City of Port Gary Broz — City of Edna Public Works Director Lavaca City Manager 700 Main St., Ste. 201 City Manager 126 W Main Victoria, TX 77901 202 N. Virginia St. Edna TX 77957 kgill@victoriatx.org Port Lavaca, TX 77979 gbroz@cityofedna.com Phone: (361) 485-3340 jweaver@portlavaca.org Phone: (361) 782-3122 Phone: (361) 827-3601 Sean Stibich - Port of Victoria John Johnston, PE — Victoria Executive Director County 1934 FM 1432 County Engineer Victoria, TX 77905 JJohnston@vctx.org sean@portofvictoria.com Phone: (361) 580-6050 Phone: (361) 212-9516 CONCLUSION By offering a wide range of civil design services from conceptual studies through planning, design, and construction management, we have successfully coordinated and managed infrastructure improvement programs for local, regional, and state level agencies. CivilCorp's committed personnel for this project have extensive design and planning experience in both unincorporated and urbanized areas. We look forward to the opportunity to assist Calhoun County. 11 Calhoun County: New Amenities at Bill Sanders County Park Page 15 L- STATE OF TEXAS {} AFFIDAVIT COUNTY OF Victoria {} Randy Janak being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Vice President of CivilCorp, LLC having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 4611 E. Airline Rd. Ste: 300 Victoria, TX 77904 (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed j. to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, rpartnership, company, association, organization or corporation not herein named or disclosed. s Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that priorto the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to urnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the onditions a requirements contained in the bid/proposal. LSignature ofAffia t Randy Janak- Vice President Printed Name and Title of Affiant 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 L-IV' day of IVOVP, vvyxr , 20')-k . • ... JENNIFERGALVANCAMPBELL My Notary ID # 132207820 o.E. Expires November27, 2027 Notary Stamp/Seal Page 29 of 52 I 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. Randy Janak- Vice President 11 /01 /2024 Name and Title of Authorized Agent Date Signature of Authorized Agent I am unable to certify to the above statements. My explanation is attached. L Page 32 of 52 L I 1-, q Certification Regarding Lobbying (To be submitted with each bid or offer exceeding $100,000) t 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 [l 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, Civi[Corp, LLC , certifies or affirms the truthfulness and accuracy of each -\ statement of i s ce i tiflcation and disclosure, if any. In addition, the Contractor understands and agrees that the provision of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Randy Janak - Vice President Printed Name and Title of Contractor's Authorized Official 11 /01 /2024 Lj, Page 33 of 52 L 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 local governmental entity. CivilCorp does not have a business relationship with Calhoun County 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.) 31 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 F� No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? ElYes 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 he v ndor has given the local government officer or a family member of the officer one or more gifts as described inle n 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 --- 11 /01 /2024 Sigr ature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us pa"V#E# J/30/2015 L 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 (findividual, last name, first name, MI): di(ferenl from 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 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) Page 37 of 52 I [_, I HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 851' Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Randy Janak do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.¢ov/purchasing/publications/divestment.php of Authorized Vice President Title of Authorized Official l_1 Janak Printed Name of Authorized Official 11 /01 /2024 Date Page 38 of 52 I 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) M icertifythat CivilCorp, LLC (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Randy Janak - Vice President Printed Name and Title of Authorized Agent 11/01/2024 Date L' is a "Resident Bidder" of Texas as LPage 39 of 52 I I W 9 Request for Taxpayer Give Form to the Identification Number and Certification requester. Do not Rev. October Rev. send to the IRS. he Treasury )apartment of the Treasury �temal Revenue Service ► Go to www.irs.gov/FormW9 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. ESP Associates, Inc. 2 Business name/disregarded entity name, if different from above CIvIICorp, LLC 3 Check appropriate box for federal tax classification of the person whose name Is entered on lue 1. Check only one of the 4 Exemptions (codes apply only to m a m following seven boxes. certain entities, not individuals; see instructions on page 3): n � ❑Individual/sole proprietor or 2 C Corporation 118 Corporation ❑Partnership ❑Trust/estate single -member LLC Exempt payee code (if any) ❑ Limited liabllity company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► `p } Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting «15 0 LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is that code (it any) C another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC Q. Is disregarded from the owner should check the appropriate box for the tax classification of its owner. d ❑Other (see instructions) ► (Applies ro accounhmalnhlnee wises the USJ W 5 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) is 4611 E. Airline Road, Suite 300 Co 6 City, state, and ZIP code Victoria, Texas 77904 7 List 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 l backup withholding. For Individuals, this is generally your social security number (SSN. However, fora - m _ F resident alien, sole proprietor, or disregarded entity, sae the Instructions for Part i, later. For, 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 Employer identification number Number To Give the Requester for guidelines on whose number to enter. 5 6 - 0 5 9 9 7 3 7 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 (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 ngLrq% fired to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. �t8n 9lgnatura of / Here U.S. parson► !/ 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 Il (EIN), 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) Cat. No. 10231X L Date► /, / 2 2 v • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. if you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Form W-N (Rev. 10-2018) ACORO® CERTIFICATE OF LIABILITY INSURANCE OwTe (MM/OD rrvY 09/18/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND ORALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Certificates NAME: Klein AgencY•LLC ucNE t: (410)832-7600 (VC, No: (410)832-1849 P.O. Box 219 15r 11_ carts@kleinagencyllc.wm ADDRESS: INSURERS AFFORDING COVERAGE NAM# INSURERA: The Phoenix Insurance Company 25623 Tlmonlum MD 21094 INSURED INSURER B: The Charter Oak Fire Insurance Company 25615 ClvilCorp, LLC INSURER, Travelers Property Casualty Co. ofAmerica 25674 INsuRER o: Hartford Ins Co of the Midwest 37478 4611 E. Airline Road INSURERE: XL Specialty Insurance 37885 Suite 300 INSURER F: Victoria TX 77904 COVFRACFS CERTIFICATE NUMBER: 24-25 CIvlCorp REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE 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 INBD WVD POLICY NUMBER POLICY EFF MMIDO POUCYEXP MIDO UNITS x COMMERCIAL GENERAL LIABILITY CURRENCE $ 1,000,000 CLNMS-MADE �X_ OCCUR S EaocourancB $ 1,000,000 (Any one parson) $ 10,000 x Contractual Liability L SADV INJURY r�NEML $ 1,000,000 A 630OX661601 09/30/2024 09/30/2025 GEN'LAGGREGATE LIMITAPPLIES PER: AGGREGATE $ 2,000,000 POLICY ❑X JET LOC TS-COMP/OPAGG $2.000,000 $ OTHER: AUTOMOBILE LIABILITY D SINGLE LIMIT Ee exltlen[ $ 1,000,000 BODILY INJURY (Per pennon) $ X ANYAUTO B OWNED F7 SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 810OX63655A 09/30/2024 09/30/2025 BODILY INJURY(Pereeddent) $ PROPERTY DAMAGE eraccidan[ $ X UMBRELLAUAB I - OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS UAB CLAIMS -MADE CUPDX770958 09/30/2024 09/30/2025 AGGREGATE $ 10,000,000 DEO I I RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA 30WEOL6HCB 09/30/2024 09/30/2025 v ^STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE E 1,000,000 If yea, deeedba under DESCRIPTION OF OPERATIONS below E.L.OISEASE-POLICYLIMIT 1,000,000 $ Each Claim $5,000,000 E Professional Liability DPR5034446 09/30/2024 09/30/2025 Aggregate $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD101,Addltlonal Romero Schedule,maybeaaachedlfmorespacelerequlred) If required by an insured written wntracl, executed prior to any loss, the certificate holder is an Additional Insured on a primary and non-contributory, basis under the General Liability and Auto Liability Policies subject t0 all policy terns and conditions. If required by an insured written contract, executed prior to any loss, Waiver of Subrogation is provided for General Liability, Auto Liability, and Workers Compensation Policies subject to all policy terms and conditions. Umbrella Policy follows form over General Liability, Auto Liability, and Employer's Liability Policies. 30 day notice of cancellation, 10 day for non-payment. *Evidence of Coverage' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (919115 ACUKO GUKPUKAI IUN. All rlgms reservea ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Lmt apdwf d by Ben Galva. on Feb 14, 2024 at 09:53 AM M SAM.00w CMILCORP LLC CIVILCORP LLC Unique Entity ID DF6EHJ596WS5 Registration Status Active Registration Physical Address 4611 E Airline RD STE 300 Victoria, Texas 77904.4771 United States CAGE/NCAGE 583M1 Expiration Dale Feb 13, 2025 Mailing Address 4611 E Airline RD STE 300 Victoria, Texas 77904 United States Purpose of Registration All Awards Doing Business as Division Name Division Number (blank) (blank) (blank) Congressional District State Country of Incorporation URL Texas 27 Texas / United States (blank) Registration Dales Activation Date Submission Date Initial Registration Date 1(� Feb 15, 2024 Feb 14, 2024 Oct 16, 2008 F Entity Dates CC Entity Start Date Fiscal Year End Close Date -. Oct 29, 2007 Dec 31 Immediate Owner CAGE Legal Business Name -� 1TYE0 ESP ASSOCIATES, INC. Highest Level Owner CAGE Legal Business Name (blank) (blank) 1 Executive Compensation In your business or organizalion's preceding completed fiscal year, did your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) receive both of the following: 1.80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements and 2. $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants, subgrants, and/or cooperative agreements? No Does the public have access to information about the compensation of the senior executives In your business or organization (the legal entity to which this specific SAM record, represented by a Unique Entity ID, belongs) through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986? Not Selected Proceedings Questions Is your business or organization, as represented by the Unique Entity ID on this entity registration, responding to a Federal procurement opportunity that contains the provision at FAR 52.209-7, subject to the clause in FAR 52.209-9 in a current Federal contract, or applying for a Federal grant opportunity -1 which contains the award term and condition described in 2 C.F.R. 200 Appendix XII7 No Does your business or organization, as represented by the Unique Entty ID on this specific SAM record, have current active Federal contracts and/or / grants with total value (including any exemised/unexercised options) greater than $10,000,000? Not Selected Within the last five years, had the business or organization (represented by the Unique Entity ID on this specific SAM record) and/or any of its principals, in connection with the award to or performance by the business or organization of a Federal contract or grant, been the subject of a Federal or State (1) criminal proceeding resulting in a conviction or other acknowledgment of fault; (2) civil proceeding resulting in a finding of fault with a monetary fine, penalty, reimbursement, restitution, and/or damages greater than $5,000, or other acknowledgment of fault; and/or (3) administrative proceeding resulting in a finding of fault with either a monetary fine or penalty greater than $5,000 or reimbursement, restitution, or damages greater than $100,000, or other 1 acknowledgment of fault? Not Selected �) hftps.-IA=.govlendty/DF6EHJ596WS51coreData?stalls uff Page l of4 Last updated by Ben G&,v, on Fe614, 2024 of 09:53AM CMLCOBPLLC Active Exclusions Records? No I authorize my entity's non -sensitive information to be displayed in SAM public search results: Yes Business Types Entity Structure Other Profit Structure For Profit Organization Entity Type Business or Organization Organization Factors Limited Liability Company Socio-Economic Types Check the registrant's Reps 8, Cents, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA -certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the SBA supplemental pages during registration. Accepts Credit Card Payments Debt Subject To Offset No No EFT Indicator CAGE Code 0000 683MI Electronic Funds Transfer _... _._. _.... __. __._ .... Account Type Routing Number Lock Box Number Checking ""'" 59 (blank) Financial Institution Account Number WELLS FARGO BANK •"•'•"*32 Automated Clearing House Phone (U.S.) Email Phone (non-U.S.) 3615745114 timothy.michalskl@wellsfargo.com (blank) Fax 3615745568 Remittance Address CIVILCORP, LLC 4611 E Airline RD STE 300 Victoria, Texas 77904 United States EIN *'*""2981 Tax Year (Most Recent Tax Year) 2008 Address 4611 E Airline RD STE 300 Victoria, Texas 77904 Accounts Receivable POC 0 1. Connie Dooley, Accounts Manager cdooley@ctvilcorp.us 3615707500 Type of Tax Applicable Federal Tax Name/Title of Individual Executing Consent President Signature BEN GALVAN Taxpayer Name CIVILCORP LLC TIN Consent Dale Feb 13, 2024 Nov 01, 202406:48: 01 PM GMT 6eps:llsam.govlentiylDF6EHJ596WN51coreData?staWa all Page 2 of4 Loet updated by Ben Oalvnn on Feb 14, 2024 at 09:53 AM CIMCOAPLLC Electronic Business A 4611 E Airline RD STE 300 Ben Delver, President Victoria, Texas 77904 fbgalvan@civilcorp.us United States 3615707500 Kathryn Patterson 4611 E. Airline RD kpatterson@civilcorp,us Ste: 101 3615707500 Victoria, Texas 77904 United States Government Business l - P. 4611 E. Airline RD STE 300 Ben Galvan, President Victoria, Texas 77904 bgalvan@civileorp.us United States 3615707500 Kathryn Patterson 4611 E. Airline RD kpatterson@civilcorp.us Ste: 101 4 3615707500 Victoria, Texas 77904 1 l United States NAICS Codes Primary NAICS Codes NAICS Title Yes 541330 Engineering Services . 237310 Highway, Street, And Bridge Construction 541340 Drafting Services 541370 Surveying And Mapping (Except Geophysical) Services 561990 All Other Support Services Product and Service Codes J ( PSC PSC Name C200 Architect And Engineering. General C212 l Architect And Engineering- General: Engineering Drafting, Not Cad/Cam C219 Architect And Engineering- General: Other r' H356 Inspection -Construction And Building Materials R404 Support- Professional: Land Surveys-Cadastral (Non -Construction) �.I KIT Size Metrics Annual Revenue (from all IGTs) (blank) Worldwide Annual Receipts (in accordance with 13 CFR 121) Number of Employees (in accordance with 13 CFR 121) $21,000,000.00 106 Location Annual Receipts (in accordance with 13 CFR 121) Number of Employees (in accordance with 13 CFR 121) J (blank) (blank) Industry -Specific Barrels Capacity Megawatt Hours Total Assets (blank) (blank) (blank) This entity did not enter the EDI information Page 30f4 Last updated by Ben Golvan on Feb 14, 2024 at 09:53" CMLCOBPLLC This entity does not appear in the disaster response registry. I' I L Nov 01, 2024 06 48 01 PM GMT hups://sam.gov/entiry/DF6EX✓596WS51coreData?status=null Page 4 of4 rq-CivilCorp Randy Janak, PE, CFM Project Manager & Vice President - Victoria Randy Janak is the Vice President of the Victoria Office and has been providing civil engineering services for the past 18 years. He graduated from the University of Texas with a Bachelors Degree in Civil Engineering and is a Texas Registered Professional Engineer. In 2005, he joined Landtech Consultants' Victoria, Texas office, now CivilCorp, LLC, providing site development, utility, and transportation engineering to local and state agencies as well as private developers. He has designed and managed public works projects, including street rehabilitation, water, sewer and drainage infrastructure projects, for various cities and counties. He has designed and managed site development projects for commercial, residential, and industrial facilities. He has prepared schematic and final designs for rural, urban, and highway systems involving new location, rehabilitation, relocation, and widening. He has performed hydrology and hydraulic analysis using HEC-RAS, PondPack, WINSTORM, and HY-8 programs. He has also prepared the design of water, sanitary sewer, and drainage infrastructure to facilitate proposed structures. Additional tasks have included developing traffic ' control plans, storm sewer design, and signing and pavement marking layouts. He has developed Final Plats and Storm Water Pollution Prevention Plans for various commercial and residential projects. Mr. Janak's sample projects include: I, 11 Placido Benavides Street - City of Victoria, TX: CivilCorp completed plans, specifications and bid documents for the new street extension of Placido Benavides in the City of Victoria. Mr. Janak was the Design Engineer for the project which included over 10,000 If of 8"-16" water mains and over 8,000 If of 8"-18" sewer mains. ; EDUCATION: B.S., Civil Engineering,1997 University of Texas REGISTRATION: Texas Registered Professional Engineer, 2002, Cart. #90185 TexasCertified Floodplain Manager, Cart. #0983-06N - College Park Water and Sanitary Sewer Improvements, City of Victoria: Mr. Janak served as the Project Manager as CivilCorp prepared the plans and estimate for water and sanitary sewer improvements for the streets in College Park Subdivision. Water main replacement totaled 12,500 feet and sanitary sewer line replacement by both traditional open cut and CIPP lining methods totaled 10,000 feet. Replacement of all services, fire hydrants, valves, and manholes were also included in the plans. 2021 Bond Project, City of Edna: Mr. Janak served as the Project Manager as CivilCorp prepared the plans and bid documents for roadway, water, and sanitary sewer improvements for various streets in Edna. Road improvements were based on existing street conditions and included varying combinations of subgrade rehab, base rehab, prime, seal coat, and onyx surface treatments. Streets to be rehabbed also included replacing aging water and sewer lines. Water main replacement totaled over 14,500 feet and sanitary sewer line replacement by both traditional open cut and pipe bursting methods totaled over 10,000 feet. Replacement of all services, fire hydrants, valves, and manholes were also included in the plans. American Rescue Act— Gilbert Road Drainage Improvements, City of Edna: Mr. Janak served as the Project Manager as CivilCorp performed the topographic survey and prepared the plans, specifications, and estimates for drainage improvements along Gilbert Road. Drainage improvements included adding storm sewer (18" to 48") and inlets to alleviate drainage issues along Gilbert Road. Design also included ditch and driveway culvert improvements. American Rescue Act— North Street Drainage Improvements, City of Bay City: Mr. Janak served as the Project Manager as CivilCorp performed the topographic survey and prepared the plans, specifications, and estimates for drainage L r4-CivilCorp improvements along North Street. Drainage improvements included adding box culvert and concrete -lined ditch to alleviate drainage problems with five parallel 36" pipes that had collapsed. Sam Houston Drive Reconstruction Project - City of Victoria, TX: CivilCorp completed plans, specifications and bid documents for the reconstruction of Sam Houston Drive in the City of Victoria. Mr. Janak was the Design Engineer for the r' project. This street section was two miles in length and consisted of four lanes of traffic with a continuous left turn lane and was constructed as a concrete street. All sidewalks and ramps were designed at all intersections to meet ADA standards. In addition, the existing storm sewer system was analyzed and redesigned in sections to improve drainage. Proposed 8"-16" water mains and 8"-15" sewer mains were designed to replace the aged existing underground lines. Acme Trucking Waterline Extension - Victoria, TX: Mr. Janak was the Design Engineer for the project which included extending an 8" water main across US 59 to provide water service to Acme Trucking. Design included boring water main under mainlanes and frontage roads with steel encasement pipe. Coordinated with TxDOT during design and permitting. Baker Hughes Joint Facility, Corpus Christi, TX. Project Engineer for the design of new parking, driveways, and truck staging area and waterlsewer extensions to serve new Baker Hughes facility in Corpus Christi. Public water/sewer improvements included over 900 If of 12" water main extension and 10" sanitary sewer main extension. Water and sewer lines were placed in 25' utility easement adjacent to SH 44 ROW. Coordinated with City of Corpus Christi and TxDOT for design of utilities and site. Tuscany Subdivision, Off -site Water/Sewer Project, Victoria, TX: Project Manager for off -site water and sanitary sewer improvements to serve new Tuscany single-family subdivision in Victoria. Design included 5,200 If of new 12" water line, including fire hydrants, valves, and placement of an automatic flushing device. Design also included 4,600 If of new 15" gravity sanitary sewer line with 13 new manholes. Bonaire Terrace & Sunset Heights Waterline Project, City of Port Lavaca, TX: Project Engineer for preparation of the plans, specifications, and estimate for a water line improvement project replacing over 3,000 feet of 4" water line and 1,900 r feet of 6" water line. Hospital Waterline Improvement Project, City of Port Lavaca, TX: Project Engineer for preparation of the plans, specifications, and estimate for a water line improvement project replacing over 1,000 feet of 4" water line and 3,100 feet of 6" water line. Texas CDBG No. 7215031 Bay City Sewer Improvements Project, City of Bay City, TX: Project Engineer for preparation of the plans, specifications, and estimate for a sanitary sewer improvement project replacing over 8,000 feet of sewer line by pipe bursting. 2013 Capital Improvements Project, City of Port Lavaca, TX. Project Engineer for preparation of the plans, specifications, and estimate for the following three projects that were combined and bid together: George Street Sewer Collection System Improvements, Alamo Heights Water Distribution System Improvements, and Bayfront Water Distribution System Improvements projects. These three projects included replacing over 2700 feet of 8" and 15" sanitary sewer line and 5400 feet of 6" water line. Texas CDBG No. 728350 Bonorden Water Distribution System Improvements, City of Port Lavaca, TX: Project Engineer for preparation of the plans, specifications, and estimate for a water line improvement project replacing over 5,300 feet of water line located in various City streets. Texas CDBG No. 712290 Sewer Collection System Improvements, City of Port Lavaca, TX. Project Engineer for preparation of the plans, specifications, and estimate for a sanitary sewer improvement project replacing over 2,000 feet of 8" sanitary sewer line. 0 I■ I 0 rilcivilcorp ENGINEERS• SURVEYORS Ben L. Galvan, PE, RPLS Ben Galvan, PE, RPLS, brings over 30 years of surveying and design experience, including 13 years of TOOT experience. He holds registrations as both a Texas Registered Professional Engineer and a Texas Registered Professional Land Surveyor. He currently oversees completion of survey and engineering projects from contract negotiations, issuance of work orders, QAIQC, field surveying, calculations, mapping, and final review of deliverables. He has assisted local and state agencies with all aspects of surveying, engineering, maintenance, rehabilitation, and widening of rural, urban, and highway systems and bridge facilities. He has prepared feasibility, route and location studies, diagrammatic layouts, and developed schematic plans including required environmental documents, right-of-way maps and public hearings for up to 12 miles of roadway improvements. He has completed plans for construction of new water and sanitary sewer facilities, relocation of existing facilities, topography, DTMs, preliminary and final plans, specifications, and estimates packages for minor and major roadway and bridge projects. The associated tasks have included developing paving details, utility coordination, and the design for utility replacements or upgrades. His experience includes a wide variety of transportation projects encompassing city, county, farm -to -market, state highway, and complex roadway designs consisting of paving, storm drainage, roadway design and alignments, traffic control, signing/pavement marking design, utility coordination, QAIQC, design review and analysis, field coordination, and construction administration. He is well versed in both the engineering and surveying requirements for transportation projects. Mr. Galvan's sample projects include the following: Placido Benavides Street - City of Victoria, TX: Mr. Galvan served as QAIQC Manager as CivilCorp completed plans, specifications and bid documents for the new 2-mile street extension of Placido Benavides in the City of Victoria. Overall $9 million dollar project design included paving, drainage and utility improvements. The new street was classified as an arterial street and ultimately will include two lanes in each direction separated by a grass median. This first phase was designed with the two lanes to be constructed with concrete pavement on the west side of the median. President EDUCATION: B.S., Civil Engineering,1986 Texas A&I University MBA, Management, 1994 University of Houston, Victoria, Texas REGISTRATION: ' Texas Registered Professional Engineer, 1991, Cart. #69918 Texas Registered' Professional Land Surveyor,1998, Cart. #5229 Ben Wilson Dr. Survey, Victoria, TX: Mr. Galvan served as QAIQC Manager as CivilCorp completed the project including modifying an existing 5lane roadway into a 3-lane roadway. CivilCorp was tasked with performing a topographic survey of the project limits and determining the existing right of way. In addition, CivilCorp utilized a UAV to provide updated aerial imagery and supplemental 2D and 3D information to aid the project design team. CivilCorp was also tasked with creating survey documents required to abandon parts of the existing right of way needed to facilitate the reduction to a smaller roadway. College Park Water and Sanitary Sewer Improvements, City of Victoria: Mr. Galvan served as QAIQC Manager as CivilCorp prepared the plans and estimate for water and sanitary sewer improvements for the streets in College Park Subdivision. Water main replacement totaled 12,500 feet and sanitary sewer line replacement by both traditional open cut and CIPP lining methods totaled 10,000 feet. Replacement of all services, fire hydrants, valves, and manholes were also included in the plans. 2021 Bond Project, City of Edna: Mr. Galvan served as QAIQC Manager as CivilCorp the plans and bid documents for roadway, water, and sanitary sewer improvements for various streets in Edna. Road improvements were based on existing street conditions and included varying combinations of subgrade rehab, base rehab, prime, seal coat, and onyx r4CMICorp surface treatments. Streets to be rehabbed also included replacing aging water and sewer lines. Water main replacement totaled over 14,500 feet and sanitary sewer line replacement by both traditional open cut and pipe bursting methods totaled over 10,000 feet. Replacement of all services, fire hydrants, valves, and manholes were also included in the plans. Sam Houston Drive, Victoria, Texas: Mr. Galvan served as QAIQC manager for the complete reconstruction of for this $24 million dollar, 2-mile, 5-lane section of Sam Houston Drive between Laurent Street and US 59 Business in Victoria. The project involved complete survey and design of the roadway, water, sanitary sewer and drainage systems. Several utilities required and horizontal and vertical control was established for the project. Control was established in accordance ' with the latest requirements of the City of Victoria. John Stockbauer Dr. Reconstruction, City of Victoria, Texas: Mr. Galvan served as QAIQC manager as CivilCorp prepared plans, specifications and bid documents and provided construction management for the reconstruction of this $8 million dollar reconstruction of John Stockbauer Drive. This project was 2 miles in length and included the improvements to the water and sewer lines. Coordination with gas, phone, cable, and pipeline companies was critical during the entire construction process. The project also included a traffic signal on the adjacent US 59 ROW which required placement of conduit throughout the utility densified area. CivilCorp monitored the installation, adjustments and kept accurate records for all construction services related to this project. This included status reporting to the TOOT, utility companies and the city. Leon Street Reconstruction, City of Port Lavaca: Mr. Galvan served as QAIQC Manager for preparation of the plans, specifications, and estimate for the Reconstruction of Leon Street including drainage and utility line improvements. Project included reconstructing an existing 1,700-foot-long 2-lane roadway. Project also included designing an underground storm sewer system and 6-inch water main to replace the existing 6-inch main. Jackson Street Reconstruction, City of Port Lavaca: Mr. Galvan served as QAIQC Manager for preparation of the plans, specifications, and estimate for the Reconstruction of Jackson Street including drainage and utility line improvements. Project included reconstructing an existing 1,700-foot-long 2-lane roadway. Project also included designing an underground storm sewer system and 6-inch water main to replace the existing 2-inch main. San Antonio Street Reconstruction, City of Port Lavaca: Mr. Galvan served as QAIQC Manager and assisted with preparation of plans, specifications, and estimate for San Antonio Street Reconstruction project for the City of Port Lavaca. Project included reconstructing existing 800-foot-long 2-lane roadway and redesigning existing storm sewer system. Project also included design of 4-inch water main and service connections to replace existing 2-inch water main. Ball Airport Rd Extension, City of Victoria, Victoria County, Texas: Mr. Galvan served as QAIQC Manager to extend Ball Airport Rd from Glascow St to Tuscany Dr., tying to Northside Rd north of Victoria. The project included 4900 If of 18" to 72" RCP storm sewer. The system was designed to accommodate increased runoff, reducing the need for detention due to future development along the project. The increased capacity of the drainage system was limited to the outfall system & budgeted funding for the project. The proposed 3300 If pavement section consisted of geogrid on top of subgrade, 8" flex base, prime & a seal coat, & 25' wide x 8" cont reinf conc pvmt with mono curb. A 5' sidewalk with ADA ramps along one side of the street was also included, along with diamond grinding & sealing of joints on 5300 sy of existing jointed concrete pavement. I r I L r4-civilcorp I Kee Yean Yang, PE Senior Project Engineer Mr. Yang started his career with Excelsis, Inc. (now CivilCorp LLC) immediately after he graduated in 2002. He has 17 years worked on varying aspects of civil engineering design related to highway transportation projects. He performed design work on various PS&E projects; tasks included hydrologic study, hydraulic design and storm sewer design. In addition, he performed GEOPAK Road to develop geometric design, GEOPAK drainage to analyze and develop storm sewer system, OpenRoads to develop 3D corridor model and created cross sections. He has also utilized HEC-HMS for hydrologic calculations and HEC-RAS to perform hydraulic analysis for bridges and bridge scour evaluation for on -system and off -system bridge replacement projects and utilized HY- 8 to analyze proposed/existing drainage structures. PROJECT EXPERIENCE: FM 601FM 2818 Interchange Improvements Project in Brazos County, TxDOT Bryan District: Approximate 2.23 miles of roadway improvement project included widening of FM 2818 and a diverging diamond at FM 60 over FM 2818. Mr. Yang served as drainage design task leader for this project he performed hydrologic studies, roadway hydraulic design and analyzed proposed storm sewer system, prepared culvert layouts and design cross culverts and special inlets and manhole details, analyzed existing and proposed cross drainage structures hydraulic conditions, created drainage miscellaneous details, prepared quantity summaries and cost estimate. SH 71 Reconstruction Project in Wharton County, TxDOT Yoakum District: Widening 1.44 mile of urban roadway from a 3-lane section to a 5- lane section has a combination of both curb and gutter with an enclosed storm drain system and open side ditches. Mr. Yang served as task leader, responsible for hydroloic studies and roadway hydraulic design to analyzed proposed storm sewer system, analyzed existing and proposed cross drainage structures hydraulic conditions, created drainage miscellaneous details, modified TxDOT Drainage Standards for inlets and manholes, prepared quantity summaries and cost estimate. EDUCATION: Bachelor of Science Civil Engineering, 2000 Oklahoma State University Master of Science Civil Engineering, 2002 Oklahoma State University CERTIFICATION: Texas Registered Professional Engineer, Certification #116180 IH 10 Seguin Improvements Project in Guadalupe County, TxDOT San Antonio District: Approximately 2.40 miles of frontage roads improvements project. Mr. Yang served as drainage design task leader duties including hydrologic studies, roadway hydraulic design and analyzed proposed storm sewer system, prepared culvert layouts and design cross culverts and special inlets, analyzed existing and proposed cross drainage structures hydraulic conditions, created drainage miscellaneous details. US 380 Widening Project in Denton County, TxDOT Dallas District The project included the construction of the widening approximately 10.45 miles of an existing four lane highway to a six -lane divided urban highway. Responsible for aspects of drainage including designed and analyzed proposed storm sewer system, prepared storm sewer layouts, created drainage miscellaneous details, prepared quantity summaries and cost estimated. SPURS 53 Reconstruction Project in Bexar County, TxDOT San Antonio District; Served as a drainage task engineer for an approximate 0.62 mile widen roadway from 2 lanes to 4 lanes and provide continuous left turn lane, bike lanes and sidewalks. Responsible included designed and analyzed storm sewer system, created drainage miscellaneous details, prepared quantity computations and summaries. (2014) Gilbert Road Drainage Improvement Project, City of Edna The project included preparing the plans and bid documents for drainage improvements for along Gilbert Rd, Dewberry Ln, Alba St, Sunny Ln, and Asbeck Ln. in Edna. Drainage improvements along Gilbert Rd included designing an underground storm sewer pipe system with surface inlets to help alleviate flooding issues along Gilbert Rd. Storm sewer pipe outfalled at Dry Creek. Additional Limprovements to surrounding roads included ditch excavation and driveway pipe cleaning and replacement when necessary. I I r4_civilcorp ENGINEERS. SURVEYORS Wm. Patrick Hohit, RPLS Registered Professional Land Surveyor Wm. Patrick Hohlt has over 20 years in land surveying and project management. He became licensed with the State of Texas as a Registered Professional Land Surveyor in January 2002. As a Registered Professional Land Surveyor, he has the necessary skills to locate and establish right-of-way lines and property lines, as well as effectively manage field crews and office operations on any project. He has prepared numerous topographic maps and drawings for city, county, and state projects. His experience includes managing and coordinating a large variety of survey projects, in rural and urban areas, including right-of- way surveys, topographic surveys, control surveys, and construction lay out. His project locations have been across the state of Texas. Mr. Hohlt's sample projects include the following: Alta/Land Title Survey 18155 Chisholm Trail, Houston, Harris County, Texas: This project was on a 3.62-acre tract of land. Along with establishing horizontal and vertical control, we were tasked with tying in and drafting all the current improvements which included several buildings, parking lots, underground utilities and elevations and contours on the property. Research also had to be done to determine the boundary of the property and to identify the adjacent property owners. Alta/Land Title Survey 22.58 Acres, Victoria, Victoria County, Texas: This project was on the site of a 22.58-acre manufactured home park. After establishing horizontal and vertical control, we were tasked with tying in and drafting all the current improvements which included the buildings, roads, parking lots and underground utilities on the property. Research also had to be done to determine the boundary of the property and to identify the adjacent property owners. Yr EDUCATION: Assoc. Degree Victoria College Victoria, TX. ,- 1988 REGISTRATION: Registered Professional Land Surveyor:, License #5523': Red River Street, Utility and Road Reconstruction, Victoria, Victoria County, Texas: This project was for the City of Victoria and was 112 mile in length. The project including setting horizontal and vertical control and mapping both all above ground features within the right of way of Red River Street and mapping and researching the underground utilities. IH 10 El Paso, Texas: This project was along 3 miles of an existing divided highway located just outside of El Paso Texas. As Project manager, I was tasked with coordinating field and office staff. We began with setting horizontal and vertical control along the highway. The work was for supplementing an existing aerial survey of the work area. This meant tying in all surface features that could not be identified from the aerial data, which included signs and culverts. In addition, the crews had to locate the existing right of way boundary and all the sub surface utilities that were marked on the ground. All the data was analyzed and processed in the office and mapped for the client. Both 2-dimensional and 3-dimensional mapping had to be processed for this project. SH 21 over the Trinity River, Madison and Houston County, Texas: Coordinated field and office staff to perform a topo survey of over 1 mile of right-of-way for the preparation of a new bridge over the Trinity River. The project included establishing horizontal and vertical control as well as working with sub -contractors to perform a gradient boundary survey and a hydrographic survey of the river. This required a tremendous effort of field coordination and scheduling as well as contact with private owners for the right of entry to survey across their property. Both 2D and 3D mapping had to be processed for this project. FM 234 and FM 822, Jackson County, Texas: Coordinated field and office staff to perform topographic surveying of over 12 miles of right-of-way. The project included establishing horizontal and vertical control, as well as utility coordination and mapping. This project also included establishing the existing right of way, downloading, processing and analyzing all the field data and mapping in both 2D and 3D files. L North Heights Utility Replacement, Victoria County, Texas: The field crew will tie in all the existing improvements within the right- of-way of each street. Office personnel will then prepare a drawing which is a record/report of all the existing field data and includes the ground/surface elevations of every shotlitem in the drawing. This information is then reviewed by the designing engineer who Luses this data to prepareldesign construction plans for the new improvements that are needed for the project L L L r4CMICorp FAIN f. `cHS .9uR Vc'1Q 1s Bennett K. Downs Senior Design Technician Bennett (Ben) Downs has over 35 years of highway and bridge design and construction experience in the public and private sector. He worked for 30 years with the Texas Department of Transportation in the Yoakum and San Antonio Districts and retired at the end of August 2014. During his time at TxDOT he prepared plans for a large variety of projects ranging from major highways on new location to on system bridge projects for TxDOT and off -system bridge projects for local governments. During his service at the TxDOT Yoakum District Office his duties included serving as the off -system bridge project coordinator, working with local governments on bridge projects from project inception through plan preparation, to project letting. V i PROJECT EXPERIENCE: t City of Port Lavaca Independence Drive Street and Drainage Improvements Project Design Technician for the Independence Drive Street and Drainage Improvement project. ' Work included reconstructing and widening from two lane open ditch street to two lanes with continuous left turn lane with curb & gutter, new 10' shared use path and new underground storm drainage/open ditch system. Role on assignment: Project Design Technician 2021 Bond Project, City of Edna, Texas Project Design Technician for the roadway rehab portion of the project as CivilCorp prepared the plans and bid documents for roadwa water and sanita sewer im rovements for various streets in Edna Road zzz Yi EDUCATION: Attended University of ` Texas at Austin 1981-1983 Attended Texas A&M University, College Station _1983-1984 t y, I ry p improvements were based on existing street conditions and included varying combinations of subgrade rehab, base rehab, prime, seal coat, and onyx surface treatments 2015 Sidewalk Improvement Project, City of Wharton, Texas: Mr. Downs helped develop plans, specifications and estimate to remove and replace 3800' of sidewalk and curb and gutter and adding 400 SY of ADA compliant curb ramps on ( Milam and other streets in the City of Wharton. The project was TxDOT funded with matching City funds. The engineer's i estimate is $950,000. City of Bay City Sidewalk Improvement Project CivilCorp developed plans, specifications and estimate to remove and replace 800 SY of sidewalk including steps, brick pavers, driveways and drainage improvements on 6th St at Ave H. The project removed the existing concrete sidewalk and replaced it with brick pavers with an underlying sand bed over a concrete foundation. All pedestrian elements were constructed to ADA compliance and the project was funded with a TDA-ORA grant. �. The project was completed for $263,266 US 77/LP463, Victoria County, Texas: Mr. Downs, under the direction of three different Area Engineers, prepared complete PS&E for several phases of US 77/LP 463 from Salem Road to south of US 87 through the city of Victoria, Texas. These high profile projects were new location roadway with main lanes and frontage roads and included several highway overpasses with retaining walls, a railroad overpass, three stream crossing bridges at Spring Creek, multiple bridge class 1 , and minor roadway culverts, and storm drain along the frontage roads. The projects required development of drainage areas, hydrologic studies and extensive use of multiple types of hydraulic analysis software for the different hydraulic structures, including TxDOT Culvert Program, Winstorm, HEC-2, HEC-RAS and others. A portion of the projects included joint bidding for utility work with the city of Victoria. The projects were designed and constructed in several phases requiring coordination for continuity of both construction work and traffic handling throughout all of the phases. These multi -phase projects began design around 1998 and were completed in 2005 to 2006. L L r rjCivilCorp FNGINCER5 �3ufIV cl UR3 Various Highways in the TxDOT Yoakum District. In the course of preparing complete PS&E for roadway rehabilitation, bridge replacement and widening, and HES (Safety) projects, Mr. Downs' duties included hydrologic data development and hydraulic analysis and design of highway bridges and culverts for replacement, extensions and placement of safety treatments. He performed analysis on existing bridges and culverts for hydraulic capacity and efficiency (many without previous hydrologic or hydraulic design information), and designed replacement structures or added capacity structures if needed, and analyzed proposed design improvements to structures for hydraulic impacts. This work took place from 2004 to 2010 and included the following projects (list is not all inclusive): - FM 1300 in Wharton County — developed hydrology and hydraulically analyzed existing culverts for the extension and addition of safety end treatments. - FM3422 in Calhoun County — developed hydrology and hydraulically analyzed existing bridge class culverts and smaller culverts for extensions and addition of safety end treatments. Analyzed and determined where to install new culverts for flood relief. - FM 444 in Victoria County — developed hydrology and hydraulically analyzed existing bridge class culverts to be replaced for added capacity, analyzed existing small culverts for extensions and added safety end treatments. - FM 530 in Jackson County — developed hydrology and hydraulically analyzed existing bridge class box culvert for replacement with a new structure using HEC-RAS. - FM 1822 in Jackson County - developed hydrology and hydraulically analyzed existing bridge class culverts and smaller culverts for extensions and addition of safety end treatments. Analyzed and determined where to install new culverts for flood relief. - FM 2143 in Calhoun County - developed hydrology and hydraulically analyzed existing bridge class and smaller culverts for the extension and addition of safety end treatments. - FM 3084 in Calhoun County - developed hydrology and hydraulically analyzed existing culverts for the extension and addition of safety end treatments. Jurek Road in Calhoun County. Developed PS&E to replace off -system bridge with bridge class culvert in Calhoun county. Established hydrology and analyzed existing and proposed hydraulics with HEC-RAS. Completed in 2009. FM 237 at 12 Mile Coleto Creek in Victoria County. Developed PS&E for bridge widening. Developed hydrology utilizing comparative gage data analysis and performed complete hydraulic analysis with HEC-RAS including potential scour calculations. Completed in 2010. TxDOT San Antonio District., From late 2010 to 2013 Mr. Downs served in the TxDOT Regional Office in San Antonio as ' a Contract Specialist working on and managing consultant contracts as well as Advanced Funding Agreements with local government agencies. In 2013 Mr. Downs transferred to the TxDOT San Antonio District Design section where he prepared PS&E packages for several roadway rehabilitation projects, including drainage structure and hydraulic analysis and design, as well as a traffic phasing plan for a major interchange project in the city of San Antonio. In August, 2014 Mr. Downs retired from TxDOT and went to work for CivilCorp in September of 2014. City of Victoria — Placido Benavides Street Project. Under the direction of Mr. Randy Janak, P.E. with CivilCorp, Mr. Downs developed the majority of the PS&E for the Placido Benavides Street Extension project in the city of Victoria. This work included hydrologic and hydraulic calculations for the centerline structures, one of which is a new proposed structure on Whispering Creek. This area is in an existing floodplain, and required a Conditional Letter of Map Revision (CLOMR) to IJ present to FEMA as part of plan development. Mr. Downs duplicated the existing FEMA model, done originally in HEC-2, to the currently required HEC-RAS format. In this process, several errors were discovered in the original FEMA model that had to be corrected in the new working HEC-RAS model to be used for analysis of the changes to the floodplain caused by the new proposed stream crossing culvert. The corrected model was updated to reflect future as built conditions and submitted I_ to FEMA for review in June of 2016. Working closely with the consultant hired by FEMA for review, the CLOMR and all supporting documents were approved in January, 2017. l LJ r4lCivilCorp Zane Charbula Graduate Engineer Mr. Charbula is a Graduate Engineer in the Victoria Office and has been providing civil engineering services for the past 3 years full time. He had two summer and two winter worth of internship experience beforejoining the team full time. He graduated from Texas A&M University Kingsville with a Bachelors Degree in Civil Engineering. In 2021, he joined CivilCorp, LLC, providing site development and utility engineering to local agencies as well as private developers. He has designed site development projects for commercial, residential and industrial facilities. He has designed publicworks projects, including street rehabilitation, water, sewer and drainage infrastructure projects, for various cities and counties. He has performed hydrology and hydraulic analysis using GEOPAK Drainage, WINSTORM, and HY-8 programs. He has also prepared the design of water, sanitary sewer, and drainage infrastructure to facilitate proposed structures. Mr. Charbula's sample projects include: PROJECT EXPERIENCE: Bon -Aire & Morningside, City of Victoria, TX: Mr. Charbula assisted with preparation of the plans and specifications for the Reconstruction of Bon -Aire & Morningside subdivision in the City of Victoria including drainage and utility line improvements. This I ' / h bb' 5 880 If f 't er includin manholes and EDUCATION: B.S., Civil Engineering, 2021 Texas A&M University, - Kingsville protect Included rep ac ng re a mg , o sane ary sew g providing over 21,000 If of new waterline as wells as fire hydrants, valves, and services. This project also included designing an underground storm sewer system and. Design also included analyzing drainage system for entire neighborhood using GEOPAK Drainage. College Park, City of Victoria, TX: Assisted with preparation of the plans and specifications for the Reconstruction of Bon - Aire & Morningside subdivision in the City of Victoria including drainage and utility line improvements. This project included replacing/rehabbing over 9,950 If of sanitary sewer including manholes and providing over 12,500 If of new waterline as wells as fire hydrants, valves, and services. This project also included designing an underground storm sewer system and. Design also included analyzing drainage system for entire neighborhood using GEOPAK Drainage. Speedy Stop, Rockport, TX Mr. Charbula assisted with preparation of the plans and details for a Speedy Stop store in Rockport, including the demolition, design, and construction of a new parking lot and underground storm infrastructure using ADS Nyloplast system. This project included drainage analysis as well. Ganado CDBG Sewer, City of Ganado, TX: Assisted with sanitary sewer improvements to serve the City of Ganado as well as plans preparation and details. Design included 2,045 If of new 6"-8" gravity sanitary sewer line with 10 new manholes. The sanitary sewer was installed using two methods, the remove and replace method and pipebursting method. Ganado CDBG Sewer & Water, City of Ganado, TX: Assisted with water and sanitary sewer improvements to serve the City of Ganado. Design included 40,000 If of new 2-8 water line, including fire hydrants, valves, and services throughout the entire project. Design also included over 20,000 If of new 8"-12" gravity sanitary sewer line with 38 new manholes as well as services throughout the entire project. Edna 2021 Bond Project, Edna, TX: Mr. Charbula assisted with preparation of the plans and specifications for the partial reconstruction of the City of Edna including ditch rehabilitation and utility line improvements. This project included replacing over 8,900 If of sanitary sewer with services including 41 manholes and providing over 14,500 If of new watedine as wells as fire hydrants, valves, and services. Seadrift CDBG, City of Seadrift, TX: Assisted with water line improvements to serve the City of Seadrift as well as plans preparation, details, and bid docs. Design included 2,600 If of new 2" & 6" water line including valves and services. I L F Ramses Macias, EIT Education Bachelor of Science, Civil Geotechnical Engineer Engineering, 2018, University of Texas Tyler - Houston Location Professional Experience Associate of Science, Mr. Macias serves as the Geotechnical Senior Staff Engineering in Terracon's Engineering Science, 2016, San Angleton office. He develops field programs specific to each project. During Jacinto College implementation of boring programs, he coordinates with field personnel. He develops laboratory programs, evaluates laboratory and field data, and Registrations/ provides recommendations for design and construction with respect to site Certifications grading, foundations, and pavements. 63863 Engineer -In -Training, Texas, He performs geotechnical calculations such as deep and shallow foundation Work History design, soil Potential Vertical Rise (PVR) calculations, and slope stability Terracon Consultants, Inc., analysis. He conducts, supervises, and coordinates geotechnical field Senior Staff Engineer, exploration and testing using ASTM and Department of Transportation (DOT) January 2022 - Present standards within Texas. Terracon Consultants, Inc., Geotechnical Staff Engineer, Mr. Macias' experience includes development of geotechnical and construction August 2019 -January 2022 material laboratory testing programs, performing pavement design, analysis, and field assessments, preparing geotechnical reports, providing earthwork Terracon Consultants, Inc., recommendations, performing calculations and design review; and completing Geotechnical Field Engineer, field assessment for energy, commercial, municipal, and county and state August 2018 - August 2019 structures and infrastructure. His training with both geotechnical field operations and laboratory testing makes him an asset to the team. He performs and supervises geotechnical laboratory tests and performs quality control on geotechnical field drilling operations to ensure high quality client deliverables. Geotechnical projects include energy, commercial, municipal, and county and state structures and infrastructure. He is involved in preparing proposals, managing project budgets, and writing geotechnical engineering reports. Project Experience Bay City Wastewater Treatment Plant Additions - Bay City, Texas J Project manager for geotechnical engineering for the proposed additions to the Bay City wastewater treatment plant. The additions included an administration building, elevated headwork structures, influent lift station, disinfection facility, blower building, dewatering buildings, aeration basin, and RAS/WAS pump station. The scope of services included field exploration, laboratory testing and project delivery. Ten borings were drilled from depths ranging from 15-25 feet. I ' Brazoria County Courthouse Expansion - Angleton, Texas The project includes various improvements near the existing Courthouse building including the following: ■ Addition of a five -story building adjacent and connect to the existing Courthouse, with a footprint of about 6 50,000 to 60,000 square feet ■ A new five -story administration building with a footprint of about 100,000 to 120,000 square feet ■ Addition of parking areas ■ Reconstruction of the existing parking and pedestrian walkways. City of Angleton Utility Expansion - Angleton, Brazoria County, Texas Project manager for geotechnical engineering for the proposed utility expansion in Angleton, Texas. The expansion included 2,00 linear feet of eight -inch diameter sanitary sewer line 13 feet below grade by open cut or trenchless method and 1,170 linear feet of 16-inch diameter waterline at 5-15 feet below grade by open cut rTerracon or trenchless method. Provided a geotechnical report that included boring logs with field and laboratory data, stratification based on visual soil classification, groundwater levels observed during and after completion drilling, 1 l site and boring location plans, subsurface exploration procedures, description of subsurface conditions, pipeline 111 construction considerations consisting of uplift pressures, lateral earth pressures, and bedding and backfill. r' Bally to Jones Creek Transmission Line — Freeport to Lane City, Texas The project involves the design and construction of a transmission line with a length of approximately 45 miles in Brazoria, Matagorda, and Wharton Counties, Texas. The proposed transmission line traverses from CenterPoint ]ones Creek Substation in Brazoria County, Texas to CenterPoint Bailey Substation in Wharton County, Texas. Ramsey Solar Project - Wharton, Texas The proposed development will include a photovoltaic (PV) solar power facility. The power facility will also include invertors, transformers, switchgear and buried or overhead power lines. In addition, a substation is planned as a part of this project. We anticipate the solar array field grade will follow the existing site grade with minimum grading required to bring the site to finished grade. Brazoria County Solar Project — West Columbia, Texas The proposed development will include a photovoltaic (PV) solar power facility on approximately 1,500 acres. The power facility will also include invertors, transformers, switchgear and buried or overhead power lines. In addition, a substation is planned as a part of this project. We anticipate the solar array field grade will follow the existing site grade with minimum grading required to bring the site to finished grade. �J ii kwmcon I r Mr. Boswell is a regulatory specialist providing strategic permitting and EXPERIENCE compliance services related to federal, state, and local environmental regulations. He works closely with clients and regulators to identify, evaluate, and document biologically sound, practical, and legally compliant permitting and compliance ' wetland delineation and mitigationbanking strategies. After obtaining his Bachelor's and Master's degrees in Entomology from Texas A&M University he has continued his passion for the outdoors by . environmental permitting working as an environmental consultant. He began his environmental career with the Ducks Unlimited Texas Regional Office working with both public and private . stream and habitat restoration land owners in efforts to restore degraded wetland habitat on their property. He continued his environmental consulting career with Houston -area consulting firms endangered species studies specializing in waters of the U.S., Clean Water Act permitting, and threatened and endangered species work. SKILLS Mr. Boswell has sixteen years of professional scientific experience and in late 2022 . AxcGIS created Compass Environmental Solutions with Matt Chastain. Mr. Boswell has focused his career on resolving complex wetland permitting challenges and he has * report preparation managed and obtained over 100 Section 404 and Section 10 regulatory permits along the Texas gulf coast alone. In addition to working with the Galveston ' project management USACE, Mr. Boswell has similarly worked and collaborated with individuals from . stream modeling USFWS, EPA, NOAA, NMFS, NRCS, TPWD, GLO, and TCEQ on various projects including Habitat Conservation Plans, Incidental Take Permits, Habitat , risk analysis and management Management Plans, Baseline Biological Inventories, and Mitigation Banking Instruments. In addition, he routinely supervises projects requiring a broad range AWARDS, HONORS, of other environmental due diligence investigations involving waters of the U.S., hazardous materials, and critical environmental features. MEMBERSHIPS Through years of experience Mx. Boswell has worked with numbers engineering ' 2010—present. Ducks Unlimited firms, many major residential and commercial developers, and public entities. His Life Sponsor project and client experience within the Fort Bend County and Greater Houston area include: TWDB, TX -DOT, Fort Bend County, The City of Richmond, ' present. Houston Museum of Natural Science numerous Municipal Utility Districts, Fort Bend County Toll Road Authority, The Muse City of Conroe, The City of Huntsville, LJA Engineering, EHRA, Odyssey EDUCATION Engineering, Costello, Cobb, Fendley, & Associates, Harvest Green, Imperial - Johnson Development, DR Horton, Energy Transfer Company, RES-Americas, Stantec, Legend Homes, Academy Development, Oxy Petroleum, Exxon -Mobile ' TO a A&MUMS m orgy, The Woodlands Campus; the Islands of Rockport, Port Bay Club Mitigation Texas A&M Un vets ty Bank, the City of Rockport, and many others. Mr. Boswell has extensive , 2007: BS Entomology experience working with the USACE, USFWS, TPWD, and NMFS in successful Texas A&M University wetland and seagrass mitigation projects, consisting of delineation, design of mitigation, implementation, and supplemental monitoringefforts. I-, PROJECT EXPERIENCE • Fort Bend County Drainage District — Buffalo Bayou Watershed Protection: Mr. Boswell managed field surveys, client and agency communication, Clean Water Act Pennitting, threatened and endangered species surveys and general project coordination for the Buffalo Bayou rehabilitation projects. These projects stretched from north of Interstate 10 along the bayou and into Barker Reservoir. Mr. Boswell worked with the USACE, NRCS, and FEMA to ensure compliance with all NEPA aspects of the projects. 1 ` *(NRCS and FEMA Related) o Jan. 2019-Dec. 2019 - Mr. Adam Wright, adam.Wright@fortbendcomgtx.gov, 281-342-0141 • Harris County MUD #50 — Texas Water Development Board EID Project: Mr. Boswell managed the entire TWDB-0801, "EID" process from proposal generation, fieldwork oversight, permitting, agency coordination, EID document drafting and submission, as well as TWDB direct coordination and liaison with the engineer of record (CobbFendley). Project was completed and received approval from TWDB within the projected timeline without significantdelays. o Jan 2018-May 2018 - o Ms. Amber Hurd, AHurd@cobbfendley.com, 936.224.7114 • Sienna Plantation MUD #1 - Texas Water Development Board EID Project: Mr. Boswell provided his environmental team with oversight and management experience on a separate TWDB project in Fort Bend County, Texas. Mr: Boswell directly assisted his team member in order to f streamline the project preparation and submittal to TWDB. t o Dec. 2016-May 2017 o Chad Hablinski, chablinski@costelloinc.com, 713.783.7788 Fort Bend County Toll Road Authority — FBCTRA Segment B2: Mr. Boswell led field crews in the delineation of 200 acres of semi -developed property in Fort Bend County. The project consists of the proposed extension of the Fort Bend County Toll Road through Sienna Plantation. Mr. Boswell managed the drafting and submission of a Standard Individual Permit with all appropriate appendices to the USACE. Mr. Boswell has helped secure financially responsible mitigation credits through an approved mitigation bank and is currently assisting the USACE in the drafting of the final decision document for the project. o Jan. 2017-Dec 2018 o Gary Gehbauer, GGehbauer@bgeinc.com, (281)558-8700 • Fort Bend County Engineering — 2017 Mobility Projects: Mr. Boswell led field staff and J scientists in the environmental investigation of approximately 35 different roadway improvement/creation projects. In most cases, investigation consisted of a Phase I Environmental Site Assessment, wetland delineation, threatened and endangered species survey, providing our professional recommendations for work moving forward. In some instances the project impacts required the need for a no PCN NWP 14 be drafted and submitted to the client to be kept on file. Mr. Boswell assisted the county with minor revisions to bank stabilization and outfall placement which allowed them to bypass direct coordination with the USACE. o March 2018 —Current o Stacy Slawinski, Stacy.Slawinski@fortbmdcomtytx.gov, 281-633-7508 • Fort Bend County Engineering — 2012 Mobility Projects: Mr. Boswell led field staff and scientists in the environmental investigation of approximately ten different roadway improvement/creation projects. In most cases, investigation consisted of a Phase I Environmental Site Assessment, wetland delineation, threatened and endangered species survey, providing our �. professional recommendations for work moving forward. In some instances the project impacts required the need for a no PCN NWP 14 be drafted and submitted to the client to be kept on file. Mr. Boswell assisted the county with minor revisions to bank stabilization and outfall placement which allowed them to bypass direct coordination with theUSACE. o March 2015-Dec 2017 o Stacy Slawinski, Stacy.Slawinski@fortbendcountytx.gov, 281-633-7508 l.� iI I, I-, COMPASS �'' ENVINUNl�ENiIE SQLN110N3 With more than 18 years of experience in the consulting industry, Mr. Chastain has managed and conducted a diverse may of marine natural resources fieldwork along the Texas and Louisiana coast. He has supervised and participated in the development and design of both mitigation and restoration areas within Texas and Louisiana, as well as supervised and assisted in the survey and collection of detailed baseline information of marine resource and ecological communities. Mr. Chastain has also utilized his extensive knowledge of coastal and estuarine systems, vegetation, marine resources (reefs, seagrass beds, etc.) turbidity, salinity, pH, conductivity measurements, temperature variations, hydraulics, and soils/substrate to determine the placement, depth, and frequency of mitigation creation. He has implemented both planned and "flexible" design plans based on existing t or unknown field conditions. Mr. Chastain has managed and participated in multiple restoration and creation projects including design and oversight, [ harvesting and planting, aquatic invasive species control, site maintenance, l and adaptive management. EXPERIENCE Maxine natural resource surveys, investigations, and evaluations Reef mitigation, design, implementation, and evaluation TES species and habitat surveys NEPA documentation Outside of marine resource investigations, mitigation, and design, Mr. SKILLS Chastain has performed hundreds of waters of the United States, including delineations/jurisdictional determinations throughout coastal and wetlands, delineations /) g multidisciplinary team leadership plains regions of Texas, Louisiana, and Mississippi. He has utilized GPS and GIS technologies for mapping significant natural resources. Mr. Chastain problem solving performed habitat and wildlife assessments, endangered and threatened species assessments, U.S. Army Corps of Engineers (USAGE) and state SPECIAL TRAINING environmental permitting for impacts to waters and wetlands, wetland AND CERTIFICATION mitigation creation and monitoring, and habitat restoration. He holds an MNRD in natural resource development and a BS in renewable natural 2020. ' Biologist DEB Certified resources, both from Texas A&M University. He is also accredited as a Professional Wetland Scientist (PWS). . 2019. I.DNR Permitted Biologist RELEVANT PROJECT WORK 2019-2023. Chesapeake SonarWiz Training Louisiana Artificial Oyster Reef Investigation ♦ Senior Project Manager 2012: Professional Wetland On three separate occasions, Mr. Chastain was contracted by the Louisiana Scientist, Society of Wetland Department of Wildlife and Fisheries (LDWF) to document and assess Scientists between 28 and 34 inshore artificial oyster reefs throughout the coast of Louisiana, once in 2014, again in 2018, and a third time in 2023. Mr. 2008: Wetland Delineation Training Course, Wetland Chastain managed and conducted comprehensive water bottom assessments Training Institute using multibeam echosounders, detailed bathymetry, and subsequent ground-truthing efforts. Surveys focused on the artificial reef placement area EDUCATION and included between 2 to 400 acres surrounding each reef location. Supporting biological information and detailed maps were then used to PP $ $r P MNRD natural resource development, development, Texas A&M l verify reef location and evaluate reef integrity. 2014-Present. University, College Station Calcasieu Lake Water Bottom and Benthic Characterization Survey * Senior ' resources, TexasrenewaA&M resources, Texas A&M ce L Ecologist/Hydrographer , University, College Station Mr. Chastain led and managed field efforts for an oyster reef assessment and L I, ' substrate characterization on—15,000 acres of public waters in the southern portion of Calcasieu, near Hackberry, Louisiana for LDWF. Mx. Chastain oversaw field efforts and surveys, including operating the side -scan sonar, single beam echo sounder, and RTK GPS, as well as oversaw field staff who hand poled and recorded data. Once complete, Mr. Chastain and his team processed all of the datasets, compiled an database for review, and coordinated with LDWF on results and recommendations for implementation of new oyster restoration and seeding projects as well as potential new private lease area within the site ( boundaries and adjacent waters. Mt. Chastain also assisted LDWF with review and comparison of the I current dataset to past surveys, to aid staff with additional planning and projections.2021-2022. Breakwater Repair and Dredging Project, Corpus Christi, Texas Senior Project Manager The City of Corpus Christi contracted with LAN Engineers to repair, replace, and rehabilitate portions of the century -old breakwater surrounding the Corpus Christi Marina as well as dredging shoaled material to accommodate continued boat access and navigation in Corpus Christi, Nueces County, Texas. Mr. Chastain led the permitting effort, including project kickoff, oversight of all fieldwork and surveys, compilation of permit applications and submittals, and agency coordination. Mr. Chastain's Texas -based team performed all fieldwork for this project, including a waters of the U.S. delineation with both marine and terrestrial surveys, threatened and endangered species assessment, and cultural resource survey. Under Mr. Chastain's direction, staff biologists compiled all pertinent reports and permitting documents per USACE — Corpus Christi Field Office standards. Due to project demands and an iterative review process, the permitting for this project 1 was determined during approvals, resulting in several changes to the permit application, all overseen by Mr. Chastain. Mr. Chastain also oversaw navigating the permit application through the USACE process, working with the project team on an avoiding and minimization impacts, and coordinating with the USACE on response to agency inquiries, response to Public Comments, and a final Decision Document. Although originally proposed as a SIP, the project was approved under several NWPs, including #3 (Repair and Rehabilitation), #35 (Maintenance Dredging), and #16 (Decant Water from Upland Containment Areas), saving budget and long-term monitoring and management costs, thanks to Mr. Chastain's intimate knowledge of the permitting process and professional relationships with USACEstaff. Morgan Harbor Water Bottom and Benthic Characterization Survey ♦ Senior Ecologist/Hydrographer Mr. Chastain led and managed field efforts for an oyster reef assessment and substrate characterization on -8,000 acres of public waters in Morgan Harbor, near Hopedale, Louisiana for LDWF. Mr. Chastain oversaw field efforts and surveys, including operating the side -scan sonar, single beam echo sounder, and RTK GPS, as well as oversaw field staff who hand poled and recorded data. Once complete, Mr. Chastain and his team processed all of the datasets, compiled an database for review, and coordinated with LDWF on results and recommendations for implementation of new oyster restoration and seeding projects as well as potential new private lease area within the site boundaries and adjacent waters. 2021-2022. ( Drum Bay Water Bottom and Benthic Characterization Survey ♦ Senior Ecologist/Hydrographer Mr. Chastain led and managed field efforts for an oyster reef assessment and substrate characterization on —900 acres of public waters in Drum Bay, south of Hopedale, Louisiana for LDWF. Mr. Chastain oversaw field efforts and surveys, including operating the side -scan sonar, single beam echo sounder, and RTK GPS, y as well as oversaw field staff who hand poled and recorded data. Once complete, Mr. Chastain and his team processed all of the datasets, compiled an database for review, and coordinated with LDWF on results and recommendations for implementation of new oyster restoration and seeding projects as well as potential new private lease area within the site boundaries and adjacent waters.2021. L I r r4CIvilCorp ENGINEERS • SURVEYORS 4611 E. Airline Rd. Ste: 300 Victoria, TX 77904 Randy Janak, PE, CFM rjanak@civilcorp.us (361) 570-7500 Texas PE Firm Cert#10283 0 I L 11 (- STATEMENT OF QUALIFICATIONS f ENGINEERING, ARCHITECTURAL, & SURVEYING, SERVICES "§' PS EN INEERS o" Request for Qualifications (RFQ) for Engineering, Architectural 05,q` �. and Surveying Services -For CMP Cycle 29 Grant, GLO ��� OJt1i, Contract No. 25-003-009-E702 New Amenities at Bill Sanders G County Park Project RFQ #2024-11 TEXAS REGISTERED PROFESSIONAL ENGINEERING FIRM: F04188 205 W. LIVE OAK- PORT LAVACA, TX 77979 P: (361) 552 - 4509 F: (361) 552 - 4987 Table of Contents COVER LETTER COMPANY NARRATIVE STAFFING PROFILE ENTITY JUSTIFICATION A B C D MAJOR SUB -CONSULTANT INFORMATION E REFERENCES SCOPE OF WORK / SERVICES LITIGATION HISTORY REQUIRED FORMS 17 [a Iw I I Cover Letter I-, I t }. �hn"{}+`1y jljrin`'"1�i�fi ;i ei y G& W Engineers9 Inc Honorable Richard H. Meyer Calhoun County Judge 211 S. Ann St. 3' Floor, Suite 301 Port Lavaca, Texas 77979 November 4, 2024 Dear Honorable Richard H. Meyer, G&W Engineers, Inc. is pleased to submit our Statement of Qualifications (SOQ) for your consideration for providing professional engineering, architectural and surveying services to the Calhoun County, Texas. We offer an experienced team of in-house civil/structural, land surveying, electrical, and mechanical engineering professionals who have experience in the various facets of building design, utility, municipal, and marine / environmental engineering. G&W understands that Calhoun County intends to enter into a professional services contract to assist the County in engineering/architectural/surveying services, partially or fully funded through GLO allocation. G&W is a privately held firm, registered in the state of Texas as TBPE F-04188 and has no record of substandard work or unethical practice. G&W has no potential conflicts of interest. I invite you to closely review the enclosed resumes of the professional team proposed for the requested services. G&W Engineers, Inc. has worked extensively with local governments since being formed in 1979. This past experience, together with our knowledge of pertinent county design considerations, will provide technical expertise and an efficient project design solution, centered on effective communication with the. County. Thank you for allowing us to submit our qualifications. We look forward to the opportunity to answer any questions you may have and to work with the County. If you require additional information, please do not hesitate to contact me. Sincerely, G&W Engineers, hne ' /` 4 Brian Novian, P.E President �, +361.5524509 lig.L{i��i>,��L;u..�erv_cr{in ® gwengineeis.��'ordpresn.con� I' Company Narrative E- 1 I, I' L f;fy EN INFERS G&W ENGINEERS, INC G&W Engineers, Inc. has been in business as an engineering firm under their present name since they were incorporated in the State of Texas in 1979. G&W is a privately held firm, registered in the State of Texas as TBPE F-04188. G&W is a multi - disciplined consulting engineering firm that offers a broad range of engineering services, including civil, structural, marine, mechanical, electrical, instrumentation, project planning, design and inspection. Our Company headquarters are in Port Lavaca, Texas, G&W offers an experienced team of planners, surveyors and engineers that have worked on many local, state and federally -funded projects consisting of a variety of improvement projects in this general region of the state. We believe our past experience with these types of projects will provide them with the complete technical capability to expedite the planning, design, and construction phases of associated projects. PROJECTS Alarm Systems Biomass Systems Cathodic Protection Chemical Docks for Ships andBarges Commercial Electrical Design Concrete and Masonry Conveyor Systems • Drainage and Floodplain Studies Dust Collecting Systems Erosion Protection Ethanol Terminals Fire Protection Systems Foundation Design Harbors, Docks, Piers Heating Ventilation and Air Conditioning Evaluation and Design KEYQUALFICATION& PRINCPLES. G&W has established excellent working relationships with many regulatory and permitting agencies. • G&W has maintained a reputation throughout the years as technically proficient, capable, competent, reliable, and trustworthy local engineering service provider. • G&W always stays on the job until the project is complete, not when the budget runs out. • G&W's client satisfaction is important, engineer smart solutions on time and on budget in order to exceed client expectations. • Landfill Design and Development • Marine Bulkheads • Municipal Electrical Design • Oil and Gas Terminals • Parks and Sports Complexes • Petroleum and Ag Based Terminals Power Generation Railroad Terminals • Roads and Streets • Solar Power Systems • Steel Structures • Subdivision: Planning and Design • Utility Treatment Facilities OUR SERVICES • Civil Engineering • Controls Engineering • Electrical Engineering Mechanical Engineering Marine Engineering • Process Engineering GIS Control Cabinet Fabrication Control Systems Programming Construction Management Land Surveying Procurement Windstorm Inspections G&W Engineers maintains a complete suite of up-to-date engineering and design tools and discipline specific 3D computer aided design/drafting tools. We also have a fully -staffed surveying department, experienced in all types of surveying and fully equipped for Global Positioning System (GPS) surveying, along with up-to-date, state-of-the-art computer -aided design/drafting (CARD) facilities. µ. G&W maintains a well -established quality assurance and quality control (QA/QC) program, which enables our professional team to achieve desirable cost-effective solutions for the client within often demanding schedules. Our in-house reviews assure quality control by focusing on meeting the client's intent for the study, assessment, design and/or construction; conforming to the terms of the agreement; maintaining scheduling requirements; keeping costs within the budget and carefully L reviewing all reports for clarity, completeness, technical accuracy, consistency of format. A� _, We are especially pleased that a large portion of our work involves repeat j„ business, which demonstrates not only our technical expertise, but also J our personal commitment to all of our current and former clients t, G&W offers an experienced team of planners, surveyors and engineers that have worked on a multitude of industrial, marine, drainage, roadway, petrochemical, oil/gas, and water/wastewater improvements. We believe our past experience with these types of projects and our local presence will provide the client with the complete technical capability to expedite the completion of the planning, design, and construction phases, so that the project can be fully executed within the shortest amount of time possible. G&W and its professional team stand ready to bring your L I Staffing Profile I G&W is prepared to commit responsive resources of our facilities and professional personnel with the creative insight to assist and consult Calhoun County, Texas, as requested. Additionally, engineering support will be provided by G&W's in-house staff of surveying technicians, staff engineers, CADD technicians, construction oversight personnel and engineering assistants. Additional staff will be allocated if the need arises and will be under the direct supervision of the assigned Project Manager during the preparation of technical documents and construction drawings. G&W is fully staffed with several different Project Managers, each with various different backgrounds. Thus, it ensures that your projects needs are taken care of. Depending on the type of project G&W will assign the best fitted Project Manager, Mr. Mason has a broad range of engineering knowledge and successful project experience. Mrs. Jasek has experience knowledge and background with road design as well as drainage. Her time working at TxDot and the City of Bay City has proved to be a valuable leader and communicator at G&W. Proposed Project Managers Marla Jasek, P.E. CFM Mrs. Jasek has successfully completed many grant projects involving roads and drainage. Her attention to detail, through planning, and linear communication when working with entities and their grain administrators will bring you a piece of mind that your project is in the right hands. Scott P. Mason, P.E. Mr. Mason has gained a lot of recognition for his efforts regarding Texas' recent projects and is fully prepared and available to assist you with your projects. He has successfully led grant projects to completion and has played key roles in representing public entities to ensure that they are properly funded and also coordinated many entities grant funds. Mr. Mason is the qualified professional engineer to be tasked with your future grant projects. For more of Scott and Marla's expertise, please look over their detailed resumes. Scott P. Mason, P.E. Civil/Marine/Windstorm Engineer 361-552-4509 x237 smason@Rwenaineers.com Best Individual Engineer in Calhoun County 2023 e�Weersi EDUCATION B.S., Biological & Agricultural Engineering, Mr. Mason has over twelve (12) years of experience in the Civil and Environmental Texas A&M — College Station, TX 2013. fields, with design and project management related to marine projects, municipal water, sanitary sewer and storm sewer projects, residential and commercial land development A.S. Science, Blinn College — Bryan, TX 2009 projects, airport projects, public water systems and storm water drainage projects. Mr. r Mason has been responsible for all phases of a project from preliminary conception to L execution of record drawings. He has worked closely on projects with the Texas REGISTRATION Commission on Environmental Quality to ensure compliance regarding public and private projects, as well as, the Texas Water Development Board for projects funded by ( Registered Professional Engineer, Civil ! various mechanisms, as well as, projects funded by the Community Development Block Texas Serial No. 127893 Grant program. He has extensive experience with technical engineering reports Louisiana Serial No. 42827 representing municipalities and private interest groups for submission to governmental Windstorm Appointed Qualified Inspector agencies by practicing sound engineering judgment. Mr. Mason strives to provide Texas Department of Insurance quality engineering solutions for a wide range and size of projects. PUBLIC PROJECTS EXPERIENCE o Little Chocolate Bayou Park, Calhoun County 2017-Present Lead Project Engineer, G&W Eneineers. Inc.. Port Lavaca. Texas. o Six Mile Boat Ramp, Calhoun County o Magnolia Beach Boat Ramp, Calhoun County Responsible for all civil engineering related projects, public representation, drafting staff and environmentally conscious design o Little Chocolate Boat Ramp, Calhoun County for public and private projects. Ongoing work includes being the o Generators, City of Port Lavaca primary contact for the FEMA Public Assistance Program for disaster o Generators & Pumps, City of LaWard related damages and for the Texas Water Development Board grant o Generator & Lift Stations, City of Seadrift program by representing local Water Control Improvement Districts Alamo Beach Drainage, Calhoun County and Municipalities. Mr. Mason also previously served as the District �10 Engineer for the Victoria Comity W.C.I.D. #1, which included plan o 120k Ground Storage Tank, CCWSC reviews, responsible engineering decisions for the district, which o Smart Water Meter System, POCID included maintenance decisions of the water, sewer system, and waste fo Bayfront Seawall, City of Seadrift water treatment plant. Currently serves as Victoria County W.C.I.D. L o Bayfront Restroom, City of Seadrift #2 District Engineer. Other work involving engineering solutions, o Parking Lots, Tidehaven ISD cost estimates and reports for local navigation districts regarding projects and large port expansion projects. Mr. Mason also has (' o Rockport Harbor Breakwater, ACND extensive experience in Marine related projects including, o Fulton Harbor Breakwater, ACND breakwaters, piers, marinas, boat ramps and coastal structures. Lastly, o Pavilion Restoration, ACND Mr. Mason has served as project engineer for dozens of subdivision o Rattlesnake Kayak Launch, ACND projects both large and small. o Maintenance Building, ACND 2013-2017 Civil Engineer•, Urban Engineering Victoria. Texas. o Cove Harbor Building, ACND o Beach Entrance, ACND Design of multiple public water systems, including permitting, o Pier Repairs, Calhoun County engineering plans and specification for said systems. Water and sewer o Dispatch Building, Calhoun County utility replacement design for historical regions of cites including 0 121hto 151h ST. Erosion, City of Seadrift large scale projects for the City of Victoria. Commercial and residential development, including but not limited to, roadway design, drainage design, utility design, pier and bulkhead design, cost COMMITTEES estimates and mitigation design. Assisted with the Victoria ISD traffic Wharton County Junior College study and provided project coordination and oversight. Work related L, Engineering Design Department to large apartment complexes and subdivision developments. Advisory Committee L Marla Jasek, 1 .E., CFM enQi ee s \Z1004 Civil Engineer 361-552-4509 x223 j' marlal 2wengineers com - Mrs. Jasek has over thirty (30) years of experience in the Civil Engineering, with design, construction, and project management related EDUCATION to roadways, bridges, traffic systems and traffic safety projects; highway beautification and Main Street projects; municipal water, sanitary sewer and stonn sewer projects; municipal buildings and building B.S., Civil Engineering, University of Texas inspections; residential and commercial land development projects; airport — Austin, TX 1992, projects; and storm water drainage projects. Mrs. Jasek has been responsible for all phases of a project from prelhnhnary conception to project closeout. Throughout her career, she has worked closely with various public agencies, developers, and contractors to ensure all conditions of grants and funding agreements are met. Mrs. Jasek has also REGISTRATION overseen numerous projects as they relate to infrastructure improvements and disasters including projects funded through FHWA, FEMA, HMGP, TDEM, CDBG, TWDB, HGAC and the GLO. She has Registered Professional Engineer, Civil extensive experience preparing technical engineering reports, project Texas Serial No. 83938 budgets, funding agreements, contract documents, project specifications, (' and plans. Mrs. Jasek's career has been dedicated to serving the citizens of Certified Flood Plain Manager Texas and the communities that she represents. Certificate No. 2858-15N EXPERIENCE l t 2020-Present ProiectEiwineer, G&WEnrineers Inc Port Lavaca Texas Responsible for civil engineering and commercial EJ development projects. Prepares engineering documents for traffic studies, flood plain management and various permits. 2013-2020 Assistant Director ofPublic Works City ofBay City, Texas L Assisted the Director of Public Works with all departments and duties. Directly supervised and coordinated work for Street and Bridge, Facility Maintenance, the Building Department (permitting), Fleet, Recycling and office personnel. Served as primary contact for all new development. Worked with various agencies and consultants on grant application submittals, design review and construction projects. Lead on city's Hurricane Harvey damage assessment and reconstruction efforts. 1993-2013 Texas DenarhnentofTransyortation Yoakum District Texas Highest position held was the District Director of Transportation Operations. Worked in the Yoakum District office in multiple sections including traffic, planning/design, construction and maintenance. Also worked in the Yoakum Area Office. Coordinated with various cities and counties for TxDOT programs (Safe Routes to School, Keep Texas Beautiful, etc.) and in executing advanced funding agreements for local projects. I" I L Brian P. Novian, P.E. e President 361-552-4509 x238 noviali@gwenamcers.com EDUCATION B.S., Electrical Engineering, University of Texas at Austin, 1982. REGISTRATION Registered Professional Engineer, Electrical, Mechanical Texas Serial No. 63931 PROJECTS EXPERIENCE I/E Engineering Manager o Economizer / Fly Ash / Bottom Ash / Scrubber Systems (>30) o Bulk Terminals RaillTruck (>12) o Bulk Terminals Barge/Ship (>8) o Water Booster Pump Stations /Wastewater Plants (>10) o Automated Fire Fighting Control Systems (>3) o Groundwater Remediation Control Systems (>4) o Solar / Wind / Biomass Power Systems — (>6) o Security Systems — Video, Access Control, Detection, Analytical (>10) Process Engineering & Project Management Experience o Alternative Energy Production — Heat Recovery / Waste Incineration / Biogas / Solar o Conventional Energy Production — All Fossil Types o Underground and Overhead Power Distribution (up to 33kv) o Delayed Coking o Vapor Recovery and Destruction o Bulk Conveying Systems o Product Recovery —Vapors (Refrigeration), Fine Solids (Dust Collectors / Bag Houses) o Distillation Processes — Alcohol, Hydrocarbons, Purification o Efficiency Analysis — Heat Rate / Cycle Performance / Regenerative Process Control System Architecture o Working knowledge with the following control system architectures: o Foxboro I/A; Honeywell TDC3000; A/B — all Types; Delta V; Modicon; GE Mr. Novian is the President of G&W Engineers, Inc. and has over 27 years of Process Engineering, Project Management, and Electrical Engineering experience. He has extensive experience in power, chemical, refining, municipal and marine environments with special emphasis on process design/analysis, power generation, and process control systems. Mr. Novian specializes in developing a given process from conception, to production, including control algorithms, and operational performance analysis/enhancement. He is experienced in a multitude of process control / relief valve sizing, rupture disk sizing, flow sizing, and equipment sizing applications utilizing API and NFPA codes and possesses a fall working knowledge of the NEC. He can also develop batch, sequential and/or continuous control strategies in the following technologies: Pneumatic; Hardwired; Discrete/Analog; Ethernet; Digital (Fieldbus) Wireless. L Henry A. Danysh, R.P.LS. Lead Surveyor��, 361-552-4509 x233 hdanyshAagwengmeers.com EDUCATION Advanced Survey Technician Program at Texas A&M University, 1982 Annual Continuing Education Credit Hours. REGISTRATION Registered Public Land Surveyor Texas Serial No. 5088 Mr. Danysh has over 30 years of surveying experience, completing a wide variety of projects in the public, private, and industrial sectors. Mr. Danysh manages the survey crews and coordinates all field and office scheduling for the surveying department. He has expertise in all aspects of Boundary and Engineering Design Surveying, including over 15 years of experience preparing design and right-of-way surveys for TxDOT projects throughout the region. Henry performs the final preparation and Quality Control review of all Legal Descriptions and Plats. Marron J. Gann Construction Observer/ Engineering Designer e�' 361-552-4509 x255 dgann(a p,ongineers com Mr. Gann has over twenty (20) years of training and experience in the construction industry. His experience includes a general knowledge of mechanical, electrical, structural, and civil design projects, operation and maintenance concerns, materials testing, as well as equipment operations. He is well established in his capability to evaluate, document, coordinate, and schedule all necessary operations during construction to ensure compliance with the intent of the plans and specifications as well as all applicable construction standards and local, state, and federal requirements. He has provided periodic and continuous on -site representation on numerous projects, including utility system improvements projects in the locales of Nordheim, Bloomington, Ganado, LaWard, and Port O'Connor, Texas. Darron provides daily coordination, communication, scheduling and observing of all construction activities applicable material testing procedures. Mr. Gann's detailed documentation skills allow for the chronological recreation of the construction phase of all projects, as may be required. Darron holds a D Wastewater Treatment Operator License, a D Water Operator License, and a Customer Service Inspector (CSI) License. When not assigned as a Construction Observer, Mr. Gann assists in the office, with his CADD capabilities and general knowledge of design requirements, in the preparation of detailed plans and specifications relating to municipal "Public Works" type projects. His experience in the preparation of contract documents has enhanced his ability to review and interpret detailed construction plans and specifications to ensure full compliance with the intent, and document the procedures accordingly. 1998-Present Construction Observer/Engineering Designer, G & W Engineers, Inc., Port Lavaca, Texas 1997-1998 HVAC Installation, Maintenance and Repair, Coastal Refrigeration, Port Lavaca, Texas 1996-1997 Self Employed, Construction, Maintenance and Repairs, Commercial & Residential 1988-1996 Foreman/Equipment Operator, J.K. Farm and Ranch 1987-1988 Foreman, Port Sheetmetal, Port Lavaca, Texas L I I, Entity Justification Ij I [; G&W Engineers, as mentioned in our introduction, employs a skilled Uwe', set of professionals and supporting members for accomplishing a Mh wide range of complex engineering projects. G&W is confident thatour diversely qualified staff provides sound engineering performance and that our multi-dicipline firm provides a major benefit to our clients, in being what we consider to be a "One -Stop" engineering firm. G&W is highly interested in potential project(s). Providing professional services to those affected by a natural disaster and/or representing a client for projects with the purpose of mitigating future impacts, is a priority for G&W, as we understand the circumstances and impacts of such positive projects. Staffing and professional consultation representing the client will be provided by G&W. Implementation and oversight of qualified and available staff will be of the utmost importance to G&W. G&W will be able to allow for work to commence immediately following an executed agreement. G&W Engineers, Inc. understands that Calhoun County, Texas, is requesting qualifications from experienced individuals, firms, companies, or other entities to provide Engineering, Architectural, and Surveying Services — CMP Cycle 29 Grant, GLO Contract NO. 25-003-009-E702 New Amenities at Bill Sanders County Park, RFQ #2024-11 to Calhoun County, Texas, which may include but is not limited to providing information, professional services, advice, producing deliverables and more. The specific project involves survey, drainage design, roadway design, construction documents, and construction phase services. Calhoun County anticipates utilizing funds to complete engineering services necessary to implement projects, surveys and studies at Bill Sander County Park. The park projects will include activities such as expansion of existing boating parking lot by 1,000 square feet, with striping and Americans with Disabilities Act (ADA) designations and construction a 13,000- foot walking trail throughout the park. Our competent professional team stands ready to assist the you and ensure that your project is a priority and stays a priority. G&W has provided engineering expertise for federally funded projects for over forty (40) years and recently has worked extensively with over seven (7) public entities which includes dozens of projects with GLO, FEMA, and TDEM funding. The team at G&W is highly qualified to take on the potential project outlined in the scope above. Proper G&W staff is available and will be allocated immediately should G&W be selected as the engineering firm for vour nroiects. L Major Sub - Consultant Information 11 G&W Engineers, Inc. does not anticipate using any Sub -Consultants for this project. I 1, I r List of References 1, Over the years, G&W Engineers has successfully completed numerous park projects, showcasing our commitment to enhancing community spaces. We invite you to call our references listed to below. For our previous relevant projects within the past few years see below. ( Mr. David Hall Commissioner Pot 1 Calhoun County 305 Henry Barber Way David.Hall@calhouncotx.org 361.552.9242 Mr. Keith Barrett Harbor Master Aransas County Navigation District 911 Navigation Circle Rockport, Texas aransasnav l gy ahoo. com 361.729.6661 Mr. Kenneth Reese Department Head: Public Utilities City of Seadrift 501 Main Street Seadrift, TX 77983 reeseII08@yahoo.com 361-649-6525 • Rockport Beach Pavilion Restoration Project o G&W was responsible for providing a preliminary damage assessment along with budgetary cost estimating, which was submitted to FEMA, and provided planning and restoration design plans for four (4) 3,800 SF ea. pavilions damaged by Hurricane Harvey. The project included windstorm design, roof replacement, HVAC repairs/upgrades, electrical and lighting, providing bidding support in accordance with federally funded projects and mitigation measures to ensure that the restored pavilions will be less susceptible to future disasters. • Rockport Beach Bird Observation Deck Project o This project included adding a 14'x20' natural thatch roof with round cedar members and construction of an access walkway. • Rattlesnake Point Kayak Launch Restoration Project o G&W worked with the Aransas County Navigation District to restore the boat/ kayak launch at Rattlesnake Point which was damaged as a Result of Hurricane Harvey (2017). This project was a federally funded project by FEMA PA, in which G&W had to work closely with the District to ensure the project met all federal requirements. • Rockport Beach Walk / Jog Trail Rehabilitation Project L o This project included rehabilitant of an existing walk / jog trail which includes minor paving fixes in areas where the existing trail is cracked from heaving and increasing the I elevation of the trail in an area where it is susceptible to storm water inundation and d resurfacing the entire trail with HMAC. • Rockport Beach Entrance Improvements Project o G&W worked with the Aransas County Navigation District to revitalize the historic and much used Rockport Beach Entrance. This included careful designing and planning to ensure that the new look would meet increasing guest usage as well as improve the look of the entrance for years to come. This project included the design of two new guard houses / ticket booths as well as various road improvements. • Little Chocolate Bayou Park Project o G&W worked with Calhoun County Precinct No. 1 to help with plans to improve Little Chocolate Bayou Park. This included elevated covered area with ramps and sensory activities at the structure including tic-tac-toe, driving wall, monkey bar sets, a ziplines, a merry go round, swing sets, slide, compliant surface and retainage, all necessary earthwork to facilitate a complete playground package. • Chocolate Bayou Boat Ramp t o G&W worked with Calhoun County Precinct No. 1 to create plans and obtain permits j through the USACE for the construction of anew 20' wide by 60' long boat ramp and t 150 linear feet of new vinyl bulkheading for the County Boat Ramp. G&W also worked with the Commissioner to provide appropriate documentation to the Texas Parks and Wildlife department. The project reclaimed existing shoreline and streamlined it to ensure a boat ramp area would last and be utilized for years to come. This project has provided the county citizens with a new hot fishing spot both day and night. • A.D. Powers Bayfront Park Seawall Restoration Project o This project included over % of a mile of new seawall bulkheading design, raising the elevation of the cap by 2 feet and placing a new bigger wall in front of the existing wall. j The design also incorporated amor stone in front of the new wall, brand new drainage L system and grading behind wall to allow for longer life with water being forced away from the wall. A new section of wall will be extended on the east side to the 3rd street bridge abutment and filled in to stream line the flow of water and create less "pockets" for higher forces of water and in return erosion. This project G&W assisted with our subconsultant to provide USACE individual permit and is funded by FEMA and GLO. j( The original wall was built in the early to mid 1960s. L, • A.D. Powers Bayfront Park Restroom Project o Installation of a pre -fabricated windstorm rated two stall restroom on a new concrete ffoundation, new sidewalk and parking, concrete retaining wall, appropriate fill as L required, installation of utility services and demolition of the existing restroom for a complete project in place. • Restore A.D. Powers Bayfront Park West End Improvements o This project consisted of the installation of a new courtesy pier, bollards, mooring piers, limestone access and parking area, appropriate fill as required, and demolition and removal of the existing dock for a complete project in place. L CITY • City of Austwell • City of Bayside ` • City of Bay City • City of Edna • City of El Campo • City of Gando • City of Goliad • City of Gonzales • City of LaWard • City of Nordheim • City of Point Comfort • City of Port Lavaca • City of Seadrift • City of Victoria COUNTY • Calhoun County • Goliad County • Matagorda County • Refugio County • Wharton County GOVERNMENT_AGENCIES WE HAVE WORKED WITH: • Community Development Block Grant (CDBG) • Federal Emergency Management Agency (FEMA) • Texas General Land Office (TGLO) • Texas Historical Commission (THC) • Texas Parks and Wildlife Department (TPWD) • US Army Corps of Engineers (USAGE) OTHER CLIENTS: • Aransas County Navigation District • Bay City I.S.D. • Calhoun County Navigation District • Cape Carancahua P.O. A. • Cape Carancahua W.S.C. • Ganado I.S.D. • Guadalupe Blanco River Authority • Lavaca Navidad River Authority • Lower Colorado River Authority • Matagorda County Navigation District • Matagorda County W.C.I.D. #5 • Matagorda County W.C.I.D. #6 • Matagorda Waste Disposal & W.S.C. • Port Lavaca Port Commission • Town of Fulton • Texas Department of Transportation • Tidehaven I.S.D. • South Central Calhoun County WCID #1 • Van Vleckl.S.D. • Victoria County W.C.I.D. #1 • Victoria County WC.I.D. #2 • Victoria I. S.D. • Port O'Connor I.D. • Jackson County W.C.I.D. #1 Services L I Services • Initial and final engineering and design support • Bid and award Support • Contract management and construction oversight. • Design of shore protection projects and coastal structures; • Design of outdoor recreational infrastructure such as pavilions, walking trails, and ' parking lots; - • Economic analysis of public and/or private recreational and environmental benefits and cost allocation strategies; • Development of construction plans and specifications, bid documents, and bid analysis; • Regulatory issues and permitting management and oversight; • Construction management and oversight; • Geotechnical and geophysical investigations necessary for the design of coastal engineering construction projects; • Monitoring and data collection; • Marsh and wetland monitoring; • Management planning and sediment source identification and quantification; • Storm hazard analysis, failure analysis, probability, and certainty; • Study of long-term response to coastal hazards, such as hurricanes, severe rain events and river overflow; • Independent engineering review of all above -mentioned services. General Requirements • Coordinate, as necessary, between Calhoun County and its service providers (i.e., 1_ Engineer, Environmental, Contracted Construction Company, and Grant 1 Administrator, etc.) regarding project design services; • Provide monthly project status updates; • Funding release will be based on deliverables identified in contract Initial Engineering and Design Support L• Provide all project information necessary to ensure timely execution of the environmental review; • Provide preliminary engineering, investigations, and drawing sufficient to achieve the preliminary design milestone, including at a minimum: a) Cross sections/elevations b) Project layout/staging areas c) General notes d) Special notes e) Design details f) Specifications L g) Utility relocation designs h) Construction limits, including environmentally sensitive areas that should be avoided during construction i) Required permits j) Quantities k) Estimate of construction costs to within +/- 25% 1) Schedules for design, permitting, acquisition and construction • Design surveying, topographic and utility mapping; • Perform subsurface explorations for project sites, as necessary; • Prepare horizontal alignments/layouts for all proposed project alternatives necessary to fully describe the project scope, anticipated limitations and potential impacts; • Recommend value engineering options (alternative design, construction methods, procurement, etc.) that may efficiency, expedite the schedule, or reduce project costs for Calhoun County; • Identify, acquire and submit all necessary permits and approvals required for design approval and construction; • Submit all necessary deliverables to the appropriate entity for review and comment. Adjust project and/or design to satisfactorily address any comments, as necessary; • Prepare plans and profiles, including vertical design information for the selected alternative; • Identify and address potential obstacles to project implementation (i.e., pipelines, easements, permitting, environmental, etc.) prior to moving forward with the final design; • Support Calhoun County with acquisition or property/servitudes/right-ow-way documentation as required by the City to facilitate the project, preparing right of way surveys and /or property boundary maps and legal descriptions of parcels to be acquired. Engineering and Final Design Support • Prepare plans and profiles, including necessary design information for the selected alternative sufficient to achieve all detailed design milestones. • Provide information to appropriate individuals for the development of environmental fund release reports and floodplain maps; • Identify, acquire and submit all necessary permits and approvals required for design approval and construction; • Provide hard copy, if necessary, reproducible plan drawings and bid documents, in addition to electronic copies to Calhoun County, upon design completion, and as requested during design. Electronic copies should be in the native format (AutoCad DWG) along with PDF packages and should contain all corresponding references, databases, or files associated with the completed design documents; L, • Assist Calhoun County and any service provider related to the project with all necessary documentation to ensure compliance with all Program requirements and regulations. f Bid and Award Support t - a) Submit appropriate items and support Calhoun County in the development of complete bid package b) Prepare and assist Calhoun County in the advertisements for bid solication; c) Support development and issuance of bid -related documents necessary - to complete bid process (e.g., bid proposal form, bid addenda and supporting documentation); d) Attend and support Calhoun County at pre -bid conference and bid opening; e) Support Calhoun County with ongoing communication during bid process; f) Support Calhoun County to complete bid tabulation and evaluation responses and provide recommendation for award; g) Support Calhoun County to negotiate and finalize contract documents, including issuance of the Notice to Proceed, in accordance with program and Calhoun County requirements; h) Support Calhoun County in the conducting of a preconstruction conference Contract Management and Construction Oversight a) Ensure delivery of Calhoun County project in accordance with contract; b) Provide ongoing Construction Oversight Reports detailing the status of construction for Calhoun County project; c) Review all service provider submittal to ensure compliance with construction contract and documents and provide recommendations to Calhoun County; d) Provide periodic and final inspections and test reports, as required for the project; �J e) Provide on -site supervision and oversight of construction activities at a minimum on bi-weekly basis or as directed by Calhoun County; f) Review Construction Change Orders and provide recommendation to lCalhoun County as to appropriate action; 1, g) Review invoice/draw requests and provide recommendation to Calhoun ( County as appropriate action, in compliance with the construction contract f l documents; h) Obtain independent cost estimates for validation purposes, as required; i) Review and respond to requests for information/clarification j) Support Calhoun County with issue identification and claims resolutions; k) Develop a final "as built" report of quantities, drawing, and specifications; 1) Issue to Calhoun County, for execution, a Certificate of Construction - Completion within 30 days of final inspection approval; m) Deliver "as -built' drawings to Calhoun County within 30 days of project completion; n) Host and/or attend project coordination meetings in person, by phone, or by video conference, which may or may not fall during normal business hours; o) Perform other contract management and construction oversight duties as required to ensure success of the Calhoun County project; p) Provide necessary certifications to regulatory agencies of project completion and compliance (ex. TCEQ); q) Submit all final invoices within 60 days after contract or work order expiration Specialized Services -: a) Provide Geotechnical Investigations as may be required for a project; b) Provide detailed surveying as may be required for a project; c) Provide site specific testing as may be required for a project; d) Provide archeological studies as may be required for a project; e) Provide planning studies as may be required for a project; f) Provide feasibility studies as may be required for a project; g) Provide legal documentation for property and/or easements to be acquired (i.e., field notes, etc.); h) Provide Phase I and Phase II environmental site assessments as requested. F, Litigation History G&W Engineers, Inc. does not have any previous Litigation History pending over the past three (3) years. I, Required Forms 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. 2024.1228897 G&W Engineers, Inc. Port Lavaca, TX United States Date Filed: 10/21/2024 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: 9 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 underthe contract. RFQ 2024.11 ENGINEERING, ARCHITECTURAL AND SURVEYING SERVICES FOR CMP CYCLE 29 GRANT, GLO CONTRACT NO. 25-003- 009-E702 NEW AMENITIES AT BILL SANDERS COUNTY PARK 4 Name of Interested Party City, State, Country (place of business) Nature of Interest (check applicable) Controlling Intermediary Novian, Brian Port Lavaca, TX United States X Danysh, Henry Port Lavaca, TX United States X Gohlke, Anthony Port Lavaca, TX United States X Sappington, Michial Port Lavaca, TX United States X 5 Check only If there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is Brian Novian and my date of birth Is 01/23/1960 My address is 205 W. Live Oak Street PortLavaca TX 1 77979 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed In CALHOUN County, State of TEXAS on the 21 day of October zD 24. (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V4.1.0.48da51f7 L STATE OF TEXAS 0 AFFIDAVIT COUNTY OF Calhoun {} Brian Novian being first duly sworn, deposes and says: that he or she is (Type or Print Name) the President of G&W Engineers, Inc. having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 205 West Live Oak Street (Type or Print Physical and Mailing Address) who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. ( i Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other i bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a r, bid/proposal or withdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, L organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the cions nd requirements contained in the bid/proposal. Signature of Affiant Brian Novian President Printed Name and Title of Affiant SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath, states that the facts contained in the above are true and correct, this 4th day of November 20 24 AnY !r Vrt.� a:4PA 48n,, GLYNIS ICING Notary Public, State of Tex Comm. Expires 06-20.2021gr7flNotajr L Notary Stamp/Se°+� Notary ?.�1147037.5 Page 29 of 52 r 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. Brian Novian, President Name and Title of Authorized Agent 2L Signature of Authorized Agent 11/04/24 LI am unable to certify to the above statements. My explanation is attached. Page 32 of 52 {r 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 l 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, G&W Engineers, 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 Brian Novian President Printed Name and Title of Contractor's Authorized Official 11/04/24 Date Page 33 of 52 f, 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. t Name of vendor who has a business relationship with local governmental entity. G&W Engineers, 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.) 2J Name of local government officer about whom the information is being disclosed. N/A Name of Officer 4J Describe each employment or other business relationship with the local government officer, ore 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 IFAv 11 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. s ❑ Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 4 11/04/24 Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us p4�pN§tq5V/30/2015 I, Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nublic burden disclosure) 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract X a. bid/offer/application X a. initial filing X b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan For material change only: c. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. 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: 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, tart name, first name, MI): di/fereni fi»m No. IOa) Gast 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 Brian NOvlan representation of fact upon which reliance was placed Print Name: by the tier above when this transaction was made or President 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.: 361-552-4509 Date: 11/04/24 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) Page 37 of 52 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 85th Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Brian Novian , do herebyverify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently, 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.gov/purchasing/publications/divestment.l)hp G&W Engineers Company Name �_. Signature of Authorized Official President Title of Authorized Official Brian Novian Printed Name of Authorized Official 11/04/24 Date Page 38 of 52 RESIDENCE CERTIFICATION Pursuant to Texas Government Code §2252.001 et seq., as amended, Calhoun County requests Residence Certification. §2252.001 etseq. 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) X I certifythat G&W Engineers is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. /1 = / Z Signature of Authorized Agent Brian Novian, President Printed Name and Title of Authorized Agent 11/04/24 Date r L I- Page 39 of 52 I "/MP Request for Taxpayer Give Form to the Form V (Ray. October 201a) Identification Number and Certification requester, Do not Depanment of theTreasury Internal Revenue Service ► Go to www.irs.gov/FarmW9 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. I 2 Businessnameldlsregarded en iry name, ifdlfferent from above 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 m following seven boxes, certain entities, not Individuals; see. p IndlvlduaVsole proprietoror C Corporation ElS Corporation El Partnership ❑ TruaVestate Instructions on page 3): . 0 �'�. y single -member LLC. Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=G corporation, S=S corporation, P=Partnership) ► `0 2 Note: Cheek the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting. �i •e5 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) a' 0 is disregarded from the owner should check the appropriate box forthe tax classification of Its owner. a ❑ Other (see Instructions))- (Applies(eaccoeetsindelolaadoulslde, We U,S). N a Address (number, �s�tre%et, and apt. or suite no.) See Instructions. Requester's name and address (optional) kAyt 6 City, State, and.ZIF code r ! o �y —''t t G` 7 List account numbera):here (optional) rur TIN In the appropriate box. Tr withholding. For Individuals, this alien, sole proprietor, ordisrega number on line: f'to avoic N). However; for ter. For other see How to get ( ' Note: If the account is in more than one name, see the Instructions for line 1. Also see What Name and iL Number To Give the Requester for guidelines on whose number to enter. I N HHa-,17,e ia.4, VrrYGlLVr1 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer Identification number (orI am waiting for a number to be issued to me); and 2. i am not subject to backup withholding because: (a)) 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 Yam f , ono longer subject to backup withholding; and i 3..1 am a U.S. citizen or other U.S. person (definedbelow); 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 youhave 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 cure roperly, cancellation of debt, contributions town individual retirement arrangement (IRA), and generally, payments other than Interest and div�sl ds, you a .not: required to sign the certification, but you must provide your correct TIN. Seethe instructions for Part II, later. Sign Slgnature..of L Here U.S. careeni! ? Yl General Insir ctions �) W es Section referencr o the internal Revenue Code -unless' Lisa 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.lrs.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 obtainyour correct taxpayer Identification number (TIN) which may be your social security number (SSN), Individual taxpayer identification number ([TIN), adoption taxpayer Identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other .amount reportable on an Information return. Examples of Information returns Include, but are not limited to, the following. Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, Inc1(idingkhose from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes,awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9:only if you are a U.S. person (including a resident alien), to provide -your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) / i R CERTIFICATE OF LIABILITY INSURANCE DATE'(MMIDO/YYYY) 3/4/2024 THIS CERTIFICATE IS ISSUED AS.A MATTER OF INFORMATION ONLY ANDCONFERSNO 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 art ADDITIONAL INSURED, the policy(les) must have ADDITIONAL. INSURED provisions or be Endorsed. If SUBROGATION IS. WAIVED; subject to file terms and conditions of the policy, certain policies may require an endorsement. A statement. on this certificate does, not confer eights to the certificate holder in lieu of such endbrsement(s: PRODUCER The Risk Specially Group,LLC 675 Bering DC, Ste. 9175 Houston TX 77067 CGNT AME• Gi Deanna Der RHOx a ,713m552-1900ac Na,713-513-54Ii E-MAIL. ADDRESS, ddVen@r1EkspeOIaltygroup COrn INSURERSAFFORDING COVERAGE NAIC.q INsURER:A: Allied World Surplus Lines. Ins 24319. INSURED GaWENGI-Oi Q•& W Engineers,.. Inc. 205 W. Live Oak Pad Lavaca TX 77979 INSURERS: INSURERCJ INSURER D" INSURBREJ _ INSURERF'.: Lr4lVCKHUCvr vgry 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 SUCHT.OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS �LTN TYPEOFINSURANCE AOOL SUER FOLICYNUMBER POLICYEFF MMIDG/YYYY POLICY EXP `MMIDORYYY. LIMITS '. COMMERCIALGENERALDABILITY CLAIMS4AAOE ❑rOCCUR. EACHOCCURRENCE s CA WE PREM S5a Ee acairtence 5 1 MEDEXP'A1 anepenbn)' PERSONAL EAOVIINJURY 'S. GEN'LAGGREOATELIMITAPPUES FEM 09HERALAGGREGATE' PRODUCTS • CQMPIOP AGG S P.RO• IOC. POLICY ❑ JECT Y OTHER: AUTOMOSILELIABILITY COMB, ED SING EUMIT Eeacafdenl '.I :4 -ANY AUTO BODILY INJURY (Per Rena.) BOOILY INdURY(Perac Idenl) -OWNED. SCHEDULED- AUTOSONLY AUTOS HIRER OWNED AUTOS -ONLY AUTOS ONLY PROPERTY DAMAGE. drarcldZ 51 ..It UMERELLALIAB` OCCUR. EACHOCCURRENCE AGGREGATE. ,S: EXCESSLIAR CLAIM3:MADE DEG RETENTIONS' WORKERS COMPENSATION S ANTE ERH S E.L. EACH ACCIDENT S. AND EMPLOYERS' LIABILITY YIN ANYPROPRIET)RIPARTNENEXECURVE E.LmSEASE-EAEMPLOYE S A OFFICER/MEMBEREXCLUDEDY ❑.R/A.. (Mandit!., I. NH) If Yea.deecdba Under DESCRIPTION'OF OPERAT10143 I Udw P,arauIw.IUebnB.P011Wdn. 'dwresmadW 0014.r1841 3112024 31112025: E.L. DISEASE -POLICY LIMIT Per Claim Unill AEstegme Limit S .88,000;0p0 ss;000,000 DESCRIPTION OF OPERATIONS ILOCATIONB/ VEHICLES (ACORD Jai,. Add(lianel RemarNasch.defe, may be ameft.d if mOrp apa001. 1.q.iied) CERTIFICATE' HOLDER ..n,.�,• SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE :EXPIRATION. DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY' PROVISIONS. AUTNORIZEO REPRES ENTATIVE "`5/4"", @.19Sti.2015 ACORD CORPORATION: All rights reserved. ACORO 25 (2016/03) The ACORD name and logo are. registered marks of ACORD CERTIFICATE' OF LIABILITY INSURANCE OATE(MMmmYYYY) 218512024 THIS CERTIFICATE IS ISSUED AS A.MATTEROF INFORMATION ONLY AMD'GONFERS NO RIGHTS UPON THE CERTIFICATE, HOLDER THIS CERTIFICATE DOES NGT 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:. 1F 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 requirean endorsement: A Statement, on this.certificate does not confer rights to the certificate holder in Ilea of such andorsemengs). PRUDDCER Frost Insurance Agency, Inc. 6835 N, Main Victorla TX7.7904 CONTACT N E Margery Halt PHONE , 361-58049657 1a -:Na, e-MAL A TAIEL. hall frosiinsurance:com' . INSURER(B.AFEORDING COVERAGE' NAIL# INSURER:A': T6xasMu(Nal Insurance Go. 22945 INSURED OA9 N•1 - ,3 9 W Engineers Inc Z05 W Live Oak Port Lavaca TX77979 INSURER.a:-Continental: Casualty Company 20443 INSURER.C: INSURER'D, INSURERF: - THIS. 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Home Search Data Bank Data Services Help ll < Entity Workspace Show Workspace For Non -Federal Entities Non -Federal Entities BioPreferred Reporting Service Contract Reporting Filter By LKeyword Entity LStatus f , ❑ Work in Progress Registration f ❑ Submitted Registration ❑ Active Registration ❑ Inactive Registration ❑ IDAssigned ❑ Pending ID Assignment https://sam.gov/workspace/em/entities/non-federal?statusCode=4 See All Alerts 0 00 Get Started v M rM 1/3 1 10/30/24, 8:55 AM SAM.gov I Entity Workspace Expiration Date l FSD Number Address Update Results per page 1 of 1 i 25 G & W ENGINEERS, INC Active Registration Unique Entity ID: Doing Business As: g Purpose Registration P NGXGN75VRSWB - (blank) AllAwards CAGE/NCAGE: Physical Address: 1 3E6T3 205 W LIVE OAK ST ' PORT LAVACA, TX 77979-4232 USA Feedback J Our Website Our Partners About This Site Acquisition.gov gf Our Community USASpending.gov `- Release Notes Grants.gov System Alerts More Partners Policies Customer Service Terms of Use Help [ Privacy Policy Check Entity Status `-' Restricted Data Use Federal Service Desk Lhttps://sam.gov/workspace/em/entities/non-federal?statusCode=4 v v v Reset G Sort by Expiration Date Ascending Expiration Dote Mar 20,2025 2/3 10/30124, 8:55 AM SAM.gov I Entity Workspace [[[ Freedom of Information Act External Resources Accessibility Contact ® AS WARNING This is a U.S. General Services Administration Federal Government computer system that is "FOR OFFICIAL USE ONLY." This system is subject to monitoring. Individuals found performing unauthorized activities are subject to disciplinary action including criminal prosecution. This system contains Controlled Unclassified Information (CUI). All individuals viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part 2002 and GSA Order CIO 2103.2 CUI Policy. . a ..'4%�L Ihttps://sam.gov/workspace/em/entities/non-federal?statusCode=4 3/3 At Alk D U M B A N n g i n ca e i i n g C� • Prepared for: CALHOUN COUNTY, TX The Honorable Richard H. Meyer Calhoun County Judge Calhoun County Courthouse 211 S. Ann St., Suite 301 Port Lavaca, TX 77979 PROJECT: RFQ 2024.11 Engineering, Architectural, and Surveying Services CMP Cycle 29 Grant, GLO Contract No. 25-003-009-E702 Introductory 1,,.etter ♦: V FtE3 A N October 29, 2024 The Honorable Richard H. Meyer Calhoun County Judge Calhoun County Courthouse 211 S. Ann Street, Suite 301 Port Lavaca, TX 77979 RE: Calhoun County RFQ 2024.11 for CMP Cycle 29 Grant GLO Contract No. 25-003-009-E702 Dear Judge Meyer: Urban Engineering is pleased to submit its qualifications to provide professional engineering services to Calhoun County in support of the New Amenities at Bill Sanders County Park projects. Our firm is thoroughly familiar with county & municipal -related construction projects, regulatory agency permitting procedures, federally -funded projects and state -funded projects. We have successfully designed and administered construction of numerous projects throughout the area and specifically those for & in Calhoun County and surrounding counties. Significantly, Urban Engineering has been recently engaged by Calhoun County to prepare plans for the impending Bill Sanders Park — Swan Point Bulkhead & Pier Construction project, and we also prepared plans for Calhoun County projects at the Boggy Bayou Nature Park and Hog Bayou Boat Ramp. In related park projects, Urban Engineering prepared plans for City of Port Lavaca regarding improvements at the Bayfront Peninsula Park that included construction of approximately 3,020 linear feet of a 10-foot-wide concrete multi -use path. Further, Urban Engineering prepared plans for the Bayfront Pier in Seadrift for Calhoun County in 2013 and prepared plans in 2006 for the West Side Calhoun County Navigation District for the successful construction of the existing boardwalk and bird observation platform at the Boggy Bayou Nature Park. We have also prepared plans for many projects for the Matagorda County Navigation District No. 1 and for the Matagorda County-Palacios Seawall Commission. Given our proximity to the project area, we can rapidly and proficiently respond to needed tasks. We will dedicate the time required to complete our tasks within established deadlines, and we will provide both practical and economical solutions to project improvements. Urban Engineering is proud of its reputable track record and long list of satisfied clients. We are genuinely interested in this project and appreciate the opportunity to submit our qualifications. Please feel free to contact me concerning this project at (361) 578-9836 or by email at mglaze@urbanvictoria.com. Sincerely, f Matt A. Glaze, P.E. Vice President MAG/dmf EJ L, 2004 N. COMMERCE, VICTORIA, TX'77901 • 361.578.9836 • URBANVICTORIA.COM • TREF# F-160 Company profile NAME OF FIRM FEDERAL TAX ID NO. BUSINESS ADDRESS CONTACT FIRM ESTABLISHED YEARS IN BUSINESS TYPE OF ORGANIZATION FIRM INCORPORATED L TREF# PRINCIPALS Company Narrative Victoria Engineering, Inc. dba Urban Engineering 74-2293101 2004 N. Commerce Street, Victoria, Texas 77901 Ray M. Bridges, President Phone: 361.578.9836 rbridges@urbanvictoria.com February 1, 1981 43 Corporation December 1983 F-160 Ray M. Bridges, P.E., President - PE# 68789 Matt A. Glaze, P.E., Vice President - PE# 99253 Cheyanne B. Fromme, P.E., Senior Engineer - PE# 124832 Thomas A. Schmidt, P.E., CMO - PE# 39213 Urban Engineering, located in Victoria, Texas, is a civil engineering firm specializing in Residential and Commercial Development Planning and Design, Marine Construction Design and Public Works Design. Urban Engineering, together with its sister company, Urban Surveying, Inc., currently employs 30 people, which include five Registered Engineers, two Registered Surveyors, one Survey Coordinator, ten drafting/CAD Technicians, six survey crew members and six administrative support personnel. Urban Surveying, Inc. is co -located with Urban Engineering in Victoria and also maintains offices in Cuero and San Antonio, Texas. Ray M. Bridges, P.E., Matt A. Glaze, P.E., Cheyanne B. Fromme, P.E. and Thomas A. Schmidt, P.E., the principals of Urban Engineering, along with with Terry T. Ruddick, R.P.L.S. and chief executive officer of Urban Surveying, Inc., strive to provide hands-on expertise and client -specific creative solutions for the successful completion of assigned projects. Urban Engineering has been actively involved in numerous projects designed to improve the quality of life in Victoria, the surrounding counties and the Central Texas Gulf Coast regions. Urban Engineering strives to protect the client's interest and to provide the best objective solutions based on proven principles, contemporary methods, creative thinking, good judgment, and wealth of experience. f) Dedicated to the growth of the r, LOCAL COMMUNITY The staff of Urban Engineering includes persons with training and experience in the fields of civil engineering, city planning, traffic engineering, land planning, hydraulics, geotechnical engineering, and land surveying. In addition, relationships are maintained with firms and individual consultants engaged in such diverse fields as landscape architecture, economics, ecology, real estate, and law. Because of this training and experience, Urban Engineering can provide a wide variety of [ services from preliminary planning studies to detailed f ' construction plans and supervision of construction. Urban Engineering has a proven track record and consumers can depend on Urban Engineering to get projects completed in the most timely, professional and accurate manner. Urban Engineering has consistently demonstrated its high -quality engineering capabilities in the past, continues its expertise and dedication in the present and is well -prepared to assume more challenging projects in the future. SERVICES PROVIDED > Residential Subdivision Planning & Design > Commercial Site Development > Public Works Design > Commercial & Residential Master Plans L: > Capital Improvement Studies & Plans > Rate Studies J > Drainage Studies > Street & Paving Design > Wastewater Collection, Treatment & Lift Stations > Water Supply & Distribution > Water Wells, Water Treatment & Storage L, > Storm Water Quality > Business District Renovation t_ > Park Planning & Development > Marine Construction Design > Financial Analysis & Cost Projections > Land Surveying > Traffic Studies & Traffic Impact Analysis > Construction Phase Services & Construction Administration 3 ETHICAL STANDARDS In providing professional engineering services, Urban Engineering always assumes a position of responsibility to the physical, sociological, and economic needs of the community it serves. The firm adheres to codes of practice of the various professions. It has no commercial affiliations with realtors, contractors, manufacturers, or others having a vested interest in services or supplies. Since its founding in 1981, Urban Engineering has given equal consideration to all groups, public or private, large or small, requesting consulting services. Occasionally, certain assignments from clients are not accepted when such action is in the best interest of the client or the firm. Usually, when this situation arises, a project obviously is in direct conflict with the public interest. For this reason, as a general practice, projects are not accepted that are clearly contrary to sound, adopted plans of the community. HISTORY OF URBAN ENGINEERING Urban Engineering was formed in 1965 by Larry Urban and his brother, Gene Urban, in Corpus Christi, Texas. In 1966, they purchased McClendon and Associates, an engineering consulting firm in Corpus Christi. The acquisition included a number of McClendon's key personnel and an archive of historical engineering records dating back to 1944. In 1981, an associate office was established in Victoria, Texas. Thomas A. Schmidt was selected to serve as chief engineer and managing partner of the Victoria office. In December of 1983, the firm in Victoria was incorporated using the corporate title of Victoria Engineering, Inc.; however, the firm continues to do business as Urban Engineering. Since 1981, Urban Engineering has provided a wide variety of engineering services in the Victoria area, from preliminary planning studies through detailed plans and supervision of construction. Urban Engineering has been a regional firm dedicated to the growth of the local community. The company currently provides enginE Calhoun, Jack Victoria, DeWitt Aransas CountIE Lavaca, Seadrif Palacios, Victo Portland and RouNyul L. Engineering assignments are performed in Victoria, but additional specialized support and manpower are available from Urban Engineering in Corpus Christi, with whom the firm continues to maintain its longtime business and professional ties. Urban Surveying, Inc. performs its operations in the same community areas as Urban Engineering. To better serve the public demand, Urban Surveying, Inc. moved its Karnes City office to Cuero, DeWitt County in July of 2006 and opened an office in San Antonio, Bexar County in November of 2012. Urban Engineering is an Equal Opportunity Employer. 4 Staffing & personnel Staffing Profile 43 05 05 04 01 YEARS OF REGISTERED CAD SUPPORT SUB EXPERIENCE ENGINEERS TECHNICIANS PERSONNEL CONSULTANT Urban Engineering is available immediately to provide its professional services to Calhoun County. Principals of the firm are Mr. Ray M. Bridges, P.E., Mr. Matt A. Glaze, P.E., Ms. Cheyanne B. Fromme, P.E., and Mr. Thomas A. Schmidt, P.E. Mr. Bridges, Mr. Glaze and Ms. Fromme often collaborate on the firm's larger projects allowing each to benefit from the other's experiences. This cooperative effort, along with a solid common-sense approach to problem solving, is the key to the continuing success of the business. Mr. Glaze will serve as the point of contact regarding the RFQ and will seal and sign project work products. RAY M. BRIDGES, P.E., PRESIDENT Urban Engineering • 2004 N. Commerce, Victoria, TX 77901 361.578.9836 • rbridges@urbanvictoria.com MATT A. GLAZE, P.E., VICE PRESIDENT Urban Engineering • 2004 N. Commerce, Victoria, TX 77901 361.578.9836 • mglaze@urbanvictoria.com CHEYANNE B. FROMME, P.E., SENIOR ENGINEER Urban Engineering • 2004 N. Commerce, Victoria, TX 77901 361.578.9836 • cbode@urbanvictoria.com L THOMAS A. SCHMIDT, P.E., CHIEF MARKETING OFFICER Urban Engineering • 2004 N. Commerce, Victoria, TX 77901 361.578.9836 • tschmidt@urbanvictoria.com LJ EMMA M. TUCKER, P.E., STAFF ENGINEER Urban Engineering • 2004 N. Commerce, Victoria, TX 77901 L361.578.9836 • eandruss@urbanvictoria.com 5 1e1361111 Matt Glaze is a highly experienced and accomplished Vice President and Partner, with a strong background in project development and leadership. He has extensive design experience across a broad range of projects, including public works, marine, and environmental projects. In his role, he has been responsible for designing and overseeing numerous major thoroughfare projects, utility replacements, water plants, and lift station rehabilitations, as well as flood protection projects. He has also worked on marine projects such as port expansions, bulkhead replacements, and public fishing piers, as well as environmental projects such as living shoreline breakwaters for erosion control and habitat restoration. His experience includes improvements for municipal public works/grant projects in several locations, including Victoria, Cuero, Palacios, Point Comfort, Port Lavaca, Bay City, and Goliad, as well as commercial properties in Victoria and residential subdivisions in Victoria, Port O'Connor, and Palacios. Mr. Glaze has a wealth of experience and expertise in the design and implementation of a wide range of projects. Mr. Glaze has a philosophy of leaving things better than how he found them, both in his personal life and in his professional work. This approach reflects a desire to make a positive impact and create lasting value in everything he does. By striving to leave everything better than how we found it, we can create a ripple effect of positive change and make a meaningful impact on the world. In his professional work, this philosophy translates into a commitment to delivering high - quality work that exceeds expectations and adds value to the communities and organizations he works with. MEMBERSHIPS > Victoria Business & Education Coalition > Coastal Conservation Association > National Rifle Association > Arbor Day- Member r ORGANIZATIONAL CHART r------------ - - - - -- --- RAY M. BRIDGES, P.E. MAT - PRINCIPALS ! PRESIDENT VICE PRESIDENT t. i Ll STAFF ENGINEER t L' LL-_---_----- ® ® SUB -CONSULTANT L SENIOR ENGINEER CMO 0 Justification Just'ification If selected as an engineering firm to provide services to Calhoun County, Urban Engineering would initiate a positive approach and systematic methodology for performing and successfully completing assigned project tasks. Being a local firm, we would bring not only our engineering expertise, but also our vast understanding of the local community and who we're working for. Our proximity to Calhoun County provides for expedited response time and superior service. To accomplish this project, we would: 1. Become thoroughly familiar with the County's goals and objectives. 2. Completely understand the scope of work and all facets associated with the project. 3. Establish a trustworthy business relationship with the County. 4. Assign trained and experienced personnel to the project, sustain job performance and be a team player. 5. Design, process & expeditiously produce the plans for each phase of the project with precision, accuracy and efficiency. 6. Maintain project continuity during the processes of all phases of the assigned project and resolve any issues that may occur. 7. Maintain open lines of communication with the County and all project participants. 8. Utilize our state of the art tools, techniques and compatible applications software to produce an end product that meets all project requirements and acceptance by the County. Urban Engineering possesses a broad knowledge of regulatory compliance and permitting procedures associated with the TWDB, GLO, TDA, TCEQ, USACE, TxDOT and FEMA. We foresee no problems with accepting, initiating and completing assigned tasks associated with the design of the plans and specifications of this project for Calhoun County. H I PROJECTS FOR CALHOUN COUNTY 2023, Boggy Bayou Nature Park Improvements, Phase 1 Coastal Management Program Cycle 25 GLO Contract No. 21-060-013-C673 Prepared plans and specifications for the construction of approximately 2,000 linear feet of bollard fencing along the park road and other areas to protect sensitive vegetation, the enlargement of the boardwalk terminus to 20' x 15', and an ADA ramp at the Boggy Bayou Nature Park in Port O'Connor. Contractor: Shirley & Sons Construction Co., Inc. of Cleveland, TX Cost: $88,520 Status: February 2023 — April 2023 2023, Hog Bayou Public Boat Ramp Bulkhead Improvements [ Designed, prepared plans and specifications for the construction of 166 linear feet of marine [ bulkhead at the Hog Bayou Public Boat Ramp in Calhoun County, Texas. Contractor: Shirley & Sons Construction Co., Inc. of Cleveland, TX Cost: $160,298 l Status: June 2023 — August 2023 2013-2014, Seadrift Bayfront Pier Designed, prepared construction plans and specifications for the construction of an approximately 300-foot timber fishing pier, including 4 concrete parking spaces and 350 linear feet of concrete sidewalks, located along the San Antonio Bay shoreline in Seadrift. Contractor: Shirley& Sons Construction Co., Inc. of Cleveland, TX Cost: $372,003 Status: May 2013 - January 2014 0 PARK -RELATED CONSTRUCTION PROJECTS 2022, City of Port Lavaca, Bayfront Peninsula Park Walking Trail & Park Improvements Construction of approximately 3,020 linear feet of a 10-foot-wide concrete multi -use path including drainage improvements and the addition of site solar lights, benches, trash receptacles, a bike rack and a water fountain at the Bayfront Peninsula Park in Port Lavaca. Contractor: K-C Lease Service, Inc. DBA Matagorda Construction & Materials of Bay City, TX Cost: $542,666 f, Status: January 2022 — July 2022 2021, City of Port Lavaca, Bayfront Peninsula Park Parking Lot & Sidewalk Improvements Designed, prepared construction plans and specifications for the regrading and reclaiming the existing drive aisle and parking area, providing standard and ADA parking spaces, constructing new ADA accessible concrete sidewalks, drainage improvements, erosion control and the addition of site lights at the Bayfront Peninsula Park in Port Lavaca. Contractor: Sylva Construction, LLC of Port Lavaca, TX Cost: $361,160 Status: January 2021 —October 2021 10 FMARINE -RELATED CONSTRUCTION PROJECTS > BOGGY BAYOU BIRD OBSERVATION PLATFORM West Side Calhoun County Navigation District Designed, prepared plans and specifications for the construction of a 630-foot observation boardwalk with a 145-square foot bird observation platform, and associated access and parking at Boggy Bayou in Port O'Connor. Construction was performed by Shirley & Sons Construction Co., Inc. in May 2006. ' > REDFISH LAKE LIVING SHORELINE Calhoun County, TX Urban Engineering along with the Matagorda Bay Foundation and the Port Alto Association completed a living shoreline project in Redfish Lake, near Carancahua Bay in Calhoun County. Urban Engineering prepared plans and permit documents for approval from the U.S. Army Corps of Engineers and Texas General Land Office for the project. The Matagorda Bay Foundation obtained a grant from the Texas Hurricane Harvey Mini -Grant Program to secure materials for the project. Urban Engineering and the Port Alto Association organized volunteers to bag oyster shell, haul it to the project site and construct the project. u 11 1. 1, > TURNING BASIN #4 Matagorda County Navigation District No. 1 Urban Engineering obtained the U.S. Army Corps of Engineers permit, prepared plans, specifications & performed contract administration for the construction of a fourth turning basin at the Port of Palacios. The basin construction consisted of 2,400 linear feet of new steel bulkhead with an exposed height of 20 feet. The turning basin was constructed to a depth of 12 feet below MSL & required the excavation of 320,000 cubic yards of soil. Construction was performed by Shirley & Sons Construction Co., Inc. of Cleveland, Texas > SEADRIFT BAYFRONT PIER Calhoun County, TX Urban Engineering designed, prepared construction plans and specifications forthe construction of an approx. 300 foot timber fishing pier, including 4 concrete parking spaces and 350 linear feet of concrete sidewalks, located along the San Antonio Bay shoreline in Seadrift. 12 > MULTIPLE PROJECTS IN SOUTH BAY MARINA, PALACIOS, TEXAS Matagorda County Navigation District No. 1 Urban Engineering was selected to perform several projects as part of the Matagorda County Navigation District's development of the South Bay Marina located in Palacios, Texas. Newly acquired by the Navigation District, the existing Marina was a dilapidated facility in desperate need of repair. Among the improvement projects were: • Bulkhead Replacement — This included the construction of 1,110 linear feet of fiberglass bulkhead in and along the existing Marina at 8th Street and South Bay Boulevard. • Maintenance Dredging — With the assistance of Dredge America, the harbor was dredged to a depth of nine feet to accommodate the influx of recreational vessels. • Construction of 24 Covered Boat Stalls with Power Lifts — The covered boat slips can accommodate boats up to 30 feet in length. The Power Lifts can raise boats weighing up to 8,500 pounds. Shirley & Sons Construction performed the work under the direction of Urban Engineering. Construction of an additional non -covered Boat Dock including eight timber finger piers and a timber breakwater pier — The eight timber finger piers and one breakwater pier create 17 open slips. Each slip can accommodate power boats or sail boats up to 40 feet in length. Construction included a new parking lot, sidewalks, fencing, electrical system and plumbing system. > PALACIOS MULTI -USE NATURE CENTER PALACIOS PRAIRIE WETLANDS Urban Engineering designed, prepared construction plans and specifications forthe construction of an approx. 250-foot wetland observation pier with a kayak launch, 75-foot bird watching platform, 850-foot nature trail and associated accessible parking area in Palacios. 13 > FALCON POINT LODGE & SUBDIVISION MCC Realty, LP and Seadrift Ranch Partners, Ltd Urban Engineering performed the design and permitting tasks required for the construction of a bulkhead and fishing pier located at the Falcon Point Lodge in Seadrift, Texas. Falcon Point Ranch is 6,000 acres located on San Antonio Bay and features guided hunting and fishing. Urban Engineering also performed the site layout for the main lodge and additional lodging facilities, the development of a freshwater pond and the permitting and design of a state approved public water supply system. The freshwater pond was designed at varying depths to enhance and encourage waterfowl visitation. Later, Urban Engineering designed a 100 lot waterfront residential subdivision which included an additional freshwater lake, public approved water and sewer system, streets and drainage. > LAKE BASTROP NORTH SHORE PARK Lower Colorado River Authority (LCRA) Urban Engineering performed the design,plans and specifications for the construction of a boat ramp, timber bulkhead, boat dock and fishing pier forthe North Shore Park located on Lake Bastrop. Urban Engineering also provided the design and project oversight for the construction of a temporary coffer dam to facilitate dredging of the boat ramp. 14 > PALACIOS PAVILION FISHING PIER PHASE XXVIII-A Matagorda County, TX - Palacios Seawall Commission Urban Engineering prepared plans and specifications for the reconstruction of the timber Pavilion Pier and increased the length of the pier's T-head in Palacios. In 2018, repairs were made to the pier's T-head due to damage sustained by Hurricane Harvey in 2017. Urban Engineering prepared the plans and specifications for this project. > EAST BAYSHORE DRIVE BAG WALL REPLACEMENT Matagorda County, TX - Palacios Seawall Commission Prepared plans and specifications for replacing approximately 542 linear feet of concrete bag wall with vinyl bulkhead along East Bayshore Drive. 15 > THE SANCTUARY AT COSTA GRANDE DH Texas Development, LP Urban Engineering designed and prepared plans for the construction of approx.7,500 square feet of floating boat docks and designed plans for the construction of fixed wooden boat docks for 40-50 foot sport fishing vessels for this 768 lot canal subdivision in Port O'Connor, Texas. Plans and specifications were also prepared for the construction of a boat ramp, 8,000 feet of timber bulkheading, a temporary timber bridge for - construction access and three wetland observation piers. Urban Engineering also provided project administration and quality control forthe overall project plus value re -engineering services for the water distribution & pump station, sanitary sewer collection system and streets. Construction was performed by Shirley & Sons Construction Co., Inc 16 > PORT OF PALACIOS TURNING BASIN #3 PUBLIC BOAT RAMP & ACCESS IMPROVEMENTS Matagorda County Navigation District No. 1 Prepared plans and specifications for approximately 6,000 square yards of hot mix overlay on an existing parking lot, construction of concrete parking spaces and ADA ramps for an existing boat ramp located in Turning Basin No. 3 at the Port of Palacios. > PALACIOS PUBLIC FISHING PIER (1ST STREET PIER) City of Palacios, TX j Urban Engineering prepared plans and specifications for the construction of an approx. 350 linear foot lighted timber fishing pier in the South Bay Park in Palacios. In 2018, the pier was replaced due to damage sustained by Hurricane Harvey in 2017 and with funds provided through the Matagorda County Palacios Seawall Commission. Urban Engineering prepared the plans and specifications for this L- ` project. 17 > PALACIOS SHIPYARD BULKHEAD REPLACEMENT Matagorda County Navigation District No. 1 Prepared plans and specifications for approximately 440 linear feet of steel bulkhead replacement, approximately 71 linear feet of bulkhead cap repair and an alternate to repair approximately 275 linear feet of bulkhead cap in Turning Basin No. 2 and No. 3 in Palacios. > PALACIOS PORT MAINTENANCE AND DOCK REPAIRS Matagorda County Navigation District No. 1 Prepared plans and specifications for approximately 2,700 linear feet of bulkhead cap repairs and replacement of timber fenders, timber fender piling and mooring piling in Palacios. 18 > PORT OF PALACIOS MAINTENANCE AND DOCK REPAIRS Matagorda County Navigation District No. 1 Prepared plans and specifications for the removal of approximately 800 feet of steel bulkhead cap and removal and replacement of approximately 180 timber pilings in Palacios. > PALACIOS TURNING BASIN NO. 1 WEST DOCK REPAIRS - PHASE 2 Matagorda County Navigation District No. 1 Prepared plans and specifications for the construction of approximately 357 linear feet of steel bulkhead on the west side of Turning Basin No. 1 in Palacios. 19 F� Other Marine -Related Construction Projects City of Port Lavaca Port Lavaca, TX > 2022, City Harbor Upper Dock Repairs F > 2021, Smith Harbor Dredging > 2021, Scully's Bulkhead & City Harbor Dock Finger Pier Repairs > 2021, City Harbor Docks Repairs > 2021, Nautical Landings Marina Floating Dock B Repairs 2020, Nautical Landings Marina & Bayfront Park Repairs > 2013, Nautical Landings Marina > 2011, Floating "A" Dock, Nautical Landings Marina City of Seadrift Seadrift, TX > 2023-2024, Municipal Harbor Improvements EDA Award Number 08-79-05328 > 2022, Municipal Harbor Repairs Joint Grant Assistance Project FEMA PA-06-TX-4332-PW-00443 and GLO CDBG-DR Contract No. 20-065-103-C278 > 2022, Bayfront Park Pier Repairs Joint Grant Assistance Project FEMA PA-06-TX-4332-PW-03840 and GLO CDBG-DR Contract No. 20-065-103-C278 > 2020, Municipal Harbor Debris Removal-FEMA Project No. PA-06-TX-4332-PW-05298 Matagorda County Navigation District No.1 Palacios, TX > 2022, Dock Improvements (Docks B, C, F & G) FEMA Alternate Project DR-4332-TX (PA ID No. 321- UPU2Q-00) > 2020, Port Repairs — Hurricane Harvey > 2013, Port Maintenance and Dock Repairs > 2012, Turning Basin No. 1 Bulkhead Replacement > 2012, Port Maintenance and Dock Repairs > 2010, Turning Basin No. 1 West Dock Repairs — Phase 1 > 2010, Port Maintenance and Bulkhead Repairs > 2009, Turning Basin No. 2 Bulkhead Repair > 2004, Turning Basin No. 1 Bulkhead Replacement > 2002, Shipyard, Phase 11 > 2002, Shipyard, Phase I > 2000, Pier Dock H, Ramp Modification >1999, Pier Dock H, Extension 20 r ' Matagorda County - Palacios Seawall Commission Palacios, TX > 2022-2023, Palacios Seawall Concrete Repairs > 2022, South Bay Park Beach Nourishment - Phase 2 > 2021, Jensen Point Boat Ramp Improvements > 2020, Hurricane Harvey - Various Seawall Repairs > 2020, Tran & Zamarripa Property Bulkhead Repairs > 2016, South Bay Park - Beach Nourishment > 2014, Appelt Property Shoreline Protection > 2013, East Bayshore Drive Reconstruction > 2014, Turtle Point Bulkhead Repairs > 2012, Grassy Point Bulkhead -Phase 2 > 2011, Pavilion Demolition > 2011, Shoreline Protection - Margerum Boulevard, Perryman Avenue & Collegeport Bulkhead Repair > 2009, Oyster Lake Park Bulkhead > 2009, Grassy Point Bulkhead 2005, Phase XXXIII, Turtle Bay Cove Bulkhead > 2003, Phase XXXII, Carl Park Breakwater > 2003, Phase XXX, Crawford Basin Bulkhead > 2003, Phase XXXI, Collegeport Bulkhead > 2002, Phase IX, Grassy Point Breakwater Modifications > 2001, Phase XXV-B, East Bay Yacht Harbor Improvements > 2000, Phase XXIX - Crawford Channel > 2000, Phase XXVII, Grassy Point Bait Camp t > 1999, Phase VI, Railroad Park Boat Ramp Modifications > 1999, Phase XXV-A, East Bay Yacht Harbor Improvements > 1999, Phase XVI, Extension "GLO Property > 1999, Phase XXVI, Replacement of East Bay Fishing Pier & Courtesy Dock > 1999, Phase XXIII, Trull Property Lamar Improvement District Lamar, TX > 2023-2024, The Reserve at St. Charles Bay - Buffer Zone Revetment Replacement > 2016, The Reserve at St. Charles Bay - Compensatory Mitigation Plan > 2015, The Reserve at St. Charles Bay Phase 1 Bulkhead City of Bay City Bay City, TX > 2020, Riverside Park Boat Ramp Improvements Other State -Funded Construction Projects > 2015, City of Port Lavaca, Coastal Management Program, Cycle 18 Grant (GLO, NOAA) > 2005, City of Palacios, Coastal Management Program, Cycle 8 Grant (GLO, NOAA) > 2002, City of Palacios and Matagorda County-Palacios Seawall Commission, Coastal Management Program L 21 I, Texas Department of Rural Affairs Texas General Land Office Disaster Recovery Projects > 2014-2015, Matagorda County Navigation District No. 1 Disaster Recovery Turning Basin No. 1 West Dock Repairs — Phase 2 Engineering Contract No. DRS015052 Grantee Contract No. DRS220112 > 2010-2011, City of Port Aransas, 2009 Disaster Recovery Engineering Contract No. DRS015052 Grantee Contract No. DPS010147 > 2010-2011, City of Point Comfort, 2009 Disaster Recovery Engineering Contract No. DRS015052 Grantee Contract No. DRS010145 > 2011, City of Point Comfort, Disaster Recovery Water and Wastewater Treatment Plant Backup Generators > 2010, Matagorda County Navigation District No. 1 Disaster Recovery Turning Basin No. 1 West Dock Repairs — Phase 1 Engineering Contract No. DRS015052 `` Grantee Contract No. DRS010112 t M 22 Other Grant -Related Municipal &CountyProjects > 2024-Current, City of Cuero, Waterline Improvements GLO CDBG-MIT Contract No. 22-085- 057-D314 > 2024-Current, City of Cuero, Downtown Revitalization Project TxCDBG Contract No. CDM22- 0024 > 2024-Current, City of Cuero, San Antonio Street Water Plant Improvements GLO CDBG-MIT Contract No. 22-085-057-D314 > 2024-Current, City of Palacios, Water System Improvements TxCDBG Contract No. CDV21- 0027 > 2024-Current, County of Refugio, Humble Camp Colonia Water System Improvements TxCDBG Contract No. CFC22-0126 > 2024-Current, City of Palacios, Downtown Revitalization Project Additional Sidewalk TxCDBG Contract No. CDM21-0045 > 2024-Current, City of Edna, Generators for Water & Wastewater Facilities Hazard Mitigation Grant Program (HMGP) DR-4332-122 > 2024-Current, City of Palacios, City Wide Drainage Improvements GLO CDBG-MIT Contract No. 22-085-048-D301 > 2023-Current, City of Seadrift, Municipal Harbor Improvements EDA Award Number 08-79- 05328 > 2023-Current, Matagorda County, Van Vleck Lift Stations Improvements GLO CDBG-DR Contract No. 20-065-123-C430 > 2023-Current, Matagorda County, Midfield Generators GLO CDBG-DR Contract No. 20-065- ( 123-C430 [ > 2023-Current, Matagorda County, Van Vleck Street & Drainage Improvements & Marlin Drive Improvements GLO CDBG-DR Contract No. 20-065-123-C430 > 2023-Current, City of Palacios, Downtown Revitalization Project TxCDBG Contract No. CDM21-0045 > 2022, City of Edna, TxCDBG 7219130, Sanitary Sewer Improvements - Additional Streets > 2022-2023, Matagorda County, Markham Sanitary Sewer Improvements, GLO CDBG-DR Contract No. 20-065-123-C430 > 2022-Current, City of Victoria, GLO CDBG-DR Contract No. 20-065-055-C165 > 2021-2022, City of Seadrift, Bayfront Park Pier Repairs Joint Grant Assistance Project FEMA PA-06-TX-4332-PW-03840 and GLO CDBG-DR Contract No. 20-065-103-C278 > 2021-2022, City of Seadrift, Municipal Harbor Repairs Joint Grant Assistance Project FEMA PA-06-TX-4332-PW-00443 and GLO CDBG-DR Contract No. 20-065-103-C278 > 2021-2022, City of Seadrift, Water Storage Tanks, GLO CDBG-DR Contract No. 20-065-103- C278 > 2021-2022, City of Cuero, Infrastructure Improvements, CDBG=DR GLO 20-065-063-C181 > 2021-2022, City of Edna, CDBG-DR GLO 20-065-032-C109, Sanitary Sewer Improvements L> 2021, City of Bay City, TxCDBG 7219029, Water Improvements > 2021, Matagorda County, TxCDBG 7219261, Water Improvements > 2021, City of Edna, TxCDBG 7219130, Sanitary Sewer Improvements > 2020, Municipal Harbor Debris Removal - FEMA Project No. PA-06-TX-4332-PW-05298 > 2020, City of Palacios, TxCDBG 7218351, Water Improvements L 23 > 2019-2020, City of Palacios; TxCDBG 7217172, Downtown Revitalization Program > 2019, City of Edna, TxCDBG 7217111, Sanitary Sewer Improvements > 2017-2018, Matagorda County, TxCDBG 7216321, Water & Sanitary Sewer Improvements > 2017, City of Cuero, TxCDBG 7215101, Wastewater Improvements > 2016-2017, City of Palacios, TxCDBG 7215359, Water Improvements > 2015-2016, TxDOT CSJ No. 1313VICTR, Victoria Regional Airport Water Improvements > 2015-2016, City of Cuero, TxCDBG 7214110, Wastewater System Improvements > 2014-2015, Victoria Regional Airport, Wastewater System Improvements Coastal Impact Assistance Program, Grant No. F12AF00630 > 2014, City of Point Comfort, TxCDBG 712281, Water Improvements > 2012-2013, City of Palacios, TxCDBG 711359, Water and Sanitary Sewer Improvements > 2012-2013, Texas Department of Agriculture - Texas Capital Fund t Downtown Revitalization Grant Program City of Cuero, Downtown Sidewalk Improvements >2011-2012, City of Palacios, TxCDBG 710541, Wastewater System Improvements > 2010-2011, City of Goliad, TxCDBG 729299, Sanitary Sewer Improvements > 2011, Texas Department of Agriculture - Texas Capital Fund (2009) Downtown Revitalization Grant Program City of Cuero, Downtown Sidewalk Improvements > 2009-2010, City of Point Comfort, TxCDBG 728650, Sanitary Sewer System Improvements E , > 2010, City of Point Comfort, TxCDBG 728650, Water and Sanitary Sewer Improvements > 2008-2009, City of Point Comfort, Lift Station Rehabilitation (SEP Grant #2007-009) > 2009, City of Goliad, TxCDBG 727169, Sanitary Sewer Improvements > 2008-2009, City of Palacios, TCDP 727359, Sanitary Sewer Improvements > 2008, TCDP 725881, Victoria County Water Control & Improvement District #2 (' > 2006-2007, City of Palacios, TCDP 725651, Water and Sanitary Sewer Improvements t > 2002, City of Palacios, TCDP 721611, Sanitary Sewer Improvements > 1999-2000, TCDP 718731, Victoria County Water Control & Improvement District #2 > 1999, City of Palacios, TCDP, Sewer Services Replacement > 1995, TCDP, Quail Creek Municipal Utility District > 1988, TCDP, City of LaWard, Sewer & Street Improvements > 1987, TCDP, City of LaWard, Wastewater Collection System 24 I' Governmental Clients Let our reputation speak for itself. (' CLIENT SATISFACTION IS THE BEST MEASURE OF URBAN ENGINEERING'S f : CAPABILITIES. THE FOLLOWING LIST INCLUDES NAMES, ADDRESSES, CONTACT PERSONS, TELEPHONE NUMBERS AND EMAIL ADDRESSES OF SOME OF URBAN'S (' GOVERNMENTAL CLIENTS: fl CITY OF VICTORIA CITY OF PORT LAVACA I r. P.O. Box 1758, Victoria, TX 77902-1758 P.O. Box 105, Port Lavaca, TX 77979 Mr. Ken Gill, P.E., Director of Public Works Ms. JoAnna P. Weaver, P.E., City Manager &City 361.485.3381 •kgill@victoriatx.gov Engineer361.827.3601 •jweaver@portlavaca.org CITY OF EL CAMPO CITY OF SEADRIFT 315 E. Jackson St., El Campo, TX 77437 501 S. Main St., Seadrift, TX 77983 Mr. Kevin Thompson, Director of Public Works Ms. Tracey Johnson, Mayor Pro Tern 979.541.5075 • khompson@cityofelcampo.org 361.785.2251 • tracey.citycouncil@gmail.com CITY OF BAY CITY CITY OF EDNA 1217 Avenue J, Bay City, TX 77414 126 W. Main St., Edna, TX 77957 Mr. Herb Blomquist, Director of Public Works Mr. Gary Broz, City Manager 979.323.1637 • hblomquist@cityofbaycity.org 361.782.3122 • gbroz@cityofedna.com CITY OF CUERO QUAIL CREEK MUNICIPAL UTILITY DISTRICT ( P.O. Box 660., Cuero, TX 77954 515 Chukar, Victoria, TX 77905 Mr. Wayne Berger, City Manager Mr. Daniel Jimenez, District Manager 361.275.3476 • citymanager@cityofcuero.com 361.572.0810 • gcmud@yahoo.com [ CITY OF PALACIOS MATAGORDA COUNTY P.O. Box 845, Palacios, TX 77465-0845 1700 7th St., Rm 301, Bay City, TX 77414 Mr. Rick Cink, Mayor The Honorable BobbySeiferman - 361.972.3605 • rcink@cityofpalacios.org Matagorda County Judge 979.244.7605 • cojudge@co.matagorda.tx.us 25 Major Sub -Consultant information ir Onsultaln-Fs 1. Surveying Services will be provided through necessary subcontracts with Urban Surveying, Inc. of Victoria, Texas. Urban Engineering has no financial interest in the activities performed by this subconsultant. (See attached profile and resume) L L 26 r SUB -CONSULTANT �1 URBAN SURVEYING, INC. Urban Surveying, Inc. (USI) was founded in January 1993 in Victoria, Texas by Terry T. Ruddick, R.P.L.S., who is the company's current C.E.O. and managing partner. USI is a Texas Licensed Surveying Firm in good standing and a member of the Victoria, Cuero, Seadrift, Port O'Connor and Bandera Chamber of Commerce. Urban Surveying, Inc. has grown into a regional firm providing surveying services throughout the Coastal Bend, Hill Country, Central and South Texas. At present, two registered professional land surveyors are employed with the company and have over 50 years combined experience. USI's field crews have comparable years of service and are well versed in using GPS and Total Stations. Urban Surveying, Inc. has fully staffed offices in Victoria, Cuero and San Antonio. Services performed include boundary and topographic surveys, aerial imaging, high precision 3D laser scanning, construction staking, pipeline, unit and location surveys. In addition USI has full smoke testing capabilities. Urban Surveying, Inc. is D.O.T. compliant and all employees regularly attend safety meetings and have opportunities to further their knowledge of surveying procedures. Urban Surveying, Inc. field crews use equipment that includes the following: > Trimble R8 GPS Systems > Trimble R10 GPS Systems > Leica ScanStation C10 • • U VS I Land Surveying+Aerial Imaging 91nce1991 Urban Surveying, Inc. office technicians use state of the art software including the following: > Trimble Business Center > Microstation versions 7&8 > Carlson Survey CAD 2013 embedded with intelliCAD 7.2 > Carlson Survey CAD 2013 embedded with AutoCAD > Nikon Totalstation series DTM520, DTM522, DTM352 with data collectors > Autolevels — Wild & Nikon > Polaris Rangers 4WD with trailers • RD 8000 pipeline locators > RD 4000 pipeline locators > Full range of smoke testing equipment > Leica Geosystems 3D laser scanning software Urban Surveying, Inc. Aerial Imaging technicians use state of the art equipment and software including the following: > eBee senseFly fixed wing Unmanned Aerial Vehicle (UAV) > DA Phantom 4 rotary UAV > eMotion 2 ground station software > Map Pilot for DJ ground station software > Pix4Dmapper Pro aerial imaging software > Virtual Surveyor aerial imaging software 27 C.E.O. and managing partner of Urban Surveying, Inc., Mr. Ruddick assumes responsibility for and is actively involved in all facets of operations. Mr. Ruddick joined Urban Engineering in Victoria, TX in 1984 and has been responsible for the completion of numerous boundary and topographic surveys including deed research, supervision of field crews, calculations, drafting, the preparation of metes and bounds descriptions and construction staking. Many of these projects have been for the improvement of water and wastewater systems and facilities. Since the founding of Urban Surveying, Inc. in January 1993, Mr. Ruddick has added full GPS capabilities, and most recently aerial imaging and high precision 3D laser scanning to the firm's list of services. Mr. Ruddick is certified by the FAA as a Remote Pilot for small unmanned aircraft systems. He has piloted the eBee senseFly fixed wing UAV, the DJI Phantom 4 rotary UAV and the Parrot Anafi in Victoria, Calhoun, Bexar, DeWitt & Brazoria counties to provide aerial photography, digital orthomosaic images and topographic mapping in support of engineering projects. PROFESSIONAL ORGANIZATIONS > Texas Society of Professional Surveyors > Past President, Guadalupe Valley Chapter 14, TSPS REGISTRATIONS > Registered Professional Land Surveyor, State of Texas # 4943 • FAA Remote Pilot Certificate Number 3965314 28 References References Organization: City of Port Lavaca, TX Contact: JoAnna P. "Jody'Weaver, P.E., City Manager & City Engineer Phone: 361.827.3601 Scope of Work: Bayfront Peninsula Park Walking Trail & Park Improvements Prepared plans and specifications for the construction of approximately 3,020 linear feet of a 10-foot-wide concrete multi -use path including drainage improvements and the addition of site solar lights, benches, trash receptacles, a bike rack and a water fountain at the Bayfront Peninsula Park in Port Lavaca. Project Dates: January 2022 — July 2022 Project Status: Successfully Completed Organization: Matagorda County - Palacios Seawall Commission Contact: Craig Wallis, Chairman Phone: 361.972.5012 Scope of Work: Jensen Point Boat Ramp Improvements Prepared plans and specifications for the demolition of the existing parking area and the construction of approximately 1,220 square yards of 6-inch concrete pavement including pavement striping, site fencing and other miscellaneous improvements at the Jensen Point Boat Ramp in Palacios. This project also includes the demolition of the existing courtesy dock and the construction of an L-shaped, timber courtesy dock with a timber kayak launch. Project Dates: May 2021 — December 2021 Project Status: Successfully Completed Organization: Matagorda County Navigation District No. 1 i Contact: Victor Martinez, Jr., Port Director Phone: 361.972.5556 Scope of Work: Turning Basin #3 Public Boat Ramp & Access Improvements l Prepared plans and specifications for approximately 6,000 square yards of hot mix overlay on an existing parking lot, construction of concrete parking spaces and ADA ramps for an, existing boat ramp located in Turning Basin No. 3 at the Port of Palacios. ( Project Dates: February 2018 — January 2019 Project Status: Successfully Completed Scope of Work I° SCOPE OF WORK Based upon your Request for Qualifications (RFQ), Urban Engineering has outlined basic and special engineering services to Calhoun County regarding the CMP Cycle 29 Grant, GLO Contract No. 25-003-009-E702 New Amenities at Bill Sanders County Park project. Our engineering services for the aforementioned project are as follows: A. Preliminary and Final Design Plans and Specifications 1. Prepare a preliminary report with an estimated budget. 2. Prepare detailed plans and technical specifications for the construction of the amenities within the allowable budget. 3. Submit the drawings and specifications to Calhoun County for review and approval. 4. Upon completion of any revisions by Calhoun County, prepare final quantity takeoff for establishment of construction costs. I , 1. Coordinate with Calhoun County on specific pre -bid opening & bid opening dates and times to be specified in the advertisement for bids. 2. Complete the advertisement for bids and schedule required notices for publishing in the local area newspaper(s). 3. Prepare and provide construction documents including all contract document information for the bidding and construction of the project. 4. Provide the necessary copies of project manuals, plans and specifications for bidding and construction of the project. 5. Attend pre -bid and bid opening conferences. 6. Tabulate, analyze and review bids from all bidders for completeness and accuracy. 7. Provide Calhoun County with the project bid tabulation and a recommendation for selection of a contractor. 8. Prepare and issue the Notice of Award and Notice to Proceed, as directed by Calhoun County. C. Construction Administration L 1. Coordinate and attend a pre -construction meeting. 2. Supervise the construction of the project, provide the necessary periodic construction inspections with the Contractor and Calhoun County's Inspector, and coordinate field testing, as necessary. L3. Review and approve work change orders. L 30 4. Review, approve and submit Contractor's monthly payment estimate requests to Calhoun County. S. Coordinate and attend the substantial completion and final inspection of the project with the Contractor and Calhoun County's Inspector. 6. Prepare and submit a Certificate of Construction Completion. 7. Provide Calhoun County with paper and digital copies of the record drawings. D. Other Special Engineering Services 1. Attend project meetings, as necessary. 2. Coordinate with Calhoun County and contractor on strategies to determine safe, alternate traffic routing during construction. 3. Coordinate with Calhoun County and contractor on methods of notification to residential and commercial customers concerning utility service interruptions. 4. Coordinate with Calhoun County concerning surveying services and/or geotechnical investigations that may be required for the project. These services may be subcontracted directly with the respective companies or through Urban Engineering at cost +10%. 5. If required, coordinate and conduct discussions with TxDOT pertaining to E routing, permitting, etc. L, 31 Litigation History Litigation History There have been no alleged or significant contractural failures involving Urban Engineering. Also, no civil or criminal litigations or investigations are pending over the last three (3) years against Urban Engineering. Certifications &For s f STATE OF TEXAS {} f COUNTY OF Victoria {} Matt A. Glaze AFFIDAVIT being first duly sworn, deposes and says: that he or she is (Type or Print Name) the Vice President of Victoria Engineering, Inc. dba Urban Engineering having its (Type or Print Title) (Type or Print Name of Company/Firm) principal address at 2004 N. Commerce St., Victoria, Texas 77901 i (Type or Print Physical and Mailing Address) ( who submits herewith to Calhoun County the attached bid/proposal; that he or she is the person whose name is signed to the attached bid/proposal; that said bid/proposal is genuine; that the same is not sham or collusive; that all statements of fact herein are true; and that such bid/proposal was not made in the interest or behalf of any person, partnership, company, association, organization or corporation not herein named or disclosed. Affiant further deposes and says: that the bidder/proposer has not directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interests of Calhoun County, or of any other bidder/proposer, or anyone else interested in the bid/proposal contract; and that the bidder/proposer has not in any manner sought by collusion to secure for himself/herself/itself/themselves an advantage over any other bidder/proposer. Affiant further deposes and says: that prior to the public opening and reading of bids/proposals, said bidder/proposer: a) did not, directly or indirectly, induce or solicit anyone else to submit a false or sham bid/proposal; b) did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder/proposer or anyone else would submit a false or sham bid/proposal, or that anyone should refrain from submitting a bid/proposal orwithdraw their bid/proposal; c) did not, in any manner, directly or indirectly, seek by agreement, communication or conference with anyone to raise or fix the bid price/proposal of said bidder/proposer or of anyone else, or to raise or fix any overhead, profit or cost element of their price/fee or of that of anyone else; d) did not give, offer 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/proposal; and e) did not, directly or indirectly, submit their bid/proposal price or any breakdown thereof, or the contents thereof, or divulge information or data relative hereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent, thereof, to any individual or group of individuals, or to any official, employee or agent of Calhoun County prior to the official opening of this bid/proposal. Affiant further deposes and says: that the bid price(s) or proposed fees contained in this bid/proposal have been carefully checked and is submitted as true and correct, agrees to furnish any and/or all items/services upon which bid prices or proposed fees are awarded and upon the co�and re�ents contained in the bid/proposal. 6� Signature of Affiant Matt A. Glaze, Vice President Printed Name and Title of Affiant 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 SO /06 C-X- 20�. Notary StaWea / otl/re of Notary �Public = Page 29 of 52 1, 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. Matt A. Glaze, Vice President 10/29/2024 Name and Title of Authorized Agent Date Signature of.Authorized Agent I am unable to certify to the above statements. My explanation is attached. Page 32 of 52 1l 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 I 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). Victoria Engineering, Inc. dba Urban Engineering The Contractor, , certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any. Signature of Co ractor's Authorized Official Matt A. Glaze, Vice President Printed Name and Title of Contractor's Authorized Official L 10/29/2024 L Date Page 33 of 62 1, 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. 1J Name of vendor who has a business relationship with local governmental entity. Victoria Engineering, Inc. dba Urban Engineering z El Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) .2J Name of local government officer about whom the information is being disclosed. NOT APPLICABLE 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 CIQ as necessary. NOT APPLICABLE 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 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 F---] No s 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. NOT APPLICABLE s Check this box if the vendor has given the local government officer or afamily 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 10/29/2024 ign ture o vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us pa&g�gjo/30/2016 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES n This disclosure form shall be completed by the reporting entity, whether sub awardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 I U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a i covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. (' 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the sub awardee, e.g., the first sub awardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Sub awardee," then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., 'RFP-DE-90-001" 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, jJ enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services,and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). t 11, The certifying official shall sign and date the form, print his/her name, title, and telephone number. f According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348- LLL 0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and f reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction -i Project (0348-0046), Washington, DC 20503 Approved by OMB 0348-0046 I, 1, Page 36 of 62 [, Approved by OMB NOT APPLICABLE Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for nublic burden dkrinsnre) 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: 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): dfferentfromNo. 10a) (last naive, 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 $10,006 and not more than $100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97) Page 37 of 52 HOUSE BILL 89 VERIFICATION FORM Certification Required by Texas Government Code Section 2270.001 The 851h Texas Legislature approved new legislation, effective September 1, 2017, which amends Texas Local Government Code Section 1, Subtitle F, Title 10, Government Code by adding Chapter 2270 which states that a government entity may not enter into a contract (which includes contracts formed through purchase orders) with a company for goods or services unless the contract contains a written verification from the company that it: 1) Does not boycott Israel; and 2) Will not boycott Israel during the term of the contract Pursuant to Section 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, (authorized official) Matt A. Glaze , do hereby verify the truthfulness and accuracy of the contents of the statements submitted on this certification under the provisions of Subtitle F, Title 10, Government Code Chapter 2270 and that the company named below: 1) Does not boycott Israel currently; 2) Will not boycott Israel during the term of the contract; and 3) Is not currently listed on the State of Texas Comptroller's Companies that Boycott Israel List located at https://comptroller.texas.goy/purchasing/publications/divestment.php Victoria Engineering, Inc. dba Urban Engineering Company Signature of Authorized Official Vice President Title of Authorized Official Matt A. Glaze Printed Name of Authorized Official 10/29/2024 Date Page 38 of 52 I, r 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) Q✓ I certify that Victoria Engineering, Inc. dba Urban Engineering is a "Resident Bidder" of Texas as (Company Name) defined in Government Code §2252.001. Signature of Authorized Agent Matt A. Glaze, Vice President Printed Name and Title of Authorized Agent 10/29/2024 Date Page 39 of 52 I" Request for Taxpayer Give Form to the Form (Rev, October2016) Identification Number and Certification requester. Do not Departmentofthe Treasury Internal Revenue Service P- Go to www:.[rs.gcv1FormW9 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. Victoria Engineering 2 Business name/disregarded entity name, if different from above Urban Engineering m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see a p ❑ Individuallsole proprietor or ❑ CCorporation R SCorporation ❑ Partnership ❑TrusVestato instructions on page 3); d c single -member LLC Exempt payee code (d any) ❑ Umited liability company. Enter the tax classification (C—C corporation, S=S corporation, P=Partnership)► `o Note: Check the appropriate box in the line above forthe tax classification of the single -member owner. Donotcheck Exemption from FATCA reporting IE e 'C LLC if the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC is LLC that Is disregarded code (it any) p' another 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. ❑ Other (we instructions) ► ptapNssroeccounmmahmM•CaWcH a,. us! y s Address (number, street, and apt or suite no.) See Instructions, Requester's name and address (optianali 1 2004 Commerce St CALHOUN COUNTY m 202 S ANN ST, PORT LAVACA TX 77979 6 city, state, and ZIP code Victoria, Texas 77901 361-553-4610 FAX: 361-553.4614 7 Ust account number(s) here (aptlonal) 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 Isgenerally your social security number (SSN. However, fora M resident alien, sole proprietor, or disregarded entity, see the Instructions for Pert 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 1 Number To Give the Requesterfor guidelines on whose number to enter. r C 1 Under penalties of perjury, I certify that: I _ 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 ll 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 f 3.1 am a U.S. citizen or other U.S. person (defined below); and t 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 1 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. �'yrr Signature of .� Here U.S. person► A General Instructions Section references are to the Internal Revenue Code unless otherwise noted. �.; Future developments. For the latest Information about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to www.1rs.gov/FormW9. Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), individual taxpayer Identification number (ITIN), adoption taxpayer Identification number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an Information return. Examples of Information returns Include, but are not limited to, the following. -; • Form 1099-INT (Interest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-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 networktransactions) • 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 Forth W-9 only If you are a U.S. person Qncluding 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. Y Cat No. 10231X (Rev. 10-201 e) Page 40 of 52 F, Li Li L L A� o® CERTIFICATE OF LIABILITY INSURANCE DnrE(mmmor y l 10/18/2024 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 Frost Insurance -Victoria P O Box 2525 Victoria TX 77902 CONTACT NAME: Margery Hall PHONE FAX E ' 361-580-9057 ac Na Aooaless: 'hall frostinsurance.com INSURERS AFFORDING COVERAGE NAICA INSURER A: Arch Insurance Company 11150 INSURED URBAENG-02 INSURER B: Victoria Engineering, Inc. dba Urban Engineering; Urban Surveying, Inc INSURER C: INSURER D: 2004 North Commerce INSURERE: Victoria TX 77901 INSURERF: C0VFRArFS CFRTIFICATF NIIMRFR-1A7AI1AAn1 RFVISION NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED. BY PAID CLAIMS. INSR TR TYPE OF INSURANCE ADDL SUBR ppLICV NUMBER MOLICYYW MMIDC� LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR AGE TO RNTED PDRMAEMISE$ EaEeccurmnce $ MED EXP(Any one parson) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PRO- ❑ JECT LOC PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea eccident $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTYDAMAGE Per ...ideal) $ HIRED NON -OWNED AUTOS ONLY HAUTOS ONLY UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION ANDEMPLOYERVLIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICEWMEMBEREXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below EL.DISEASE - POLICY LIMIT $ A Professional Liability PAAEP0007109 10/20/2024 10/20/2025 Each Occurence $2,000,000 Aggregate $2,000,000 Deductible $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Calhoun County 211 S Ann St, Ste 301 Port Lavaca TX 77979 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The ACORD name and logo are registered marks of ACORD 10/28/24, 10:49 AM SAM.gov I Search IM An official website of the United States government Here's how you know -r _SAM*Gov 0 0O !0 Home Search Data Bank Data Services Help Search All Words e.g.1606N020Q02 Search Results Saved Searches �Select Domain Entity Information + All Entity Information Entities l; Disaster Response Registry Responsibility/Qualification LI ' II (' Exclusions Filter By — Keyword Search For more information on how to use our keyword search, visit our help guide Simple Search Search Editor OAny Words o All Words f O Exact Phrase I https://sam.gov/search/?page=l&pageSize=25&sort=-relevance&index=ei&sfm%5BsimpleSearch%5D%5BkeywordRadio%BD=ALL&sfm%5BsimpleS... 1/3 10/28/24, 10:49 AM SAM.gov I Search e.g. 123456789, Smith Corp Entity ^ Entity Name VICTORIA ENGINEERING, INC. x Unique Entity ID: UFQYF4UAG9S9 Unique Entity ID e.g. HTYR9YJHK65L CAGE/NCAGE 1, Location v Status ^ O Active 1 Inactive i Reset C1 Sort by Showing 1-1 of 1 results Relevance f VICTORIA ENGINEERING, INC. 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All individuals viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part 2002 and GSA Order CIO 2103.2 CUI Policy. � ANI.gov An officiai website of the U.S. General Services Administration p https://sam.gov/search/?page=1&pageSize=25&sort=-relevance&index=ei&sfm%5BsimpleSeamh%5D%5BkeywordRadio%5D=ALL&sfm%5BsimpleS... 3/3 10/28/24, 10:52 AM SAM.gov i Search i An official website of the United States government Here's how you know C SAM*Gov® 0 00 0 i Home Search Data Bank Data Services Help l Search All Words e.g. 1606N020002 Search Result Saved Searches ' ! 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Individuals found performing unauthorized activities are subjectto disciplinary action including criminal prosecution. This system contains Controlled Unclassified Information (CUI). All individuals viewing, reproducing or disposing of this information are required to protect it in accordance with 32 CFR Part 2002 and GSA Order CIO 2103.2 CUI Policy. SA o ov An Official eAfebsite of the U.S. General Services Administration I hops://sam.gov/search/?page=l &pageSize=25&sort=-relevance&index=ei&sfm%5Bsimple5earch%50%58keywordRadio%5D=ALL&sfm%5Bsimple5... 313 CERTIFICATE OF INTERESTED PARTIES FORM 1295 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. 2024-1232146 Victoria Engineering, Inc. dba Urban Engineering Victoria, TX United States Date Filed: 10/29/2024 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. RFQ 2024.11 Engineering Services in connection with RFQ 2024.11 for CMP Cycle 29 Grant GLO Contract No. 25-003-009-E702 for Calhoun County, Texas 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I intermediary Urban, Larry Corpus Christi, TX United States X Schmidt, Thomas Victoria, TX United States X Bridges, Ray Victoria, TX United States X Glaze, Matt Victoria, TX United States X Fromme, Cheyanne Victoria, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION Matt A. Glaze 11-2-78 My name is and my date of birth is 2004 N. Commerce St. Victoria TX 77901 USA My address is , (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Victoria Texas 29th October 24 Executed in County, State of , on the _day of , 20. (month) (year) Signature o authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V4.1.0.48da51f7 Thank We appreciate the opportunity & look forward to discussing further. e n g i n e e r i n g 2004 N. COMMERCE, VICTORIA, TX 77901 361,578.9836 • URBANVICTORIA.COM • TREF# F-160 NO-( ICE OF MEETING — 11/13/2024 15. Consider and take necessary action to issue a County credit card to EMS Assistant Director Clint Macek with a credit limit of $5,000. (RHM) Page 12 of 16 Debbie Vickery From: Dustin.lenkins@calhouncotx.org (Dustin Jenkins) <Dustin.Jenkins@calhouncotx.org> Sent: Thursday, November 7, 2024 10:10 AM To: debbie.vickery@calhouncotx.org Cc: Rhonda Kokena;john.mayne@calhouncotx.org; Clint Macek Subject: Credit Card for New Assistant Director Debbie, Could you place a request to have a Credit Card issued to Clint Macek with a limit of $5,000.00 on the next Commissioners Court agenda? Clint is our New Assistant Director for Calhoun County EMS. Thanks! Very Respectfully, J. Dustin Jenkins, DMin, MBA, LP' Director of Emergency Medical Services 705 Henry Barber Way Calhoun County, TX dustin.jenkins@calhouncotx.org (361)571-0014 Calhoun County Texas #16 NOTICE OF MEETING — 11/13/2024 16. Consider and take necessary action to lift or retain the county burn ban. (RHM) pass Page 13 of 16 #17 I NOTICE OF MEETING - 11/13/2024 17. Accept Monthly Reports from the following County Offices: a) Justice of the Peace Pct 1 - October, 2024 b) Justice of the Peace Pct 3 - October, 2024 c) Justice of the Peace Pct 4 - October, 2024 d) Justice of the Peace Pct 5 - October, 2024 e) County Clerk - October, 2024 f) District Clerk - October, 2024 g) County Treasurer - May and July, 2024 h) Sheriffs Department - October, 2024 i) Floodplain Administration - October, 2024 RESULT:' AOROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct2 SECONDER -'David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner HaII; Lyssy, Behrens, Reese Page 14 of 16 Calhoun Count7Floodplain Administtma Lion 211 South Ann Street, Suite 301 Port Lavaca, TX 77979-4249 Phone: 361-553-4455/Fax: 361-553-4444 e-mail: kim.grall@calhouncotx.org October 2024 Development Permits Report For Commissioners Court: November 13th, 2024 New Homes - 6 Renovations/Additions -1 Mobile Homes -1 Boat Bams/Storage Buildings/Garages - 2 Commercial Buildings/RV Site - 3 Addition - 0 Fence - 0 Pool - 0 Drainage - 0 Pipeline - 0 Total Fees Collected: $720.00 Receipt numbers: 920517, 920518, 920519, 920520, 920521, 920522, 920523, 920524, 920525, 920526, 920527, 920528, 920529 r County Judge SHERIFF'S OFFICE MONTHLY REPORT Oct-24 BAIL BOND FEE $ 510.00 CIVIL FEE $ 563.50 CASH BOND JP#1 $ 7,732.20 JP#2 JP#3 $ 1,544.00 JP#4 $ - JP#5 $ 1,004.50 SEADRIFT MUN. $ - PC MUN $ 4,322.50 PROPERTY SALE PRE-INDITMENT TOTAL: $ 15,676.70 1 O O O O O N O O m O 0 0 P N O O O IO O O O O O p O O< O O O lO O O O O r l O P� 0 0 l9 o O m O p O m e e l o O• -1 r Y N O m l9 m O r o 0 o O O q N W N m O m ^1 IV O O O O O O O O O O O O O O O 000 O 1 o a O a p p o 0a p o 0 0 0 o O o o ^^ 00000000000000 N N O O O O O O O O O N N O O O O O O 999 o �O W N 4O N N lO Q� �p 10 q W P •-I q F m N N ({\\�\\\\\\\\\\\\� � N rl P ri F T N \+mil N �C O .i O O O O O O O N O O ei O N O O O O W V! Ul O O N W O O T O N P O P .0. O ••I N T N N p ti M N O O O O O O O O O O N O O O O O O IO N O O O O N O N O O O N O< N O O O O N N P N N N O O O O O O O O O N N O O O O O O N 'I O O O N O Ill ONO rl r+ < O O O O O r N F T N ••1 N t0 F M W W W W W W W W W W W W W coca O O O Oman O O 0 ❑ O O 0008008 O O O O O O D U U U U U V U U U U U V U U V U U a s a s a s a a s a s a m UUc�tf U c+z0r, r, uc�c�c�c� 000 � zzzzzzz°z°zzzzzz zzz o p o o p N N o 0 0 o N eu coror In M W m N W W fWe. W W O cW-1 nWi M .> O s, wZ W"rt V �W V U M 4 6 W wm W N OwF OHO N r m S U O z m w z Z w a OG M O F wai W j U W E g W G r up F E Y I -I w awa I -I [G m O W M N ❑ W W O W E H p .j IU-I CW'• p a- 4 0 F m N N w Q. w W O W O M w O O H\ F F w 3:Z W Qw NG.m F wN N 6 RilE go S yU �WI gSOt4/i9 9'.1:-I 'm W O o m t4J m\ iyy�e CG [zQQm�� y��U 94 IQ-IU FC KUUU cTWWWWAAOgyl C. W QU2 w mCCm-]-.1 CaM Q £cQiU� NCU ro y. ywj0 4448 a u W W O S Vmi W U O tFll UM N� n o u s y a V U CALHOUN COUNTY CLERK MONTHLY REPORT RECAPITUATION OCTOBER 2024 - OFFICIAL - PUBLIC DESC GLCODE CIVIL/FAMILY CRIMINAL RECORDS PROBATE TOTAL DISTRICT ATTORN EY FEES 1000-44020 $ 130.77 $ 130.77. BEER LICENSE 1000-42010 $ 5.00 $ 5.00 COUNTY CLERK FEES 1000-44030 $ 118.00 $ 261.53 $ 11,767.40 $ 206.00 $ 12.352.93 APPEAL FROM IP COURTS 1000-44030 $ - $ - COUNTY COURT ATLAW RIJURY FEE 1000-44140 $ - JURY FEE 1000-44140 $ - $ - $ - ELECTRONICFILINGFEESFORE-FILINGS 1000-44058 $ - $ - $ - $ - $ - JUDGE'S EDUCATION FEE 1000-44160 $ - $ - $ - $ 15.00 $ 15.00 JUDGE'S ORDER/SIGNATURE 1000-44180 $ 28.00 $ - $ - $ 54.00 $ 82.00 SHERIFF'S FEES 1000-44190 $ - $ 112.93 $ - $ 100.00 $ 212.93 VISUAL RECORDER FEE 1000-44250 $ 31.72 $ 31.72 TIME PAYMENTFEE- COUNTY "NEW2020" 1000-44332 $ 45.00 $ 45.00 COURT REFPORTER FEE 1000-44270 $ 50.00 $ - $ - $ 75.00 $ 125.00 RESTITUTION DUE TO OTHERS 1000-49020 $ - ATTORNEY FEES -COURT APPOINTED 1000-49030 $ - $ - APPELLATE FUND (TGC) FEE 2620-44030 $ 10.00 $ 15.00 $ 25.00 COURT FACILITY FEE FUND 2648.44030 $ 40.00 $ $ - $ 60.00 $ 100.00 TECHNOLOGY FUND 2663-44030 $ 26.15 $ '26.15 COUNTYJURYFUND •'NEW2020-- 2669.44030 $ 20.00 $ 6.54 $ - $ 30.00 $ 56.54 COURTHOUSE SECURITY FEE 2670-44030 $ 40.00 $ 65.38 $ - $ 60.00 $ 165.38 COURT INITIATED GUARDIANSHIP FEE 2672-44030 $ 90.00 $ 90.00 COURT RECORD PRESERVATION FUND 2673-44030 $ - $ - $ - $ - COURTREPORTER SERVICEFUND•'NEW2020" 2674-44030 $ 19.61 $ 19.81 RECORDS ARCHIVE FEE 267544030 $ 3,650.00 $ 3,650.00 COUNTYSPECIALTY COURT •-NEW2020" 2676-0 030 $ 130.77 $ 130.77 COUNTY DISPUTE RESOLUTION FUND 2677-44030 $ 30.00 $ - $ - $ 45.00 $ 75.00 DRUG& ALCOHOL COURT PROGRAM 2698-44030-005 $ - $ - JUVENILECASE MANAGERFUND 2699-44033 $ - $ - FAMILY PROTECTION FUND 2706-44030 $ - $ - JUVENILE CRIME & DELINQUENCY FUND 2715-44030 $0.00 $ - LANGUAGE ACCESS FUND 2725-44030 $ 6.00 $ - $ - $ 9.00 $ 15.00 PRE-TRIAL DIVERSON AGREEMENT 2729-44034 $ 234.00 $ 234.00 LAW LIBARY FEE 2731-44030 $ 70.00 $ 105.00 $ 175.00 RECORDS MANAGEMENT FEE -COUNTY CLERKK 2738-44380 $ - $ 3,690.00 $ 3,690.00 RECORDS MANGEMENT FEE - COUNTY 2739-44030 $ 60.00 $ 163.46 $ 45.00 $ 268A6 FINES -COU NTY COU RT 2740-4SO40 $ 1,404.11 $ 1,404.11 BOND FORFEITURE 2740-45050 $ - $ - STATE POLICE OFFICER FEES - STATE (DPS) (20%) 7020-20740 $ 0.07 $ 0.07. CONSOU DATED COU RT COSTS -COUNTY 7070-20610 $ - $ - CONSOUDATED COU RTCOSTS -STATE 7070-20740 $ - $ - CONSOLIDATED COURTCOSTS-COUNTY "NEW20207072-20510 $ 1IL76 $ 112.78 CONSOLIDATED COURTCOSTS-STATE •-NEW2020"7072-20740 $ 1,014.87 $ 1,014.87 IUDICIALAND COURT PERSONNELTRAINING -ST (100% 7502-20740 $ - $ - $ - $ - DRUG& ALCOHOL COURT PROGRAM -COUNTY 7390-20610 $ - $ - DRUG& ALCOHOL COURT PROGRAM -STATE 7390-20740 $ - $ - STATEELECTRONICFILINGFEE -CIVIL 7403-22887 $ - $ - $ - $ STATE ELECTRONIC FILING FEE CRIMINAL 7403-22990 $ - $ - EMS TRAUMA -COUNTY (10%) 7405-20610 $ 208.36 $ 208.36 EMS TRAUMA - STATE (90%) 7405-20740 $ 23.15 $ 23.15 CIVIL INDIGENT FEE -COUNTY 7480-20610 $ - $ - $ - CIVIL INDIGENT FEE -STATE 7480-20740 $ - $ - $ - JUDICIALFUNDCOU FIT COSTS 7495-20740 $ - $ - JUDICIALSALARY FUN D- COUNTY (10%) 75D5-20610 $ - $ - JUDICIAL SALARY FUND - STATE (90%) 7505-20740 $ - $ - JUDICIALSALARYFUND(CIVIL&PROBATE) - STATE 7505-20740-005 $ - $ - $ - TRAFFIC LOCAL (ADMINISTRATIVE FEES) 7538-22884,1000-44359 $ 6.90 $ 6.90 COU RT COST APPEAL OF TRAFFIC REG(IP APPEAL) 7538-22985 $ - BIRTH - STATE 7855-20780 $ 183.60 $ 183.60 INFORMAL MARRIAGES - STATE 7855-20782 $ - $ - JUDICIAL FEE 7855-20786 $ - $ - $ - $ - FORMAL MARRIAGES -STATE 7855-20788 $ 300.00 $ 300.00 NONDISCLOSURE FEE - STATE 7855-20790 $ - $ - $ - $ - $ - TCLEOSECOURTCOST -COU NTY(10%) 7856-20610 $ - $ - TCLEOSECOURTCOST - STATE (90%) 7856-20740 $ - $ - IURYREIMBURSEMENTFEE -COUNTY (10% 7857-20610 $ - $ - JURY REIMBURSEMENT FEE -STATE (90%) 7857-20740 $ - $ - CONSOLIDATEDCRT COSTS - STATE(PR, FAM CV) S94J 7858-20740 $ 137.00 $ - $ 137.00 STATE TRAFFIC FI N E- COUNTY (5%) 7860-20610 $ - $ - STATE TRAFFIC FINE - STATE (95%) 7860-20740 $ - $ - STATE TRAFFIC FINE . COUNTY (4%) 91112019 7860-20610 $ 4.80 $ 4.00 STATE TRAFFIC FINE - STA TE (96%) 91112019 7860-20740 $ 110.31 $ 110.31 10P2 J,UNEPORTSWONTMLY UTOR AND TREASURER REPORTS12UP103124TRFASURER REPORTS.Av 11/'.. CALHOUN COUNTY CLERK MONTHLY REPORT RECAPITUATION OCTOBER 2024 OFFICIAL PUBLIC DES[... GLOODE CIVIL/FAMILY CRIMINAL RECORDS PROBATE TOTAL INDIGENT DEFENSE FEE -CRIMINAL- COUNTY (10%) 7865-20610 $ - $ - INDIGENT DEFENSE FEE -CRIMINAL- STATE (90%) 7865-20740 $ - $ - TIME PAYMENT - COUNTY (50%) 7950-20610 $ - $ - TIME PAYMENT -STATE (50%) 7950-20740 $ - $ - BAIL JUMPING AND FAILURE TOAPPEAR -COUNTY 7970-20610 $ - BAIL JUMPING AND FAILURE TOAPPEAR -STATE 7970-20740 $ - DUEPORTIAVACAPD 9990-99991 $ 10.00 $ 10.00 DUE SEADRIFT PD 9990-99992 $ - $ - DUE TOPOINT COMFORT PD 9990-99993 $ - $ - DUE TOTEXAS PARKS&WILDLIFE 9990-99994. $ - $ - DUE TOTEXAS PARKS& WILDLIFE WATER SAFETY 9990-99995 $ - DUETOTABC 9990-99996 $ - DUE TOATI-ORNEYADLITEMS 999099997 $ - DUE TOOPERATING/NSF CHARGES/DUE TO OTHERS 7120-20759 $ $ $ 330.00 1 $ 500.00 $ 830.00 $ 609.00 $ 4,123.00 $ 19,926.00 $ 1,409.00 $ 26,067.00 TOTAL FUNDS COLLECTED $ 26,067.00 0.00 FUNDS HELD IN ESCROW: $ - AMOUNT DUE TO TREASURER(2DR'S):'$ 25,227.00 TOTAL RECEIPTS:;$ 26,067.00 AMOUNT DUE TO OTHERS (LESS SF'S): $ MODE REGISTRY DEPOSITS, CASH :ASH ON HAND: REGISTRY OF COURT FUNDS (PROSPERITY) EGINNING BOOK BALANCE .9/30/2024 _ FUND RECEIVED DISBURSEMENTS ENDING BOOK BALANCEI 10/31/1024 ENDING BANK BALANCE OUTSTANDING DEPOSITS" OUTSTANDING CHECKS" $ 59808.62 $ 2:500.00 1 "BALANCE OF CASH BONDS" "OTHER REGISTRY ITEMS" "IBC CASH BOND CHECKS - 10/31/2024 $ 66A93.62 I "TOTAL REGISTRY FUNDS" Reconciled: $ fFRTIFIfaTFC r1F NFNn1 ITS HFI n IN TRI ICT. PPnRPFRITV rrANIt CD'S Date Issued Balance..: Purchases/ Whhcrawals Balance. 913012024.. Interest 10131124 10440 1/24/2018 $ $ $ 10441 1/24/2018 $ $ 10442 1/24/2018 $ 1,324.06 $ 8.82 $ 1,332.88 10443 1/25/2018 $ 1,324.06 $ 8.82 $ 1.332.88 10444 1/25/2018 $ 9,998.88 $ 66.60 $ 10,065.48 10445 1/25/2018 $ 9,998.88 $ 66.60 $ 10,065.48 10446 1/25/2018 $ 9,99"S $ 66.60 $ 10,065.48 10449 6/9/1955 $ 21,224.73 $ 21,224.73 10454 3/2/2018 1 $ $ 10455 3/2/2018 $ $ 10486 8/26/2020 $ 6,136.65 $ 6,136.65 10495 12/22/2021 $ 35,750.07 $ 35,750.07 10496 12/22/2021 $ 35,750.05 $ 35,750.05 10504 2/14/2023 $ 11,395.03 $ 77,395.03 10505 2/14/2023 $ 9,664.95 $ 9,664.95 TOTALS: $152,666.24 $ 217.44 $ $ 152,783.68 8 / WL / /7 lQowm(2S/ 11/4/2024 Submitted by: Anna M Goodman, County Clerk Date Ri and Meyer, Calhoun County Jude Date 2 0 F 2 U.M.REPORTSWONTHLVAAUDITOR AND TREASURER REPORTM20M.103124.TRFASUNER REPORT$ Am 11AIX24 v,, Au J� EACE N011 MONTH OF REPORT YEAR OF REPORT REVISED 02/02/2022 ADMINISTRATION FEE -ADMF BREATH ALCOHOL TESTING - BAT CONSOLIDATED COURT COSTS -CCC STATE CONSOLIDATED COURT COST-2020- '3,1 �" LOCALCONSOLIDATED COURT COSL 2020 "7 COURTHOUSE SECURITY -CHS CJP CIVIL JUSTICE DATA REPOSITORY FEE -CJDR CORRECTIONAL MANAGEMENT INSTITUTE - CMI '.. CR CHILD. SAFETY - CS CHILD SEATBELT FEE -CSBF CRIME VICTIMS COMPENSATION -CVC DPSC/FAILURE TO APPEAR - OMNI -DPSC - ADMINISTRATIONS FEE FTAIFTP (aka OMN0- 2020 ELECTRONIC FILING FEE -EEF FUGITIVE APPREHENSION - FA GENERALREVENUE-GR' CRIM- IND LEGAL SVCS SUPPORT -IDF: JUVENILE CRIME & DELINQUENCY - JCD JUVENILE CASE MANAGER FUND - JCMF JUSTICE COURT PERSONNEL TRAINING - JCPT `.. JUROR SERVICE FEE-JSF':-'. LOCAL ARREST FEES-LAf LEMI LEDA -I LEOC OCL PARKS & WILDLIFE ARREST FEES -PWAF STATE ARREST FEES -SAF -' SCHOOL CROSSING/CHILD SAFETY FEE - SOP i SUBTITLE C. SUBC ". STATE TRAFFIC FINES -EST 9.1.19. STF iz TABC ARREST FEES -TAF _'.°:: TECHNOLOGY FUND -TF TRAFFIC - TFC "1.. LOCAL TRAFFIC FINE- 2020 '.. TIME PAYMENT -TIME ' TIME PAYMENT REIMBURSEMENT FEE. 2020 TRUANCY PREVENTION/DIVERSION FUND -TPDF LOCAL& STATE WARRANT FEES -WRNT fSJ COLLECTION SERVICE FEE-MVBA-CSRV '.. :1,41 DEFENSIVE DRIVING COURSE -CDC DEFERRED FEE' - OFF 7( DRIVING EXAM FEE- PROV OIL FILING FEE -FFEE STATE CONSOLIDATED CIVIL FEE -2022 ' '21 LOCAL CONSOLIDATED CIVIL FEE -2022 `. - 4; FILING FEE SMALL CLAIMS. FFSC JURY FEE -JF COPIESICERTIFED COPIES - CC INDIGENT FEE -.CIFF or INDF JUDGE PAY RAISE FEE -JPAY '. SERVICE FEE -SFEE 'dE OUT -OF -COUNTY SERVICE FEE- ELECTRONICFILINGFEE -EEF CV EXPUNGEMENT FEE EXPG: EXPIRED RENEWAL -EXPR ABSTRACT OF JUDGEMENT -AOJ ALL WRITS- WOP / WOE-: CPS FTA FINE -DPSF /: :. 3f utucrvOC a VVCI Vt1I r.CO - Lvvr PARKS B WILDLIFE FINES -PWF I': 210 SEATBELTNNRESTRAINEO CHILD FINE - SEAT t, : JUDICIAL & COURT PERSONNEL TRAININGJCPT P ` OVERPAYMENT (OVER $/0)-OVER OVERPAYMENT (S10 AND LESS) : OVER RESTITUTION - REST PARKS & WILDLIFE -WATER SAFETY FINES-WSF MARINE SAFETY PARKS &WILDLIFE-MSO TOTAL ACTUAL MONEY RECEIVED ENTER LOCAL WARRANT FEES ').: .:."'AS6.98 RECORD ON TOTA. PAGE GP HILL COUNTRY SOFMARE MO REPORT STATE WARRANT FEES $154,44 RECORD OR TOTAL PAGE OR HILL COUNTRY SOPMAR-E MOREPORT TO OTHERS: AMOUNT INCLUDE D R REQUESTING UISBCRSE!YNT TO CCISD- 50% of Fine OM JV cases - "0.00':PLEASE TO DA RESTITUTION FUND 0.00 PLEASE a:cwDE OR REQussTwc Dlseuss=MENT JND OF OVERPAYMENTS 0.00 PLEASE INCLUDE- DR PEOUEsrwG DISBURSEMENT OF -COUNTY SERVICE FEE 0.00 PLEASE INCLUDE OR REQUESTING DISBURSEMENT d. BONDS 0.00 PLEASE INCLUDE 0P. REQUESTING DISBURSEMENT (IF FFOU REDI Treasurer's Receipts MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/1/2024 COURT NAME: JUSTICE OF PEACE NO. 1 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 ACCOUNT NUMBER ACCOUNT NAME AMOUNT CR 1000.001-45011 FINES 5,290.64 CR 1000-001-44190 SHERIFF'S FEES 825.32 ADMINISTRATIVE FEES: DEFENSIVE DRIVING 30.00 CHILD SAFETY 0.00 TRAFFIC 74.70 ADMINISTRATIVE FEES 862.10 EXPUNGEMENTFEES 0.00 MISCELLANEOUS 0.00 CR 1000-001-44361 TOTAL ADMINISTRATIVE FEES 966.80 CR 1000-001-44010 CONSTABLE FEES -SERVICE 450.00 CR 1000-001-44061 JP FILING FEES 5.00 CR 1000-001-44090 COPIES / CERTIFIED COPIES 0.00 CR 1000-001-49110 OVERPAYMENTS (LESS THAN $10) 5.50 CR 1000-001-44322 TIME PAYMENT REIMBURSEMENT FEE 218.24 CR 1000-001-44145 SCHOOL CROSSING/CHILD SAFETY FEE 0.00 CR 1000-999-20741 DUE TO STATE -DRIVING EXAM FEE 0.00 CR 1000-999-20744 DUE TO STATE-SEATBELT FINES 0.00 CR 1000-999-20745 DUE TO STATE -CHILD SEATBELT FEE 0.00 CR 1000-999.20746 DUE TO STATE -OVERWEIGHT FINES 0.00 CR 1000-999-20770 DUE TO JP COLLECTIONS ATTORNEY 1,468.20 TOTAL FINES, ADMIN. FEES & DUE TO STATE $9,229,70 CR 2670-001-44061 COURTHOUSE SECURITY FUND $247.95 CR 2720-001.44061 JUSTICE COURT SECURITY FUND $0.98 CR 2719-001.44061 JUSTICE COURT TECHNOLOGY FUND $203.58 CR 2699-001.44061 JUVENILE CASE MANAGER FUND $1.01 CR 2730-001.44061 LOCAL TRUANCY PREVENTION & DIVERSION FUND $250.02 CR 2669-001 44061 COUNTY JURY FUND $5.00 CR 272$.Ob1�t4061^- - JUS I EE OIJR 11P1 --T,IF $325a- GR 2677=601 44061 QOUNTY.;DISPUTE RED _ LU i,QN Uf1D 66f00' CR 272AW)I LAAbAl STATE ARREST FEES DPS FEES 35.72 P&W FEES 11.63 TABC FEES 0.00 CR 7020-999-20740 TOTAL STATE ARREST FEES 47.35 CR 7070-999-20610 CCC-GENERAL FUND 3.57 CR 7070-999-20740 CCC-STATE 32.09 DR 7070-999-10010 35.66 CR 7072-999-20610 STATE CCC- GENERAL FUND 310.02 CR 7072.999.20740 STATE CCC- STATE 2,790.16 DR 7072-999-10010 3,100,18 CR 7860-999-20610 STF/SUBC-GENERAL FUND 0.52 CR 7860.999-20740 STF/SUBC-STATE 9.91 DR 7860-999-10010 10.43 CR 7860-999-20610 STF- EST 9/1/2019- GENERAL FUND 49.11 CR 7860-999-20740 STF- EST 9/1/2019- STATE 1,178.66 DR 7860-999-10010 1.227.77 Page 1 of 3 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/1/2024 COURT NAME: JUSTICE OF PEACE NO. 1 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 CR 7950-999-20610 TP-GENERAL FUND 12.50 CR 7950-999-20740 TP-STATE 12.50 DR 7950-999-10010 25.00 Page 2 of 3 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/1/2024 COURT NAME: JUSTICE OF PEACE NO. 1 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 CR 7480-999-20610 CIVIL INDIGENT LEGAL-GEN. FUND 0.00 CR 7480-999-20740 CIVIL INDIGENT LEGAL -STATE 0.00 DR 7480-999-10010 0.00 CR 7865-999-20610 CRIM-SUPP OF IND LEG SVCS-GEN FUND 0.18 CR 7865-999-20740 CRIM-SUPP OF IND LEG SVCS-STATE 1.61 DR 7865-999-10010 1.79 CR 7970-999-20610 TL/FTA-GENERAL FUND 24.52 CR 7970-999-20740 TL/FTA-STATE 49.05 DR 7970-999-10010 73.57 CR 7505-999-20610 JPAY- GENERAL FUND 0.93 CR 7505-999-20740 JPAY-STATE 8.33 DR 7505-999-10010 9.26 CR 7857-999-20610 JURY REIMB, FUND- GEN. FUND 0.32 CR 7857-999-20740 JURY REIMB. FUND- STATE 2.89 DR 7857-999-10010 3.21 CR 7856-999-20610 CIVIL JUSTICE DATA REPOS.- GEN FUND 0.00 CR 7856-999-20740 CIVIL JUSTICE DATA REPOS.- STATE 0.00 DR 7856-999-10010 0.00 CR 7502-999-20740 JUD/CRT PERSONNEL TRAINING FUND- STATE 0.00 DR 7502-999-10010 0.00 7998-999-20740 TRUANCY PREVENT/DIV FUND - STATE 0.55 7998-999-20701 JUVENILE CASE MANAGER FUND 0.55 DR 7998-999-10010 1.09 7403-999-22889 ELECTRONIC FILING FEE - CV STATE 0.00 DR 7403-999-22889 0.00 7858-999-20740 STATE CONSOLIDATED CIVIL FEE 273.00 273.00 TOTAL (Distrib Reg to Oper Acct) $15,175.55 DUE TO OTHERS (Distrib Reg Attchd) CALHOUN COUNTY ISD 0.00 DA - RESTITUTION 0.00 REFUND OF OVERPAYMENTS 0.00 OUT -OF -COUNTY SERVICE FI 0.00 CASH BONDS 0.00 PARKS & WILDLIFE FINES 1,748.45 WATER SAFETY FINES 0.00 TOTAL DUE TO OTHERS $1,748.45 TOTAL COLLECTED -ALL FUNDS $16,924.00 LESS: TOTAL TREASUER'S RECEIPTS $16,924.00 REVISED 02/02/2022 OVER/(SHORT) $0.00 Page 3 of 3 jtrTF OF?F CALHOUN DISTRIBUTION A1_ REQUEST COUNTY Lr.1,.•. .��� • 201 West Austin DR# 450 A 45597 .t•oFcrt�. PAYEE PAYOR Name: Calhoun County Oper. Acct. Official: Hope Kurtz Address: Title: Justice of the Peace, Pct. 1 City: State: Zip: Phone: ACCOUNT NUMBER DESCRIPTION AMOUNT 7541.999.20759.999 JPl Monthly Collections - Distribution $15,175.55 OCTOBER 2024 V# 967 TOTAL, 15,175.55 Signature of Official 0 Date JUSTICE OF PEACE NO.3 iRT OCTOBER T 2022 - 2024 ...WOE AMlM REVISED 02/0212021 NIA'iFATON PPP. AbL1P' tOOO` 8F CONS< STA7ECON :: `-LDCACCN I ^ CHILD SAFET CHILD SEATBELTFEE-. CRIME VICTIMS COMPENSATION GCtAll IIOG xInseGne' nul ELECTRONIC FILING FEI FUG ITIVE APPREHENSI( GENERAL REVENL CRIM - ]NO LEGAL SVCS SUPPCR JUVENILE CRIME & DEUNOUENC` JUVENILE CASE MANAGER FUND: JUSTICE COURT PERSONNEL TRAINING JUROR SERVICE FEi LOCALARRESTFEEI PARKS & WILDLIFE ARREST FEES - STATEARRESTFEW SCHOOL CROSSINGICNILD SAFETY FEE `SUBTITLE:C- STATE TRAFFICC FINESEST:B 1,1 TABC ARREST FEE: TECHNOLOGY FUI TRAFFIC LOCAL TFIMF1C FINI THE PAYEJENT COLLECTION SE : DEFENSIVE URIV STATE CONSOI LOCALCONSOI FILING fE CCOPIE; IN01 JUDO OUT:q ELECTRO EX 9 ABSTRAI UCENS PARKS, OVERPAYMEI R FE 867.44 110,37 30.00 42.81 SAO 52.14 00114 30.08 SM 160.00 278:61 10AO 242:00 126.00 198.00 225M 1,135,27 110.00 AMOUNT 150.00' ENTER LOCAL WARRANTFEES(_ STATE WARRANT FEES ---I DUE TO OTHERS: Al O T CCISO- ofF.OIe MI JVicesta DUE TO DA RESTiMIONFIIND REFUND OF OVERPAYMENTS OUT -OF -COUNTY SERMCE FEE CASHBONDS TOTAL DUE TOOTHERS INT:. �„. R�m"mk Rv.I[51NappmraERwi xciwl nzlaEa[ain0aa0As0ewt 00 0.FASEN0.WE nR PlLUE8iNQOp9U6FAlwf OD R.SssEnp.IwE aRr�auesrxooseuaeruwr 00 0.5tsEMRUnF, 6RIEW@'rWnnSBUtt9@IwIIF PCWf®) INf,. � aiwl*8omACTUALTr r*esR"pls MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/l/2024 COURT NAME: JUSTICE OF PEACE NO.3 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 ACCOUNTNUMBER ACCOUNTNAME AMOUNT CR 1000-001-45013 FINES 1,153.12 CR 1000-001-44190 SHERIFF'S FEES 202.52 ADMINISTRATIVE FEES. DEFENSIVE DRIVING 10.00 CHILD SAFETY 0.00 TRAFFIC 36.08 ADMINISTRATIVE FEES 292.00 EXPUNGEMENT FEES 0.00 MISCELLANEOUS 0.00 CR 1000-001-44363 TOTAL ADMINISTRATIVE FEES 338.08 CR 1000-001-44010 CONSTABLE FEES -SERVICE 225.00 CR 1000-001-44063 JP FILING FEES 0.00 CR 1000-001-44090 COPIES / CERTIFIED COPIES 0.00 CR 1000-001-49110 OVERPAYMENTS (LESS THAN $10) 0,00 CR 1000-001-44322 TIME PAYMENT REIMBURSEMENT FEE 6.24 CR 1000-001-44145 SCHOOL CROSSING/CHILD SAFETY FEE 0.00 CR 1000-999-20741 DUE TO STATE -DRIVING EXAM FEE 0.00 CR 1000-999-20744 DUE TO STATE-SEATBELT FINES 0.00 CR 1000-999-20745 DUE TO STATE -CHILD SEATBELT FEE 0.00 CR 1000-999-20746 DUE TO STATE -OVERWEIGHT FINES 0.00 CR 1000-999-20770 DUE TO JP COLLECTIONS ATTORNEY 276.51 TOTAL FINES, ADMIN. FEES & DUE TO STATE $2,201.47 CR 2670-001-44063 COURTHOUSE SECURITY FUND $59.63 CR 2720-001-44063 JUSTICE COURT SECURITY FUND $0.00 CR 2719-001-44063 JUSTICE COURT TECHNOLOGY FUND $48.68 CR 2699-001-44063 JUVENILE CASE MANAGER FUND $0.00 CR 2730-001-44063 LOCAL TRUANCY PREVENTION & DIVERSION FUND $60.85 CR 2669-001-44063 COUNTY JURY FUND $1.22 CR 2728-001-44063 JUSTICE COURT SUPPORT FUND $160.00 CR 2677-00144063 COUNTY DISPUTE RESOLUTION FUND $30.00 CR 2725-00144063 LANGUAGE ACCESS FUND $18.00 STATE ARREST FEES DPS FEES 26.43 P&W FEES 1.00 TABC FEES 0.00 CR 7020-999-20740 TOTAL STATE ARREST FEES 27.43 CR 7070-999-20610 CCC-GENERAL FUND 0.00 CR 7070-999-20740 CCC-STATE 0.00 DR 7070-999-10010 0.00 CR 7072-999-20610 STATE CCC- GENERAL FUND 86,74 CR 7072-999-20740 STATE CCC- STATE 780.70 DR 7072-994-10010 867.44 CR 7860-999-20610 STF/SUBC-GENERAL FUND 0.00 CR 7860-999-20740 STF/SUBC-STATE 0.00 DR 7860-999-10010 0.00 CR 7860-999-20610 STF- EST 9/1/2019- GENERAL FUND 24.05 CR 7860-999-20740 STF- EST 9/1/2019- STATE 577.09 DR 7860-999-10010 601.14 Page 1 of 2 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/1/2024 COURT NAME: JUSTICE OF PEACE NO.3 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 CR 7950-999-20610 TP-GENERAL FUND 0.00 CR 7950-999-20740 TP-STATE 0.00 DR 7950-999-10010 0.00 CR 7480-999-20610 CIVIL INDIGENT LEGAL-GEN. FUND 0.00 CR 7480-999-20740 CIVIL INDIGENT LEGAL -STATE 0.00 DR 7480-999-10010 0.00 CR 7865-999-20610 CRIM-SUPP OF IND LEG SVCS-GEN FUND 0.00 CR 7865-999-20740 CRIM-SUPP OF IND LEG SVCS-STATE 0.00 DR 7865-999-10010 0.00 CR 7970-999-20610 TUFTA-GENERAL FUND 10.00 CR 7970-999-20740 TUFTA-STATE 20.00 DR 7970-999-10010 30.00 CR 7505-999-20610 JPAY-GENERALFUND 0.00 CR 7505-999-20740 JPAY - STATE 0.00 DR 7505-999-10010 0.00 CR 7857-999-20610 JURY REIMB. FUND-GEN. FUND 0.00 CR 7857-999-20740 JURY REIMB. FUND- STATE 0.00 DR 7857-999-10010 0.00 CR 7856-999-20610 CIVIL JUSTICE DATA REPOS: GEN FUND 0.00 CR 7856-999-20740 CIVIL JUSTICE DATA REPOS: STATE 0.00 DR 7856-999-10010 0.00 CR 7502-999-20740 JUD/CRT PERSONNEL TRAINING FUND- STATE 0.00 DR 7502-999-10010 0.00 7998-999-20740 TRUANCY PREVENT/DIV FUND - STATE 0.00 7998-999-20701 JUVENILE CASE MANAGER FUND 0.00 DR 7998-999-10010 0,00 7403-999-22889 ELECTRONIC FILING FEE - CV STATE 0.00 DR 7403-999-22889 0.00 7858-999-20740 STATE CONSOLIDATED CIVIL FEE 126.00 126.00 TOTAL (Distrib Req to Oper Acct) $4,221.85 DUE TO OTHERS (Distrib Req Attchd) CALHOUN COUNTY ISO 0.00 DA - RESTITUTION 0.00 REFUND OF OVERPAYMENT: 0.00 OUT -OF -COUNTY SERVICE FI 0A0 CASH BONDS 0.00 PARKS & WILDLIFE FINES 101.15 WATER SAFETY FINES 0.00 TOTAL DUE TO OTHERS $101.15 TOTAL COLLECTED -ALL FUNDS $4,323.00 LESS: TOTAL TREASUER'S RECEIPTS $4,323.00 REVISED 02/02/2021 OVER/(SHORT) $0.00 1 Page 2 of 2 9� /�' //- /3- 2 11/04/2024 10:48Calhoun County JP 4 (FAX)3617852179 P,001/005 Facsimile Cover Sheet Date: November 4, 2024 y Page (s) 5 p (Including Cover) FROM: JUSTICE COURT PCT. 4, CALHOUN COUNTY 103 W. Dallas Street, P.O. Box 520 Seadrift, Texas 77983 FAX: 1-361-785-2179 PHONE: 361-785-7082 TO: County Commissioner Court Office Attn: FAX: 361-553-4444 PHONE: 361-553-4600 i Ref: October 2024—JP4 Monthly Money Distribution Report Please give me a call if you have any questions. Thank you, Patsy Spence, JP4 Court Clerk Judge 'Wes(ey J. munt 11/04/2024 10: 48 Ca I houn County JP 4 I (FAX)3617852179 P.002/005 ENTER COURT NAME: jJUI5TIGE OF F ENTER MONTH OF REPORT 10CTOBER ENTER YEAR OF REPORT 2024 CODE AMOUNT CASH BONDS ADMINISTRATION FEE • AOMF BREATH ALCOHOL TESTING - SAT ) CONSOLIDATED COURT COSTS• CCG y STATE CONSOLIDATED COURT COST. 2020 372.00 LOCAL CONSOLIDATED COURT COST-2020 84.00 COURTHOUSE SECURITY -CRS CJP CIVIL JUSTICE DATA REPOSITORY FEE -CJDR CORRECTIONAL MANAGEMENT INSTITUTE -CMI DPSCIFAILURE TO APPEAR-OMNI.OPSC ADMINISTRATION FEE FTAIFTP pHR OMNO. 202D 30.00 ELECTRONIC FILING FEE- EEP FUGrtNE APPREHENSION - Fq GENERAL REVENUE-GR CRIM- IND LEGAL SVCS SUPPORT- IDF 20.00 PARKS & WILDLIFE ARREST FEES - PWAF STATE ARREST FEES• SAF 10,00 SCHOOL CROSSING/CHILD SAFETY FEE • SCF SUBTITLE C- SUBC STATE TRAFFIC FINES -EST 9A.10-STF 194.69 TAEC ARREST FEES -TAF TECHNOLOGY FUND -TF TRAFFIC, TFC LOCAL TRAFFIC FINE-2020 11.68 TIME PAYMENT -TIME TIME PAYMENT REIMBURSEMENT FEE•2020 ! TRUANCY PREVENTIONIDIVERSION FUND -TPOF LOCAL & STATE WARRANT FEES - WRNT fi COLLECTION SERVICE FEE-MVBA•CSRV 168.2T I DEFENSIVE DRIVING COURSE- DOG DEFERRED FEE -OFF DRIVING EXAM FEE- PROV OL FILING FEE -FFEE STATE CONSOLIDATED CIVIL FEE.2022 42.00 LOCAL CONSOLIDATED CIVIL FEE -2022 98.00 FILING FEE SMALL CLAIMS - FFSC JURY FEE -JF COPIESICERTIFED COPIES -CC INDIGENT FEE • CIFF or IN13F JUDGE PAY RAISE FEE. JPAY SERVICE FEE -SFEE 7S.00 OUT -OF -COUNTY SERVICE FEE ELECTRONIC FILING FEE• EEF CV i EXPUNGEMENTFEE•EXPO EXPIRED RENEWAL- EXPR ABSTRACT OF JUDGEMENT- AOJ ALL WRITS - WOP / WOE OPS FTA FINE- DPSF LOCAL FINES - FINE 487.69 -JUDICIAL & COURT PERSONNEL TRAINING-JCPT • OVERPAYMENT (OVER SIG) -OVER • OVERPAYMENT (610 AND LESS)• OVER RESTITUTION. REST PARKS& WILDLIFE -WATER SAFETY FINES-WSF MARINE SAFETY PARKS & WILDLIFE- MSO TOTAL ACTUAL MONEY RECEIVED 81.818.20 TYPE: AMOUNT TOTAL WARRANT FEES0. ENTER LOCAL WARRANT FEES �RECOMONMTR4M[EOFHILLWUMRr80GNlFR[Mo. REPO" STATE WARRANT FEES_50.00 RECORDDN TDIAIIPAOE OF HILL COLHURY SOMME KO.REPORT DUETOOTHERS: AMOUNT I DUE TO CC180- 50% of Fine On JV ca0$ 0.00 PIRMHOLIHE CAR RH3EmNG MMEWNT DUE TO OA RESTITUTION FUND 0110 ,,,INCLUDE DR STMOrlvallAwy REFUND OF OVERPAYMENTS 0.00 ttMEE u&YUDE D.0. PEOUEFINemEPIRNMEM OUT -OF -COUNTY SERVICE FEE 0,00 REAEEMME D.RIECUEFTerHODURIEI&NT CASHSONDS 0AD REMEMMANE D.0. P80VEDnxOdBDUR9:NENTDFFEWIN:01 TOTAL DUE TO OTHERS— 60.00 TREASURERS RECEIPTS FOR MONTH: AMOUNT CASH, CHECKS. M.Oj & CREDIT CARD 59618.20 CsII bem ACTOALTnuFurees Rweiple TOTAL TREAS. RECEIPTS 8151e.20 11/04/2024 10;48Calhoun County JP 4 (FAX)3617852179 P.003/005 z MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/4/2024 COURT NAME: JUSTICE OF PEACE NO, 4 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 ACCOUNTNUMBER ACCOUNTNAME AMOUNT CR 1000-001-45014 FINES 457.56 CR 1000.001.44190 SHERIFF'S FEES I 28.00 ADMINISTRATIVE FEES: DEFENSIVE DRIVING 0.00 CHILD SAFETY 0.00 TRAFFIC 11.68 ADMINISTRATIVE FEES 30.00 EXPUNGEMENT FEES 0.00 MISCELLANEOUS 0.00 CR 1000-001-44364 TOTAL ADMINISTRATIVE FEES 41.68 CR 1000-001.44010 CONSTABLE FEES -SERVICE 75.00 CR 1000-001-44064 JP FILING FEES 0.00 CR 1000-001-44090 COPIES / CERTIFIED COPIES 0.00 CR 1000-001-49110 OVERPAYMENTS (LESS THAN $10) 0.00 CR 1000-001-44322 TIME PAYMENT REIMBURSEMENT FEE 0.00 CR 1000-001-44145 SCHOOL CROSSING/CHILD SAFETY FEE 0.00 CR 1000-999.20741 DUE TO STATE -DRIVING EXAM FEE 0.00 CR 1000-999.20744 DUE TO STATE-SEATBELT FINES 0.00 CR 1000-999-20745 DUE TO STATE -CHILD SEATBELT FEE 0.00 CR 1000-999-20746 DUE TO STATE -OVERWEIGHT FINES 0.00 CR 1000-999-20770 DUE TO JP COLLECTIONS ATTORNEY 156.27 TOTAL FINES, ADMIK FEES & DUE TO STATE $757.61 CR 2670-001-44064 COURTHOUSE SECURITY FUND $29.40 CR 2720-001-44064 JUSTICE COURT SECURITY FUND $0.00 CR 2719-001-44064 JUSTICE COURT TECHNOLOGY FUND $24.00 CR 269MOl-44064 JUVENILE CASE MANAGER FUND $0.00 CR 2730-001-44064 LOCAL TRUANCY PREVENTION & DIVERSION FUND $30.00 CR 2669-001-44064 COUNTY JURY FUND $0,60 R 2728-001-44064 JUSTICE COURT SUPPORT FUND $50.00 R 2677-001-44004 COUNTY DISPUTE RESOLUTION FUND $10.00 R 2725-001-44064 LANGUAGE ACCESS FUND $6,00 STATE ARREST FEES DPS FEES 2.00 P&W FEES 0.00 TABC FEES 0.00 CR 7020-999-20740 TOTAL STATE ARREST FEES 2.00 CR 7070-999-20610 CCC-GENERAL Ff�ND 0.00 CR 7070-999-20740 CCC-STATE I 0.00 DR 7070-999-10010 0.00 CR 7072-999-20610 STATE CCC- GENERAL FUND 37.20 CR 7072-999-20740 STATE CCC- STATE 334.80 DR 7072-999-10010 372.00 CR 7860-999-20610 STF/SUBC-GENERAL FUND 0.00 CR 7860-999-20740 STF/SUBC-STATE 0.00 DR 7880-999-10010 0.00 CR 7860.999-20610 STF- EST 9/l/2019- GENERAL FUND 7.79 CR 7860-999.20740 STF- EST 9/l/2016- STATE 186.90 DR 7860-999-10010 194.69 Page 1 of 3 11/04/2024 10;49Calhoun County JP 4 (FAX)3617852179 P. 004/005 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/4/2024 COURT NAME: JUSTICE OF PEACE NO.4 MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 CR 7950-999.20610 TP4ENERAL FUND 0.00 CR 7950-999.20740 TP-STATE 0.00 DR 7950-999.10010 0.00 Page 2 of 3 11/04/2024 10;49Calhoun County JP 4 (FAX)3617852179 P.005/005 MONTHLY REPORT OF COLLECTIONS AND DISTRIBUTIONS 11/4/2024 COURT NAME: JUSTICE OF PEACE NO, 4 MONTH OF REPORT: OCTOBER L YEAR OF REPORT: 2024 CR 7480-999-20610 CIVIL INDIGENT LEGAL-GEN. FUND 0.00 CR 7480-999-20740 CIVIL INDIGENT LEGAL -STATE 0.00 DR 7480-999-10010 0.00 CR 7865.999-20610 CRIM-SUPP OF IND LEG SVCS-GEN FUND 0.00 CR 7865-999-20740 CRIM-SUPP OF IND LEG SVCSSTATE 0.00 DR 7865-999-10010 0.00 CR 7970-999-20610 TUFTA-GENERA4FUND 0.00 CR 7970-999-20740 TL/FTA-STATE 0.00 DR 7970.999-10010 0.00 CR 7505-999-20610 JPAY - GENERAL FUND 0.00 CR 7505.999-20740 JPAY-STATE 0.00 DR 7505-999-10010 0.00 CR 7857-999-20610 JURY REIMS. FUND- GEN. FUND 0.00 CR 7857-999.20740 JURY REIMS. FUND- STATE 0.00 DR 7857-999.10010 0.00 CR 7856.999-20610 CIVIL JUSTICE DATA REPOS.- GEN FUND 0.00 CR 7856-999-20740 CIVIL JUSTICE DATA REPOS: STATE 0.00 DR 7856.999-10010 0.00 OR 7502-999-20740 JUD/CRT PERSONNEL, TRAINING FUND- STATE 0.00 DR 7502-999-10010 0.00 7998-999-20740 TRUANCY PREVENT/DIV FUND - STATE 0.00 7998.999.20701 JUVENILE CASE MANAGER FUND 0.00 DR 7998-999-10010 0.00 7403-999-22889 ELECTRONIC FILING FEE - CV STATE 0.00 DR 7403.999-22889 0.00 7858-999.20740 STATE CONSOLIDATED CIVIL FEE 42.00 i i 42.00 TOTAL (Distrib Req to OperAcct) $1,518.20 DUE TO OTHERS (Dlstrlb Req Atichd) CALHOUN COUNTY ISD 0.00 DA - RESTITUTION 0100 REFUND OF OVERPAYMENTS 0.00 OUT -OF -COUNTY SERVICE FI 0.00 CASH BONDS 0.00 PARKS & WILDLIFE FINES 0.00 WATER SAFETY FINES 0.00 TOTAL DUE TO OTHERS $0.00 TOTAL COLLECTED -ALL FUNDS $1,518.20 LESS; TOTAL TREASUER'S RECEIPTS $1,518.20 OVER/(SHORT) $0.00 Page 3 of 3 / i / 3 ` --K CALHOUN COUNTY, TEXAS COUNTY TREASURER'S REPORT MONTH OF: MAY 2024 BEGINNING ENDING FUND FUND BALANCE RECEIPTS DISBURSEMENTS FUND BALANCE OPERATING FUNDS: GENERAL 43.638,516.60 S 7.895.799.42 $ 4.529,015.94 $ 47,005.300.08 AIRPORT MAINTENANCE 39,932.57 105A4 1,407.45 38.530.56 APPELLATE JUDICIAL SYSTEM 5B9.60 238.08 827.68 COURT FACILITY FEE FUND 15,187.20 954.07 16,141.27 COASTAL PROTECTION FUND 3,647,819.36 499.38 271016.50 3,376.601.24 COUNTY AND DIST COURT TECH FUND 10,036.29 80.32 10,116.61 COUNTY CHILD ABUSE PREVENTION FUND 961.34 0.97 962.31 COUNTY CHILD WELFARE BOARD FUND 2,069.99 0.28 2,070.27 COUNTY JURY FUND 4A04.47 217.30 4,621.77 COURTHOUSE SECURITY 261,912.28 1,591.63 264.95 263,238.96 COURT INITIATED GUARDIANSHIP FUND 18.979.90 332.59 19.312.49 DIST CLK RECORD PRESERVATION FUND 42,828.49 15.85 42,844.34 COURT REPORTERS SERVICE FUND 1,436.88 33.36 1,470.24 CO CLK RECORDS ARCHIVE FUND 357.465.74 4,108.84 361,574.58 COUNTY SPECIALTY COURT FUND 13,599.61 435.47 14,025.08 COUINTY DISPUTE RESOLUTION FUND 15.112,51 842,59 15,955.10 DONATIONS 155,143.45 1,490.61 616.42 156,017.64 DRUGIDWI COURT PROGRAM FUND -LOCAL 27,229.97 6.28 27,236.15 JUVENILE CASE MANAGER FUND 6,10123 27.52 352.68 5,776.07 FAMILY PROTECTION FUND 14,692.99 2.01 14,685.00 JUVENILE DELINQUENCY PREVENTION FUND 9,396.41 1.28 9,397.69 GRANTS 1.092,076.39 14.095.00 9.000.54 1,097,170.85 JUSTICE COURT TECHNOLOGY 93,89903 36%51 299.99 93,969.25 JUSTICE COURT BUILDING SECURITY FUND 4,591.78 14.44 4,606.22 LATERAL ROAD PRECINCT #1 3,740.74 0.51 3,741.25 LATERAL ROAD PRECINCT#2 3,740.74 0.51 3,741.25 LATERAL ROAD PRECINCT #3 3.740.74 0.51 3,741.25 LATERAL ROAD PRECINCT#4 3,740.74 0.51 3.741.25 LANGUAGE ACCESS FUND 4,511.35 219.34 4,730.69 JUROR DONATIONS -HUMANE SOCIETY 3,65830 60.50 3,718.80 JUROR DONATIONS- VETERANS SERVICES 1,584.62 0.22 1,584,84 JUSTICE COURT SUPPORT FUND 18,610.54 635.18 19,245.72 PRETRIAL SERVICES FUND 89,869.23 212.28 90,081.51 LOCALTRUANCY PREVENTIOWDIVERSION FUND 32,011.65 362.47 32,374.12 LAW LIBRARY 207,797.09 1.694.39 2,533.88 206,957.60 LAW ENF OFFICERS STD. EDUC. (LEOSE) 30,327.95 4.14 30,332.09 POC COMMUNITY CENTER 41,984.64 3.805.74 4,839.22 40,951.16 RECORDS MANAGEMENT -DISTRICT CLERK 215.03 0.50 215.53 RECORDS MANAGEMENT -COUNTY CLERK 245.334.33 4,183.52 249,517.85 RECORDS MGMT & PRESERVATION 72,140.87 1,872.40 7013.27 ROAD&BRIDGE GENERAL 1,516,851.08 24,885.93 1,541.737.01 OPIOD REMEDIATION FUND 48.323.28 &60 48.329.88 6MILE PIERIBOAT RAMP INSUIUMAINT 7,247.39 0.99 7,248.38 CAPITAL PROJ - BOGGY BAYOU NATURE PARK 387,883.07 10,000.00 377.883.07 CAPITAL PROJ AMERICAN RESCUE PLAN ACT OF2021 559,381.14 253,938.96. 305,442.18 CAPITAL PRO) KING FISHER PARK 48.615.00 48,615.00 CAPITAL PROD MAG INDIANOLA BEACH PAVILLIONS 167,166.67 167,166.67 CAPITAL PROD- CDBG DR INFRASTRUCTURE 746.831.01 36,634.05 151,900.53 631,564.53 CAPITAL PROJ-CDBG-MIT INFRASTRUCTURE 425,263.31 388,140.55 37,122.76 CAPITAL PROI CHOCOLATE BAYOU BOAT RAMP 169.595.01 169,595.01 CAPITAL PROJ - ELECTION MACHINES 0.00 (0.00) CAPITAL PROI-LOCAL ASSISTANCEITRIBAL CONSISTENCY 161184.74 48,129.00 113,055.74 CAPITAL PROI -JAIL ROOF 500000.00 500,000.00 CAPITOL PROI- OLIVIA HATERIUS PARK IMPROVMENTS 112392.00 034.31 107,757.69 CAPITAL PROJ -RB INFRASTRUCTURE 224245.44 224,245.44 CAPITAL PROI ENERGY TRZ#1 149841.30 49,906.80 199,748.10 CAPITAL PROJ- BRIGHTON ROAD BRIDGE 938500.00 938,500.00 CAPITAL PROJ AIRPORT RUNWAY IMPROVEMENTS 77461.35 77,461.35 CAPITAL PROJ MAGNOLIA BEACH EROSION CONT 700D0.00 70,000.00 CAP PROJ MAG BEACH RESTORATION/ CRABBIN BR 0.00 30,359.00 30,359.00 - CAPITAL PRO] - EMS TRAINING BUILDING 229243.01 L875.00 227,368.01 CAPITAL PROJ EVENT CENTER 79927.09 7A927.09 CAPITAL PROI FIRE TRUCKS & SAFETY EQUIP 6448.68 6,448.68 CAPITAL PRO] - GREEN LAKE PARK 8984.79 8,984.79 CAPITAL PROD HATERIUS PARKBOAT RAMI' 0.00 - CAPITAL PRO HOG BAYOU IMPROVEMENTS 6276.69 6276.69 CAPITAL PROJ PORT ALTO PUBLIC BEACH 0.00 0.00 CPR). SWAN POINT SHORELINE RESTORATION 98776.00 98776.00 CAPITAL PROJ HURRICANE HARVEY FEMA 0.00 - CAPITAL PROJ IMPROVEMENTS PROJECTS ODO - CPRI- SWAMP POINT BULKHEAD IMPROVEMENT 15000.00 15,000.00 CAPITAL PROD HOSPITAL IMPROVEMENTS 2335858.73 9,756.07 2,327,102.66 CAPITAL PROD -MMC LOANS 2500000.00 2.500,000.00 ARREST FEES 591.58 198.39 789.97 BAIL BOND FEES(HB 1940) 151.50 480.00 15L5D 480.00 CONSOLIDATED COURT COSTS (NEW) 310.49 704,24 280.41 734.32 CONSOLIDATED COURT COSTS 2020 2.511.14 7,753.12 2.510,89 7,753.37 DNA TESTING FUND 250.48 2,19 0.45 252.22 DRUG COURT PROGRAM FUND -STATE 1.99 2.55 1.73 2.81 8,085,247.82 5,720,715,97 5 ISURTOTALSi Page 1 of 3 BEGINNING ENDING FUND FUNDBALANCE RECEIPTS DISBURSEMENTS FUNDBALANCE OPERATING FUNDS -BALANCE FORWARD $ 61.831,987.20 $ 8,085.247.82 $ 5.720.725.97 S 64.196.509.05 ELECTION SERVICES CONTRACT 72,209.07 12,822.42 171.31 84,860.18 ELECTRONIC FILING FEE FUND 0.00 30.88 30.88 EMS TRAUMA FUND 239.21 865.60 112.64 992.17 PINES AND COURT COSTS HOLDING FUND 7,847.31 7,847.31 INDIGENT CIVIL LEGALSERVICE 57.30 57.30 JUDICIAL FUND (ST. COURT COSTS) 0.00 - JUDICIAL& COURT PERSONNELTRAINING FUND 4.49 5.00 9.49 JUDICIAL SALARIES FUND 52.41 147.61 43.93 156.19 JUROR DONATION -TX CRIME VICTIMS FUND 312.00 312.00 JUVENILE PROBATION RESTITUTION 381.57 116.00 355.00 142.57 LIBRARY GIFT AND MEMORIAL 42,634.75 5.82 42,640.57 MISCELLANEOUS CLEARING 14,718.97 426.29 648.43 14.496.83 STATE CRIMINAL NON DISCLOSURE FEE FUND REFUNDABLE DEPOSITS 2,000.00 2,000.00 STATE CIVIL FEE FUND 43.25 451.60 3.50 491.35 CIVIL JUSTICE DATA REPOSITORY FUND 0.30 0.79 0.31 0.78 JURY REIMBURSEMENT FEE 35.62 72.35 36.82 71.15 STATE CONSOLIDATED CIVIL FEE FUND 168.00 2,792.60 2,960.60 SUBTITLE C FUND 372.10 1.223.28 231.70 1,363.68 $OPP OF CRIM INDIGENT DEFENSE 15.76 35.13 14.61 36.28 TIME PAYMENTS 117.40 73.09 211.36 '20.871 TRAFFIC LAW FAILURETO APPEAR 364.92 327.74 400.96 291.70 UNCLAIMED PROPERTY 45.885.91 0.15 10.00 45,876.06 TRUANCY PREVENTION AND DIVERSION FUND 175.60 _ 30.06 62.55 143.11 BOOT CAMPDJAEP 147.43 147.43 JUVENILE PROBATION 436.209.92 87.448.25 67.299.77 456.358.40 S 62.455,980.49 $ 8,192,122A8 $ 5.790,328.76 $ 64,857,774.21 SUBTOTALS TAXES IN ESCROW 0.00 0.00 TOTAL OPERATING FUNDS s 62ASS.98OA9A.790.328.76 S OTHERFUNDS D A FORFEITED PROPERTY FUND 34,400.86 43.71 34,444.57 SHERIFF NARCOTIC FORFEITURES 54,956.36 34,001.53 138.00 88.719.89 CERT OF OB-CRTHSE REF SERIES 2010 533.964.95 6.019.74 539,984.69 CERT OF OR-CRTHOUSE I&S SERIES 2012 31,545.75 369.84 31,915.59 CAL. CO. FEES&FINES 115634.91 80,985.17 107.875.30 88744.58 3 MEMORIAL MEDICAL CENTER OPERATING 792,051.53 4,159,750AS C200,504.97 $ 751,297.01 MONEY MARKET 111,493.32 231.36 $ 111.724.68 INDIGENT HEALTHCARE 9,201.66 4.151.86 4,196.92 9,156.60 PRIVATE WAIVER CLEARING FUND 437,82 0.56 438.38 CLINIC CONSTRUCTION SERIES 2014 543.86 0.69 544.55 NH ASFORD 159,142.92 595.957.26 637,864.97 117,235.21 NH BROADMOOR 146,057.99 501.630.29 519,965.10 127,723.18 NH CRESCENT 122,744.90 730,779.17 765,039A4 89,484.63 NH FORT BEND 85,841.19 255,78L44 288,839.25 52,784.38 NH SOLERA 152,909.70 799,866A6 858,992.79 93.793.37 NH GOLDEN CREEK 129,969.38 569,998.52 619,508.57 80.459.33 NH SOLERA DACA 0.00 0.00 NH ASHFORD DACA 0.00 0.00 NH BROADMOOR DACA 0.00 0.00 NH GULF POINTE PRIVATE PAY 834.11 3,940.67 4,774.78 NH GULF POINTE MEDICARFI MEDICADE 65.193.91 58,020.35 116,022.37 7,191.89 NH BETHANY SENIOR LIVING 397,909.83 866.185.02 1,129.786.24 134,309.61 NH TUSCANY VILLAGE 400.651.35 761.799.90 869.799.18 292 651.07 2,574,983.47 S 9.308 093.00 S 10.010.508.80 S 1,872,567.67 TOTAL MEMORIAL MEDICAL CENTER FUNDS DRAINAGE DISTRICTS NO.6 44.287.78 $ 120,07 S 44.407.85 NO.8 159,618.43 1.131.94 U6.10 160,634.27 NO. 10-MAINTENANCE 98,064.15 628.63 157.81 98,534.97 NO. 11-MAINTENANCElOPERATING 33075.90 3.274.75 5,001.40 334,649.25 NO. II -RESERVE 228.91SA6 290.84 229.209.30 S 867M .72 S 5,446.21 S 5.27531 $ 867435.64 TOTAL DRAINAGE DISTRICT FUNDS CALHOUN COUNTY WCID #1 OPERATING ACCOUNT 346,698.59 638.79 37,277.61 $ 310,059.77 PAYROLLTAX 1.052.18 174.74 S 877.44 TOTAL WCID FUNDS S 347.750.77 5 310.937.21 CALHOUN COUNTY PORT AUTHORITY MAINTENANCE AND OPERATING $ 95.748.57 44336.36 $ 140084.93 CALHOUN COUNTY FROST BANK $ $ S 3,885747.53 9357,875.59 10,015,794.11 3191025A5 TOTAL MMC, DR. DIST., NAV. DIST. WCID&FROST $ 67,112,130.8.3 $ 17,671,419.06 $ 15,914,126.37 $ .68,832,608.98 TOTAL ALL FUNDS Page 2 of 3 N LESS: CHRTOF DEN FUND OUTSTNDG DEP/ PLUS: CHECKS BANK FUND BALANCE OTHERITEMS OUTSTANDING BALANCE OPERATING" S 64,857,774.21 S 59,428.56 S 505,453.62 S 6,803,79927 58,500,000.00 OTHER D A FORFEITED PROPERTY FUND 34,444.57 34,444.57 SHERIFF NARCOTIC FORFEITURES 89.719.89 82.00 88.801.89 CERT OF OH-CRTHSE REF SERIES 2010 539,984.69 1,038.70 539,945.99 CURT OF OB-CRTHOUSE I&S SERIES 2012 31.915.59 24.09 31.891.50 CAL. CO FEES & FINES 88,744.58 4,357.50 10,093.80 94,480.88 MEMORIAL MEDICAL CENTER OPERATING # 751,297.01 980,988.35 1,732,285.36 MONEY MARKET 111,724.68 111,724.69 INDIGENT HEALTHCARE 9.156.60 502.14 9.658.74 PRIVATE WAIVER CLEARING FUND 438.38 438.38 CLINIC CONSTRUCTION SERIES 2014 544.55 544.55 NH ASHFORD 117,235.21 117.2.35.21 NH BROADMOOR 127,723.19 127,723.19 NH CRESCENT 8SA84.63 88,484.63 NH FORT BEND 52.784.38 5178438 NH SOLERA 93,793.37 93,793.37 NH GOLDEN CREEK 80.459.33 80,459.33 NH SOLERA DACA 0.00 0.00 NH ASHFORD DACA 0.00 0.00 NH BROADMOOR DACA 0.00 0.00 NH GULF POINTE PRIVATE PAY 4.774.78 4,774.78 NH GULF POINTE MEDICAD&MEDICARE 7,191.89 7,191.89 NH BETHANY SENIOR LIVING 134.308.61 134,308.61 NH TUSCANY VILLAGE 292,651.07 292,651.07 DRAINAGE DISTRICT: NO.6 44.407.85 45.54 44,362.31 NO.8 160,63327 68.12 160,566AS NO, 10 MAINTENANCE 98,534.97 9.66 27.20 98,552.51 NO. 11 MAINTENANCE/OPERATING 334,649.25 I94A8 923.50 335.377.87 NO. I l RESERVE 229,209.30 229,209.30 CALHOUN COUNTY WCID #1 OPERATING ACCOUNT 310.059.77 310.059.77 PAYROLLTAX 877.44 877.44 CALHOUN COUNTY PORT AUTHORITY MAINTENANCE/OPERATING ••n" 140,084.93 140,084.93 CALHOUN COUNTY FROST BANK 0.00 0.00 TOTALS S 68 932 60898 S 58 65167.05 IA99.070.61 S 11.7 12 Sq • "'1'HEDBPOSI'1'URY FOR CALHOUN COUNTY WCIDIS IN'I'BRNA'1'IONAL HANK UFCOMMERCE-POK'I'LAVACA THE DEPOS11ORY FOR CALHOUN CO. NAVIGATION DIS'1'KICI'IS FIKS'1'NA'1'IONAL BANK -POK'1'LAVACA ""•• 2'1-tB DBPOSN'URY FOR CALHOUN COUNTY PRUS'1IS FRUS'I' BANK- AUS'I'IN. TEXAS ••*e EASTWEST BANK CDs - $18,794.839.62 i#°' NEXBANK MONEY MKT ACCT-DALLAS, TEXAS -S 38A60,986A5 THE DEPOSITORY FOR ALL OTHER COUNTY FUNDS IS PROSPERITY BANK, PORT LAVACA Court costs and fees collected and reported may not be current and up-to-date a to n -cot Ipliance b ter ounty offices. I hereby certify that the current balances are correct to all monies that have been received by u y Tre. rer , o t�l's report. mTd COUNTY REASURER s Page 3 of 3 CALHOUN COUNTY, TEXAS COUNTY TREASURER'S REPORT MONTH OF: JULY2024 BEGINNING ENDING FUND FUND BAMNCE RECEIPTS DISBURSEMENTS FUNDBAMNCE OPERATING FUNDS: GENERAL $ 44,947,293.03 $ 3,316,920.80 $ 5.138,115.85 $ 43,126,087.98 AIRPORT MAINTENANCE 22.425.18 124.94 15,588.61 6,961.51 APPELLATE JUDICIAL SYSTEM 932.79 149.48 1,082.27 COURT FACILITY FEE FUND I6564.97 600.73 17,165.70 COASTALPROTECTION FUND 3.376,959.00 743.75 3,091.50 3.374.61 L25 COUNTY AND DIST COURT TECH FUND 10,177.82 65.38 10,243.20 COUNTY CHILD ABUSE PREVENTION FUND 962.99 0.56 963.55 COUNTY CHILD WELFARE BOARD FUND 2.070.80 80.46 2,15126 COUNTY JURY FUND 4,704.39 175.25 4,879.64 COURTHOUSE SECURITY 264,242.96 1,269.70 265,512.66 COURT INITIATED GUARDIANSHIP FUND 19.497.40 394.29 19.891.69 DIST CLK RECORD PRESERVATION FUND 42.955.22 19.44 42.874.66 COURT REPORTERS SERVICE FUND 1.497.81 15.62 1,513A3 CO CLK RECORDS ARCHIVE FUND 364.936.43 3,480.37 368,416.80 COUNTY SPECIALTY COURT FUND 14.347.12 366.95 14,714.07 COUNTY DISPUTE RESOLUTION FUND 16.483,85 536.44 17,020.29 DONATIONS 156.270.37 765.87 73.09 156.963.15 DRUG/DWI COURT PROGRAM FUND -LOCAL 27.244.35 21.31 27,265.66 JUVENILE CASE MANAGER FUND 5.376J5 16.61 525.34 - 4,867.42 FAMILY PROTECTION FUND 14,688.73 3.24 14,691.97 JUVENILE DELINQUENCY PREVENTION FUND 9,40D.08 2.07 9,402.15 GRANTS 1.104.263.01 18,104.29 13,676.58 1.108,690.72 JUSTICE COURTTECHNOLOGY 94,313.46 399.05 94.712.51 JUSTICE COURT BUILDING SECURITY FIND 4,619.42 9.31 4,627.73 LATERAL ROAD PRECINCT#1 3,742.20 0.82 3,743.02 LATERAL ROAD PRECINCT#2 3.742.20 0.8E 3,743.02 LATERAL ROAD PRECINCT#3 3742.20 3,743.02 LATERAL ROAD p4 OS2 0.8E 3,743.0E ACCESS FUND ACCESS FUND LANUJUROR 4,920.83 141.84 DO JUROR DONATIONS - HUMANE SOCIETY 3,799.74 I60.35 3,980.47 58 JUROR DONATIONS VETERANSTFUND,ERVICES 1,595.24 0,300.61 6035 1.645.59 1.730.08 FUSHCEL RTFVND 429.84 SERTCESF PRETRIALSERVICESFUND 90,104.39 9Q104.66 90,124.23 LOCALTRUANCYPREVGNTIONR)IVERSION FUND 38.63 33,166.29 LAW LIBRARY 0?,744.47 230.339.80 231.15 1,231.69 2,597.23 06,378.39 206,346A8 LAW EDUC.(LL-OSE) 30d39.29 COMMUNITYNFOFIl CENT 41.626.29 9.1B 7,850.❑ 4,836.38 44,649.08 d4,216.45 RDSMATIYCENTER RECORDS RECORDS MANAGEMENT-DISTRICI'CLERK 215.86 0.59 216.45 RECORDS MANAGEMENT -COUNTY CLERK 250,329.97 3.465.13 1,000.00 252.795.10 RECORDS MGMT & PRESERVATION 75.110.59 1,199.06 76.309.65 ROAD&BRIDGEGENERAL 1,565.157.52 25AB4.96 1.590.64248 OPIOD REMEDIATION FUND 48341.16 10.65 48.352.81 6MILE PIERIBOAT RAMP INSUR/MAINT 3,468.22 0.76 IA02.48 2.06650 CAPITAL PROF- BOGGY BAYOU NATURE PARK 336,321.07 15.700.00 320,621.07 CAPITAL PRO]- AMERICAN RESCUE PLAN ACT 2021 303.926.63 224.997.25 78,929.38 CAPITAL PROD- KING FISHER BEACH PARK 48.615.00 48,615.00 CAPITAL PROI MAG_INDIANOLA BEACH PAVILIONS 167.166.67 167,166.67 CAPITAL PROD- CDBG DR INFRASTRUCTURE 631,564.53 151.9W.53 63,927.84 719537.22 CAPITAL PROF -CDBG-MIT INFRASTRUCTURE 49%999.77 499.999,77 CAPITAL PROT CHOCOLATE BAYOU BOAT RAMP 169595.01 169.595.01 CAPITAL PROJ - ELECTION MACHINES 0.00 (0.00) CAPITALPROJ-LOCAL ASSISTANCEATRIBALCONSISTENCY 79.557.86 79,557.96 CAPITALPROI-JAIL ROOF 500.000.00 500.000.00 CAPITOLPROI. OLIVIA HATERNS PARK IMPROVMENTS 107757.69 3,460.97 104.296.72 CAPITAL PROF -RB INFRASTRUCTURE 224,245.44 224.245.44 CAPITAL PROD ENERGY TR2#I 199.748.10 199,748.10 CAPITAL PROF - BRIGHTiN ROAD BRIDGE 933.500.00 469.276.00 464,224.00 CAPITAL PRO] AIRPORT RUNWAY IMPROVEMENTS 107,101.23 107,101.23 CAPITAL FEW MAGNOLIA BEACH EROSION CONT 70AD0.00 70,000.00 CAPITAL PRO]- BILL SANDERS PARK IMPROVEMENTS 109,273.99 109.273.99 - CAPTPROJMAGREACH RESTORATION/CRAB FIRED -1,139.00 4,614.00 3,475.00 CAPITAL FEW- EMS TRAINING BUILDING 22A,018.01 500.00 223,518.01 CAPITAL PROD EVENT CENTER 79,927.09 79927.09 CAPITAL PRO] FIRE TRUCKS & SAFETY EQUIP 6.448.68 6,448.68 CAPITAL ?ROT - GREEN LAKE PARK 8.984.79 8,984.79 CAPITAL PROF HATERIUS PARK(BOAT RAMP 0.00 CAPITAL PRO HOG BAYOU IMPROVEMENTS 6.276.69 6,276.69 CAPITAL PROT PORT ALTO PUBLIC BEACH 0.00 0.00 CPRJ- SWAN POINT SHORELINE RESTORATION 98,776.00 99,776,00 CAPITAL PROF HURRICANE HARVEY FEMA 0.00 - CAPITAL PROF IMPROVEMENTS PROJECTS 0.00 CPRJ- SWAN POINT BULKHEAD IMPROVEMENT 15.000.00 15,000.00 CAPITAL PROF HOSPITAL IMPROVEMENTS 2,327,102.66 2.327.102.66 CAPITAL PROF -MMC LOANS 0.00 ARREST FEES 918.00 115.00 441.4E 591.58 BAIL BOND FEES (HE 1940) 1,005.00 450.00 IA55.00 - CONSOLIDATED COURT COSTS (NEW) 1,191.75 413.86 1,575.53 30.08 CONSOLIDATED COURT COSTS 2020 14,751.37 8.079.16 22830.28 0.25 DNA TESTING FUND 253.80 32.00 35.77 250.03 DRUG COURT PROGRAM FUND -STATE 4.09 I531 19.14 ". 5 SURTOTALS $ 60.075.486.41 S 3.659.691.96 $ 6.097.885.25 $ 57.637.293.1E Page 1 of 3 COUNTY TREASURER'S REPORT MONTH OF: JULY 2024 BEGINNING ENDING FUND FUNDBAIANCE RECRIPTS DISBURSEMENTS FUNDBAIANCE OPERATING FUNDS -BALANCE FORWARD S 60,075,486.41 $ 3,659.691.96 $ 6.097,885.25 $ 57.637,293.12 ELECTION SERVICES CONTRACT 75.579.61 16.55 172.27 75.423.89 ELECTRONIC FILING FEE FUND 31.37 31.06 62.43 - EMS TRAUMA FUND 1.918.77 552.27 2.344.47 126.57 PINES AND COURTCOSTS HOLDING FUND 7,847.31 7,847.31 INDIGENT CIVIL LEGAL SERVICE 57.30 57.30 JUDICIAL FUND (ST. COURT COSTS) 0.00 - JUDICIAL & COURT PERSONNEL TRAINING FUND 9.49 5.00 IDOD 4.49 JUDICIAL SALARIES FUND 222.35 97.22 310.99 8.58 JUROR DONATION -TX CRIME VICTIMS FUND 312.00 IOO.OD 412A0 JUVENILE PROBATION RESTITUTION 278.57 73.0D 351.57 LIBRARY GIFT AND MEMORIAL 42,651.40 9.39 42,660.79 MISCELLANEOUS CLEARING 51.811.67 1.007.92 37,533.39 15.286.20 STATE CRIMINAL NON DISCLOSURE FEE FUND 0.00 REFUNDABLE DEPOSITS 2,000.00 2,000.0D STATE CIVIL FEE FUND 939.95 402.30 1.302.50 39.75 CIVIL JUSTICE DATA REPOSITORY FUND 1.33 0.20 1.54 (0.01) JURY REIMBURSEMENT FEE 110.00 37.18 148.38 (1.20) STATE CONSOLIDATED CIVIL FEE FUND 4.780.66 2,038.72 6,651.38 169.00 SUBTITLE C FUND 2.869.53 2.071.34 4.800.47 140.40 SUPP OFCRIM INDIGENT DEFENSE 58.32 18.41 75.58 1.15 TIME PAYMENTS 71.06 40.07 205.09 (93.96) TRAFFIC LAW FAILURE TO APPEAR 504.74 135.69 676.47 (36.04) UNCLAIMED PROPERTY 50,730.09 0.24 170.00 50.560.33 TRUANCY PREVENTION AND DIVERSION FUND 163.14 8.57 29.31 142.40 BOOT CAMP/1JAEP 147.43 147.43 JUVENILE PROBATION 450.343.09 159.18 89.940.39 360.561.89 S 60,768,925.59 $ 3.666,496.27 $ 6.242.319.90 S 58,193,101.96 SUBTOTALS TAXES IN ESCROW ODD O.OD 607689],59 S 366649&27 6242319.90 S 58193101.96 TOTALOPERATING FUNDS OTHERFUNDS D A FORFEITED PROPERTY FUND 56,646.17 71.50 11,530.00 45,187.67 SHERIFF NARCOTIC FORFEITURES 76.210.53 96.71 228.00 76,079.24 CERT OF OB-CRTHSE REF SERIES 2010 546.868.76 5.811.14 352.679.9D CERT OF OB-CRTHOUSE I&S SERIES 2012 32.036.07 135.34 32,171.41 CAL. CO. FEES & PINES 86.024.71 112 631.76 112.287.33 96,369.14 MEMORIAL MEDICAL CENTER OPERATING 2.219,916.66 $ 7.040.348.82 3 4.187,440.62 $ 5,071,824.86 MONEYMARKET 5,034.00 S 4.90 $ 3,038.90 INDIGENT HEALTHCARE 9,178.48 9,084.93 8,402.82 91860.59 PRIVATE WAIVER CLEARING FUND 438.92 0.56 439.48 CLINIC CONSTRUCTION SERIES 2014 545.22 0.69 545.91 NH ASFORD 264,558.41 537,274.80 732,805.82 69,027.39 NH BROADMOOR 373,406.04 580,131.92 886,173.94 67,364.02 NH CRESCENT 431,154.63 926.664.03 1.284,332.21 72,986.45 NH FORT BEND 98,232.23 159,678.52 245.812.00 12.098.73 NH SOLERA 388.898.22 642.147.66 976,385.14 54,660.74 NH GOLDEN CREEK 240,045.28 579,606.23 547,610.04 272.041.47 NH SOLERA DACA 0.00 ODD NH ASHFORD DACA 0.00 ODD NH BROADMOOR DACA 0.00 ODD NH GULF POINTE-PRIVATE PAY 1,220.98 3,101.83 4,322.81 NH GULF POINT PLAZA MEDICARE/MEDICAID 17,525.11 55,839A7 69.650.26 3.714.32 NH BEMANY SENIOR LIVING 301,18&06 243,864.54 510.950.11 34.102,49 NH TUSCANY VILLAGE 418.207.52 940.414.50 1.104.211.81 154.410.21 TOTAL MEMORIAL MEDICAL CENTER FUNDS 4768,549.76 S 11,618163.40 S 10554.274.77 S 5832439.39 DRAINAGE DISTRICTS NO.6 44,3S4.36 108.16 $ 44,492.52 NO.8 160,832.29 204.34 161,036.63 NO. 10-MAINTENANCE 99.471.21 148.87 99,620.08 NO. 11-MAINTF.NANCE/OPERATING 316.350.40 2.203.45 45,674.49 272,879,36 NO. I LRESERVE 229.491.11 291.57 229 ]82.fi8 TOTAL DRAINAGE DISTRICT FUNDS S 850.529.37 S 2.956.39 S 45 674.49 S 807.811.27 CALHOUN COUNTY WCID BI OPERATING ACCOUNT 270.792.69 45.62 7.425.35 263,412.96 PAYROLLTAX 676.76 4400.00 3.076.76 S 271469.45 2.445.62 7.425.35 S 266J489.72 TOTAL WCID FUNDS CALHOUN COUNTY PORT AUTHORITY MAINTENANCE AND OPERATING 96 56.5.81 373.62 96CALHOUN COUNTY FROST BANK CLOSED 5987114.39 5 1I023939.03 S 10,607374.61 0003TOTAL TOTAL MMC, DR. DIST.. NAV. DIST, WCID&FROST $ 67,553,826.22 S 15.409,181.75 $ 16,973,739.84 $ 65,989 ALL FUNDS Page 2 of 3 COUNTY TREASURER'S REPORT MONTH OF: JULY3024 BANKRECONCIUATION LESS: CERLOFDEPI FUND OUTSTNDG DEFY PLUS: CHECKS BANK FUND BALANCE OrHERITEMS OUTSTANDING BALANCE OPERATING * $ 58.193.101.96 164,624.56 285,013.39 $ 3.813.490.79 54,500,000.00 OTHER D A FORFEITED PROPERTY FUND 45.187.67 45,187.67 SHERIFF NARCOTIC FORFEITURES 16.079,24 82.00 76.161.24 CURT OF OB-CRTHSE REP SERIES 2010 552,679.90 3.399.86 549.280.04 CERT OF OB-CRTHOUSE I&S SERIES 2012 32,17L41 4.08 32.167.33 CAL. CO FEES & FINES 86.369.14 9.276.20 20,795.53 97,878.47 MEMORIAL MEDICAL CENTER OPERATING# 5,071,824.86 697.621.13 5.769.445.99 MONEYMARKET 5,038B0 5.038.90 INDIGENT HEALTHCARE 91860.59 4,844.77 502.14 5,517.96 PRIVATE WAIVER CLEARING FUND 439.48 439.48 CLINIC CONSTRUCTION SERIES 2014 545.91 545.91 NO ASFORD 69.027.39 69.027.39 NH BROADMOOR 67,364.02 67,364.02 NHCRESCENT 72,986.45 72.986.45 NH FORT BEND 12,098.75 12,098.75 NH SOLERA 54.660.74 54.660.74 NH GOLDEN CREEK 272041.47 272,041.47 NH SOLERA DACA 0,00 0.00 NH ASHFORD DACA 0.00 0.00 NHBROADMOORDACA ODD 0.00 NO GULF POINT PRIVATE PAY 4,322.81 4,322.81 NH GULF POINTE• PLAZA MEDICARE MEDICAID 3,714.32 3714.32 NH BETHAN SENIOR LIVING 34,102.49 34,102.49 NH TUSCANY VILLAGE 154,410.21 154,410.21 DRAINAGE DISTRICT: NO.6 44,492.52 51.77 44,440.75 NO. 8 161,036.63 161,036.63 (0.00) NO. 10 MAINTENANCE 99.620.08 12.46 99.607.62 NO. 11 MAINTENANCE/OPERATING 272,879.36 37.90 272,841.46 NO. 11 RESERVE 229,792.68 229,782.68 CALHOUN COUNTY WCID MI OPERATING ACCOUNT 263,412.96 263,412.96 PAYROLL TAX 3.07676 3.076.76 CALHOUN COUNTY PORT AUTHORITY MAINTENANCFI)PERATING "" 96.939.43 96.939A3 CALHOUN COUNTY FROSTBANK CLOSED 0.00 TOTALS is 65.989.M.13 5 54.843.1101.11 1004004.19 12149984.09 aaaa THE DEPOSITORY FOR CALHOUN COUNTY WCID IS INTERNATIONAL BANK OF COMMERCE -PORTLAVACA "sa THE DEPOSITORY FOR CALHOUN CO. NAVIGATION DISTRtCf IS FIRST NATIONAL BANK -PORT LAVACA a as THE DEPOSITORY FOR CALHOUN COUNTY FROST IS FROST BANK - AUSTIN. TEXAS *"<* EASTWEST BANK CDs - $19,712,029.96 "xxs NEXKANK MONEY MKTACCT-DALLAS, TEXAS-$43,257,346.S0 THE DEPOSITORY FOR ALL OTHER COUNTY FUNDS IS PROSPERITY BANK, PORT LAVACA Court costs and fees collected and reported may not be current and up-to-date due to non-compliance by other county offices. hereby certify that the current balances are correct to all monies that haecen o1ceived by the Cyupty'Treasurer as Of the date of this report. i J. / I A! „i 7 . \ COUNTY Page 3 of 3 i ERCOURT NAME: _ DISTRICT CLERK ENTER MONTH OF REPORT OCTOBER CR` REBATES,ON Pf(EYIOUS E%PEN$EB 5.Y2 RR R):I(aBc�TAdPcyt DArfv yes 1.4T.4 0.a9 cRTED�NOLPcY�gyDlDls[&eociJij GR AT.YtVSk.,Mvl' $TATET(NFFIQ F�NE CR CR §N�EiI�F 200.62 ' -N:S CR-FINE@ 894.62 _ OR -SUBTOTAL' 6350695 CV-STXT6 REIMB TIREIV-000URT C6$7$ Cy COPIES 152.10 ` CV -CLERK'S FEE@ 554.00 CV =COURT RECOM$ FRE$ET4VATION FIN. CV+REC6R63 MOMT FEE-, DIETRIGT;CLERK eV STENOCIRAPHER C=SiIER�FF'SJURj1FE 176.00 :: CY-LAW L®BABY 245.00 QV (STATE)PIV4, LYLAW CV{STAT jOTRER2Hf!N l AM IAW . CVySTATE}OTH6RICNfT. pRL,CEE6ING_ CV JURY FEE 100.00 CV:�OL1Dj1V QiV-7 RES0LG_ NN¢ 109A0 ,, CV ^RECOF{OS �SjOATCR6RV FUND-6LERN 330.00 6fW.RTF(PI{BESCURf[Y 140.00 ,. tq�ldUAOEACCESS PUNO 21.00 (N ,SHERIFF'S SSRV�C 'FEE 300A0 - �1CY tDUE i`OJjSj1ERE CV •CRT A<'f 01Fj{'Eq AF`FEES C�FBLDSUPPOR7 CV.IU61CJAL&CaURTPERSPNN LTriFINi�TO,FEE CV-JUDICIAL$pLAilE@' ' CV-AJSF XW CV COUKrFAMWFBEFUND '140.00 LLO/,A PJDF`,QhFE(TURES CV xSTA1E ECiRONICTTLINOFEE GV CDU(�[IY ELECtt{ONIO�EILy40�EE GV PAMILYpROTEQTiONFEE C4-Ab4ipC16N BU�[tIC1FVRAL STATSfEE C`pUE'[f7S7ATE TECnf�ON019060$L)RE CY UUL;Iij STAOf(kSQLIDATEDFEEPO 466.00 ;OV-6VERpgYMEr ' CV OL)TOF-COUNTY SVG OFOFfATION 86.00 CV -SUBTOTAL 5?�B48 t0 xTOTAl4A$R L4ECEIPTS 66361.OA NSF QHECK§ DUE TO OTHERS AMOUNT TTORNEKAENERA4 RE$,T,ITLMON' TmumE P. o.afAUEfiiMGpEEL2tiAlw1 0 AREM"Mmmsems OUFOF UNIY'@6RVICEFEE 85.00 eev-=E E. 1 EFU14PB 6F OVWAYMEws s OUETO 6THES ,(f r1TD-stpPPera b t t, 6R 0.00 12648 [. -nmE r_0 nm�erwcweuu w 1"fi8t TALOUE`TO0 ERS 21148 REASURERB RECEIPTS,FOFVMONI'H' CASH, CHECK. M.O.s&CREDIT CARDS .54.OBC-I..I.bfro.ACTUALT"..e.R,uipl *Treasurer KeceiPE NUmoers: F20240CT006,012,028) MONTHLY REPORT OF COLLECTIONS AND DISTR SUTIONS ACCOUNT NUMBER COURT NAME: DISTRICT CLERK MONTH OF REPORT: OCTOBER YEAR OF REPORT: 2024 ACCOUNT NAME DEBIT CREDIT 1000-001-44190 SHERIFF'S SERVICE FEES $500A2 1000-00144140 JURY FEES $100.00 1000-001-44045 RESTITUTION FEE $0•00 1000-001-44020 DISTRICT ATTORNEY FEES $0.00 1000-00149010 REBATES -PREVIOUS EXPENSE $5.22 1000-00140030 REBATES -ATTORNEYS FEES $1,475.12 1000.00144058 DISTRICT CLERK ELECTRONIC FILING FEES $0.00 1000-OD14022 TIME PAYMENT REIMBURSEMENT FEES $31.29 1000-001-43049 STATE REIMB- TITLE N-D COURT COSTS $0.00 DISTRICT CLERK FEES CERTIFIED COPIES $152.10 CRIMINAL COURT $` .87 CIVIL COURT $564.00 STENOGRAPHER $175.00 CN FEES DIFF $0•DO 1000.00144050 DISTRICT CLERK FEES $895.97 1000-999-20771 FAMILY VIOLENCE FINE $0.00 1000.999-10010 CASH -AVAILABLE $3,008.22 2706-00144055 FAMILY PROTECTION FEE $0.00 27M999-10010 CASH - AVAILABLE $0.00 2740-00145055 FINES - DISTRICT COURT $694.62 2740-999.10010 CASH - AVAILABLE $894.62 2620-00144055 APPELLATE JUDICIAL SYSTEM $35.00 2620-999-10010 CASH - AVAILABLE $36.00 2648-00144055 COURT FACILITY FEE FUND $140.00 2648-999.10010 CASH -AVAILABLE $140.00 2670-001-44055 COURTHOUSE SECURITY $140.62 2670-999.10010 CASH - AVAILABLE $140.62 2673-00144055 CRT RECS PRESERVATION FUND- CO $0.00 2673-999-10010 CASH -AVAILABLE $0.00 2725-00144055 LANGUAGE ACCESS FUND $21.00 2725-999-10010 CASH - AVAILABLE $21.00 2739-00144055 RECORD MGMT/PRSV FUND - CLERK $332.68 2739-929-10010 CASH -AVAILABLE $332.68 2737-00144055 RECORD MGMTIPRSV FUND -DIST CLRK $0.30 2737-999-10010 CASH - AVAILABLE $0.30 2731-00144055 LAW LIBRARY $245.00 2731-999-10010 CASH - AVAILABLE $245.00 2663-00144050 CO & DIST CRT TECHNOLOGY FUND $0.49 2663-999-10010 CASH - AVAILABL $0.49 7040-999-20740 BREATH ALCOHOL TESTING - STATE $0.00 70404999-10010 CASH -AVAILABLE $0.00 2867-00144055 CO CHILD ABUSE PREVENTION FUND $1.45 2857-999-10010 CASH - AVAILABLE $1.45 7502-999-20740 JUDICIAL & COURT PERSONNEL TRAINING FUND -STATE $0.00 7502-999-10010 CASH-AVAILABE $0.00 7383-999-20610 DNA TESTING FEE - County $0.37 7383-999-20740 DNA TESTING FEE - STATE $3.31 7383-999-10010 CASH - AVAILABLE $3.68 7405-999-20610 EMS TRAUMA FUND - COUNTY $4.97 7405-999.20740 EMS TRAUMA FUND - STATE $44.77 7405-999-10010 CASH - AVAILABLE $49.74 707D-999-20810 CONSOL. COURT COSTS- COUNTY $1•02 7070-999-20740 CONSOL. COURT COSTS - STATE $9•22 7070-999-10010 CASH - AVAILABLE $10.24 7072-999-20610 STATE CONSOL COURT COSTS- COUNTY $56•94 7072-999-20740 STATE CONSOL. COURT COSTS- STATE $512.50 7072-999-10010 CASH -AVAILABLE $509.44 2898.00144030-010 DRUG CRT PROG FEE - COUNTY (PROGRAM) $1.41 2698-999-10010-01D CASH -AVAILABLE $1.41 739"99-20810.999 DRUG COURT FROG FEE - COUNTY (SVC FEE) $0.28 7390-999-20740-999 DRUG COURT FROG FEE - STATE $1.13 7390-999-10010-999 CASH -AVAILABLE $1.41 7865-999-20610.999 CRIM - SUPP OF IND LEGAL SVCS - COUNTY $0.01 7885.999-20740-999 CRIM - SUPP OF IND LEGAL SVCS - STATE $0.13 7865-999-10010-999 CASH -AVAILABLE $0.14 776D•999-20790-010 CRIM - DUE TO STATE - NONDISCLOSURE FEE $0.00 776D-99940010A10 CRIM - DUE TO STATE - NONDISCLOSURE FEE $0.00 7950.999-20810 TIME PAYMENT - COUNTY $0•80 7950-999.20740 TIME PAYMENT - STATE $0.59 7950-999.10010 CASH - AVAILABLE $1.19 7505-999-20810 JUDICIAL SUPPORT-CRIM - COUNTY $0.05 7505.999-20740 JUDICIAL SUPPORT-CRIM - STATE $0.45 7605-999.10010 CASH - AVAILABLE $0.50 7505-999-20740-010 JUDICIAL SALARIES -CIVIL - STATE(42) $0.00 7505-999-10010-010 CASH AVAILABLE $0.00 2740-00145050 BOND FORFEITURES $0.00 2740-999-10010 CASH - AVAILABLE $0.00 2729-001.44034 PRE-TRIAL DIVERSION FUND $0.00 2729-999-10010 CASH - AVAILABLE $0.00 7857-999-20810 JURY REIMBURSEMENT FUND- COUNTY $0.08 7857-OW20740 JURY REIMBURSEMENT FUND- STATE $0.69 7857-999-1001D CASH - AVAILABLE $0.77 7880 QW20810 STATE TRAFFIC FINE- COUNTY $0.00 7880-999-20740 STATE TRAFFIC FINE- STATE $0.00 7860-999-10010 CASH - AVAILABLE $0.00 7403-999-22888 DIST CRT - ELECTRONIC FILING FEE - CIVIL $0.00 7403-999-22991 DIST CRT - ELECTRONIC FILING FEE - CRIMINAL $0.54 CASH - AVAILABLE $0.54 DISTRICT CLERK FEES $123.11 CASH - AVAILABLE $123.11 RECORD MGMT/PRSV FUND - COUNTY $76.94 CASH - AVAILABLE $76.94 COUNTY JURY FUND $3.08 CASH -AVAILABLE $3.08 COURTHOUSE SECURITY $30.7B CASH - AVAILABLE $30.78 CO & DIST CRT TECHNOLOGY FUND $12.31 CASH -AVAILABLE $12.31 COUNTY SPECIALTY COURT FUND $76.94 CASH -AVAILABLE $76.94 TOTAL: $323.16 7855-999-20784-010 DIST CRT - DIVORCE & FAMILY LAW - STATE $0.00 7855-999-20657-010 DIST CRT - DIVORCE & FAMILY LAW - COUNTY $0.00 7855-999-20792-010 DIST CRT -OTHER THAN DIVORCEIFAMILY LAW - STATE $0.00 7855-999-20658-010 DIST CRT -OTHER THAN DIVORCEIFAMILY LAW - COUNTY $0.00 7855-999-20740-010 DIST CRT - OTHER CIVIL PROCEEDINGS - STATE - 7855-999-20610.010 DIST CRT - OTHER CIVIL PROCEEDINGS - COUNTY - 7855-999-20790-010 DUE TO STATE - NONDISCLOSURE FEE $0.00 7855-999-10010-010 CASH - AVAILABLE 0.00 2677-001-44050-999 COUNTY DISPUTE RESOLUTION FUND $105.00 2677-999-10010-999 CASH - AVAILABLE $105.00 7858-999-20740-999 DIST CLK - DUE TO STATE CONSOLIDATED FEE 2022 $456.00 7858-999-10010-999 CASH AVAILABLE $456.00 TOTAL (Distrib Req to Oper Acct) $6,465.76 $6,142.60 DUE TO OTHERS (Dlstr/bReq(s)attached) ATTORNEY GENERAL (RESTITUTION) 0.00 OUT -OF -COUNTY SERVICE FEES 85.00 REFUND OF OVERPAYMENTS 0.00 DUE TO OTHERS 126.48 TOTAL DUE TO OTHERS $211,48 REPORT TOTAL - ALL FUNDS 6,354.08 PLUS AMT OF RETURNED CKS 0.00 LESS: TOTAL TREASURER'S RECEIPTS (6,354.08) Revised 04/03/23 OVER / (SHORT) $0.00 DISTRICT COURT iTATE COURT COSTS REPORT SECTION I: REPORT FOR OFFENSES COMMITTED 01/1120 - Present 01/01104 - 12131/19 09/01/01 - 12131103 09/01/99 - 08131/01 09/01/97 - 08/31/99 09/01/95 - 08/31/97 DNA TESTING FEES EMS TRAUMA FUND JUV. PROS. DIVERSION FEES JURY REIMBURSEMENT FEE INDIGENT DEFENSE FUND STATE TRAFFIC FEES DRUG CRT FROG FEE SECTION II: AS APPLICABLE STATE POLICE OFFICER FEES FAILURE TO APPEAR/PAY FEES JUD. FUND-CONST. CO. CRT. JUD. FUND -STATUTORY CO. CRT. MOTOR CARRIER WEIGHT VIOLATIONS TIME PAYMENT FEE DRIVING RECORD FEE JUDICIAL SUPPORT FEES ELECTRONIC FILING FEE - CR NONDISCLOSURE FEES - CR TOTAL STATE COURT COSTS CIVIL FEES REPORT BIRTH CERTIFICATE FEES MARRIAGE LICENSE FEES DECL. OF INFORMAL MARRIAGE ELECTRONIC FILING FEE - CV NONDISCLOSURE FEES - CV JUROR DONATIONS JUSTICE CRT. INDIG FILLING FEES STAT PROB CRT INDIG FILING FEES STAT PROB CRT JUDIC FILING FEES STAT CNTY CRT INDIG FILING FEES STAT CNTY CRT JUDIC FILING FEES STAT CNTY CRT -JUDICIAL SUPPORT CONST CNTY CRT INDIG FILING FEES CNST CNTY CRT JUDIC FILING FEES OCTOBER 2024 OCTOBER COLLECTED COUNTY STATE �ggg4Y! 56.94 512.50 $10.24 1.02 9.22 3.68 0.37 3.31 49.74 4.97 44.77 $0.77 0.08 0.69 $0.14 0.01 $0.13 $0,00 - $0.00 $2.82 $1.69 1.13 $1.19 0.60 0.59 $0.50 0.05 0.45 $0.54 $0.54 $0.00 $0.00 $639.06 $ 65.73 $ 573.33 OCTOBER COLLECTED COUNTY STATE $0.00 0 $0.00 $0= $0.00 DIST CRT DIV & FAMILY LAW. 0 $0.00 - - DIST CRT OTHER THAN DIV/FAM LAW 0 $0.00 - - DISTCRTOTHERCIVILFILINGS 0 $0.00 - - FAMILY PROTECTION FEE JUDICIAL SUPPORT FEE 0 $0.00 $0.00 JUDICIAL & COURT PERSONNEL TRANING FEE 0 $0.00 - $0,00 2022 STATE CONSOLIDATED FEE 4 $456.00 S456.00 COUNTY DISPUTE RESOLUTION FUND 105.00 105.00 TOTAL CIVIL FEES REPORT $ 561.00 $ $ 561.00 TOTAL BOTH REPORTS $ 1,200.06 $ 65.73 $ 1,134.33 CALHOUN DISTRIBUTION COUNTY REQUEST 201 West Austin DR# 420 A 45602 PAYEE PAYOR Name: Calhoun County Oper. Acct. Official: Anna Kabala Address: Title: act clerk City: State: Zip: Phone: ACCOUNT NUMBER DESCRivnON AMOUNT 7340-999-20759-999 DWct Clerk Monthly Collection - Distribution $6,142.60 OCTOBER 2024 TOTAL[ 6,142.60 Signature of Offlaal ) Date #18 NOTICE OE MEETING—1-1/13/2024 18. 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 15 of 16 i Mi s M T N O O O PR 0 c z U) M I z o n v 3 i a z n a 4! z � n z m E 3 c c n 1 r t In Z O Z m m m n r• c v N 0 a m 2 z e 0 Z o g 3 3 m T 2 ZO m o N a 0 Z m m m 1y O 0 C Z m D c c m m O D r O � q e 0m �C: no >z� AI D c m m A m T M' m; v o m a a: m m -1; m Ze N Ae a 3: 00 m m 0? 70 v O E z zE 0 '" m: a: 1 A C: y m€ 0 FA O ow 00 c Z U) N m c O �Lu A y m Z Cm PA o C 0 n m m mn C O g B� ) @ m ■ ME kk m z �) m z) k § § §k 2 Mj M( § 2) z ) k �§ § ) I ) \\� ■ IN m: § % �i ■ ■ »; m ■ 1 J 3i ■ z: 30 ■ -j; $ B a; ■: o m� � k 2 k §\ \)}d>■ �\ - 4 ME Z| d\§)) z■ 6®fa M\ \\ �= g» m§ ` M) ; o■ m §( ) A§§§§§§ Z= ; 233E§§ T_ / Rococo o: %22§K/ Xk , 2 o§ - ■ \ \ 0= z. § / 0= j � § M/ __■§ m m= �k ■ z■ �■ � _�■ WE \ \§§§§gym§ WE $■§ ■ ■ „@/�■ ) 9 s\\\\)mm■ 3 kE cn 3\ 2 m| m m§ ; ■E mME § % mE » a z§ ; G �) z il i m) ' � e) § r) & m) 2) s WE � k k k N N 6] up pap �� rn rn w � O W W O m 0 m A A C m m mmy D vw1- m m 3 m 3j m D e 000 zzz� O O V '••' m m v m m z a N o z • Z O i s 0 D W ti m ;0A 0 xm 0 0 c m ;u Ama �`n� 0 m a � ea c a O co m 'imp v � 0 m z A C T m m rn e N 11 Z O O O A 0 33C 3c)c)0 2zzz S O a = 0 N a O o ~O n 3 yO s �m o O O o m T M' z o m m T z �E m ZE N �e Z � a€ • v M: m � m r: Rio m Z C in T C `I e x c a z A m U) 0 c 0 m m O a r 8 x N N M A R O O (AD (Ap m m 0' z o m= O T m T M5 m z -l_ i 3= m ME °< m_ m =_ � C= z z_ A M C C `CAI C C- pp 0= y O N _- v: M: a: 3 M: Z: O N: U: N; 0: m: M: JJz: l: Z: o: Ae O: W m N `�; rn O o e z N m amo Z-dm Z O A r A m r�meaa ?z� O K r. r U O m z z a o �c�oZ e 7 O O 7 O Op i z z �+ 3 i v; z m Z m ^� -zi Z 3: in Ze O me m •• to o c€ 2 c)e Z m m: n A p: C �? 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(AA o W ym�o�oo= m�v000� m m 0 0 0 0 0 0 0 O v 3c)c)c)QG)c) X m yzzzzzz Z p a � i w a N 3 O O r rD' Vi O to O E9 Efl H3 63 EA EA T O O O O O O M M T a pzp E9 (A fA EA ffl EA T T O O O O O O O O in r W a 0 O D r O A A A �a A O O O O O O O e mc C ;a DO W m GG _ y(nO zN Na r C mm n c 2 0 CD co co co co �o e z z z z z 00000 c)c) ,n 00 zzzzz z z z z z a 3 O O O fA O O O T O 0 0 0 0 0 0 NN Uri eeq�q T O O O O O O O N W W fp W (A fA O O O O O O 0 0 0 0 0 0 mm 3 i z y m m X v: m: �o a: W zi Q C 0 n m m rZn a C O D 0 z z 0 W A 0 M m =o A m 2 z n w O a r v AO m O 0 m m no M A T O W[7m� O C) z < mnC) m O - K( m> �z m z co co co co coZ e z z z z z 00000 O O O O O zzzzz z z z z z Pi Csp C�C fR EA EA EA EA !A E9 fA T T O o 0 0 0 0 0 0 fR fA Efl fA EA 1A fA fA T O 0 0 0 0 0 0 0 T T ITV N fA H3 EAJ (WT O u �n0000<no T T N IAV O N O EA fA fA�S N N O (T O O O O !l1111 fA fA O N O J (T O O 0 0 (T O O (T O n a O C z ffA T 2 O p- m- m= Z =_ �= Z_ _0 a= 3= m=_ - O= O=_ a= p= a=_ o W n`Oiwa-' coca 3>m map Z z 7J A m{< m C p w M m -z ;0 m a Cn Z o C p= z �I co co co aN, y0 = W n (OD (OD (00 i p = A 3 e Q G)= C)6000 m m�cic� C �= m Zzzz z= m== Z���s s 2 =_ z o oz=_CNN N pp 3 O � a a VI fA EA EA ffl T T m=_ m= O o000 Z= O= W www W �J T 91 W RS1 Ul= O O coo Of = m m mC�o tali W W amp O 0 o o o � cco M a O z n n O C z (AA p= m=- t �E 4 4_ = 3 Z= .1_ z= m==== pi m: N: a: 3 m; Z; -I Z; O? Ul i O; 0 0 i y m m 3 D D m m m m z 1 1 O D r O O O O c 0 v � Z �ONf N O V •• O V ro V a v Cm N o O V O J CO (p (D N N N 0 0 0 0 N O S 'v N A m A 3 T a m m -q O �U5ZZmA < D O � { r -u O m Z m O D O 0 z t0 o a DOOWMW_ z z z z z z o J 0 0 0 0 0 D G)OOnn zzzzzz a 3 p�yp 9 EA EA fA ffl fA T T Im I Z aie 1•CII T 000000 n O ^NdN N �"az J V� A Ol T tR (A A A W N W A O v: m: �o a: W 3 m: Z: Zp 0: 0 J O O e 000 zz z z z z � a 3 O 0: m: a: 3€ m: z: .q: N V O Z 0 n m m m n C Z O A m z c m 0 1 r A A A A x A � A A A A A 0 0 0 0 0 N A W N O ,e m m m m Z m m m m m m m m m m m 0 c c c c c c c 0 � -1 1 1 �00000 O m m m m m m 0 0 0 0 0 i; C, m m m m m -f T-u-0"OT tnmmmmm� 1 D D D D D m 000001PI 3 m m m m m A m M m m A m M m m 0 0 0 0 0 Z Z Z Z Z 00000 co comm�o cox e ZZZZZZ 000000 O AOA 0 0 0 0 � � � Z 1 1 1 1 1 1 x 3 T rn w rn JII O 01 W (O O � v W W (A EA fA Efl Efl T t0 ip N O) W m O Ut � x a N O Z a c 0 m m i In O a c �C m G m Z c m C vE o m: 0: a: W -IE 3@ m: Z Z: O€ -5 e cn co co co x e ZZZZ 0000 0 O AO A0A z z Z Z 1 1 1 1 z ills m Coco T 4 O+ v a w� a 1 W W J (T W c 0 m m i m O m Lm Oc i m m Z c m v= m= �o = a= 70 = -I = m= Z=_ Z= to #19 NOTICE OF MEETING — 1.1/1.3/2024 19. Aooroval of bills and Davroll. IRHMI MMC Bills: RESULT: APPROVED [UNANIMOUS! MOVER: David Hall, Commissioner Pct l eel SECONDER: Vern Lyssy,;Commissioner Pct;2 AYES: -Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County Bills: RESULT: APPROVED [UNANIMOUS] , MOVER:"David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct.2 AYESr Judge Meyer, Commissioner Hail, Lyssy; Behrens, Reese` Adjourned 10:30am Page 16 of 16 C to O y mON°bBmH K N H x d ] e o bd N c m r ° w and w w z .'. 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LAVA EIlELTBU'k1iG AP jK,PAYiMEJ9;f;5} -- $: 3S"f,4C TE11 1 NURSING HpME UpL EXEE _Q`PPAItI(a371EIfi�_6171/ERAIMTtY1A'DISReRB:.. $ .. 3�1,31i��68'� SSRUkN6TOFAL01ffi$UR$RN1pM[S+/APPdiOUECS1NevegiUeC'93',iOEat S IAM,, Orl.'; MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 13.2024 PAYABLES AND PAYROLL 11/7/2024 Weekly Payables 11/7/2024 Patient Refund 11/12/2024 McKesson-340B Prescription Expense 11/12/2024 Amerisource Bergen-3406 Prescription Expense Prosperity Electronic Bank Payments 11/12/2024 90 Degree Benefits- employee Insurance claims 11/12/2024 90 Degree Benefits- employee insurance claims 11/12/2024 90 Degree Benefits -employee Insurance claims 11/12/2024 Expert Pay -Child Support 11/12/7,024 Pay Plus -Patient Claims Processing Fee 11/12/2024 Amerisource Bergen Overage 11/12/2024 Authnet Gateway 12/12/2024 Credit Card Processing Fee 11/12./2024 Credit Card Lease Fee '", P.A;Y'RBLE5 t1YIRY]64tA1!1D E6E mi T, OO N1CaBAd±11WPy},t?NFYfE(+k7S'+ ..... 260,989.52 1,220.88 6,115.79 2,725.12 20,130.00 9,949.50 8,789.90 570.69 604.54 112.45 41.10 821.75 335.53 TRANSFER BETWEEN FUNDS FROM MMC TO NURSING HOMES 11/7/2024 MMC Operating to Ashford -Correction of Insurance payment deposited into MMC Operating in error 2,909.85 11/7/2024 MMC Operating to Solera-Correction of insurance payment deposited into MMC Operating in error 1,842.67 11/7/2024 MMC Operating to The Crescent -Correction of insurance payment deposited Into MMC Operating in error 24,709.86 11/7/2024 MMC Operating to Golden Creek Healthcare -Correction of Insurance payment deposited into MMC Operating in error 31,985.72 11/7/2024 MMC Operating to Gulf Pointe Plaza -Correction of Insurance payment deposited Into MMC operating In error 39166,72 11/7/2024 MMC Operating to Tuscany Village -Correction of insurance payment deposited into MMC operating in error 64,927.52 11/7/2024 MMC Operating to Bethany -Correction of Insurance payment deposited into MMC Operating In error 17,259.78 NURSING HOME UPL EXPENSES 11/12/2024 Nursing Home UPL-Cantex Transfer 340,784.61 11/12/2024 Nursing Home UPL-Nexion Transfer 125,065.48 11/12/2024 Nursing Home UPI. -HMG Transfer 39,371.18 11/12/2024 Nursing Home UPL-Tuscany Transfer 110,057.01 11/12/2024 Nursing Home UPL.HSLTransfer 20,730.43 OTAi'7i�NUR61N6di!lON7E,UJALN 57.4NEN6Effi' _ $' fi36jU06i6t INTER -GOVERNMENT TRANSFERS 11/12/2024 DSH 2020-Audit Overpayment 441.47 11/12/2024 CHIRP IGTSFY25 70,813.11 11/12/2024 RAPPS IGT SFY25 42,636.99 1lQITF4L INTER*Gi®�9f•<f;1�1LdFENtfi`FRWN5EBR5..,•" ... `.. . .. ._ � _1'1�3j892��: .tY:Ybs1'OTALrR161dLFRSE�i}ENRStAr$P'(iDNSearNOSTer�ibpi`n1k3s'3D2�1. - T. AWFiVIED By THE COUNTY AUDITOM ON NOV 0 7 2U24 MEMORIAL MEDICAL CENTER 11/07/2024 0 12:30 AP Open Invoice List ap_open_invoice.template Due Dates Through; 11/22/2024 OAl.HQWN COUNTY. MAR g Veridor#/Ventlor Name Class Pay Code A1680 Y AIRGAS USA, LLC • CENTRAL DIV M J Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 9154910753 10123/20210/21/20211/20/202 290.46 0.00 0.00 290A6 41 J9155088393 10/30/20210/28/20211/22/202 160.57 0.00 0.00 160.57./ Vendor Totals: Number Name Gross Discount No -Pay Net A1680 AIRGAS USA, LLC - CENTRAL DIV 451.03 0.00 0.00 451.03 Vendor#/ Vendor Name Class Pay Code 14028 ✓ AMAZON CAPITAL SERVICES JInvoice# Comment Tran DI Inv Ot Due DI Check DI Pay Gross Discount No -Pay Net 13L6PCGJG6W9 10121/20210121/20211/201202 105.72 0.00 0.00 105,72 11I-WILYOF007 10/21120210/21/20211/20/202 61.23 0.00 0.00 61.23 10VLLOLORWNP 101291202 101231202 11/221202 17.98 0100 0.00 17.98 J Vendor Totals: Number Name Gross Discount No -Pay Net 14028 AMAZON CAPITAL SERVICES 184,93 0.00 0.00 184.93 Vendor# /Vendor Name Class Pay Cade A1360 �/ AMERISOURCEBERGEN DRUG CORP W Invoice# Comment Tran Dt Inv Dt Due Or Check DI Pay Gross Discount No -Pay Net J804987288 11/04120210/31/20211/201202 10.65 0.00 0100 10.65 Vendor Totals: Number Name Gross Discount No -Pay Net A1360 AMERISOURCEBERGEN DRUG CORP 10.65 0.00 0.00 10.65 Ventlor# / Vendor Name Class Pay Code A2218 J AOUA BEVERAGE COMPANY M Invoiced Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 177346 10131120210124120211/18/202 60,50 0.00 0.00 60,50 / V/ .� 177350 10/31/202 10/24/202 11118120P 44.00 0.00 0.00 44.00 J177347 10/311202.10124/20211118/202 29.00 0.00 0.00 29.00 J Vendor Totals: Number Name Gross Discount No -Pay Net A2218 AQUA BEVERAGE COMPANY 133.50 0.00 0.00 133,50 Vendor# /Vendor Name Class Pay Code A2271 V ARTHREX, INC W Invoice# Comment Tran Dt Inv Dt Due DI Check Dt Pay Gross Discount No -Pay Net J922117293 10/29/202 10/24/202 10/241202 330.00 0.00 0.00 3$0.00 ✓/ Vendor Totals: Number Name Gross Discount No -Pay Net A2271 ARTHREX, INC $30.00 0.00 0.00 330.00 Vendor#/ Vendor Name Class Pay Code 11247 AVENO NETWORKS Invoice# Comment Tran Ol Inv Dt Due Ot Check Di Pay Grass Discount No -Pay Net 15153 10/31/202 11101/202 11116/202 4.000.00 0.00 0,00 4.000,00 / MC.L'n-jr� ar C,�L J/ Vendor Totals: Number Name Gross Discount NQ�Pay Not 11247 AVENO NETWORKS 4,000.00 0.00 0.00 4,000,00 Vendor# Vendor Name Class Pay Code 14088 J AZALEA HEALTH Invoices Comment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net 110484 11105/20211/01/20211/01/202 594.00 0.00 0.00 594.00� Vendor Totals: Number Name Gross Discount No -Pay Net 14088 AZALEA HEALTH 594.00 0.00 0.00 594,00 Vendor#/Vendor Name Class Pay Code 812.20 J BECKMAN COULTER INC M Invoices Comment Tran Ot Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net J 5494858 10101/20210/21/20211/20/202 1,935.15 0.00 0.00 1,935.15 J 111621289 10/23/20210/11/20211/20/202 176.08 0.00 0.00 176.08 J/ 111622314 10/23/202 10/23/202 11117/202 119.45 0.00 0.00 119.45 J/ J5495032 10129/20210125/202111191202 1,337.05 0.00 0.00 1,337,06 J Vendor Totals: Number Name Gross Discount No -Pay Net 61220 BECKMAN COULTER INC 3,567.73 0.00 0.00 3,56773 Vendors/Vendor Name Class Pay Code 11072 J BIO-RAD LABORATORIES, INC Invoice# Comment Tran Dt Inv Dt Due DI Check Dt Pay Gross Discount No -Pay Net 007696932 10/29/202 10/16/202 11/201202 1,338.24 0.00 0.00 1,33024 J Vender Totals: Number Name Gross Discount No -Pay Net 11072 BIO-RAD LABORATORIES, INC 1,338.24 0.00 0,00 1,338.24 Vendor# /✓endor Name Class Pay Code B1600 W BRIGG5 HEALTHCARE M Invoicell Comment Tran DI Inv Dt Due Dt Check Ot Pay Gross Discount No -Pay Net B471617 10129120210/18120211/171202 305.80 0100 0.00 305.80 � rvu C�, ncRoom ���5w_e 500v� / J Ventlor Totals: Nu.mber Name Gross Discount No -Pay Net B1800 BRIGGS HEALTHCARE 305.80 0.00 0.00 305.80 Ventlor# Vendor Name Class Pay Code 14120 CALHOUN COUNTY EMS Invoice# Comment Tran DI Inv D1 Due Dt J202400 09101120210/04/20211/20/202 Check Dt Pay Gross 4,840.00 Discount 0,00 No -Pay 0.00 Net 4,840.00 J 202410 10131/20211101/20211/20/202 2,200.00 0.00 0.00 2.200,00 VendorTolals: Number Name Gross Discount No -Pay Not 14120 CALHOUN COUNTY EMS 7,040.00 0.00 0.00 7.040,00 Vendor#/ Vendor Name Class Pay Cade 14064 CAP ITAL ONE Invoice# Comment Tran Dt Inv Ot Due Dt Check DI Pay Gross Discount No -Pay Net J101924 11/06/20210/19/20211/13/202 388.82 0.00 0.00 3 2 Ylemoue'L op-k" Y-Awt,.-1"'0+- G-.pprou-p- , �y 3-1�/ VendorTolals: Number Name Gross Discount No -Pay Ne 14064 CAPITAL ONE 388.82 0.00 0.00 .82 Vendor# / Vendor Name Class Pay Code C1325 CARDINAL HEALTH 414, INC. W Invoices Comment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net .,/ 8003657055 10/29120210/13120211/221202 273.15 0.00 0.00 273.15 / J Vendor Totals: Number Name Gross Discount No -Pay Net C1325 CARDINAL HEALTH 414. INC. 273.15 0,00 0.00 273.15 Vendor# /Vendor Name Class Pay Code 14260 ./ CAREFUSION SOLUTIONS, LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check Ot Pay Gross Discount No -Pay Net / J 10023770118 111061202 101091202 11/01/202 2.00 0.00 0.00 2.00 " 10023770100 1.786.00/ 11/06/202 10/09/202 111011202 1,788.00 0,00 0.00 Vendor Totals: Number Name Gross Discount No -Pay Net 14260 CAREFUSION SOLUTIONS, LLC 1,790.00 0.00 0.00 1,790.00 Vendor# Vendor Name Class Pay Cade 10541 ,/CARESFIELD Invoice# Comment Tran Dt Inv DI Due Dt Check Dt Pay Gross Discount No -Pay Net 000007233A 10/25/20209/011202 10/01/202 272.92 0.00 0.00 272,92 SUPPLIES Vendor 'Totals: Number Name Gross Discount No -Pay Net 10541 CARESFIELD 272.92 0.00 0.00 272.92 Vendor# Vendor Name Class Pay Code 14236 J CARRIER CORPORATION Invoice# Comment Tran Or Inv Or Due Dt Check Dt Pay Gross Discount No -Pay Nei J 90404380 10/29/20210117/202111161202 12,830.00 0.00 0.00 12,830.00 / d Vendor Totals: Number Name Gross Discount No -Pay Net 14236 CARRIER CORPORATION 12,830.00 0.00 0.00 12,830.00 Vendor# Vendor Name Class Pay Code C1600,j CITIZENS MEDICAL CENTER w Invoice# Comment Tran Ot Inv Dt Due Dt Check Dt Pay Grass Discount No -Pay Net 202426 10/31/20211/05/20211106/202 50,564.04 0.00 0.00 50,564.04� OCTOBER Vendor Totals: Number Name Gross Discount No -Pay Net C1600 CITIZENS MEDICAL CENTER 50.564.04 0.00 0,00 50,564.04 Vendor#/ Vendor Name Class Pay Code 13000 J CLEARFL.Y Invoice# Comment Tran DI Inv Dt Due. Dt Check Ot Pay Gross Discount No -Pay Net J INV66/4a10A 11/07/20211/01120211/201202 1,217.28 0100 0.00 1,217.28 Vendor Totals: Number Name Gross Discount No -Pay Not 13000 CLEARFLY 1.217.28 0100 0.00 1,217.25 Vendor# ender Name Class Pay Code 11030 COMBINED INSURANCE Invoice# Comment Tran Dt Inv Di Due DI Check DI Pay Gross Discount No -Pay Not J110124A 11/07/20211/01/20211/01/202 501.72 0X0 0.00 501.72 J Vendor Totals: Number Name Gross Discount No -Pay Net 11030 COMBINED INSURANCE 501.72 0.00 0.00 501.72 Vendor#/Ventlor Name Class Pay Code 15116 V COMPUGROUP MEDICAL - EMDS INC. Involca# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 9090085871 11/011202 11/05/202 111061202 24.44 0.00 0.00 24.44 5/ J 9090005310 11/04/202 10/241202111161202 274.98 0.00 0.00 274.98 Vendor Totals: Number Name Gross Discount No -Pay Net 15116 COMPUGROUP MEDICAL - EMDS INC 299A2 0,00 0.00 299.42 Vendorit Vendor Name Class Pay Code 12044 JCULLIGAN ULTRAPURE INC. Invoicelt Comment Tran Dt Inv Dt Due Ot Check Dt Pay 103124 11/04/20211/02120211116/202 Vendor Totals: Number Name 12044 CULLIGAN ULTRAPURE INC. Vendor# Vendor Name Class Pay Code 15876 DELTA TEMP SERVICES Invoice# Comment Tran Dt Inv Dt Due Dt Check Di Pay ✓ 7184 11/05/202 10/24/202 111051202 Vendor Totals: Number Name 15876 DELTA TEMP SERVICES Vendor# Vendor Name Class Pay Code 10060 ✓ DETAR HOSPITAL ICP Invoice# Comment Tran DI Inv Dt Due Dt Check Dt Pay DT R 2410018 11 /04120211/04/20211 / 161202 OCTOBER INVOICE PERIOD Vendor Totals: Number Name 10060 DETAR HOSPITAL Vendor# Vendor Name Class Pay Code 10842 DH PACE COMPANY Invoice# Comment Tran Dt Inv Ot Due DI Check Dt Pay J ACR27016904A 10/301202 08/291202 08/29/202 Vendor Totals: Number Name 10842 DH PACE COMPANY Vendor# Vendor Name Class Pay Code 11291 DOWELL PEST CONTROL Invoice# Comment Tran Dt Inv Dt Due Dt Check Ot Pay ,/ 39297 11104120211101/202 t 1/01/202 J39028A 11/05/202 10/28/202 10/281202 Gross Discount No -Pay Net 114.15 0.00 0.00 114.15 J Gross Discount No -Pay Net 114.15 0.00 0.00 114,15 Gross Discount No -Pay Net 4,920.00 0.00 0.00 4,920.00� Gross Discount No -Pay Net 4,920.00 0.00 0.00 4,920.00 Gross Discount No -Pay Net 631.34 0.00 0.00 831.34 Gross Discount Nu -Pay Net 831.34 0.00 0.00 831.34 Gross Discount No -Pay Net 19,511.45 0.00 0.00 19,511 A5� Gross Discount No -Pay Net 19,511.45 0.00 0.00 19,511,45 Gross Discount No -Pay 50.00 0.00 0.00 505.00 0.00 0.00 Vendor Totals: Number Name Gross Discount No -Pay 11291 DOWELL PEST CONTROL 555.00 0.00 0.00 Vendor# /Vendor Name Class Pay Code 14186EPI-EDWARD PLUMBING Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay J 08091 101021202 09/19/202 10111/202 755.00 0.00 0.00 Vendor Totals: Number Name Gross Discount No -Pay 14136 EPI-EDWARD PLUMBING 755.00 0.00 0.00 Vendor# Vendor Name Class Pay Code 14700 EQUALIZE RCM SERVICES Invoice# Comment Tran Dt Inv Dt Dee Ot Check Dt Pay Gross Discount No -Pay 538458 11104/20210/31/20211104/202 86.54 000 0.00 Vendor Totals: Number Name Gross Discount No -Pay 14708 EQUALIZE RCM SERVICES 86.54 0.00 0.00 Vendor# / Vendor Name Class Pay Code 70383 ERIN CLEVENGER W Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay 102124 11/051202 101211202 11/05/202 248.96 0.00 0.00 _'a.:GGL-5 'A o5w 6 . 'ASS -712Ai - ,J 102124A 11/05/20210121/20211/051202 297.48 0.00 0.00 10 or\ a0a-'-k t-G_LQ r (An-P . q i 2-3 - q 1 ace / --q Net 50.00 505.00 / Net 555.00 Net 755.00 Net 755.00 Net 86,54 Net 86.54 Net 248.96 297.48 Vendor Totals: Number Name T0383 ERIN CLEVENGER Vendor# Vendor Name Class Pay Code F1400J FISHER HEALTHCARE M Invoice# Comment Tran DI Inv Dt Due Ot Check Dt Pay 5614680 10/02/202 ,I 09124/20211120/202 J 6317300 10102/202 10/221202 11116/202 J 6363752 10/021202 10/23/202 11117/202 J/ 0353751 10102/20210/23/20211/17/202 ./ 6363750 10102/20210/23/20211/17/202 J6422625 10/30/20210125/20211/19/202 J 6422626 10/30/20210/25/20211/19/202 J6452259 10/30/202 10/26/202 11/22/202 Vendor Totals: Number Name F1400 FISHER HEALTHCARE Vendorll Vendor Name Class Pay Code 14156 JFUJI FILM Invoice# Comment Tran Dt Inv DI Due Dt Check Dt Pay J 91552618 10/29/202 10/25/202 11120/202 Vendor Totals: Number Name 14166 FUJI FILM Vendor# Vendor Name Class Pay Code W1300J/GRAINGER M Invoice# Comment Tran Dt Inv Dt Due DI Check Dt Pay J9288021315 11105120210121120211/15/202 9292784555 11106120210/24/20211/18/202 9293137783 11/06l20210/24/20211/18/202 Vendor Totals: Number Name W1300 GRAINGER Vendor# Vendor Name Class Pay Code G7210 ./GULF COAST PAPER COMPANY M Invoice# Comment Tran DI Inv Dt Due DI Check Dt Pay J 2686867 10123120210/22/20211 /211202 Vendor Totals: Number Name G1210 GULF COAST PAPER COMPANY Vendor# Vendor Name Class Pay Cade 12380 JHEALTH SOLUTIONS DIETETICS Invoice# Comment Tran Dt Inv D1 Due Dt Check Dt Pay J100124 11/05/20211105/20211/051202 Vendor Totals: Number Name 12380 HEALTH SOLUTIONS DIETETICS Vendor# Vendor Name Class Pay Code Gross Discount No -Pay 646.44 0.00 0.00 Gross Discount No -Pay 763.00 0.00 0.00 54.81 0.00 0,00 102.60 0.00 0.00 369.79 0.00 0.00 859.48 0.00 0.00 72.28 0.00 0.00 153.48 0.00 0.00 1,260.36 0.00 0.00 Gross Discount No -Pay 3,635.80 0.00 0.00 Net 546.44 Net l 763.00 / 54.81 J/ 102.60 �/ 369.79 859.48 7228 J 153.48 1,260.36 j Net 3,636.80 Gross Discount No -Pay Net 7,908.33 0.00 0.00 7,908.33 J Gross Discount No -Pay Net 7,906.33 0.00 0.00 7.908.33 Gross Discount No -Pay Net / 96.55 0.00 0.00 96.55 ✓ 120.00 0.00 0.00 120.00 J 245.70 0.00 0.00 245.70 .� Gross Discount No -Pay Net 462.25 0.00 0.00 462.25 Gross Discount No -Pay Net 1,285.59 0.00 0.00 1,286.59 J Gross Discount No -Pay Net 1,285.59 0.00 0.00 1,285.59 Gross Discount No -Pay Net 3,400.00 0.00 0.00 3,400.00 / Gross Discount No -Pay Net 3,400.00 0.00 0.00 3,400.00 H0031 V HEB CREDIT RECEIVABLES DEPT308 Comment Tran Dt Inv DI Due of Check Dt Pay Gross Discount No -Pay Net /Invoice# ✓ 102524A 1-1/07/20210125/20211122/202 545.89 0= 0.00 9" r4 A,noixcK, bN_e, re. 4. - n-i Gpjww ecx- -S"- LI-1 S. aco i Vendor Totals: Number Name Gross Discount No -Pay Net H0031 HEB CREDIT RECEIVABLES DEPT308 548.89 0.00 0.00 J59&.89- Vendor#/ Vendor Name Class Pay Code 15928 J HOSPICE OF SOUTH TEXAS Invoice# Comment 20241030A Tran Di Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net 1 t/O6/20210/30120211106/202 150.00 0.00 0.00 150.00 Vendor Totals: Number Name Grass Discount No -Pay Nei 15928 HOSPICE OF SOUTH TEXAS 150.00 0.00 0.00 150.00 Vendor#/ Vendor Name Class Pay Code 15664 �/ HOWARD INDUSTRIES INC Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Nei J 5174892024 11/05/20210/18120211105/202 1,551.20 0.00 0.00 1,551.20 Vendor Totals: Number Name Gross Discount No -Pay Net 15864 HOW.ARD INDUSTRIES INC 1,551.20 0.00 0.00 1,551.20 Vendor# Vendor Name Class Pay Code 10630 ✓HUMANA Invoice# Comment Tran DI Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net SALLIB0001 11/06/20211/01/20211/061202 78,40 0.00 0.00 78.40 ✓/ J HARMARY0001 11/06/202 11/04/202 11/061202 90.51 0.00 0.00 90.51 ✓ Vendor Totals: Number Name Gross Discount No -Pay Net 10530 HUMANA 168.91 0.00 0.00 168.91 Vendor#/ Vendor Name Class Pay Code 11260 .( INTOXIMETERS INC M J772357 Invoiceu Comment Tran Dt Inv Dt Due DI Check Dt Pay Gross Discount No -Pay Net / 11/05/20210/25120211/19/202 80.00 0.00 0.00 moo 772407 11/06/20210128/20211/22/202 40.00 0.00 0.00 40.00 Vendor Totals: Number Name Gross Discount No -Pay Net 11260 INTOXIMETERS INC 120.00 0.00 0.00 120.00 Vendor# Vendor Name Class Pay Code 11285 J ITA RESOURCES INC Invoice# Comment MMC112024 Tran Dt Inv Dt Due Dt Check DI Pay 11/061PO211101/20211/211202 Gross 31,331.11 Discount 0.00 No -Pay 0,00 Net 31,331.11 VVV WOv'l.ar t oR ((I h .I i / J Vendor Totals: Number Name Gross Discount No -Pay Net 14285 ITA RESOURCES INC 31,331.11 0.00 0.00 31,331.11 Vendor Vendor Name Class Pay Code 1110137 ITERSOURCE CORPORATION Invoice# Comment Tran Dt Inv Dl Due Dt Check Dt Pay Gross Discount No -Pay Net 711828 11/06120Z 11/04120211/06/202 250.00 0.00 0.00 250.00 � Vendor Totals; Number Name Gross Discount No -Pay Net 11108 ITERSOURCE CORPORATION 250.00 0.00 0.00 250.00 Vendoril /Vendor Name Class Pay Code L0700 `f LABCORP OF AMERICA HOLDINGS M Invoice# Comment Tran Dt Inv Dt Due DI Check DI Pay Gross Discount No -Pay Net J42503221 J 11/06/20210/25/20211/20/202 78.87 0.00 0.00 78.87 Vendor Totals: Number Name Gross Discount No -Pay Nei L0700 LABCORP OF AMERICA HOLDINGS 78.87 0.00 0.00 78.87 Vendor#/Vendor Name Class Pay Code 1097P V M G TRUST Invoice# Comment Tran Dt Inv Dt Due Ot Check Dt Pay Gross Discount No•Pay Net J 110424 11/041202 11104/202 11/16/202 895.00 0.00 0,00 895.00 Vendor Totals: Number Name Gross Discount No -Pay J Net 10972 M G TRUST 895.00 0.00 0.00 895.00 Vendor? /Vendor Name Class Pay Code J1350 �,/ M.C. JOHNSON COMPANY INC M Invoice# Comment Tran Dt Inv Dt Due DI Check Ot Pay Gross Discount No -Pay Nei J00397323 10/011202 10/311202 11/05/202 190.66 0.00 0.00 190.66 Vendor Totals: Number Name Gross Discount No -Pay Net J1350 M.C. JOHNSON COMPANY INC 190.66 0.00 0,00 190.66 Vendor# /Vendor Name Class Pay Code M1950 ./ MARTIN PRINTING CO VJ Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Nei 80339 10/30/202 10/221202 111211202 476.00 0.00 0.00 476.00 J Vendor Totals: Number Name Gross Discount No -Pay Net M1950 MARTIN PRINTING CO 476.00 0.00 0.00 476.00 Vendor? order Name Class Pay Code M2178 MCKESSON MEDICAL SURGICAL INC Invoice# Comment Tran Dt Inv Dt Due Dt Check Di Pay Gross Discount No -Pay Net J 22814358 11/05120210/24/20211/08/202 227.66 0.00 0.00 227.66 J J 22844693 11/05120210/31120211115/202 227,66 0.00 0,00 227.66 V Vendor Totals: Number Name Gross Discount No -Pay Net M2178 MCKESSON MEDICAL SURGICAL INC 455.32 0.00 0.00 455.32 Ventlor#/ Vendor Name Class Pay Code 12588 .( MEDICAL TECHNOLOGY ASSOCIATES Invoice# Comment Tran Dt Inv Ot Due Dt Check DI Pay Gross Discount No -Pay Net J INV260040 101211202 10121/202 11/201202 2,095.50 0.00 0.00 2,005.50 J Vendor Totals: Number Name Gross Discount No -Pay Net 12588 MEDICAL TECHNOLOGY ASSOCIATES 2,095.50. 0.00 0.00 2,095.50 Vendor# andor Name 4EDIMPACT Class Pay Code 10613 HEALTHCARE SYS, INC. A/P / Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 103024 11106f202 11/01/202 11/06/202 12.38 0.00 0.00 12,38 Vendor Totals: Number Name Gross Discount No -Pay Net 10613 MEDIMPACT HEALTHCARE SYS, INC. 12,30 0,00 0.00 12.38 Vendor# Vendor Name Class Pay Code M2470VMEDLINE INDUSTRIES INC M Invoice# Comment Tran Dt Inv Dt Due Ot Check Dt Pay Gross Discount No -Pay Net / J2341085926 10/23120210122120211/161202 9,795.42 0.00 0.00 9.795.42 J 2341112538 10123/20210/23/20211/17/202 4,486.56 0.00 0100 4.486,55W ,/ 2341112537 10/231202 10/23/202 11/17/202 248.65 0.00 0.00 248.65 J 2341112529 10/23/202 10/231202 11117/202 107.06 0.00 0.00 107.06 J2341112536 10/23/202 10/23/202 111171202 100,45 0.00 0.00 106.45 J/ J/ 2341112539 10/23/202 101231202 11/171202 1,064.66 0.00 0.00 1,064.66 J 2341112535 10123/202 10123/202 11117/202 63.55 0.00 0.00 63.55 J J 2341112533 10/231202 10123/202 11/17/202 / 61.20 0.00 0.00 61.20 J/ 2341112534 10123/20210123120211/171202 2T36 0.00 0.00 27.36 J/ J2341299630 10/29/202 101231202 11/17/202 487,76 0.00 0.00 487.76 / J 2341455831 10/29/20210/24/20241/18/202 •156.80 0.00 0.00 -156.60 J/ J 2341112532 10/30/20210123/20211/17/202 70,48 0,00 0.00 70,48 J J 2341112530 10/301202 10/23/202 11117/202 723.63 0.00 0.00 723.63 Vendor Totals: Number Name Gross Discount No -Pay Net M2470 MEDLINE INDUSTRIES INC 17,085.98 0.00 0.00 17,085.98 Vendor# Vendor Name Class Pay Code 10963 J MEMORIAL MEDICAL CLINIC Invoice# Comment Tran Dt Inv Or Due Dt Check Dt Pay Gross Discount No -Pay Net 103124 11104/20210/31/20211/16/202 65,00 0.00 0.00 65.00,/ Vendor,rotals: Number Name Gross Discount No -Pay Net 10963 MEMORIAL MEDICAL CLINIC 65.00 0.00 0.00 65.00 Vendor# /Vendor Name Class Pay Code 10904 J MERCK SHARP & DOHME LLC invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net / 7017877235 11106/202 10124/202 111061202 1,743.23 0.00 0.00 1,743.23 v / Vendor Totals: Number Name Gross Discount No -Pay Net 10904 MERCK SHARP & DOHME LLC 1,743.23 0.00 0.0D 1,743,23 Vendor# Vendor Name Class Pay Code 15924 J- InvoiceN Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net J STRMIA0001 11106120211101120211106/202 130.04 0.00 0.00 130.04 / Vendor Totals: Number Name Gross Discount No -Pay Net 15924 100,04 0.00 0100 130,04 VendorN Vendor Name Class Pay Code 10538 MORRIS & DICKSON CO, LLC Involca# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Nei / J2628112 11/061202 10/30/202 11/091202 788.59 0.00 0.00 788.59 J 2624618 11106/20210/30120211/09/202 7.083.44 0.00 0.00 7,083.44 J/ J 2626337 111061202 10/30/202 11/09/202 148.58 0.00 0.00 148.58 J 2626336 11/06/20210/30/20211/09/202 752.31 0.00 0.00 752.31 J/ J 2628113 11/061202 10130/202 11109/202 11,663.46 0.00 6.00 11.663,46 ✓ J 2630685 11/06/20210/31/20211/10/202 29.33 0.00 0,00 29.33 4 J/ 2630688 11/06/202 10/31/202 11/10/202 282.26 0.00 0.00 / 282.26 d 2634220 11/061202 101311202 11/10/202 374.55 0.00 0.00 374.55 J J 2630687 11/061202 10131/202 11/10/202 45,86 0.00 0.00 45.86 J J2634219 11/06/202 10/31/202 11/10/202 48.98 0.00 0.00 48.98 J J2630686 11/06/202 10/31/202 11/10/202 30,27 0100 0.00 30,27 `/ ,l 2630680 11/06/20210131/20211110/202 21,58 0.00 0.00 21.56 J J 2830682 11/061202 10/311202 11/10/202 32.08 0.00 0.00 32.08 J2630684 11106/202 10/31/202 11/10/202 24.61 0.00 0.00 24,61 J J 2630881 11/06/202 101311202 11/10/202 97.37 0.00 0.00 97.37 J J 2630683 111061202 10/31/202 11/10/202 23.58 0.00 0.00 23.58 J 2640932 11106/202 11/031202 11/13/202 1,185.28 0.00 0.00 1,185.28 ✓ J 2640931 11/06/202 11/03/202 11/13/202 37.98 0.00 0.00 37.58 ,j 2645199 11/06/202 11/041202 11/14/202 1,041.86 0.00 0.00 1,041.86 J 2642800 11/061202 11/04/202 11114/202 30,27 0.00 0.00 30.27 J 2645200 11/061202 11/04/202 11/14/202 10.43 0.00 0.00 10.43 J2051242 1 V06/202 111051202 11/15/202 10.03 0.00 0100 10.03 J 2051241 11106/202 11105/202 11/15/202 126.32 0.00 0.00 126.32 J 2648338 11/06/202 11/05/202 11/15/202 194.74 0.00 0.00 194.74,% Vendor Totals: Number Name Gross Discount No -Pay Nei 10536 MORRIS & DICKSON CO, LLC 24,083.74 0,00 0.00 24.083.74 Vendor# /Jendor Name Class Pay Code 01418 OFITHO CLINICAL DIAGNOSTICS JInvoice# Comment Tran Dt Inv Dt Due Dt Check DI Pay Gross Discount No -Pay Net / 1653762721A 10/211202 10/171202 11/16/202 2.121.17 0.00 0.00 2,121.17�/ J1853764725 10/211202 10119/202 11/181202 1,148.18 0.00 0.00 1,148,18 ✓ Vendor Totals: Number Name Gross Discount No -Pay Net 01416 ORTHO CLINICAL DIAGNOSTICS 3,269.35 0100 0,00 3,289.35 Vendors! Vendor Name Class Pay Code P1971 1PORT LAVACA FORD JInvoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net 312902 '11/O3120211/01/20211/O6/L02 $8.50 0.00 0.00 58.50 312885 11/06/20211/01/20211/06/202 7.00 0.00 0.00 7.00 J FORD TRANSIT VEHICLE J 312951 111061202 11101/202 11/08/202 1,049.66 0.00 0.00 1.049.66 V/ FORD E350 VAN 312604 11/061202 11/011202 11/061202 195.11 0.00 0.00 198.11 313162 11 /06/202 11101/202 11/06/202 420,49 0.00 0.00 420.49 " Vendor Totals: Number Name Gross Discount No -Pay Net P1971 PORT LAVACA FORD 1,733.76 0.00 0.00 1,733.76 Vendor#I Vendor Name Class Pay Cade P2200J POWER HARDWARE W J103124 Invoice# Comment Tran Dt Inv Ot Due Dt 10/31/202 10/31/202 11116/202 Check Dt Pay Gross 150.19 Discount 0.00 No -Pay 0.00 Net 150.19 / Vendor Totals: Number Name Gross Discount No -Pay Net,/ P2200 POWER HARDWARE 150A9 0.00 0.00 150.19 Vendor# Vendor Name Class Pay Code 10372 J PRECISION DYNAMICS CORP (PDC) Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net J 9357453511 10/23/20210121120211/20/202 167,60 0.00 0.00 167,60 J 9357403925 10/29/202 101221202 11/211202 204.36 0.00 0.00 20C36 J Vendor Totals: Number Name Gross Discount No -Pay Net 10372 PRECISION DYNAMICS CORP (PDC) 371.96 0.00 0.00 371.96 Vendor# Vendor Name Class Pay Cade 15264 J REPUBLIC PAIN SPECIALISTS Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No•Pay Net 40 10129/202 10/24/202 11/201202 7,000.00 0.00 0.00 7,000.00 Vendor Totals: Number Name Gross Discount No -Pay Net 15264 REPUBLIC PAIN SPECIALISTS 7,000.00 0.00 0.00 7,000.00 Ventlor# /Vendor Name Class Pay Code 10554 .1 REPUBLIC SERVICES 4847 Invoice# Comment 0847001362202 Tran Dt Inv Of Due DI 11106/20210/26/20211/15/202 Check Dt Pay Gross 2,006.42 Discount 0.00 No -Pay 0,00 Not 2.006.42 Vendor Totals: Number Name Gross Discount No -Pay Nei 10554 REPUBLIC SERVICES #847 2,006.42 0.00 0.00 2,006.42 Vandor# Vendor Name Class Pay Code 10936 J SIEMENS FINANCIAL SEI-1ViCES Invoice# Comment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount No -Pay Net 56382500006554 11104/202 10130/202 11/19/202 1.333.33 0.00 0.00 1,333.33 Vendor Totals: Number Name Gross Discount No -Pay Net 10935 SIEMENS FINANCIAL SERVICES 1,333.33 0.00 0.00 1,333.33 Vendor#/ Vendor Name Class Pay Code S2001 ./ SIEMENS MEDICAL SOLUTIONS ING M Invoice# Comment J116626551 Tran Ot Inv Dt Due Ot 11/06120210/25/2021 V191202 Check Ot Pay Gross 3,507.72 Discount 0.00 No -Pay 0.00 Net 3,507.72 J Vendor Totals: Number Name Gross Discount No -Pay Nei $2001 SIEMENS MEDICAL SOLUTIONS INC 3,507.72 0.00 0100 3,507.72 Vendoril/Vendor Name Class Pay Code S2362 J SMITH & NEPHEW, INC. J983523326 Involco# Comment Tran Dt Inv Dt Due Dt 10/21/202 11/01/202 11115/202 Check Dt Pay Gross 1,004.93 Discount 0.00 No Pay 0.00 Net 1,004.93 J Vendor Totals: Number Name 82362 SMITH 8 NEPHEW, INC. Vendor# /Vendor Name Class Pay Cade 12472 J SOMETHING MORE MEDIA, INC. Invoicelt Comment Tran Dt Inv Dt Due Dt Check D1 Pay J 2223 10/301202 10130/202 111141202 Vendor Totals: Number Name 12472 SOMETHING MORE MEDIA, INC. Vendor# / Vendor Name Class Pay Code 12288 J SPBS CLINICAL EQUIPMENT SRVC JINV050001124 Invoice# Comment Tran DI Inv Dt Due DI Check Dt Pay 11/04/202 10/31/20211/161202 Vendor Totals: Number Name 12288 SPBS CLINICAL EQUIPMENT SRVC Vendor# Vendor Name Class Pay Code 10094 J ST DAVIDS HEALTHCARE Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay JMMCPL202409 11/01/20210130/20211116/202 SEPT CONNECTIVITY FEE Vendor Totals: Number Name 10094 ST DAVIDS HEALTHCARE Vendor# Vendor Name Class Pay Code J 10045 STAPLES Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay 6015837324 10/01/202 10/31 /20211115/202 Vendor Totals: Number Name 10845 STAPLES Ventlor# Vendor Name Class Pay Code 53960J STERICYCLE. INC Invoice# Comment Tran Dt Inv DI Due Dt Check Dt Pay J3000903568 10/21/20210/18120211/171202 Vendor Totals: Number Name S3960 STERICYCLE, INC Vendor## Vendor Name Class Pay Code S3940 STERIS CORPORATION M Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay J 12992898 101291202 10123/202 111171202 ,/ 13014382 111061202 10/24/202 11 A 81202 12997713 11/06/202 10/24/202 11/18/202 13000977 11106/202 10/25/202 11119/202 Vendor Totals: Number Name S3940 STERIS CORPORATION Vendor# /Vendor Name Class Pay Code 15396 V THIRD COAST DISTRIBUTING LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check DI Pay J103124 10/31120211/01/20211116/202 Gross Discount No -Pay Net 1,004.93 0.00 0.00 1,004.93 Gross Discount No -Pay Nei 2,525.00 0.00 0.00 2,525.00 / Gross Discount No -Pay Net 2.525.00 0.00 0.00 2,525.00 Gross Discount No -Pay Net 9,836.92 0.00 0.00 9,836.92 Gross Discount No -Pay Net 9,836.92 0.00 0.00 9,036.92 Gross Discount No -Pay Nei 375.00 0.00 0.00 375.00 / ✓ Gross Discount No -Pay Net 375.00 0.00 0.00 375.00 Gross Discount No -Pay Net 44.05 0100 0.00 44.05 / ✓ Gross Discount No -Pay Net 44.05 0.00 0.00 44.05 Gross Discount No -Pay Net 3,076.66 0.00 0.00 3.076.66 Gross Discount No -Pay Net 3.076.66 0.00 0,00 3,076.66 Gross Discount No -Pay Not 447.46 0.00 0.00 447.46 428.00 0,00 0.00 428.00 J 208.96 0.00 0.00 208.96 74.58 D,00 0.00 74.58 Gross Discount No -Pay Net 1,159,00 0.00 0.00 1,159.00 Gross Discount No. Pay Net 145.28 0.00 0.00 145.28 Vendor Totals: Number Name Gross Discount No -Pay Net 15396 THIRD COAST DISTRIBUTING LLC 145.28 0.00 0.00 145.28 Vendorlil Vendor Name Class Pay Code T3130 J TRI-ANIM HEALTH SERVICES INC M Involcek Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Nei J 600516587 11/05/202 10/23/202 11/17/202 414.59 0.00 0.00 414.59 Vendor Totals: Number Name Gross Discount No -Pay Net T3130 TRI-ANIM HEALTH SERVICES INC 414.59 0.00 0,00 414.59 Vendors Vendor Name Class Pay Code 10841 ,% TRUBRIDGE, LLC Invoice# Comment Tian DI Inv Dt Due Dt Check DI Pay Gross Discount No -Pay Net J 1025970 11/04/202 10/31/202 11116/202 200,00 0.00 0.00 200.00 / J Vendor Totals: Number Name Gross Discount No -Pay Net 10841 TRUBRIDGE, LLC 200.00 0100 0.00 200.00 Vendor# 11002 Vendor Name TRUSTAFF Class Pay Code Invoice# Comment Tran DI Inv Dt Due DI Check of Pay Gross Discount No -Pay Net 2271279 10/21120210/18/20211/171202 3262.16 0.00 000 3,262.16 Vendor Totals: Number Name Gross Discount No -Pay Net 11002 TRUSTAFF 3,262.18 0.00 0.00 3,262.16 Vendor# Vendor Name Class Pay Code 15872 J TYPENEX MEDICAL LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Nei J 24100271 11105/20210/16120211/05/202 253.62 0.00 0.00 253.62 J Vendor Totals: Number Name Gross Discount No -Pay Net 15872 TYPENEX MEDICAL LLC 253.62 0,00 0.00 253.62 Vendor#/Vendor Name class Pay Code U1064J UNIFIRST HOLDINGS INC Invoice# Comment Tran Dt Inv Dt Due DI Check Dt Pay Gross Discount No -Pay Nei J 2921045029 10/29/20210/24/20211/181202 2,229.52 0.00 0.00 2,229.52 J 2021045332 10/29/202 10124/202 11118/202 162.14 0.00 0.00 162.14 v J 2921045330 10/29/202 10/24/202 111181202 34.04 0.00 0.00 34.04 ,r 2921045331 10/29/20210/24/20211/181202 373.57 0.00 0.00 373.57 J2921045327 101291202 10124/202 11 / 18/202 89.10 0.00 0.00 89.10 / 2921045333 10/29/20210124/20211/18/202 181.86 0.00 0.00 181.86 J2921045334 10/29/202 10/24/202 11/181202 148.43 0.00 0.00 148.43 J/ J2921045328 10/29/20210/24/20211/181202 231,03 0.00 0.00 231,03 J j 2921045528 10/30/202 10/281202 11/22/202 2,543,89 0.00 0.00 2,543.891/ V 2921045529 10130/20210/28/20211122/202 137,94 0.00 0.00 137,04 Vendor Totals; Number Name Gross Discount No -Pay Net U1064 UNIFIRST HOLDINGS INC 6,131.52 0.00 0.00 6.131.52 Vendor# Vendor Name Class Pay Code V0552 VERATHON INC Invoice# Comment 80994943 Tran Ol Inv Dt Due Dt Check Dt Pay 10/31/20210/21/202111151202 J Vendor Totals: Number Name V0552 VERATHON INC Vendor# / Vendor Name Class Pay Code V1471 VICTORIA RADIOWORKS, LLC W Involcell Comment Tran Dt Inv Dt Due Dt Check Dt Pay J 24100151 11/06/20210/311202111051202 10 / %� 1014 - l o l a5/ a4 Vendor Totals: Number Name V1471 VICTORIA RADIOWORKS, LLC Vendor# /Vendor Name Class Pay Code 11110 V WERFEN USA LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay J 9111656807 10/29/20210/23/20211/171202 J 9111658060 10129/20210/24/202111181202 Vendor Totals: Number Name 11110 WERFEN USA LLC Grand Totals: Gross Discount 261,203.60 0.00 APPROVED ON NOV 0 7 H?4 Gross Discount No -Pay Net 440.00 0.00 0.00 440.00 Gross Discount No -Pay Net 440.00 0.00 0.00 440.00 Gross Discount No -Pay Net 120.00 0.00 0.00 120.00 / Gross Discount No•Pay Net 120.00 0.00 0.00 120.00 Gross Discount No -Pay Net J 1.263.87 0.00 0.00 1,253.87 51,32 0.00 0.00 51.32 ✓ Gross Discount No -Pay Net 1.305.19 0.00 0.00 1,305.19 No -Pay Net 0.00 26 60 5a ac_eo, ��q L) REOETVEO BY THE COUNTY AUDPPOH ON RUN: DATE: 11/07/24 MEMORIAL MEDICAL CENTER PAGE 1 TIME: 10:49 NOV 0 7 P024 EDIT LIST FOR PATIENT REFUNDS ARID=0001 APCDEDIT PATIENT 9.WOUN COUNTY, TH WB PAY PAT RUNBER PAYEE 4 DATE AMOUNT CODE TYPE DESCRIPTION GL NOR ------------------------------- ..___._.------- .-------------------------- ------------- '---------------- .._.__.__..__..______.___ 1596093 01 110624 1044.85 J 3 CLAIM PROCESSING ERROR 631952366 .� MISS400 O1 j 110624 871257489 ................................................. ARID=0001 TOTAL ........................................ TOTAL APPROVE) ON NOV NN0 7 Z024 CALHOC hu UN� DITi_Xit J 176.03 j 2 PAID WRONG PROVIDER- NOT MMC PATIEN 1220,88 ------------------------------------------------------------------------- 1220.88 MSKESS�N STATEMENT Asof!11/0W2024 Page: To ensure proper cook to your flcnounq detach and return this �:rrv•rrc. emu at with your remittance DC: 8115 MEdORIAL MEDICAL CENTER Customer INV SUppID: As of: 11/0812024 Page: 002 Mall to: Camp: anoo AP AMT CUE REMITTED VIA ACH OMIT TowEtnry: gist N VIRGINIA SMEEI J Slatumenl for Information rally AMT DUE REMITTm VIA ACH DEBIT f�i1R1' V4VACq T% yy9y8 Customer fi32536 Statement for Information only Data: 11/0612024 Sfling out. Due ReadveblPadond IS Number Cud: fi32536 PLEASE CHECK ANY Dale: 11/0812024 ITEMS NOT PAID (✓) Cash Amount P Amount P Rae. udele Doesn't.. Cash (g-.) F (net( F Number PF Column legend: P = Net Duo Item, F = Future Due Item, blank = Current Due Item •..,nr venom: qcc[ e4eSfo mtlAOR Fulms Due: 0.00 Pad Due: 0.00 lad payment 2.451.97 08/07/2017 Subtotals: 6.240.61 USD If Paid By 11/1212024, Pay This Amount: 6,115.79 USD It Paid After 1111212024. NY this Amount 6.240.61 USD APPROVED ON NOV 12 2024 rq�11011N COUn11,I TEXAS For AR Inquiries please contact 800-867-0333 Jw Our If Pair On Tlmo: USO 6,115.79� Diu lost If paid late: 124.82 Due It paid late: USD 6.240.61 MSKESSON STATEMENT As of: 11100/2024 Pon.: 001 mule proper roolift 1. 'mu To comma. detach and return this mu4 isub wfth your admithunce DC: oils WALMART 10991MW MED pHs Customer INV Su ID: As'ol: 11108/2024 001 Moll t.; China: 000 INIEVORAL MEDICAL CENTER AIAT DUE REMITTED VIA ACH 0 MIT Territory: 7001 VICKY KALISEJ� statement Im Ini.mmu." only AMT DUE REMITTED VIA ACH 13MIT 615 N VIRGINIA ST Customer. 256342 Statement lOr informourn only �ORT LAVACA TX 779Y9 Dme: 1110812024 Card: 256342 PUASE CHECK ANY Dole; 11/0812024 11 NOT PAID (�) III Do. Rundomij"Imust As .... I bm Dole Date Nucleon Reference Dassmictich Cash Discount Amount P (g.) F )unt Ame (ne, P Recall Customer Number 256342 WAWART 1098IINIM IVIED MS 11/02120'4 1111?12024 7630850302 20913d117 I I 51rid.. 4.39 219.56 215.17 76JOBS0382 I 1100 IP02 4 11/12,12021 7530860383 212339211 11 slmimt,. 0.01 0.32 ✓ I $111412OR4 11/12/2024 7531121260 216316336 11511 0.02 0.95 0.31 7530850303 J 11/06124324 1111 W2021 7531,153697 215227355 11 51mmics 0.02 0.95 0.93 7531121260 I 1100120P.4 I I fl 2/202.1 7531453598 R16441461 I I Wrvms. 1.42 71.09 0.93 7511453597 I 0512(12ll I I tI 2/2024 7531453599 210441461 11 51mv.1,,r 10A9 529.51 59r6" ✓ 7531453598 I 11001202 4 11/1212024 7531721577 210474216 115 Invoice 2.34 116.94 518.92 7531453590 I 11011 11/12/2024 753172157B 209167962 11 lummium 5.23 261,41 414.60 7531721577 1110612024 11112t2024 7531721579 215693182 11 sl.v.i.. 32.43 1.62l'65 256.18 1.509.22 7531121578 11 IOR12024 1111212024 7532213799 209652404 11510v.1.. 5.23 261.41 256,18 7531721579 -1' 7532213799 I 1108/2024 11112/2024 7532213800 210883893 1151mimce 0.02 0.95 0.91 J 7532213800 1 IIOOY2024 11/12/2024 7532213801 216833893 11 51"Voic. 5.28 262.98 I V013/2024 1111212024 7532213802 208704078 11 Stnv.j.. 57.23 2,801.40 257.72 2.804.23 75322�3:01 7 '322 3 02 w mhusn legend: P Pact Due Item, F w Artame 0. Item, blonR = Current Duo Ham Subtotals: 6,20B.Ifl Uso Future Do.: 0.00 sent Do.: If Paid 111 11/12/2024, Dun It Got) Paid On Time: 6,084.99 0.00 Pay TV. Amount: 6.D84.99 JSD Dim last If gold late: "M payment 488.20 If And After 1111212024, Due It 1 24.19 Paid Lroz 1104/2024 fty thlar Amount; 6.209.18 RED USD 11.200n8 APPROVED ON NOV 12 ?,AUD02A TY IT? T_ AS I CnIll" For AR Inquiries please conract 800-867-0333 MCKESSONSTATEMENT As of: 11/08/2024 page: 001 To ensure proper oretlb to your account, reach and Mum this .am,x,nY lloto slob with your mmlltence DC: 8115 HEg ORGY W PIIS ED AMT DUE REMITTVIA ACH DEBIT Customer INV SUppID: As of: 11/08/2024 Page: 001 Mail tot, came: 8000 VICMORIAI. MEDICAL CENTER R Territory; )001 VICICA XALISIX statement for summation only AMT DUE REMITTm VIA ACH OMIT 615 615 N VIRGINIA Sr J Customer. 820405 Statement for inlormalion only PDRT LAVACVgGA TX 77979 Oatm 11/08/2020 Coal 820405 PLEASE Cl ANY Dole: 11/0812024 I EMS NOT PAIDDili.(✓t Accou Nemberbl�alional nt Data Data Releronca Worse Cash DetestationDiscount Amount P (gloss) F Amount P Receivable (not) F Number I Customer Number 820405 H® PNCY WHSF/MEM ME, PHS 11104/2024 11/12/2024 7530872212 B2411-065-179036 1151npnice 0.57 20,44 / 2).8) V/ 7530872212 F- 11/04/2024 11/1212024 8901218062 0005720501 A0tlbi11 INV 6.04 0.04 s/ 0901219002 PF column legentl: P = Past Due Item, F = Future Due Item, blank = Curren Due Item TOTAL Ceatsmer Nulnbor 820405 H® PHCY W"slino M ME5PHS _— — — - ---- -- Subtotals: 28AS USD Flgure Due: 0.00 If held By 11/1212024, Due If Paid On Time: PAW Duel 0.00 Pay This Amount: 27.91 USE, USE 2i.91 Diu lest It paid late: Laal Peyr11en1 I I/04/2024 408.20 It P.IItl Alter 111/2/2029, 0.57 Due It Paid late: Pay this Amount: 28,48 USD USD 20.49 APPROVED ON NOV 12 j?jo �/t CgLLII IOCIN (N7TnURo' i(:vgg For AR Inquiries please Contact 800-867-0333 MWESSON STATEMENT �.omnaor. eusu CV6 PHCY 7416/MM MC PHS MEMORIAL MEDICAI. CENTER AMT DUE REMITTED VIA ACI1 DEBIT VICKY KALISET( Slammanl for Inlornlallon only 010 N VIRGINIA ST PONY I.AVACA Til 77979 As of: 11/0812024 Page: 001 To ensure pmper roam to your Account, detach and mlYm this stub with your remittance ls Customer m INNV Supp10: As t: 11/OBI2024 Pepe: 001 Mail to: Comp: 6000 Tomitory: 7001 AMT DUE REANTTED VIA ACH DEBIT Cud omer. 835437 Stalemem for inimmalion corny Dale: 11/08/2024 Cost: 835437 PLEASE CHECK ANY Dale: I I1O6/2024 ITEMS NOT PAID (+) ti0nnl A n- dlline Due NivabhNa raNer Ual¢ Dato Number 536 ---- Nelemnca Ooscdpti0n ---- ____— Cash Amount P Discount KAl.) F -'" —""— Amount P Receivable (net) F Numbor t. I Customer Number 839437 CVS PHCY 7416110W MC PHS ^� 11/00/2024 11/12/2024 7531719253 3649536 1151nvolcs 0.04 1.86 1.A2 d 7531719253 L PF column lo9end: P = Pael Due Item, F - Forms Due Item, blank = Current Due It.. TOTAL Customer Number 63593T CVS PHCY T4Y 6lMFlA MC PHS Subtotals: 1.86 USD Future Due 0.00 Past Due: If Paid By 1111212024, Due It Palo On Tlme: USD 1,82 0.00 Pay This Amount: 1,82 USD Dix loft if Paid late: Lem Pa Tent V 5.194.5n t 0/26/2024 If Paltl After i1112/2029, 0.04 DIf Peld Irate: ue Poy this Amount: 1.86 USD USD 1.A6 APPROVEO ON NOV 12 2024 Byf%�40ro,CAI ill For AR Inquiries pleB.se contact 800-867-0333 MSKESSON STATEMENT As of: I I/0012024 Page: 001 To ensure proper confito your acco0nq detach and mturn this ..n.Mv. a000 stub w„h your ram„lanes 9116 CVS EM PHS Cus usl4mor lNV Su 10: FP As l t i t/00/2024 Pdgo: 001 Mail to: Co.,: RIAL MEDIC MEDICAL CQ4T61 EN MCKY AMT DUE DEN ITTPD VIA 0®IT Ton to ]001 ry KAU 1 KAIISIX Sldlemanl for inlormatlo0 ugly ily AMT OUE VIA q' OMIT IT 815 N J 915 N VIRGIAVAC IA ST 9202,; Sldlantenl IDr Inlermalion onl I., mane y PoPT LAVq('.q T% ]79]9 DlICl.lat11r. Date: II/00/202�1 Cusl: 035438 PLEASE CHECK ANY Dale: 1t1001202a ITEMS NOT PAID (+) Due Hecelvablvatl0nol Aev m _........_._—__ 63aA2 36 _.._ 9i Date 4Ie Dale Number Amount P M�fe�mnca Oaxdp10n Caat, POleanu I (gm .) F Amount P Pdc vnble (net) F N mbor� I CUMOmm NOmbar 83543n CVS PHCY 747SIMEM MC MS m.�A 11/06/2024 1111212.024 7031706289 3651442 1151nvuice 0.02 1.09 1.07 J 7531706289 PP c01um0 IagOnd: P a Past Due Item, F = Future Due Item, blank = Current Due Item .. ......_..--,..................._v__.__..._.�__.—......_..__ TOTAL' Dllgamar NUmbal 035436 CVS PHCY T4']S/MF30 MC PHS Subtotals: 1.09 USD Fallen Dow: 0.00 If And By ll/12]2024, Due It Paid On Time: USD Past Due: 0.00 Pay Thin Amount: 1.07 USD Dix lost it paid In1e: 1.07 Wet Payment 11104/2024 495.20 I1 Paid After 11/12/2024, 0ue If Paitl Late: 0.02 Pay this Amcunl: 1.09 USD USD I.09 APPROVED ON NOV1 22G?& CAh10 ppNTMI6VITYAS For AR Inquiries please contact 800-867-0333 Ame�sourceBer en° STATEMENT Statement Number 68566238 g Date 11-08-2024 1 of AMERISOURCBBERGFN DRUG CORP 12727 W. AIRPORT BLVD. SUGARLANDTX ])478-610t 866 1-9655276 666.451-9655 WALGREENS 012494 3408 MEMORIAL MEDICAL CENTER 1202 N VIRGINIA ST PORT LAVACA T% 77979 2500 J AMERISOURCLBERGEN PO Box 906223 CHARLOTTE NO 282005223 1001352841037028186 Sal - Fri Due in ) Jays Net Yet Ow'. 0,09 Current 2,725.12 P.M Dee' _00 Tidal Due 2,725.12 Account Balance: 2.725.12 Account Activity -.--_.___.—_-- Document One Reference Purchase Order Document Original Last Receipt Amount Received Balance Date Date Number Numher Typa Amount 11.04.202q tt-15-202a 3194491404 ]008050G60 Invoke 102.65 11.04 2024 11.15.2024 A194491405 7W0001710 Involve O.UO 102.50 11a7 11 04 2024 1145-9024 31944014110 1008069785 Invoice 0.00 1167 2.J0 I LOA-202q 11.15 2U24 3194491497 7008050623 Invoice 0.00 J 2.30 4.56 0,00 j 4.56 1604.2024 11-15.2024 319441,140E 7008062574 Invaice 5.03 0100 / 5.R3 11,05.2024 11.16.2024 3194629692 Invoice 1,072.37 0.00 1.156.28 11.@62024 11-15.2024 3194980481 7USI165148 700BW5148 Involm „� 362B J g36.'LO g16.38 11-OB-2024 11-10.2024 .1195135161 Invoice 16.3E 0.00 1p]0 0.00 11.08.2024 11.15.2024 3195135151 7008103777 ]OOB103>A Involre 1,073,01 0,00 J 1.073.01 1 LIIB302.A 11-15-2029 31PG135152 ]004104450 9rvoice 0.07 0.U0 09] Current 1 16 Days 16-30 Days 31-fib Days 61-90 Days 120 Days_00 0.00 0.00 �11.y.Over Go9.09 _I Thank You for Your Payment Reminders Date Amount APPROVED ON Due Del_ Amount H-BB2024 --- (2.320.61) 11-1G202d 2y15_12J / NOV 1 2 ,?om g Cpt1N7y p��p )pp CALIiOUP! COI1M1IlY 1T117(A:5 -- — Total Due'. 2,725.12 J 131 1t3W ��veL i u )i l0)d }}IO]i3)< A 1414)>I Sl 51WW IIBFPttP ALYJ3 V[IOP V IJ f w; } 91111.1< 1.1—u $EY.13UfO APPROVED ON NOV 12 )ve, cni�o��i �Cou i xns Y '- �aulvz,„f SY D_ta*xMmmonpor.3e�iu�o w,rnu a ... na. '•:` -._. ,. ia,r,so asrconno a '.'/Mou a,npmr,ws,.un APPROVED ON NOV 12 ?fP4 CABIICFLP DU 1�_ITF%A5 ll9J I6ef0 9 )PIn. n taM 3elWf9f9. o p/3ry9 p 5yes9l �(3 MMuseOpninMo 0 ^ d��z]CnvU p .ILu " ��� •_ 9i f919990 3000Pg0 � 40N}PI[3 OVS � i o/MI101< >(p399310 APPROVED ON NOV 12 In �- CAR(O, j�,�yD1TWE%A8 MEMORIAL MEDICAL CENTER PROSPERITY BANK ELECTRONIC TRANSFERS FOR OPERATING ACCOUNT -- Nov 4, 2024 -Nov 10, 2024 DAN dnk DWKIVI.A IUR/20M PAY PIECES ACHIr¢m 4;110291,01U 10006011528)an 11/W024 I 'PHIS, LAC MEMOI11Al M01nMedUr PIUJP 11312265,0 TIM111114 I11116 LLC MBMONMI, MelnMedC4r Pltav 11317,265110 II/B/20)4 "I'lli I Cc M[Ml REd MmnMpdw l'Il YI131226500 11/8/2014 AMC, RITOLANCP BUD PAYMEN191p0000y258 11000112 111800 4 MEMONMI MED)KAL PAYROLL 7A0008d 1111312,650 11/1/S9 ri 61AIC COMPTBLB IIANCT08436092/41 WG 2101001, 11/Y/2024 PAY PLUS AI:Iur.ln.4269265710 1OWS9001301 P 11/6/I(M WMf OU t MFMUPAL MEDICAL C.ENTr,N 11/6/2.024 PAY PLUS ACIOlana 425757061010W698424798I I l/6/1024 1'0MS I'OMY PYM 1052 1601830 0004 POW t d256446 11M/2024 PAY PLUS ACIIhan14243W39 IGIN0697110479P 11/5/2114 MCNE,SSON ONUO AU IO ACH ACH004313291000011, I l/5/2024 F%I'fNTPAYEXPCNTPAY/400014119 INN 946931A 11/512P1a F I IMS FOMS "MI 0112182545000 A I000I2))8354 ll/5lPoI4 PUMS FOMS PYMT'52.20005W-0004 lMDI2777324 I1/5/11E`4 TOMS FENS PYMI 01221825S? WC)A 1001117815, 11/4/2024 PAY PLUS AC11Tran141198849101W06949113111 V 11/4/1024 MEBCUANI OANN00 DISCOUNT 9711611910883910000 11/4/2014 MfPJIAW DANCED DISCOUNT 971160NI388291WW 111412024 MERCHANT OANNN FEE 97116091388791000013417 I1/417WA MLPCHANT HAI2RCO FEF 9" 16011088191000011417 11/4)1034 MFNCEIAN3 HANRCD INTFPCHNP 9111W913987 good, 111412004 ALAI INC I GAIL WAY OIILING nHNG 199 10400011, MMCNotes 9N EPIP, III., Fe[• - IIwI1P InSwan.. CMim Pa'Id nls . dr.11Ilnyernn[n Clarnl Paymenlf """'I envran[r Orr' 1a1menlf(11" 1 morn, wns rrrru Pro Ilpl/la) 340B f1IC, PI.,Iarlfryers, n3,d I.d SIICGl Aavar[ 2 Pavrrmm yFFer ". t1. WI 1 Mnkyl apmwl -3 IP EId y.,Ial - Credr Car JMad[Irlrrkg p L¢aSp Ire 3Id Par,,ePayor Pe 409D1.LP, {NCE9up.PrenF1l om cad 1 Vensc M.rllnn leas, F,r CNht Grl, MEIIWAe L[•atn Flee I,.JIt lyP IAr (rPe base Fm emra ny Pavr, rrn Credit Card I'roCmilnC Fee Acard Pm[erduPre C&C dH Ca IP esgn, Fep CrAdite d Processfing Frr CladiftCard P <AaslnB Poe d JParty P y fee "Ed xwprndpr tl,zmn # ��PPT"vN1e'Cl' Oft 1\. l¢. 1L{GG Fnr ❑Pver18p. 1s 1'19' MelndrlPlMer6wlCann YQJ2.(A: On I0. 30'rr4 C(.. PROSPERITY BANK ELY.CIPONIC TRANSFERS FOR OPERATING ACCOUNT.. MIMATED APICES If41e frpi[r1n(Inn 11/1 VACUA .AI A If C0M10101N KN11 091 EU2rTAudll 0Yc,1pryrnerl IVICEI2024 - STATE COM10U11¢NNEI CIIIBPIGTSFY25 (/(f1111/0WIC014�-STAIE COM1110111iMIE3 RAPPSIGTSPY25 FrIII CIJ-----—�PC_ Nrvemher 11. 2024 MpmnOBl Metlluil Cvnter NOV 12 [071 cALftC) I?W"•OUN'' ,WN" CP51"IMndwwr_10 -45A 3 901 12.65R 69 �2.' {(� N01 33,P93 .31'L[f Ly3PI 93 C. 2a2P.61 1 Aa. C. f.IQYYTF.p� 39•l,N16,81 * OV1L! 11, rrt �l 326.316.63 wsa4 To IXI,Gp.PO At, .APJJI. YIP 1 id 9P1 4FR20 .9211 . SIR SIX S )f1.69 901 �4Yp• yo1 ,. 901 y h1,88 Wd INA5 lot H.95 01 4D0:26 901 2tP15 9P1 n V Y99 901 T 9 fl11:1d 901 OCG441B. 901 Y tk P,I64,m Annul 441:11 Y0813.11 J 42636J9 I13,891.57 L 0qw• Transaction Summary Transaction Complete Trace ## Texas Health and Human Services Commission Memorial Medical Center Operating County Page No: i or i Run Date: 111612024 Run Time:18:01:11 Transaction Summary Transaction Complete Trace # Texas Health and Human Services Commission Memorial Medical Center Operating County Payment Total I $70.A1't 11 Bank Routinq and Account Number _ Settlement Date 11/18/2024 CHIRP Amount $70,813.11 Entered B Andrew De Los Santos Page No: 1 of 1 Run Date: 111612024 Run Time: 16:21:15 Transaction Summacy Transaction Comnlete Trace # Texas Health and Human Services Commission Memorial Medical Center Operating County -Payment Total $42,636.99 bank Routing and Account Number Settlement Uate 1 11/25/2024 RAPPS Amount $42,636.99 Entered B Andrew De Los Santos Page No:1 or 1 Run Date: 11/612024 Run Time: 10:34:42 RECEIVED BY THE COUNTY AUDITOR ON NOV 0 7 2024 MEMORIAL MEDICAL CENTER 11/07/2024 10:12 AP Open Invoice List CALHOUN COUNTY, TEXAS Due Dates Through: 11/23/2024 Vendor# f/endor Name Class Pay Code 11816 J ASHFORD GARDENS Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount J 102824 10/31/20210/28/20211/23/202 2,909.85 0.00 j ns • frY* • GL . f n-Ev 1 nmc, Dpb • n r or Vendor Totals, Number Name Gross Discount 11816 ASHFORD GARDENS 2,909.85 0.00 Grand Totals: Gross Discount No -Pay 2,909.85 0.00 0.00 APPROVED ON NOV 0 7 2024 0 ap_open_i nvoice. template No -Pay Net 0.00 2,909.85 No -Pay Net 0.00 2,909.85 Net 2,909.85 RECEwM NYiNE GOUNiV AUNITIR ON 11107/2024 NOV V 7 2024 10:14 M OIbN e.'(MY, 5 Vendorit/ Vendor Name 11828 J SCLERA WEST HOUSTON MEMORIAL MEDICAL CENTER AP Open Invoice List Due Dates Through: 11/23/2024 Class Pay Code Invoiced Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount J103124 10131/202 10131/202 11123/202 1.842.67 0.00 kc\S.Prn.L—. ClLQ.P. "to mmc,bP4•"s_rr'or Vendor Totals: Number Name Gross Discount 11828 SOLERA WEST HOUSTON 1,842.67 0.00 Grand Totals: Gross 1.842,67 APPROVED ON NOV 0 7 2024 CARLHOUN (,nHOY RAS Discount No -Pay 0.00 0.00 0 ap_open_i nvoice.template No -Pay Net 0.00 1,842.67 No -Pay Net 0.00 1,842,67 Net 1,842.67 RECEIVED BY THE COUNT' AUDITOR ON NOV 0 7 202-' MEMORIAL MEDICAL CENTER 11/07/2024 0 19.19 AP Open Invoice List CALHOUN COUNTY, TEAS Due Dates Through: 11/23/2024 ap_opan_i nvolce.tomplate VendorN /Vendor Name Class Pay Code 11824 '`7 THE CRESCENT Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net J 102824A 10/31/20210/28/20211/231202 12,240.00 0.00 0.00 12,240.00 ./ / 1 n5. �(T - . GULP. ,1 Alb YrVY%C- CP-t. it Q rr d r J 102824 101311202 10/281202 111231202 5,100.00 0.00 0.00 51100.00 l� 4103124 1 10131/202 10/31/202 11/231202 7,369.86 0.00 0.00 7,369,86 J Vendor Totals: Number Name Gross Discount No -Pay Net 11824 THE CRESCENT 24,709.86 0.00 0.00 24,709.86 Grand Totals: Gross Discount No -Pay Net 24,709.86 0.00 0.00 24,709.86 APPROVED ON NOOpV 0 7 M21, CAL40CI,NU C{Irl1h 1jyDI7TFSfA R11GOVED BY THE cOUNTY AUO(TOH ON MEMORIAL MEDICAL CENTER 11/07/2024 NOV 0 7 2024 10:14 AP Open Invoice List Due Dates Through: 11/23/2024 �+��1,1 Vendor# VendoWMQUN GOUNTr'' MW Glass Pay Code 11836 V/ GOLDENCREEK HEALTHCARE Involeelt Comment Tran Dt Inv Ot Due Dt Check Dt Pay Gross Discount J 102624 10131/202 10/251202 11/23/202 4,345.00 0.00 f1S . ply'* , (1Uv , jn-M rtW)b c)IPA , , n s-f ro r J 102524C 101311202 10/251202 11123/202 362.87 0.00 L 4 102524E 10131/202 10/25/202 11123/202 1.325.41 0.00 L ` 102524A 10/31/202 10/25/202 11/231202 2.739.16 000 ..� 1. 102824A 10/31/20210/28/20211123/202 t6.47 0.00 J 102824 10131/202 10/28/202 11/231202 7.452.05 0,00 J 102924 10/31/202 10/29/202 11/231202 1,260.56 0,00 .� 103024 10/31/202101301202 11/23/202 8,894.57 0.00 J 103124 10/31/202 10/31/202 11/23/202 484.11 0.00 J 110124 1110 11202 111011202 11/23/202 5,114.63 0.00 Vendor'fotals: Number Name Gross Discount 11836 GOLDENCREEK HEALTHCARE 31,985.72 0.00 Grand Totals: Gross Discount No -Pay APPROVED ON 31,985.72 0,00 0.00 NOpV 0 7g7024 p CAIB-H UNN CCTM1l1Ai)�I70ERA5 0 ap_open_i nvoice.tem plate No -Pay Nei 0.00 4,345.00 0.00 352.87 ✓ 0.00 1,325.41 0.00 2,739.15 ✓ 0,00 16.47 ✓ 0.00 7,452.95 0.00 1,260.66 J 0.00 8,894.57 J 0.00 484.11 ✓ 0.00 6,114.63 No -Pay Net 0.00 31,985.72 Net 31,986.72 N Y�AUtNT GO R t)" 11/07/2024 MEMORIAL MEDICAL CENTER NOV 20%ti 0 10:14 AP Open Invoice List ap_open_invoice.template Due Dates Through: 11/23/2024 Vendor# Vendor PNfh W GWNiYjMS Class Pay Code 12606 J GULF POINTE PLAZA Invoice# Comment Trap Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net J 102824 10/31/20210/28/20211/23/202 5,238.23 0.00 0.00 5,238.23 i vrvvkv, . C,..q-,p . Cfi-b rmrooPb . it., yvrror l 102924 10/31/202 10/29/202 11123/202 32,876.22 0.00 0.00 32,876.22 103024 10/31/20210130120211/23/202 1,052.27 0.00 0.00 1,052.27,/ Vendor Totals: Number Name Gross Discount No -Pay Net 12696 GULF POINTE PLAZA 39,166.72 0.00 0.00 39.166.72 Grand Totals: Gross Discount No -Pay Net 39,166.72 0.00 0.00 39,166.72 APKIOVEb ON NOV 0 7��2024 pp C gF1(.Uni1 CT(111M1ITYDI rEXA$ RECEIVED BY THE COUNTY AUDITOR ON NOV 0 ( 202 MEMORIAL MEDICAL CENTER 11/07/2024 0 10:15 AP Open Invoice List ep_open_invoica.templaie CALHOUN COUNTY, TEXAS Due Dates Through: 11/23/2024 Vendor# Vendor Name Class Pay Code 13004 TUSCANY VILLAGE Invoice# Comment Tran Dt Inv Dt Due Dt Check Ot Pay J102524 Gross Discount No -Pay Net 10/31/202 10/25/202 11/23/202 3,631.78 0.00 0.00 3,631.78 J �n5 'PM-b. CAS. �(-to Mmc:. ooe . �n p rrpr 102824A 10/31/20210/28/20211/23/202 11,030.74 0.00 0.00 11,030.74 102924 10/31/202 10/29120211/23/202 32,530.00 0.00 0.00 32,530.00 l� J 103024 10131120210/30/20211/23/202 6.120.00 0.00 0.00 6,120.00 1� M 103024A 10/311202 10/30/202 11/23/202 11,615.00 0.00 0.00 11,616.00 Vendor Totals: Number Name Gross Discount No -Pay Net 13004 TUSCANY VILLAGE 64,927.52 0.00 0.00 64,927.52 Grand Totals: Gross Discount No -Pay Net 64,927.52 0.00 0.00 54,927.52 APPROVCD 01\1 NOV 20244pR N0 CASLHOLiPI COUNTYI RAS RECEIVED BY THE COUNTY AUDITOR ON 1 MEMORIAL MEDICAL CENTER 0 NOV 0 7 ZOL'r AP Open Invoice List 10/07/2024 :43 ap_open_invoice.template Due Dates Through: 11l23/2024 Vendor# Vendor N8hiI@LHOUN COUNTY, TEXAS Class Pay Code 12792 BETHANY SENIOR LIVING Invoice# Comment Tran Dt Inv Dt Due Dt Check Dt Pay Gross Discount No -Pay Net / 102524 10l31L/20210/25/20211/23/202 9,537.85 0.00 0.00 9,537.85v fylY1..Cb•cc-c mmLcp-�i• brh ,I 102824 10131/20210l28/20211/23/202 .Rrror— 1,248.23 0.00 0.00 1,248.23 J 102824A 10/31/202 10/281202 11123/202 2,773.53 0.00 0.00 2,773.53 J J 110124B 11/011202 11/011202 11/23/202 49.67 0.00 0.00 49.67 J J 110124A 11/01/202 11/01/202 11/231202 2,547.37 0.00 0.00 2.547.37 `f 110124 11/01/20211/01/20211/23/202 1,020.00 0.00 0.00 1,020,00 J J 102524A 11/07/20210/25120211/231202 83.13 0.00 0.00 83.13 ✓ \ \ r r Vendor Totals: Number Name Gross Discount No -Pay Net 12792 BETHANY SENIOR LIVING 17,259.78 0.00 0.00 17,259.78 Grand Totals: Gross Discount No -Pay Net 17,259,76 0.00 0.00 17,259.78 APPROVED ON NOV 0 7 ('(W CAL nil Jh�!;[11 tt•i�1V I i�X,ag M1temetlal Mental Center Ymrelr®13ema uvl Weekly Canter Transfer rmsp:nryA¢ann[s / a/u/znxa J/ "YL^^•, e..� aa.n ,+u nn..xw:. A.hfwd Oiid.ii 5.:lo Je 9^14:1� . ,v,r1n - _ "' 39 VY19R 3 f I9111 AididmaM atr;4s3 _ . I J i J 1e+9,r .,. ...l..0 J .j J 155:ft i9 14 "Ii3 I'111. J J J 36.4Is I, ne"111 111i G 3, jf� 1 116.111fl ucrol a, as is _nl ra a..lnrarn, ,. ,nr. zvuan Mrs A.r far rl: J .41.a3 OJm 0.. n:e NAf144 Y.nln atlnu IyS ...S 11". I M l.lnn, MI Is Pn Intnw 519.Y1 f ]1.916IJ n i n. 11,91991 La—.,a.l Nwrnl.r.11 p.:lnlnnr a 1.Rl,l J la.aYU.a 1.-1. enmw :Ww APPROVED ON .In..,, :1:1a NOV 13 2024 cnefiniiI PN �r''TPQAI; M�,ar,..rr.r, n,le am, r1.1NJ9 r,nawvJm[y���,,�� ua>un [tlneleuenpn eao[tlndae.ae^•eE0 1/11/1o1e 115 IS, 1E l9rz BL Lplz vr; 113pS 15 14,iXA i1 . lLJ9 x) .I,FA9. d] IGaIJLOI Id,J40 V1 u ArA.v / •/ 13.DIN .1- J8586).E 59.J]1.95 49,4]1.95 AMC PON310x OIPP/Camp; 3 a 3[UI1Sf:PJ J±W! 41PP/[pm 1 8 bpu 41PP/[am03 41PI/[ampA8lap3e OIPP iI Nx POx (11. P9N M. 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URl"I...l11-111CCU1F14A1i 116MJJIl 1IML 11WM I.',"LI l.1S000 IU6/l O3J \VI Rf OUI GIMU N(JI111(API CLHTIM DI IICNIaI 11/GRO]i DlPaul - ILS}013 - 11,51013 11/6/1011 II NO �(¢!0 x",,W FAR I!WMN AIAWISt5S5 5.513. J4 35]8.3$ 11/A/lO3J IIN0(C110II[C GIAVMI N6)p3i lIiWDIM93]I _ J,0361] Ip56,)S 11/9ROzz UXIIIOIIfALn,cAR(11(CUTAIPMI 1J6N3A lI u43M I,SW.W 4.SN.W 1U4R01! UXf(UIr1AlUIlRI PL IICCUIIAPRI, IM311191Wb IMIt 11 IM. 110'.fl,f(IAIA1fMJ699fiWE6 !}MVry 111Y911J 4511 j,U AOl 1.S83 JL 1L'41tOlJ ayoP fv Follm enu XC<uIM PI,II ]4 rfq dl11 ll3JG Ifi141'q / J L11A.W I', ryl 136,0JID 81.371ta Rpm 44 Tor.4 340 784.31 3M ]01 ]t Balances Overview Account Name '4357 MEMORIAL MEDICAL- $3,125,108.98 $2Al2,249.94 $3,125,108.98 $2,406,594.39 OPERATING *4365 MMC - CLINIC SERIES 2014 SERIES $547.97 $547.97 $547.97 $547.97 '4373MMC -PRIVATE WAIVER CLEARING $441.14 _ $441.14 $441.14 $441,14 '4301 MEMORIAL_` MEDICAL INH $59,833.71 $89,128.27 $59,833.71 $58,410.17 ASHFORD '4403 MEMORIAL / MEDICAL I NH $80,858.91 J $130,908,48 $80,858,91 $51,437.21 BROADMOOR `4411 MEMORIAL MEDICAL/NH $86,492.95 ,� $232,441.71 $86,492,95 $57,639.16 CRESCENT •4438 MEMORIAL MEDICAL /SOLERA@ $81,752.93 $133,308.30 $81,752,93 $41,379.62 WEST HOUSTON '4446 MEMORIAL MEDICAL I NH FORT $33,515.91 .1 $61.193.93 $33,515.91 $25,814.02 BEND '4454 MEMORIAL MEDICAL INH GOLDEN CREEK $125.318.97 $129,478.72 $125,318.97 $116,881.77 HEALTHCARE "4551 CAL CO INDIGENT $5,506.52 $5,506.52 $5,506.52 $5,506.52 HEALTHCARE _ �.,._...._...—.._... ... ..... '5433 MMC -NH GULF POINTE PLAZA - $6,662.24 $6,662.24 $6.662.24 $6,662.24 PRIVATE PAY '5441 MMC -NH GULF -- POINTE PLAZA. $32.908.94 $32,908.94 $32,908,94 $32,908.94 MEDICAREIMEDICAID *5506 MMC •NH BETHANY SENIOR $20,911.40 $20,911.40 $20,911.40 $18,105.35 LIVING MMC *3407 -NH USC TUSCANY VILLAGE $110,157.01 $110,157.01 $110,157.01 $94,148.06 '3880 MMC •BETHANY SR LIVING • DACA $100.00 $100.00 $100.00 $100.00 *2998 MMC -MONEY MAR MARKETFUNp $5,053.48 $1,005.053.48 $5,053.48 $5,053.48 Total Balance $3,775,171.06 $4,370,998.05 $3,775,171.06 $2,921,630.04 Report generated on 11/1112024 10:23:25 AM CST Page 2 of 2 Memorial Medical Center Nursing Home UPL Weekly Nexion Transfer PfOSperity Accounts 11/11/2024 Prerlaue 14 Aemunt BaglnnlnR Pendlnq Tod., O¢IlnnlnR anoant to Ba Tamferred la Nunn., Nu t RNa.. Namber Baanm Tronder0ut immler In DE,.au aalonee Name i1g.922 96 110,667.27 Q6.06349 125,31g.97 / 125,063.48 J Bank Baunm 125.31g.97 V.,4"a taw. la ealmm tOn.4l] ulguryy(sf., G.Ota ch", Neson Health of Garden Creek n/fllf{gmq Dank, N A. Neeb OnN balantte a/over j5.C4'1. willbe fmnr/coed m mtnvrnnq hamr. Here 21 Coeh erraunr be, o bar, halo. e,$,, oar MMC deOaerted to open a,o aa, APPROVW ON NOV 12 2024 CALHO NUCn fM �TF.�S Oct lntanit 255A9 No. notate:: oec Interest Adpnl ealanee/imnder Ann ��25,o63..B nooroved.—W-C-�—,/QA Can Clevenger, CEO 11111/2024 1ANX Newly T,amlaMxx uqt Tundra snmman\2o:.gxx urtTnmre, S—,,, 11.11.2a MMC PORTION 11 /IlS4l) 15 f lMl15[NS) U(..♦1.Nf55d)49l)U LldnjlgQu( rgi 111A, (alPp/Com Ol GIP P/fggpI gIPP/C6T03 6Y pfe QIPP TI Nx POPfIRN 11/A/]91i IIRRt Tf1lIPHI............ JJLWIIIIIIACCIMIlJ '954fe +,95PW 1.104 II!Ip.(fNUNI'll 1MpM11A6W 1111 dApUtl91155 - ,IA]_]U Atl),I(1 11/I/)431 III aIi I1 rIU M.511"' ffINM11[)!J(fU1....Itl) _ 9J1 n al II/I/]V1) Im I1MXX TY pAY AI(11) 1.11, WJ4 NlPl'))1p5 IWP E'1 I616 l9 lU6/]wJ \vlAt olllll(x1orN[rLL)u a/e/F GUmtx CA[(. Vf / 1u 662;E V II,WIUI IE,4liP 9U u/4no:d UeyJol 1l5/)OE! IQIX.1AIII.V)(P <U GIn 5A 1F 6J 355d)6911 J1 - Y1695 dl 31.31. SR 146(EUIf 4U10f11(N(LX11[A II AI Ffl[U[p 1EEU19541p.Yg1E)9 ),pE l(p }, U110U U[P IE 1U1549ICN915N 145/1UE1 GUALI',I 46ti 45 I.-Il(P(!M[Pf 11/51}4)i II(alr 11 llV Mall i\'(IIC[141MPM)()JCO]))II)411J J,P11A 1J �491 U) A, 11/J/)VIC I515(IMIJ3610.4)( R C00[p 5JI4M55561691) J) - 1U1666 1.I'l1U3 I i.5I I1/J/]UN 1513:IPT11511Y5I CA CA, p[P SJIfi9J255d 14911 J1 1:1)U pA 11/A/]V}! 1f Y5/fPC NSII43i(0.CUP[p S116M555d14911J1 ILllhl I.LJI O 1))AI]UEi GUIIIIMI[.LL[AI[PC UIp It (CCO1513 91A UU 11/A/VEI 11[iMli11 Ilt XVA1NI Slf XCC WIMp1A[I..N..111 M 111 1 1.1'19 (O 5R9511 / 1.3M1M1 IIJ io•1.5N AJA 667.F I16061.C6 Balances Overview Account Name *4357 MEMORIAL — —�-- MEDICAL- $3,125,108.98 $2,412,249.94 $3,125,108.98 $2,406,594.39 OPERATING '4365 MMC - CLINIC SERIES 2014 $54797 $547.97 $547.97 $547.97 *4373 MMC - PRIVATE WAIVER CLEARING $441.14 $441.14 $441.14 $441,14 44381 MEMORIAL MEDICAL INH $59,833.71 $89,128.27 $59,833.71 $58,410.17 ASHFORD *4403 MEMORIAL MEDICAL INH $80,858.91 $130,908.48 $80,868.91 $51,437.21 BROADMOOR i "4411 MEMORIAL -- MEDICAL/NH $86,492.95 $232,441.71 $86,492.95 $57.639.16 CRESCENT .._........ __.._..._. *4438 MEMORIAL ----� — MEDICALISOLERA@ $81,752.93 $133,308.30 581,752.93 $41.379.62 WEST HOUSTON `4446 MEMORIAL _------- _._ MEDICAL I NH FORT $33,515.91 $61,193.93 $33,515.91 $25,814.02 BEND *4454 MEMORIAL MEDICAL INH GOLDEN CREEK $125,318.97 $129.478.72 $125,318.97 $116,881.77 HEALTHCARE *4661 AL CO ._.________...............- INDIGENT $5,506.52 $5.506.52 $5,506.52 $5,506.52 HEALTHCARE `5433 MMC -NH GULF ` POINTEPLAZA- $6,662.24 $6,662.24 $6.662.24 $6,662.24 PRIVATE PAY *5441 MMC -NH GULF POINTE PLAZA• S32,908.94 $32,908.94 $32,908.94 $32,908.94 MEDICARE/MEDICAID *5506 MMC -NH BETHANY SENIOR $20,911.40 $20,911.40 $20,911,40 $18,105.35 LIVING *3407 MMC -NH TUSC TUSCANY VILLAGE $110,157.01 $110,157.01 $110,157.01 $94,148,06 `3660 MMC •BETHANY SR LIVING • DACA $100.00 $100.00 S100.00 $100.00 *2998 MMC •MONEY MAR MARKET FUND $5,053.48 $1,005,053.48 $5,053.48 $5,053.48 Total Balance $3,775,171.06 $4,370,998.06 $3,775,171.06 $2,921,630,04 Report generated on I I111r2024 10:23;25 AM CST Page 2 of 2 Memonal Medical Center Nursing Name UPL Weekly I1MC Transfer Prosperity Accounts 11/11/2024 / J naaum unwr aepnn, peMrnt umd..,eem Nui m. __Numi<r BNn<. _np_l.r.aal [w,t�lena rnI'll, o<wmr / roaW,Yen^.Incost IIu0,56PR. <� W1w3l6d a, i0 J Zl i11, s .1 ti uerrxl JAA.0 an .... fs-111r lne m SLE.t4 pnMw, •mernl le 9< 4ireun, B<linrun! peMlnf Ilfn,lerrea le Murll Ilemr Number 011rm. iranJer.(NI -- ra.11, 11 Ct.be,n! 0<poJl. }oErv', 0<.In I"'.,n[, Nu12.8 Nome triilry g1/i3dfdB711(MsdIi91A;.,S. nsvE saran - a.94e et J v.em.94 J aanx w!mM Il]4P 11 11— mB,i,nw IWa Raieo e,hn./Yra I., and — __)] M"ems. ,. a�•. n.ma.o. <r w r,,,,.ro,r,. m: anrrermee, ora.msrooa m mr.e=,Inr<em u<nurnnenom< nQprend: Nor<itama ,nm. "tslmm oIaas e..Lmit 1-11111 men<nurmune err. <Imgep t10 stlNi. APPROVED ON NOV 12 Ipzn CAL'NJU�,%611,1r? As ,,.. ,N . ,u„Y...t pr. p.r 3.nn.., 1:.IvVe...... ",r— v, l„tN mmc Poa ION Y glop/cam gIPP/Campo ppJl ppnIl04ap WCb U." nOY halsl9yi gIPP/COmPI 2 p gIPP/CYTEI &W,40 gIPPTI PIN PORTION 11/1/2014 HPI0 ECHO HCCldIMPMT 71600341144W00293355 .350 62 469,62 II/ IWT HNS-ECHO NCCLIIMPMi ).16003A11 IJMW29ll55 I I600 _ 6 IIPQ02.1 TIN ECHO HCCWINIVMT 74WO3411 AJ0IXp1C0 393156 J q]u3 116,00 11I 1120),I SIND ECHO HCCIAIMPMT>g6O03411 O40gp0238577 iJfil 20 2,161,20 „ MMC PORTION fiuli R6i'iee�MEs�Nea't['rwiLLi i�d "' �, ,.''.,;�i.° �a`�=��� fit` gIPP/comp 41PP/tpmpn u6cr ,rt. e r`$ ��- ]mRS1�L0J � t tleyaR IQ, 2 gIPP/COmP3 618p30 gIPPTI NH PORTION 11/6/2024 MERCI ANt dANECD DEPOSIT R963'2851R8899100001 25.)v12 25122 92 lljlj1011 MFACNANI BAYRCO DEPOSIT A9W]d516RA99INOJ1 - J,BRO RD .1.dOtl, Y1 32.886.9I 32 888 59 Balances Overview Account Name '4357 MEMORIAL — --—-------- MEDICAL - $3,125.108.98 $2,412,249.94 $3,125,108.98 $2,406.594.39 OPERATING MMC -CLINIC SERIES SERIES 2014 $547.97 $547.97 $547.97 $547.97 MMC -PRIVATE WAIVER WAIVER CLEARING $441.14 $441.14 $441.14 $441.14 '4381 MEMORIAL ��----� MEDICAL/NH $59,833.71 $89,128.27 $59,833.71 $58,410.17 ASHFORD *4403 MEMORIAL`— MEDICAL/NH $80,858.91 $130,908.48 $80,858.91 $51,437.21 BROADMOOR *4411 MEMORIAL —__-- MEDICAL / NH $86,492.95 $232,441.71 $86,492.95 $57,639,16 CRESCENT '4438 MEMORIAL MEDICAL /SOLERA@ $81,752.93 $133,308.30 $81,752.93 $41,379.62 WEST HOUSTON --- *4446 MEMORIAL — MEDICALINHFORT $33,615.91 $61,193.93 $33.515.91 $25,814.02 BEND *4454 MEMORIAL MEDICAL/NH GOLDEN CREEK $125,318.97 $129,478.72 $125,318.97 $116,881.77 HEALTHCARE '4551CAL CO INDIGENT $5,506.52 $5,506.52 $5,506.52 $5.506.52 HEALTHCARE 15433 MMC -NH GULF / POINTE PLAZA - $6,662.24 J $6,662.24 $6,662.24 $6,662.24 PRIVATE PAY '5441 MMC -NH GULF / POINTE PLAZA- $32,908.94 J $32,908.94 $32,908.94 $32,908.94 MEDICAREIMEDICAID `5506 MMC -NH BETHANY SENIOR $20.911,40 $20,911.40 $20.911.40 $18,105.35 LIVING *3407 MMC NH TUSCANY VILLAGE TUSCA YVILL $110,157.01 $110,157.01 $110.157.01 $94,148.06 '3680 MMC •BETHANY SR LIVING - DACA $100.00 $100.00 S100,00 $100.00 '2998 MMC -MONEY MARKET FUND $5,053.48 $1,005,053.48 $5,053.48 $5,053.48 Total Balance $3,775,171.06 $4,370,998.05 $3,775,171.06 $2,921,630.04 Report generated on 1111t2024 10:23:25 AM CST Page 2 of 2 Meraorlal Mautcal Center Nunin® Nome UP1 Weekly Tuscany Transfer Prosperity Accounts 1111112024 �. j tlMlnnln� xumber Nbn tis,.,am 161e11.69e 161, M1I149 1a—m IItl.M mne. nnMb+Knot Motu SEp:V.db. eum/er,.am me nu..�nano,n.. 4nln!'(n.n ortnrni h ni a bolt Lubnrn r/S I. nre, 11, ar,,,1 toaUenn[rryie:. APPROVED ON' NOV 12 2074 CAgHOl11J Cn i''ALfY ITXh.S '.din, amountto Be m.f minm. va.vu.91 a..em a.,.... He nn0ae.b(n//u1R�r.mnr nml n9.ostm frin¢mnfrr. ¢o 11/11/Mld J MMC PORTION (,p} QIPP/CamP QIPP/[OmP 2, QIPP/Comp QIPP/Comp Transinr•O.t Transfer -In 1 344 Lapse 3 48tnpse QIPPTI NH PORTION 11191202A 14120-ECH0RMAIMPMT 946002411440000234562 . J 16.068l, t6.008.95 1116/2024 WIPE OUT VILLAGE POST 'CUTE HEALTH SEMCE 163.347.69 11/6/0024 DPPPut 12,141.78 22.1,11,78 I3/61M1 HNp pChl0 xf,CNIM11PMi )44003a11440tl0@52560 - 6,929.31 6.929 al 11/5/2024 00PPLt 31.838.85 31,883.05 11/5/2014 MNB ECH0 xCCIAIhIYMi 146003411 e40000308162 9,404.0E - 9,4U4.06 11/4/2024 pOPOilt 11/4/2624 ANO-ECHO HCCLAIMPNT 74600341144000023"01 _I 1Q280.00 94n4 nR - / V 14,280.W o�nn nc Balances Overview Account Name --- -._..._..._-.._...__.._._.._ *4357 MEMORIAL ..... ... .... . MEDICAL- $3,125,108,98 $2,412,249,94 $3,125,108,98 $2.406,594.39 OPERATING '4365 MMC • CLINIC SERIES 2014 ___--._:.. $547.97 ......_.._- .------- $547.97 ----...-------_-__. $547.97 _--_..._�_ $547,97 *4373 MMC •PRIVATE WAIVER CLEARING WAIVER $441.14 $441.14 $441.14 $441.14 "4381 MEMORIAL MEDICAL INH $59,833.71 $89,128.27 $59,833.71 $58,410.17 ASHFORD ..___._ '4403 MEMORIAL ... _......... —. MEDICAL I NH $80.858.91 $130.908.48 $80,858.91 $51,437.21 BROADMOOR `4411 MEMORIAL MEDICAL I NH $86.492.95 $232,441.71 $86,492.95 $57.639.16 CRESCENT *4438 MEMORIAL MEDICAL I SOLERA @ $81,752.93 $133,308.30 $81,752.93 $41,379.62 WEST HOUSTON '4446 MEMORIAL MEDICAL I NH FORT $33,515.91 $61,193.93 $33,515.91 $25.814.02 BEND *4454 MEMORIAL MEDICALfNH GOLDE GOLDSN CREEK $125,318.97 $129,478.72 $125,318.97 $116,881.77 HEALTHCARE _ *4551 CAL CO INDIGENT $5,506.52 $5.506.52 $5.506.52 $5,506.52 HEALTHCARE *5433 MMC -NH GULF T. POINTE PLAZA- $6,662.24 $6,662.24 $6,662,24 $6,662.24 PRIVATE PAY *5441 MMC •NH GULF POINTE PLAZA - $32,908.94 $32,908.94 $32,906.94 $32,908.94 MEDICAREIMEDICAID *5506 MMC •NH _ BETHANY SENIOR $20,911A $20,911.40 $20,911.40 S18,105.35 LIVING *3407 TUSCANY VILLAGE TUSCA YVILL $110,157,01 $110,157.01 $110.157.01 $94,148.06 *3660 MMC -DACA ANY SR LIVING SR LIVING - DAC $100.00 $100.00 $100.00 $100.00 '29 MARK MMC -MONEY MARKET FUND $5,053.48 $ 1,005,053.48 $5,053.48 $5,053.48 Total Balance $3,775,171.06 $4,370,998.05 $3,775,171.06 $2,921,630.04 Report generated on 1111 U2024 10:23:25 AM CST Pape 2 of 2 Memorial Medical Center Nursmp Nome UPL W.eldy N$tT/ansf., Prosperity Accounts 11/11/2024 J J vna.,,[ J on1,e na n[[oum eslmlq mmm,. xua a. Tnnn[,,.em 1 x'n+l .mee,, a[en< rnmbnom s[no.,Jn ebtlurea a.r.rm.n roe.yyne,/_In enln<e m%N xlmyxn,n._ J i91hd\4ff&FJ1wia�=. s, ,:;+ s.e,z.oe s,ese os'� fa.naJa 2o,fu Ja 30,130.03 NnY Ba4nm 209II J0 Nob: cn„.14.... nfn—lJ Ooo»me.,,cnr/rr mto tH—, h.m[. WI3r Dl< 111-1hn,009,ehnlae.f oI51M I'll MMCOfea.rtef,.eMt.[(p�o�. APPROVED ON Nov 12 2024, CALHOl1N RP1 f10'WPA$ I.111M IYe014 ir[nlllrl\.Yr1 U[L'r l", 11-Ilnl1114 I"!.............. f 1111J tt Luwln tllllnto LW.% on m,..[n so93 xw mono o.amfon ael�nmen nanm, 3o,nou Prin ro le Cleuxnle[Cf0 it/tlNOfa MMCPOAVON Tff711L^Q.I Il4NMfJ➢ NPP/CQMPI QIPP/COMPS QIPP/CPT E QIPP/C..I.Mlol. QRP)I NMPDIIEIQN LUU S. t3 I,d93.1S 11105p L110 16111.i1 IB,n BI t! B 6S9 P5 e s p11b..3smbiuJ If, P e- . u lApoAd lw3mlL .mUVnI IIV.......... P.YT [nluli IIIW QmW 11lAllOAd IIL.1l(II AII;VC II[[N....... IfJGUNlllP 14! It/1NOPA Ilp1 1 N11 1AC Xl)fi tIJIR9A15bbUw[Ln t4 I U4IIIIIA 14 1VUI ADYI IAVAtn llll, llC 11/1140EA NDVI R5401D Bp11116C NIMnp1i 4P61B W IgSUIL ]UI IJ sill II/dlSAln IILal I111111 nIn 113VE 11<(I,V IAAM11fe6M Nl1 N I6I i SAi.53 r, A 1.91 D.668R6 Y ED,)30A3 � i0 )]O P] Balances Overview Account Name '4357 MEMORIAL MEDICAL- OPERATING $3,125,108.98 $2,412,249.94 $3,125,108.98 $2,406,594,39 '4365 MMC • CLINIC SERIES 2014 $547.97 $547.97 $547.97 $547.97 "4373 MMC •PRIVATE WAIVER CLEARING $g41.14 $441.14 S441.14 - $441.14 "4381 MEMORIAL MEDICAL INH ASHFORD $59.833.71 $89,128,27 $59,833.71 $58,410,17 "4403 MEMORIAL "---"'-` MEDICAL INH BROADMOOR S80,858,91 $130,908.48 $80,858,91 $51,437.21 '4411 MEMORIAL MEDICAL INH CRESCENT $86,492,95 $232,441.71 $86,492.95 $57,639.16 "4438 MEMORIAL MEDICAL /SOLERA@ $81,752.93 $133,308.30 $81,752.93 $41,379.62 WEST HOUSTON '4446 MEMORIAL. MEDICAL/NH FORT BEND $33,515.91 $61,193.93 $33,515.91 $25,814.02 *4454 MEMORIAL MEDICALINH GOLDEN CREEK $125,318.97 $129,478.72 $125,318,97 $116,881,77 HEALTHCARE 14551 CAL CO HEAIGENT $5,506.52 $5,506.52 $5,506.52 $5,506.52 '5433 MMC •NH GULF POINTE PLAZA• PRIVATE PAY $6,662.24 $6,662.24 $6,662.24 $6,662.24 •5441 MMC •NH GULF POINTE PLAZA• $32,908.94 $32,908.94 $32,908.94 $32,908.94 MEDICAREIMEDICAID `5506 MMC -NH BETHANY SENIOR $20,911.40 tit $20,911,40 $20.911.40 $18,105.35 LIVING TUSCA YVILL 7USCANY VILLAGE $110,157.01 $110,157.01 $110,157.01 $94,14U6 *3660 HANY SRLIVI LIVING SR LIVING • DACA $100.00 $100.00 $100.00 $100.00 *2998 MMC •N1 MARKETFUND MARKE $5,053.48 $1.005,053.48 $5,053.48 $5,053.48 Total Balance $3,775,171.06 $4,370,998.05 $3,775,171.06 $2,921,630.04 Report generated on 11/11/2024 10:23:25 AM CST Pago 2 of 2