HomeMy WebLinkAboutContract 49784-A1 CITY SECRETARY
CONTRACT N0.
FIRST AMENDMENT TO UTILITY AND INFRASTRUCTURE AGREEMENT
This First Amendment to Utility and Infrastructure Agreement (this "First
Amendment")is entered into by and between the City of Fort Worth,Texas,a home-rule
municipal corporation situated in Tarrant, Denton,Johnson, Parker, and Wise Counties,
Texas (the "C "), acting by and through its duly authorized Assistant City Manager,
Northstar Ranch, LLC, a Texas limited liability company ("Owner"); and Far North Fort
Worth Municipal Utility District No. 1 of Tarrant and Wise Counties, a municipal utility
district created pursuant to Article XVI, Section 59, of the Texas Constitution, and
Chapters 49 and 54 of the Texas Water Code, located within Tarrant, Denton and Wise
counties (the"District"), effective upon execution by all parties (the"Effective Date").
RECITALS
WHEREAS,the City,Owner and the District entered into that certain Utility and
Infrastructure Agreement dated October 12,2017(City Secretary Contract No.49784) (the
Agreement"); and
WHEREAS, the Agreement provides that the City will provide retail water and
wastewater treatment services to the Property and sets out requirements for the District
to construct off-site water and wastewater infrastructure; and
WHERE, the Property is in the area for which the City holds the certificate of
convenience and necessity ("CCN") to provide retail water service and in the area for
which the City intends to apply for a CCN to provide retail wastewater treatment service;
and
WHEREAS, the City is able to provide retail water service and wastewater
treatment service to a portion of the Property utilizing connections to existing water and
sewer mains in the Sendera Ranch development;and
WHEREAS, retail water and wastewater service by the City to the remainder of
the Property is subject to construction of off-site water and wastewater infrastructure by
the District or other parties;and
WHEREAS, pending construction of off-site wastewater infrastructure,
wastewater treatment service will be provided to up to 20 model homes constructed on
a single final platted lot (the "Model Home Lot") on a temporary basis utilizing an on-
site sanitary disposal system;and
WHEREAS,no model home may be sold to an end-user u Lot
CF is replatted into a separate lot for each model home, the wastew J@FFI .cREt%W d to
°'4'��o G�`Q CITY SECRETARY
Fo���o of FT.WORTH,TX
8p�9y First Amendment to Utility and Infrastructure Agreement-Page 1
serve such lots is re-inspected with closed circuit television video(CCPV),and the model
home is connected to the City's wastewater treatment system; and
WHEREAS, the City approved the water study for the Property prepared by
Pacheco Koch on July 9, 2018 (the "Approved Water Study'); and
WHEREAS, the City approved the sewer study for the Property prepared by
Peloton Land Solutions on June 21,2017 (the "Approved Sewer Study"); and
WHEREAS, the City, Owner and District wish to amend the Agreement
concerning construction of off-site water and wastewater infrastructure and provision of
retail water and wastewater treatment service by the City; and
WHEREAS,the Parties desire to clarify the District's ability to finance roadways;
NOW, THEREFORE, in consideration of the premises, mutual promises,
covenants, obligations, and benefits herein contained, the City, Owners, and District
agree as follows:
AGREEMENT
1. Recital D is amended to read as follows:
Owner intends to develop the Property as a mixed-use master-planned
community to be known as "Northstar" (the "Development") pursuant to a
Development Agreement with the City dated October 12,2017(CSC No.49783) in
accordance with Section 212.171, et seq., Texas Local Government Code, as
amended by that certain First Amendment dated , 2018 (CSC No.
49783-A1) (the "Development Agreement").
2. The following definitions are added to Article II:
"Approved Sewer Study" means the sewer study for the Property prepared by
Peloton Land Solutions approved by the City on June 21, 2017.
"Approved Water Study" means the water study for the Property prepared by
Pacheo Koch approved by the City on July 9,2018.
"East Tract" means an approximately 402.614-acre portion of the Property located
east of the BNSF Railroad, as shown on Exhibit H.
"Model Homes"means up to 20 model homes to be constructed on the West Tract,
as shown on Exhibit H.
First Amendment to Utility and Infrastructure Agreement-Page 2
"Revised Design Criteria and Policy" means the revised water and wastewater
design criteria and policy the City plans to adopt effective January 1,2019.
"West Tract"means an approximately 331.034-acre portion of the Property located
west of the BNSF Railroad, as shown on Exhibit H
3. Section 3.01, "Retail Water Service," is amended in its entirety to read as follows:
(a) The City shall provide retail water service to 1,285 single-family
residential lots or their equivalent in the East Tract and up to 20 model homes in
the West Tract, as shown in Exhibit H (the "Model Homes"), on the same terms
and at the City's generally applicable rates for comparable classes of customers
outside the City's corporate limits upon (i) completion of construction and
acceptance by the City of On-Site Water Infrastructure; (ii)connection of such On-
Site Infrastructure to the existing 24-inch water line in the Sendera Ranch
development and acceptance by the City; and (iii) payment of the fees described
in Sections 3.10-3.12 for such lots.
(b) The City shall provide retail water service to the remainder of the
West Tract, on the same terms and at the City's generally applicable rates for
comparable classes of customers outside the City's corporate limits upon (i)
completion of construction and acceptance by the City of On-Site Water
Infrastructure; (ii) completion of construction and acceptance by the City of the
Off-Site Water Infrastructure; and (iii) payment of the fees described in Sections
3.10-3.12.
(c) The On-Site Water Infrastructure and Off-Site Water Infrastructure
shall be constructed based on the Approved Water Study; provided, however (i)
if Owner does not submit the On-Site Water Infrastructure construction plans to
the City prior to the effective date of the Revised Design Criteria and Policy,
Owner shall redesign the On-Site Water Infrastructure construction plans in
accordance with the Revised Design Criteria and Policy; and (ii) if Owner does
not submit the Off-Site Water Infrastructure construction plans to the City prior
to the effective date of the Revised Design Criteria and Policy, Owner shall
redesign the Off-Site Water Infrastructure construction plans in accordance with
the Revised Design Criteria and Policy.
4. Section 3.03, 'Off-Site Water Infrastructure," is amended in its entirety to read as
follows:
The District shall design and construct approximately 10,200 linear feet of 16-inch
main from the Crumb Elevated Tank to the Property, as shown on Exhibit C, in
(the"Off-Site Water Infrastructure"). The schedule for construction of the Off-Site
First Amendment to Utility and Infrastructure Agreement-Page 3
Water Infrastructure shall be determined by the District in its sole discretion,
provided,however,the District and Owner acknowledge that the City's obligation
to provide retail water service to the West Tract(other than the Model Homes that
will be served pursuant to Section 3.01) is subject to construction and acceptance
of the Off-Site Water Infrastructure. If construction of the Off-Site Water
Infrastructure does not commence by December 31, 2019 based on construction
plans approved by the City, as evidenced by the signed coversheet, Owner and
the District shall submit revised construction plans in accordance with the Revised
Design Criteria and Policy. The City may modify the alignment shown on Exhibit
C after consulting with Owner and District and making reasonable efforts to
address their concerns regarding the alignment and to select a cost-effective
alignment.
5. Section 4.01, "Retail Wastewater Service," is amended in its entirety to read as
follows:
(a) The City shall provide wastewater treatment services within the East
Tract on the same terms and at the City's generally applicable rates for comparable
classes of customers outside the City's corporate limits upon (i) completion of
construction and acceptance by the City of On-Site Wastewater Infrastructure; (ii)
connection to the existing 18-inch sanitary sewer main stubbed out from the
Senders Ranch development; and (iii) payment of the fees described in Sections
3.10-3.12.
(b) Wastewater treatment services will be provided to the Model Homes
by using an on-site sanitary disposal system until the Off-Site Wastewater
Infrastructure is constructed in accordance with Subsection (c). Developer shall
not sell a model home to an end-user until the Model Home Lot is replatted into a
separate lot for each model home, the wastewater main constructed to serve such
lots is re-inspected with closed circuit television video (CCTV, and the model
home is connected to the City's wastewater treatment system.
(c) The City shall provide wastewater treatment services within the
West Tract, including the Model Homes, on the same terms and at the City's
generally applicable rates for comparable classes of customers outside the City's
corporate limits upon(i) completion of construction and acceptance by the City of
On-Site Wastewater Infrastructure; (ii) design and construction by the District of
the Off-Site Force Main, as hereafter defined; (iii) design and construction of the
Off-Site Gravity Main, as hereafter defined (provided, however, Owner and the
District have no obligation to design and construct or contribute to the costs
associated with design and construction of the Off-Site Gravity Main); and (iv)
payment of the fees described in Sections 4.07-4.09.
First.Amendment to Utility and Infrastructure Agreement-Page 4
(d) The On-Site Wastewater Infrastructure and Off-Site Wastewater
Infrastructure shall be constructed based on the Approved Sewer Study;
provided, however, if Owner does not submit the On-Site Wastewater
Infrastructure construction plans to the City prior to the effective date of the
Revised Design Criteria and Policy, Owner shall redesign the On-Site
Wastewater Infrastructure construction plans in accordance with the Revised
Design Criteria and Policy; and (ii) if Owner does not submit the Off-Site
Wastewater Infrastructure construction plans to the City prior to the effective
date of the Revised Design Criteria and Policy, Owner shall redesign the Off-Site
Wastewater Infrastructure construction plans in accordance with the Revised
Design Criteria and Policy.
6. Section 4.02, "Off-Site Wastewater Infrastructure," is amended in its entirety to
read as follows:
(a) The District shall design and construct approximately 24,000 linear
feet of 12-inch force main commencing at the lift station to be built by the District
near the U.S. 81/287 right-of-way, as shown on Exhibits D1 and D2 to serve the
West Tract(the"Off-Site Force Main"). The schedule for construction of the Off-
Site Force Main shall be determined by the District in its sole discretion. If
construction of the Off-Site Force Main does not commence by December 31, 2019
based on construction plans approved by the City, as evidenced by the signed
coversheet, Owner and the District shall submit revised construction plans in
accordance with the Revised Design Criteria and Policy. The City may modify
the alignment shown on Exhibit D1 and D2 after consulting with Owner and
District and making reasonable efforts to address their concerns regarding the
alignment and to select a cost-effective alignment;provided,however,Owner and
the District agree to make any modifications required by Tarrant County.
(b) The District and Owner acknowledge that, in addition to the Off-Site Force
Main, approximately 22,000 linear feet of 12-inch to 21-inch gravity sewer main
must be constructed from the end of the Off-Site Force Main to the existing 27-inch
sewer main at Wagley Robertson Road (the"Off-Site Gravityain'), as generally
shown on Exhibit D2,in order for the City to provide retail wastewater treatment
services to the West Tract. The District and Owner have no obligation to design
and construct or contribute to the costs associated with design and construction of
the Off-Site Gravity Main; provided, however, the District and Owner
acknowledge that the City will not provide retail wastewater treatment services
within the West Tract until the Off-Site Gravity Main is constructed and accepted
by the City. If Owner and the District elect to design and construct the Off-Site
Gravity Main, they will coordinate with adjacent landowners concerning design
and installation of such main. If construction of the Off-Site Gravity Main does
First Amendment to Utility and Infrastructure Agreement-Page 5
not commence by December 31,2019 based on construction plans approved by the
City, as evidenced by the signed coversheet, Owner and the District shall submit
revised construction plans in accordance with the Revised Design Criteria and
Policy. The City may modify the alignment shown on Exhibit D2 after consulting
with Owner and District and making reasonable efforts to address their concerns
regarding the alignment and to select a cost-effective alignment.
(c) The Off-Site Force Main and the Off-Site Gravity Main are hereafter
referred to,collectively,as the"Off-Site Wastewater Infrastructure," except where
inconsistent with this Section 4.02.
7. Section 4.03, "On-Site Wastewater Infrastructure," is amended to modify the last
sentence of that section to read as follows:
On-site sewage treatment and disposal facilities are prohibited on the Property,
save and except on-site sewage treatment disposal facilities provided to Model
Homes pursuant to Section 4.01(b) above.
8. Section 5.01(a) is amended to add the following as the last sentence of the section:
City, District and Owner acknowledge that the obligation to extend the two-way
frontage road from Northstar Parkway to Ramhorn Hill Road shall be that of
TxDOT,not the City or Owner.
9. Section 5.01(b) is amended in its entirety to read as follows:
Owner and District shall construct the following infrastructure concurrently with
the first phase of the Development, as depicted on Exhibit E: (i) north bound
deceleration lane at U.S. Highway 81/287 NBFR; (ii) north bound right turn
deceleration lane at U.S. Highway 81/287 and Northstar Parkway 4D (four lane
divided); (iii) extension of two-way operation of U.S. Highway 81/287 north
bound frontage road to Northstar Parkway; (iv) the two (2) south lanes of
Northstar Parkway from U.S. 81/287 to Sendera Ranch Boulevard; and (v)
realignment of the intersection with Bates Aston.
10. Section 5.01(c) is amended in its entirety to read as follows:
Owner and District shall construct a north bound on-ramp to U.S. Highway
81/287, as depicted on Exhibit E, before the City issues a building permit for the
858th single-family residence within the Development.
11. Section 5.01(d) is deleted.
First Amendment to Utility and Infrastructure Agreement-Page 6
12. Section 5.01(e) is amended in its entirety to read as follows:
Owner and District shall complete the two(2)northern lanes of Northstar Parkway
from U.S. 81/287 to Sendera Ranch Boulevard before the City issues a building
permit for the 1,000+h single-family residence within the Development.
13. Section 5.01(f) is deleted.
14. Section 5.02,"Dedication," is amended in its entirety to read as follows:
Within thirty(30) days after the District,the City,and/or Tarrant, Denton or Wise
County approve Road Improvements,Owner or District shall dedicate such roads
to Tarrant County, Denton County, or Wise County, as applicable, along with all
appurtenant easements and rights-of-way. If a County does not accept such Road
Improvements,the District shall assume maintenance responsibilities.
15. A new section, 5.05 "Roadways" is hereby added as follows:
The District has the authority to finance and sell bonds to finance all roadways
included within the definition of Infrastructure, including those specifically
required to be built per his Agreement,within the parameters of tax rate and other
financing conditions imposed on the District by the City in this or any other
agreements.
16. Sections 6.02(b), (c) and (d) are amended in their entirety and a new Section
6.02(e) is added, to read as follows.
(b) The City Water Department will not allow On-Site Water
Infrastructure to serve the West Tract(other than the Model Homes) to proceed to
construction until the Off-Site Water Infrastructure is under construction.
Commencement of construction of the On-Site Water Infrastructure to serve 1,285
single-family residential lots or their equivalent in the East Tract and the Model
Homes in the West Tract is not conditioned on commencement of construction of,
or greensheeting, any off-site water infrastructure.
(c) The City Water Department will not allow On-Site Wastewater
Infrastructure to serve the West Tract to proceed to construction until the Off-Site
Wastewater Infrastructure is under construction. Commencement of construction
of On-Site Wastewater Infrastructure to serve the East Tract is not conditioned on
commencement of construction of, or greensheeting, any off-site wastewater
infrastructure.
(d) The City Water Department will not greensheet On-Site Water
Infrastructure within the West Tract,except the infrastructure needed to serve the
First Amendment to Utility and Infrastructure Agreement-Page 7
Model Homes, until the Off-Site Water Infrastructure is greensheeted. The City
Water Department will not greensheet On-Site Wastewater Infrastructure within
the West Tract until the Off-Site Wastewater Infrastructure is greensheeted.
(e) Final plats may be submitted to the City for review while construction
plans for On-Site Water and Wastewater Infrastructure and Off-Site Water and
Wastewater Infrastructure, if any, required to serve land covered by the final plat
are being reviewed and approved. No building permits will be issued for the East
Tract until the portion of the On-Site Water Infrastructure and the On-Site
Wastewater Infrastructure within the final platted area for which building permits
are being issued are greensheeted by the City. No building permits will be issued
for the Model Homes until the portion of the On-Site Water Infrastructure within
the final platted area for which building permits are being issued is greensheeted
by the City. No building permits will be issued for the West Tract, other than for
the Model Homes, until the Off-Site Water Infrastructure and the Off-Site
Wastewater Infrastructure are greensheeted by the City.
17. Exhibits C, D1 and D2 and E attached hereto supersede and replace Exhibits C,
D1, D2 and E attached to the Agreement.
18. Except as specifically amended in this First Amendment, the Agreement shall
remain in full force and effect in accordance with its original terms and conditions.
IN WITNESS WHEREOF,each Party has caused this Agreement to be executed by
its undersigned duly authorized representative in multiple copies on the date or dates
indicated below.
First Amendment to Utility and Infrastructure Agreement-Page 8
ATTEST: CITY OF FORT WORTH
By:_ -/
Mary J. kWerSecretary Jay Chapa, Assistant City Manager
Date: 63 -�Xo -l6
APPROVED AS TO FORM AND
LEGALITY:
M&C-
Assistant City Att rney
STATE OF TEXAS
COUNTY OF TARRANT §
This instrument was acknowledged before me, on the day of
2018, by Jay Chapa, Assistant City Manager of the City of Fort Worth, Texas o ehalf of
said city.
s ►
Qj 14
[S ..P`B,c MARIA S.SANCHEZ Notary Public, State of Texas
* *' My Notary ID#2256490
Expires December 19,2021
Printed Name: lLl iCk -
My Commission Expires:_ 1 4
OFFICIAL RECORD
CITY SECRETARY
FT WORTH,TX
First Amendment to Utility and Infrastructure Agreement-Page 9
NORTHST CH,LLC
By:
—Zve d
Name:
Its:
Date:
STATE OF TEXAS §
COUNTY OF §
This instrument was acknowledged before me, on the N day of
Aj± .� A- , 2018, by G 1\ mac.r�,a�.� of Northstar Ranch,
LLC, a Texas limited liability company, on behalf of said limited liability company.
Notary Public, State of Texas
[SEAL]
vTINA MICHELLE LEWIS Printed Name: n0. M• l� �s
Notary Public, State of Texas
Comm, Expires 06-16-2021
Notary ID 125179689 My Commission Expires:_ Ido tea-\
Fust Amendment to Utility and Infrastructure Agreement-Page 10
FAR NORTH FORT WORTH MUNICIPAL
UTILITY DISTRICT NO. 1 OF TARRANT AND
WISE COUNTIES
1
B l�
y�
r sident, Board of Directors
Date: ' I
STATE OF TEXAS §
COUNTY OF TARRANT §
This instrument was acknowledged before me, on the 15 day of A&&A&&6j
2018, by'56,aea^ Cra,cke-At"President, Board of Directors of Far North Fort Worth
Municipal Utility District No. 1 of Tarrant and Wise Counties, on behalf of said district.
M o t---
Notary Public,State of Texas
[SEAL]
TINA MICHELLE LEWIS
�e', Printed Name: ] Ana
,Notary Public, State of Texas
Comm, Expires 06-16-2021
Notarv {D 125179689
My Commission Expires: 611 tp La,oa N
Fust Amendment to Utility and Infrastructure Agreement-Page 11
Exhibit C
Off-Site Water Infrastructure
First Amendment to Utility and Infrastructure Agreement-Page 12
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Exhibit H
Map of East Tract and West Tract
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MUNICIPAL UTILITY DISTRICT NO. 1 GRAPHIC SCALE IN FEET
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City of Fort Worth, Texas
Mayor and Council Communication
COUNCIL ACTION: Approved on 8/7/2018
DATE: Tuesday, August 7, 2018 REFERENCE NO.: L-16133
LOG NAME: 06065030 FAR NORTH FORT WORTH MUD #1 AGREEMENT AMENDMENTS
SUBJECT:
Authorize Execution of First Amendment to Utility and Infrastructure Agreement and First Amendment to
Development Agreement for the Far North Fort Worth Municipal Utility District No. 1 of Tarrant and Wise
Counties (ETJ Adjacent to COUNCIL DISTRICT 7)
RECOMMENDATION:
It is recommended that the City Council authorize the City Manager or a designee to execute the following
amendments to agreements for the Northstar development in the Far North Fort Worth Municipal Utility
District No. 1 of Tarrant and Wise Counties and to take any actions to carry out such agreements:
1. First Amendment to Development Agreement between the City of Fort Worth, Texas and Northstar
Ranch, LLC for the Far North Fort Worth Municipal Utility District No. 1 of Tarrant and Wise Counties; and
2. First Amendment to Utility Agreement.
DISCUSSION:
Far North Fort Worth Municipal Utility District No. 1 of Tarrant and Wise Counties (the District)
encompasses approximately 733 acres of land in Fort Worth's extraterritorial jurisdiction in Tarrant,
Denton and Wise counties (the Property). The Property is located east of U.S. Highway 81/287 and west
of Sendera Ranch Boulevard. The City will be the retail water and wastewater service provider to the
Property at outside city limit rates, subject to construction of off-site and on-site water and wastewater
infrastructure by the District and Northstar Ranch, LLC, owner and developer of the Property.
On December 15, 2015, the City Council adopted Resolution No. 4554-12-2015 consenting to creation of
the District and authorizing execution of Agreement Concerning Creation and Operation of Far North Fort
Worth Municipal Utility District No. 1 Mayor and Council Communication (M&C L-15844). The District was
created by order of the Texas Commission on Environmental Quality dated January 20, 2017 and was
granted road powers by the Texas Legislature by House Bill 4331 approved on May 20, 2017.
On August 15, 2017, the City Council authorized execution of a Utility and Infrastructure Agreement,
Development Agreement, and First Amendment to Agreement Concerning Creation and Operation of Far
North Fort Worth Municipal Utility District No. 1 (M&C L-16059). The Utility and Infrastructure Agreement
provides for design and construction of certain on-site and off-site water and wastewater infrastructure to
serve the Property.
Northstar Ranch, LLC and the District have asked the City to amend the Utility and Infrastructure
Agreement and the Development Agreement with respect to the phasing of construction of water and
wastewater infrastructure and roads to serve the Property. The amendment to the Utility and
Infrastructure Agreement reflects that the City will provide retail water and wastewater service to the
Logname: 06065030 FAR NORTH FORT WORTH MUD 91 AGREEMENT AMENDMENTS Page 1 of 2
eastern portion of the Property after Northstar Ranch, LLC and the District construct connections to
existing City infrastructure in the Sendera Ranch development. The City will provide retail water and
wastewater service to the western portion of the Property as off-site water and wastewater infrastructure is
constructed by Northstar Ranch, LLC, the District or other developers. The amendment will allow
Northstar Ranch, LLC to construct up to 20 model homes on the western portion of the Property, to be
served by City water service and an on-site sewer system. Sale of the model homes to end-users is
prohibited until City wastewater service is available. The amendment to the Utility and Infrastructure
Agreement also modifies the road construction requirements by Northstar Ranch, LLC and the District to
reflect the phasing of the development described above. The amendment to the Development Agreement
is consistent with the amendments to the Utility and Infrastructure Agreement.
The Property is located in FUTURE COUNCIL DISTRICT 7.
FISCAL INFORMATION / CERTIFICATION:
The Director of Finance certifies that approval of this Agreement will have no immediate material effect on
City funds. Any effect on expenditures and revenues will be budgeted in future fiscal years.
FUND IDENTIFIERS (FIDs):
TO
Fund Department Accoun?—P—roject Program ctivity BudgetReference # moun
ID ID I Year T (Chartfield 2)
FROM
IFundl Department [Accountl Project Program ctivity Budget Reference # moun
ID ID Year (Chartfield 2)
CERTIFICATIONS:
Submitted for City Manager's Office by: Jay Chapa (6122)
Originating Department Head: Randle Harwood (6101)
Additional Information Contact: Mary Elliott (7844)
Logname: 06065030 FAR NORTH FORT WORTH MUD 91 AGREEMENT AMENDMENTS Page 2 of 2
�—'11013
CERTIFICATE OF INTERESTED PARTIES FORM 1295
101`1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 it there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2018-366723
northstar developmentLLC
Fort Worth,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 06/11/2018
being filed.
Northstar developmentLLC Date Acknowl ed:
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.
none provided
land
4 Nature of interest
Name of Interested Parry City,State,Country(place of business) (check applicable)
Controlling Intermediary
Kim,Gill fort worth,TX United States X
5 Check only if there is NO Interested Party. rl
6 UNSWORN DECLARATION
My name is &I , and my date of birth is /2--/49--s7
My address is !W& cj *jAv&` C i"" .&M-n M&I---2M--. 7 lY
(street) (CRY) (state) (zip code) (oounhy)
I declare under penalty of perjury that the for, o'ng is true and correct.
Executed in County, State of M,Mt on the—LLdy of,,, �,20 Lf .
(month) (year)
ef::;,W
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.5523