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HomeMy WebLinkAboutContract 49291-CO3 (-FV Change Order Approval St-COApp03 Page 2 of 3 Cit Of Fort Worth CITY SECRETARY ORT WDRTH(,) . CoNTRACTNo._ a.G 1-03 Change Order Request Approval (Change Order Breakdown Available in Links) For Change Order Submittal No.: 03 Change Order No.: St-COApp03 Date Started: 2018-08-20 City Sec. No.: 49291 Date Due: 2018-08-31 Project Name: CO2014 - Old Decatur Rd Reconstruction, Phase 2 CO2014 DOE Numbers: Project Numbers: CPN: CO2014 Project Reconstruction of Old Decatur Road from IH-820 to Angle Avenue. Description: Project Manager: JT Auldridge City Inspector: Weyman Oden Contractor: Jackson Construction, Ltd. COUNCIL ACTION (If Required): M&C Log Name: 20OLD DECATUR ROAD PHASE 2 CO2014 - CO3 M&C Number: C-28772 M&C Date: 2018-08-07 COST AND DAYS SUMMARY: Requested Department: Cost($) Fund Account Center: Days: TPW $ 31,924.58 34014-0200431-5740010--CO2014-, 16 N n '"' $ 31,924.58 16 9 rJ Total Cost: Total Requested Days: -' < M 0 Approval Status: Approved: Yes Y\r Comments: User: Carmen Estep Date: 2018-08-21 7:32 AM OFFICIAL.k CITY SECRETARY FT.WORT49 TX https:Hprojectpoint.buzzsaw.com/_bz_web/Forms/FormPrint.aspx?Siteld=51500&ProcessI... 8/22/2018 C: W Change Order Approval St-COApp03 Page 3 of 3 Please review, approve and submit. https://proj ectpoint.buzzsaw.com/_bz_web/Forms/FormPrint.aspx?Siteld=51500&ProcessI... 8/22/2018 FORT WORTH® City of Fort Worth r Change Order Request Breakdown Project Namel Old Decatur Rd Reconstruction, Ph 2 Limits from IH 820 to N.of Angle Ave. City Sec# 1 49291 Client Project#(s)l 3180 Contractorl Jackson Construction, Ltd PM Lissette Acevedo Inspector Weyman Oden Change Order Submittal# 0 Date 5/4/2018 Dept. TPW WATER SEWER Contract Time Totals CD Original Contract Amount $4,298,923.00 $12,705.00 $8,000.00 $4,319,628.00 300 Extras to Date $85,721.75 $42,092.99 $0.00 $127,814.74 45 Credits to Date $0.00 $0.00 $0.00 Pending Change Orders(in M&C Process) $0.00 $0.00 $0.00 Contract Cost to Date $4,384,644.75 $54,797.99 $8,000.00 $4,447,442.74 345 Amount of Proposed Change Order $31,924.58 $0.00 $0.00 $31,924.58 16 Revised Contract Amount $4,416,569.33 $54,797.99 $8,000.00 $4,479,367.32 361 Original Funds Available for Change Orders $0.00 Remaining Funds Available for this CO $0.00 $0.00 $0.00 Additional Funding(if necessary) $31,924.58 $31,924.58 CHANGE ORDERS to DATE(INCLUDING THIS ONE)AS%OF ORIGINAL CONTRACT 3.70% MAX ALLOWABLE CONTRACT AMOUNT(ORIGINAL CONTRACT COST+25%) $5,399,535.00 ;gig s -JUSTIFICATION(REASONS)FOR CHANGE ORDER This change order covers RFI's 13A, 15, 16,and 17. RFI 13A modifies the limits of the concrete riprap,bridge rail,approach slab,sidewalks and concrete paving at the bridge. An apparent oversight in the issued for bid construction plans did not account for the ultimate pavement section. Additional scope of work and quantities are added to the project for concrete pavement,sidewalk and riprap resulting in additional time of 5 days. RFI 15 modifies the limits of a driveway. The existing driveway includes a detection system for the gated property,and it was determined that reconstruction of the driveway was unnecessary. Reduced scope of work and quantities are removed from the project for concrete pavement. RFI 16 modifies the pavement subgrade material to remove payment for pulverization of existing base and add flexible base hauled in from offsite. The existing onsite base proved to be unsatisfatory for the pulverization construction method;therefore,a higher quality flexible base is required. Additional scope of work and quantities are added to the project for flexible base resulting in additional time of 8 days. RFI 17 modifies the low profile concrete barrier installation as a safety precaution during the construction activities planned between IH-820 and the bridge. The construction phasing was modified from the issued for bid plans at the request of the contractor;therefore,the additional quantity was not included in the original bid. Additional scope of work and quantities are added to the project for low profile concrete barrier resulting in additional time of 3 days. In addition,reduced scope of work and quantities are removed from the project for concrete paving and sidewalk due to errors in the bid quantities. F<>x_ T�T}+ City of Fort Worth Change Order Additions Project Name Old Decatur Rd Reconstruction,Ph 2 Limits from IH 820 to N.of Angle Ave. City Sec# 49291 Client Project# 3180 Contractor Jackson Construction,Ltd PM Lisette Acevedo Inspector Weyman Oden Change Order Submittal# 0 Date 5/4/2016 AUDI MONS HEM DESCRIPTION DEPT Qty nit nit ost Total 6"FLEXIBLE bAbE,TY A,GR-1 W)I H LIUUIU EMULSION 777-- 71 39.333191ou SY s=--777= iii-T--- 7.010 LAB RIP RAP TPW 56.00000000 Y APPROACH LAB REINFORCING STEEL TPW 00000000 LS 2,465.06 13.05 7 BARRIER FREE RAMP,TYPE P-1 TPW 1.00000000 EA 5 . II-12 9 9.0 05 L W PROFILE CONCRETE BARRIER TPW 700.00000000 LF 22.0 TPW $96,585.33 WATER $0.00 SEWER $0.00 Sub Total Additions Change Order Additions Page 1 of 1 FoHr�WOR I Ft City of Fort Worth Change Order Deletions Project Name Old Decatur Rd Reconstruction,Ph 2 Limits from IH 820 to N.of Angle Ave. City Sec# 49291 Client Project# 3180 Contractor Jackson Construction,Ltd PM Lissette Acevedo Inspector Weyman Oden Change Order Submittal# 0 Date 514/2018 DELETIONS tY Unit Unit Cost Total --7-7—3213.0105 10 CONIC PV9r— I'W 159.00000000 7— 5.75 M--TF—3213,0301 6'WIDE 4"GONG SIDEWALK III-1 3213.0507 BARRIER FREE RAMP,TYPE P-2 TPW 1. 000 EA 25. 0 II-1F PULVERIZE&CSS EX 8"TEMP RD(5L8 /SY) TPW 5,795. 0000 SY 7.1 APPROACH SLAB TPW 20.0 0 Y 25.00 ,5 . TPW $64,660.75 WATER $0.00 SEWER $0.00 Sub Total Deletions64,660.75 Change Order Deletions Page 1 of 1 M/SBE Breakdown for this Change Order M/SBE Sub Type of Service Amount for this CO NONE Total $0.00 Previous Change Orders CO# DATE AMOUNT Total $0.00 Approved: Comments: User: JT Auldridge, Project Manager, TPW Signa re Date: ��ad/I I Approved: Comments: ' User: Lissette Acevedo, �LLG Program Manager, TPW Signature Date: f Approved: Comments: User: Ricardo Matute, Sr. Capital Projects Officer, TPW Signature Date: Approved: Comments: / User: Doug Wiersig, c-✓ Director, TPW Signature Date: Approved: Comments: User: Doug Black, Sr. Assistant City Attorney, LEGAL Signature Date: Approved: f Comments: User: Susan Alanis, Assistant City Manager, CMO e <- Date: pF p FR � T, Approved: Comments: ; User: Mary Kayser, City Secretary, CSO Signature Date: AS M&C: 7 a 1295: Cil t -t�- 419 OFFICIAL RECORD CITY SECRETARY FT.WORTH,TX CPN: CO2014 Change Order #3 Contract Compliance Manager: By signing, I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. c �F c Lissette Acevedo, PE, PTOE, PMP° Program Manager REQUEST FOR INFORMATION #13A Freese and Nichols (4.141 PROJECT: Old Decatur Road — IH 820 to Angle Avenue PROJECT NUMBER: OWNER: City of Fort Worth 02014 CONTRACTOR: Jackson Construction ENGINEER: Freese & Nichols, Inc. REFERENCE DATA: Specification Section No. Page No. 24 of 48 and S1.00 Paragraph No. Drawing No. Detail description: Bridge Layout and Sidewalk Transition ENGINEER'S REQUESTS: Information Interpretation X Clarification for the items described below or in the attached material referenced below: Jackson Construction requested that the City of Fort Worth review the proposed location of the MBGF, bridge rails, approach slab, concrete riprap, and sidewalks to be in accordance with City of Fort Worth and TxDOT standards. FREESE AND NICHOLS' PROPOSED SOLUTION: Freese and Nichols recommends that the contractor modify the limits of the concrete riprap, bridge rail, approach slab, sidewalks and concrete paving per the attached PDF. The estimated costs associated with these proiect modifications are shown on the attached PDF. REQUESTED BY: Todd Buckingham DATE: 4/27/2018 ENGINEER'S RESPONSE: Information Interpretation X Clarification for the items described above or in the attached material referenced: CFW agrees with the Freese and Nichols' proposed solution. RESPONSE BY: J.T. Auldridge DATE: 5/1/2018 TA4.0 CONSTRUCTION\RFI\RFI-13-X\13A\Request For Information-13A-ODR-02014.doc nJo �> 0 L sd °�o� I O oQ W F J +Lq Z K 6ww3 I LnW¢ -4 J It O QQ� aU3 "W J� 2 H aoOCC=7 Qzw O2 F-D Q �z Z ¢ w W a U Ln Ln O(D Z ¢ m W uw L w^Q W 0 pF mQ Ua� �T Z m 0 ri- F�aLL� OWa 1� O g JD +r�iammOLzn<_?cl J oF� Ln OQ }}2 wzZ wUm Q J W x Q M F Z W J 3 a'Z g O U m Of O 3 OQ ��' FLLZQw W !6u— (n +� LA in0wm~.-..-.H •-NNW to W O fa F LLj I J Q unO(D ' 00'Z9 x owa Z d J l ca L9 JF J o 00 S ry?H cv' o w v cn Z —z- 'o, L^ N 0 J voi< W� ZZ�Q o mF^mQ QODW m�,Fc�a�� 0 aEoo +nammWwQ w Z N Z J Z 2;; _j- U �� W�QZ QLLO02JU1m OH �JZ 0U V7¢ (7HJE IFnOWM N.-�F a. Zen OUW m� dC7 o_2aK auu 0se 0 a: Mm I a3 UwZ~ wm a>¢ "Z I iz LU OO FLU W K�~2 <. 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H m 1n v Q a . n1 O H H m C 0 E V N m w 7 Y O ) N U1 Q N v ON ca M d ~03 N ri c w n u E E v o x E s c m m w S O-~ > l7 u w 01 ` � � O -ON LT o.m C r w w E o v 2 � m = 4 0 0 v1 c gH m iD m m �- oouo w000L S o ¢ .. m o o O o 'x o 0 0 0 :0 'm m a fh,l Owl d eM-I LL eM-1 trf M a m n M m D1 ¢ M m M M M ¢ N m m o C � � w C J z ID 1p O ti u ID F N C a c — ra REQUEST FOR INFORMATION #15 Freese and Nichols (4.141 PROJECT: Old Decatur Road — IH 820 to Angle Avenue PROJECT NUMBER: OWNER: City of Fort Worth 02014 CONTRACTOR: Jackson Construction (JCL) ENGINEER: Freese & Nichols, Inc. (FNI) REFERENCE DATA: Specification Section No. Page No. 24 or 48 Paragraph No. Drawing No. Detail description: Driveway Profile/Tie-In at Providence Apartments (STA. 17+50) ENGINEER'S REQUESTS: Information Interpretation X Clarification for the items described below or in the attached material referenced below: JCL notified the City of Fort Worth of the loop detector and crack in the existing driveway to Providence Apartments at STA. 17+50. JCL proposed the tie-in of the proposed driveway prior to the loop detector. �7 i llllll0 ° - s FREESE AND NICHOLS' PROPOSED SOLUTION: FNI recommends to sawcut and remove the existing driveway to the point of the existing crack and the construction of a street header using the following standard detail. It is recommended that the sawcut be_a minimum of 18"from the existing saw cut (approx. 1.5" in depth)for the loop detectors. Deductions to the 10" concrete pavement quantity and the 8"flexible base quantity is recommended. EXPANSION JOINT FILLER 3" 8" EXISTING CONCRETE, . Q ~- PAVEMENT • 4 PAVEMENT eBARS EQUAL SIZE OF BARS `r v 4 SPECIFIED IN PAVEMENT REINFORCEMENT 2" PAVEMENT BAR 16" REQUESTED BY: Todd Buckingham DATE: 5/2/2018 TA4.0 CONSTRUCTIOMRFRRFI-151Request For Information-15-ODR-02014.doc ENGINEER'S RESPONSE: Information Interpretation X Clarification for the items described above or in the attached material referenced: CFW recommends that the existing concrete driveway paving remain,a street header be constructed(no dowel into the existing paving), and the existing cracks within the driveway be routed and sealed. RESPONSE BY: J.T. Auldridge DATE: 5/3/2018 ENGINEER'S RESPONSE: Information Interpretation X Clarification FNI was notified bV JCL on 5/3/2018 that the existing concrete paving was sawcut and removed 24"from the existing loop detectors as of 4/27/2018. FNI recommends that the contractor not dowel into the existing paving and construct a concrete street header per the above standard detail. RESPONSE BY: Todd Buckingham DATE: 5/7/2018 TA4.0 CONSTRUCTION\RFI\RFI-15\Request For Information-15-ODR-02014.doc rM REQUEST FOR INFORMATION#16 Freese and Nichols (4.141 PROJECT: Old Decatur Road — IH 820 to Angle Avenue PROJECT NUMBER: OWNER: City of Fort Worth 02014 CONTRACTOR: Jackson Construction (JCL) ENGINEER: Freese & Nichols, Inc. (FNI) REFERENCE DATA: Specification Section No. Page No. Paragraph No. Drawing No. Detail description: Flexible Base Quantity Clarification ENGINEER'S REQUESTS: Information Interpretation X Clarification for the items described below or in the attached material referenced below: JCL requested that the City of Fort Worth review the flexible base quantity provided in the project bid proposal. Based on a preliminary review, JCL believes that it will need to be increased to account for the high-early strength concrete area. FREESE AND NICHOLS' PROPOSED SOLUTION: Due to inaccuracy in the bid proposal quantities FNI recommends increasing the 8" flexible base quantity by 3,135 SY. This revised quantity will account for the concrete paving area and the 1' extension outside of the paving area as shown in the typical section. Additional project quantity revisions are recommended based on duplicate paving, subgrade, and sidewalk quantities at the proposed bridge. REQUESTED BY: Todd Buckingham DATE: 4/27/2018 ENGINEER'S RESPONSE: Information Interpretation X Clarification for the items described above or in the attached material referenced: CFW agrees with the Freese and Nichols' proposed solution. RESPONSE BY: J.T. Auldridge DATE: 5/1/2018 TA4.0 CONSTRUCTION\RFI\RFI-16\Request For Information-16-ODR-02014.doc REQUEST FOR INFORMATION #17 Freese and Nichols (4.141 PROJECT: Old Decatur Road — IH 820 to Angle Avenue PROJECT NUMBER: OWNER: City of Fort Worth 02014 CONTRACTOR: Jackson Construction (JCL) ENGINEER: Freese & Nichols, Inc. (FNI) REFERENCE DATA: Specification Section No. Page No. Paragraph No. Drawing No. Detail description: Quantity Clarification —Concrete Barriers Sidewalk and Pavin ENGINEER'S REQUESTS: Information Interpretation X Clarification for the items described below or in the attached material referenced below: JCL requested that the CFW review the low profile concrete barrier quantity based on the approved construction phasing and the CFW review the limits of the concrete sidewalks between Phase 1 (roundabout) and Phase 2 (arterial) of Old Decatur Road. FREESE AND NICHOLS' PROPOSED SOLUTION: Based on the modified construction phasing from the issued for construction plans, FNI recommends adding 700 LF of low profile concrete barriers to the project. This addition will be necessary for the safety of the traveling public during the construction activities planned between IH-820 and the temporary CMC driveway. FNI recommends the addition of 780 SF (covered by quantity errors described in the following sentence) four-inch concrete sidewalk on either side of the street between Phase 1 (roundabout) and Phase 2 (arterial)of Old Decatur Road that was omitted from the issued for bid plans. Based on errors in the bid quantities, it is necessary to deduct 158 SY of ten-inch concrete paving and 900 SY of four-inch concrete sidewalk. REQUESTED BY: Todd Buckingham DATE: 5/7/2018 ENGINEER'S RESPONSE: Information Interpretation X Clarification for the items described above or in the attached material referenced: CFW agrees with the Freese and Nichols' proposed solution. RESPONSE BY: J.T. Auldridge DATE: 5/7/2018 TA4.0 CONSTRUCTIONWhRFI-17TRequest For Information-17-ODR-02014.doc City of Fort Worth Departmental Request for Waiver Of MBE/SBE Subcontracting/Supplier Goal Transportation&Public Works,Capital Delivery $73,069.08 5/7/18 DEPARTMENT NAME: ESTIMATED COST / PROPOSAL DATE Old Decatur Road Reconstruction-Phase 2 CO2014 NAME OF PROJECT/BID: DOE/PROJECT NO. JT Auldridge Dige 201805ly 8y 7T5811`-05 7252 5/8/18 Dale:sol eos.oe mse i i-osoo SIGNATURE OF /PROJECT MANAGER EXTENSION DATE NIGP CODE Prior to advertisement, the contracting/managing department shall determine whether the bid/proposal is one which MBE/SBE requirements should not be applied. MBE/SBE requirements may be waived upon written approval of the M/WBE Manager. If one of the conditions listed below exists, the contracting/managing department shall notify the Manager via this form, stating the specific reason(s)for requesting a waiver. If the contracting/managing department and the Manager are in conflict over the granting of a waiver, either may appeal to the City Manager, or designee, and his/her decision is final. Please Check Applicable Reason: DA. MWBE Office: A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Department and approved by the MWBE Office, in accordance with the M/WBE or BDE Ordinance, because the public or administrative emergency exists which requires the goods or services to be provided with unusual immediacy; or OB. MWBE Office: A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Department and approved by the MWBE Office, in accordance with the M/WBE or BDE Ordinance, because the purchase of goods or services from source(s) where subcontracting or supplier opportunities are negligible; or QC. MWBE Office: A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Department and approved by the MWBE Office, in accordance with the M/WBE or BDE Ordinance, because the application of the provisions of this ordinance will impose an economic risk on the City or unduly delay acquisition of the goods or services; or OD. MWBE Office: A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Department and approved by the MWBE Office, in accordance with the M/WBE or BDE Ordinance, because the MWBE Waiver is solicited based on the sole source information provided to the MWBE Office by the managing department's project manager. Justify Commodity or Service Waiver Request: The purchase for additional work that is self-performed by the prime contractor and the non-M/WBE subcontractors identified in the original utilization plan. Please use additional sheets, if needed M WBE OFFICE USE ONLY: ✓ Patty Jean Wilson D'9"a'"signed by Patty Jean Wilson 5-10-18 Date:2016.05.10 12:26:14-05'00' Approved Signature of M/WBE Authorized Personnel Date Not Approved Signature of M/WBE Authorized Personnel Date Rev.2-20-13 8/22/2018 M&C-Council Agenda City of Fort Worth, Texas Mayor and Council Communication COUNCIL ACTION: Approved on 8/7/2018 DATE: Tuesday, August 7, 2018 REFERENCE NO.: **C-28772 LOG NAME: 20OLD DECATUR ROAD PHASE 2 CHANGE ORDER 3 SUBJECT: Authorize Execution of Change Order No. 3 to City Secretary Contract No. 49291 with Jackson Construction, Ltd, in the Amount of$31,924.58 and an Additional 16 Calendar Days to the Original Contract Time for Old Decatur Road Reconstruction Project (Phase 2) (COUNCIL DISTRICT 2) RECOMMENDATION: It is recommended that the City Council authorize the execution of Change Order No. 3 to City Secretary Contract No. 49291 with Jackson Construction, Ltd, in the amount of$31,924.58 and an additional 16 calendar days for the Old Decatur Road Reconstruction Project (Phase 2), thereby increasing the contract to an amount up to $4,479,367.32 (City Project No. CO2014) and contract time to 361 calendar days, subject to incentives earned. DISCUSSION: On May 16, 2017, Old Decatur Road from IH-820 to Angle Avenue (Phase 2) was awarded to Jackson Construction, Ltd in the amount up to $4,319,628.00 to construct one new travel lane in each direction on Old Decatur Road from Angle Avenue to Loop 820, with a continuous left-turn lane, Mayor and Council Communication (M&C C-28244). The following is a summary of Change Orders to date: Change Change Date Revised Justification Order Order Contract No. Amount (M&C) Amount 1 $67,417.65 10/26/2017 $4,387,045.65 Contractually-permitted pricing (Administrative) adjustments 2 $60,397.09 4/3/2018 $4,447,442.74 Reconcile quantities associated G-19261 with changes in site conditions 3 $31,924.58 Pending $4,479,367.32 Substitution for improved road subgrade material Change Order No. 3 in the amount of$31,924.58 includes substitution of an improved road subgrade material associated with differing site conditions and adds 16 calendar days to the contract time. The remaining funds appropriated to this project (34014) are sufficient to cover this change order in the amount of$31,924.58. M/WBE Office —A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Department and approved by the M/WBE Office, in accordance with the M/WBE or BDE Ordinance, because the purchase of goods or services from source(s)where subcontracting or supplier opportunities are negligible. The Project is located in COUNCIL DISTRICT 2. FISCAL INFORMATION /CERTIFICATION: http://apps.cfwnet.org/ecouncii/printmc.asp?id=26042&print=true&DocType=Preview 1/2 8/22/2018 M&C-Council Agenda The Director of Finance certifies that upon approval of the above recommendations and adoption of the attached appropriation ordinance, funds will be available in the current capital budget as appropriated, of the 2014 Bond Program. Prior to an expenditure being incurred, the participating department has the responsibility to validate the availability of funds. FUND IDENTIFIERS (FIDs): TO Fund'Department ccount; Project ProgramActivity Budget Reference # Amount FROM _ Fundl Department ccount Project ProgramlActivity Budget Reference # Amount ID ID i Year (Chartfield 2) i CERTIFICATIONS: Submitted for City Manager's Office by_ Susan Alanis (8180) Originating Department Head: Douglas Wiersig (7801) Additional Information Contact: Lisette Acevedo (2732) ATTACHMENTS 1. C.O. 3 Old Decatur Road.pdf (CFW Internal) 2. FID Jackson.pdf (CFW Internal) 3. Form 1295 Jackson.pdf (Public) 4. Map Old Decatur Road .pdf (Public) 5. MBE Waiver Request Jackson.pdf (CFW Internal) http://apps.cfwnet.org/ecouncil/printmc.asp?id=26042&print=true&DocType=Preview 212 C- CERTIFICATE OF INTERESTED PARTIES FORM 1295 10f1 Complete Nos.l-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1,2,3,5, and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2018-350337 Jackson Construction, Ltd 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 05/08/2018 being filed. City of Fort Worth 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. 02014 Old Decatur Rd IH820 South to Angle Ave Roundabout Nature of interest 4 Name of Interested Party City,State,Country(place of business) (check applicable) Controlling I Intermediary Jackson,Troy FORT WORTH,TX United States X Jackson, Larry FORT WORTH, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is Carmen Esteg and my date of birth is 12/03/1965 My address is 5117 Cnn VallaIc T)rivr Fnrt Worth TX , 76119 USA (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Tarrant County, State of T—, —on the Rth day of m.), 20-L8-_. (month) (year) Signature of authorized ao-ntl6f 65fitracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.5523