HomeMy WebLinkAboutContract 54437-CA1 CSC No.54437-CAl
CITY OF FORT WORTH
ASSIGNMENT
For value, received Anthony L. Brown ("Assignor"), hereby assigns to Camelot Roofing,
LLC ("Assignee"), all of its right,title and interest in and to any and all sums of money now due
or to become due from the City of Fort Worth to Assignor under PSK 14273/CSCO 54437 (the
"Contracts") and Assignee agrees to assume and perform all duties and obligations required by
Assignor under the terms of the Contracts.
This Assignment constitutes the entire agreement between Assignor and Assignee with
respect to the subject matter hereof.No modification of any provision of this Assignment shall be
effective unless in writing and signed by Assignor and Assignee. This Assignment shall inure to
the benefit of and be binding upon Assignor and Assignee and their respective successors and
assigns. This Assignment shall be governed by the terms of the original Contracts between
Assignor and various other entities and the City of Fort Worth and the laws of the State of Texas,
without application of principles of conflicts of law.
This Assignment may be executed in one or more counterparts each of which shall be
deemed an original but all of which together shall constitute one and the same instrument.
Signed signature pages may be transmitted by facsimile or e-mail, and any such signature shall
have the same legal effect as an original.
Dated the day of Vl S 1 2022.
Anthony L. Brown
(Assignor)
By:
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Title: Chief Operating Officer
Camelot Roofing, LLC
(Assignee)
By:
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Title: Chief Financial Officer
OFFICIAL RECORD
CITY SECRETARY
T. WORTH, TX
Assignment Paje i of4
NOTARY ACKNOWLEDGEMENT
On the day of 2022, personally appeared
Kr ,��a , who acknowledged o me that (s)he is the Chief Operating Officer of
Anthony L. Brown ("Assignor"), and that (s)he executed this document for the purposes and
consideration contained herein.
Anthony L. B/ own
By:
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Title: . Chief Operating Officer
SUBSCRIBED TO before me on this //t* day of , 2022.
"Pill, Linda Ann Baty Not Public in and for the State of �� C
My Commission Expires '
OW712025 My commission Expires:
ID No.133127212
NOTARY ACKNOWLEDGEMENT
On the ` day of (y � 2022, personally appeared
Owho acknowle ged to me that (s)he is the Chief Financial Officer of
Camel t Roofing,LL ("Assignee"), and that (s)he executed this document for the purposes and
consideration contained herein.
Camelot ofing,
B_
Print: ��
Title: Chief Financial Officer -
SUBSCRIBED TO before me on this ;fie day of , 2022_
Unda Ann Bahr
0 2 Commission moires Notary Public in and for the St e of `T-� &S
C74 ID No.133127212 My commission Expires:
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
CONSENT TO ASSIGNMENT
The City of Fort Worth consents to the assignment of Anthony L. Brown ("Assignor") to
Camelot Roofmg, LLC ("Assignee"), of all its rights, title, and obligation owing and all funds
due or to become due to Assignor under PSK 14273/CSCO 54437 as long as all terms required
of Assignor in said contracts are met by Assignee.
CITY OF FORT WORTH
Reginald Zeno(Aug 29,202210:39 CDT)
Aug 29, 2022
Reginald Zeno—Interim Assistant City Manager Date
Aug 18, 2022
Anthony Rousseau, Assistant Director—FMS Date
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Jannette S.Goodall(Aug29,2022 11:52 CDT ��ddp44 '
Jannette Goodall, City Secretary Date
APPROVED AS TO FORM AND LEGALITY:
John B. Strong,Assistant City Attorney
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.
Amy Connoll Aug 18,202 09:35 CDT) Aug 18, 2022
Employee Signature/Date
Assistant Director,Neighborhood Services OFFICIAL RECORD
Title CITY SECRETARY
FT. WORTH, T
Assignment Page 3 of
Form Request for Taxpayer Give Form to the
(Rev.October2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service 0-Go to www_Prs.gov/F6rmW9 for instructions and the latest information.
1 Name s shown on your in me tax return}.Name is required on this line;do not leave this line blank.
2VBusk e/disre 5rdedenti name,if d rent from above
m 3 Check appropriate box for federal tax assific ' n of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
certain entities,not individuals;see
following seven boxes. instructions on page 3)-
Q
o ElindividuaYsole proprietor or ❑ C Corporation ElS Corporation ❑ Partnership ElTrusUestate
N single-member LLC Exempt payee code Cif any)
an
Limited lobility company.Enter the tax classification(C=C corporation,S=S corporation,P-Partnership}►
o Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
_ LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code(Ff any)
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
44) ❑ Other(see instructions)► tanW fo eccoun sn s nnu wau aria rn�u.st
5 Address number sire and apt.or su'a no.)See instructions. Requester,s name and address(optwal)
lVes
u}
6 Ci ,s ,and ZIP code
7 List count numbers)here(optional)
Taxpayer Identification Number
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number
backup withholding.For individuals,this is generally your social security number(SSN)_However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part 1,later.For other
entities,it is your employer identification number(EIN).If you do not,have a number,see Now to get a
TIN,later. or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. 9*
al 0
Certification
Under penalties of perjury,l 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)l am exempt irom 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 l 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 a not required to gn the certification,but you must provide your correct TIN.See the instructions for Part 11,later.
Stgt1 Signature of s�
Here U.S.person► Date► �fse
General Instrue Ions Form 1099-DIV(dividends,including m stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise .Form 1099-MISC(various types of income,prizes,awards,or gross
noted. proceeds)
Future developments.For the latest information about developments a Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www-irs_govlFormW9. a Form 1099-S(proceeds from real estate transactions)
Purpose of Form m Form 1099-K(merchant card and third party netwnrktransactions)
An individual or entity(Form W-9 requester)who is required to file an .Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 109E-T(tuition)
identification number(TIN)which may be your social security number o Foy 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption o Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
(EIN),to report on an information 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 information return.Fxamples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
Form 1099--INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Fom7 W-9(Rev.10-2018)
Filing#:804439288 Document#:1118341240004 Filed On 2/7/2022 received by Upload
CERTIFICATE OF FORMATION
OF
CAMELOT ROOFING, LLC
(A Limited Liability Company)
ARTICLE ONE
The name of the filing entity being formed is Camelot Roofing, LLC (the
"Company").
ARTICLE TWO
The filing entity being formed is a limited liability company.
ARTICLE THREE
The purpose for which the Company is formed is any lawful purpose for
which a limited liability company may be formed under the Texas Business
Organizations Code.
ARTICLE FOUR
The street address of the Company's initial Registered Office, and the name
of its initial Registered Agent at that office, are as follows:
Anthony Brown
8309 Watercress Drive
Fort Worth, Texas 76135
CAMELOT ROOFING,LLC
CERTIFICATE OF FORMATION,PAGE 1
ARTICLE FIVE
The Company will not have Managers. The names and addresses of the
initial Members are:
Anthony Brown
8309 Watercress Drive
Fort Worth, Texas 76135
Tonie Brown
8309 Watercress Drive
Fort Worth, Texas 76135
ARTICLE SIX
The initial mailing address of the company is 8309 Watercress Drive, Fort
Worth, Texas 76135
ARTICLE SEVEN
The undersigned Organizer hereby disclaims any past or future interests in or
control of Camelot Roofing, LLC and resigns as the Organizer effective upon the
formation of the Company.
IN WITNESS WHEREOF, I have hereunto set my hand this seventh day of
February, 2022.
kv
Sharon Leal, Organizer
505 W. 15th Street
Austin, Texas 78701-1511
(512) 474-2002
CAMELOT ROOFING,LLC
CERTIFICATE OF FORMATION,PAGE 2
Camelot Roofing
1201 Robert's Cut-Off Rd.
Fort Worth,TX 76114-2524 US
817-624-7398
camelotroofing@Datt.net
City of Fort Worth
Attn:Tracy Walter
We have incorporated our DBA name, Camelot Roofing, and operating under a new tax id number.
A copy of our new W-9 is attached.
If you have any questions please feel free to contact Eugene Abernathy at eabernathv@sbcleobal.net or
camelotroofing@att.net.
Thank-you,
Camelot Roofing
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