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HomeMy WebLinkAboutContract 57159-CA1CSC No. 57159-CA1 C I TY OF FORT WORTH ASSIGNMENT For value, received Jackey R. Dunn JR ("Assignor"), hereby assigns to Romance Services Limited Liability Company ("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 CSCO 57159 (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 L, -1 day of ] a ^ U a �- 2023. Jackey R. Dunn JR (Assignor) By:L Print: L�� h d� Title: Chief Operating Officer Romance Services Limited Liability Company (Assignee) By: c2d Print:�- Title: Chief Financial Officer OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Assignment Page 1 of NOTARY ACKNOWLEDGEMENT On the o� l 4-k day of J C O LLa 1•y 2023, personally appeared Jrncke4 Nr),`T,- , who acknowledged to me that (s)he is the Chief Operating Officer of Jackey R. Dunn JR, ("Assignor"), and that (s)he executed this document for the purposes and consideration contained herein. Jackey R. Duna JR Print: �L Title: ChieOperating Officer SUBSCRIBED TO before me on this a9+4, day of �Anl,-ar� , 2023. RENAE DUNN .`tPPY Pie% Notary Public in and for the State of-7-k-6-5 c, Notary Public, State of Texas Comm. Expires 05-11-2024 My commission Expires: Or'J -I ► - a� ;°;,;��`� Notary ID 130659465 NOTARY ACKNOWLEDGEMENT On the day of 2023, personally appeared —3ZkdL2�I b"r-)rTy- , who acknowledged to me that (s)he is the Chief Financial Officer of Romance Services Limited Liability Company, ("Assignee"), and that (s)he executed this document for the purposes and consideration contained herein. Romance Se ices Jimited Liability Company By: � Print: --� -L OZ., \ r Title: Chief Financial Officer SUBSCRIBED TO before me on this o�day of ��►'� �a r� , 2023. p1Yopt I'�,, RENAE DUNN Notary Public in and for the State of—j-CV.S :�{ ; ,:Notary Public, State of Texas My commission Expires: 0S-1 1-,-Luaq '�X*; Comm. Expires 05-11-2024 Notary ID 130659465 Assignment Page 2 of CONSENT TO ASSIGNMENT The City of Fort Worth consents to the assignment of Jackey R. Dunn JR, ("Assignor") to Romance Services Limited Liability Company, ("Assignee"), of all its rights, title, and obligation owing and all funds due or to become due to Assignor under CSCO 57159 as long as all terms required of Assignor in said contracts are met by Assignee. CITY OF FORT WORTH R-a�IwCfi zmut- Reg ald Zeno (Feb 2, 202312:54 CST) Reginal Zeno- Chief Financial Officer �`1 hI e�1 XOwreaa Anthony Rous eau (Feb 2, 2023 12:51 CST) Anthony Rousseau, Assistant Director — FMS 4,d4voU��� �ORtO�a1d I.I ATTESTED BY: o * 000 0oolooloo d a d�a� n�ons�p Jannette Goodall, City Secretary APPROVED AS TO FORM AND LEGALITY: fw, gjl, J Christopher Mullins (Feb 1, 2023 09:50 CST) City of Fort Worth Assistant City Attorney Contract Compliance Manager: Feb 2, 2023 Date Feb 2, 2023 Date Feb 2, 2023 Date 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. �Q�� Feb 2, 2023 Denise Garcia (Feb 23 10:33 CST) Employee Signature/Date 02/02/2023 Title OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Assignment Page 3 of Romance Services, LLC P.O Box 136513 Fort Worth, Texas 76136 Ph. 817-232-2200 — Fx. 817-831-0559 Insured/License # M-36094 12/29/2022 City of Fort Worth 900 Monroe Street Fort Worth, Texas 76102 Re: Change from Sole Proprietor to LLC Please note that Jackey R Dunn Jr dba Romance Services is now Romance Services LLC. The effective date of the change was 01/01/2022. It took an exceeding amount of time to get this change updated with the Texas State Board of Plumbing Examiners. At last, their website is now showing this update and we are able to proceed to update our information with the city as it was the last piece that had to be done. Please know this change was due to the urging of the business's CPA for several years and it was decided to go ahead with the change. There is no change of contacts, etc. with the company. Thank you, 4Jaey unn Jr. Romance Services LLC Form W=9 Request for Taxpayer Give Form to the Identification Number and Certification requester. Do not (Rev. October2018) Department of the Treasury send to the IRS. ntemal Revenue Service ► 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. ROMANCE SERVICES LLC 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 (codes apply only to 0 cu following seven boxes. certain entities, not individuals; see a instructions on page 3): o ❑ Individual/sole proprietor or ElC Corporation ElS Corporation ❑ Partnership ElTrust/estate xn single -member LLC Exempt payee code (if any) ai c ❑✓ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► S p i3 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 LLC code (if any) danother LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member that _ is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (see instructions)► (AppfStoaccounts mainlatnedOutside the U.S.) rn 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optionao a PO BOX 136513 to 6 City, state, and ZIP code FORT WORTH, TX 76136 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid social security number backup withholding. For individuals, this is generally your social security number (SSN. However, for a - m - resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How 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. 8 7 F- 4 1 1 7 6 9 4 4 ■:Tial■ certiticatlon Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Signature of � K Date► 0/ - ©/ - aje 2 -Z Here U.S. person ► � K� General Instructio 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 1099-0 (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) ACORO® CERTIFICATE OF LIABILITY INSURANCE J%. ► DATE(MMIDDIYYYY) 12/29/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 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 Amy Cale NAME: AssuredPartners of Texas, LLC PHONE (972) 644-2688 FAX A/C No Ext : A/C, No): 500 N Central Expressway, Suite 550 E-MAIL am cote assured artners.com ADDRESS: y' @ p INSURER(S) AFFORDING COVERAGE NAIC 4 Plano TX 75074 INSURERA: Ohio Security Insurance Co. 24082 INSURED INSURER B : West American Insurance CO 44393 Jackey R Dunn, DBA: Romance Services, LLC INSURER C : PO Box 136513 INSURER D : INSURER E : Fort Worth TX 76136 INSURER F : COVERAGES CERTIFICATE NUMBER: 22-23 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUWLSUbK INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYY LIMITS X COMMERCIALGENERALLIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 D ES(EaTO D occurrence PREMISES Ea S 1,000,000 MED EXP (Any one Person) $ 15,000 PERSONAL& ADV INJURY $ 1,000,000 A BKS56229637 07/20/2022 07/20/2023 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY [g jEo- LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO B OWNEDX SCHEDULED AUTOS ONLY AUTOS BAW56229637 07/20/2022 07/20/2023 BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY S UMBRELLA LIAR OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN STATUTE ER E.L EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? NIA E.L DISEASE- EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) BID No. 22-0006, ITB Plumbing Services SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Fort Worth ACCORDANCE WITH THE POLICY PROVISIONS. 200 Texas St. AUTHORIZED REPRESENTATIVE Lower level South uu Fort Worth TX 76102 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ---- (Secretary of State Filed in the Office of the !P.O. Box Dustin, TX 78711-3697 '`. ! Secretary of State of Texas is FAX: 512/463-5709 Filing #: 804345713 12/10/2021 i € Document #: 1101542940002 ' ;Filing Fee: $300 Certificate of Formation Image Generated Electronically ° Limited Liability Company for Web Filing :i.__....._....................................................................... ........ Article 1 - Entity Name and Type ; :The fling entity being formed is a limited liability company. The name of the entity is: - :,ROMANCE SERVICES LIMITED LIABILITY COMPANY I._...._..._._..__.__.._.__........__...._.__........Article 2 - Registered Agent and Registered Office ; j __.......__........._..._._.._....._...._.....__..._.___._._.__..__.__._.__..__.__.__..._.._.._..._.__...._..........._.._..._.._.__....-__.......-__..__....____.... .... -................................................. ............................................................................................................................................. :!A. The initial registered agent is an organization (cannot be company named above) by the name of: -__ . _ _ _._ ._.___....._......____ _-. _._._..._....._..___.__......__..._._...-----_-. _.__....._-- . _-. _....._........ _..._...._._... _....__ ...._.__...._........._..... _._.... _._......_ _..__.._ .---.-.-.._ OR i ------- — - -- — —i iji✓ B. The initial registered agent is an individual resident of the state whose name is set forth below: ji ;Name: i JACKEY R DUNN Jr .:....................................................................................................................................................... .... . ---------------------------------------------------------• ------- - - - _............-::::::_:::::::::::_.:::::__ ::::.:__.::.:::::::::::.:. iC. The business address of the registered agent and the registered office address is: .. — . _..... _ _ .._... _...___ 'Street Address: '-•--'� -'�—�- �' :2580 BRUCE ST FORT WORTH TX 76111-1830 Consent of Registered Agent i �r`A. A copy of the consent of registered agent is attached. ;l OR i „i��-B. The consent of the registered agent is maintained by the entity. Article 3 -Governing Authority -- A. The limited liability company is to be managed by managers.---- ^ -�— OR IR.B. The limited liability company will not have managers. Management of the company is reserved to the members. .... .........................................................................................._............................... .......... ......................... The names and addresses of the governing persons are set forth below: J I anaging Member is RENAE D DUNN Title: Managing Member _ !Address: 2580 BRUCE ST FORT WORTH TX, USA 76111-1830 ' ;managing Member 2: JACKEY R DUNN Jr TitTit a Managing Member i ........-... _._..._..... _. _.. __.__._ ......... .... _._ ._'_.._._...__._.___..._....-----.-----........ _ _ Pddress: 2580 BRUCE ST -FORT WORTH TX USA 76111-1830 `_~_ _...__..___..___.___...~ ____ _..___..___.__ :..... .......-....._._.-....._._..---------... .....,., .--- -• ---- ------------- ._...-•-•-• :.,:...........--•--••--....--------......._..•---•-•--•-•--•-•-•••--_.....__.... . Article 4 - Purpose ._........_...-_-._..._..__..__._..__._.__......... _........ __._...__....___.._._.__...__..___._^-.-------..__.___............_...__._._..__._..._--.__....__.._..-.---___.._..___ _..... The purpose for which the company is organized is for the transaction of any and all lawful business for which limited !liability companies may be organized under the Texas Business Organizations Code. j i , i ..................................................................................................... .I Supplemental ............................................ , The attached addendum, if any, is incorporated herein by reference.] d � 1 i fj ........._.. ......._... ..__ ....... ..__._.__._..-___ .._.._ ._.. �_y..._._....__....__._.._.._..._...__._._.__._._._.___....-.___..._._._ _.__._.__._-.___..._ _. ... _. _ .. __ ___.-. _._..... ............ �.._..... _.... _..__.._. ....._...__.... _.._. .�._._. ... _ .. _ .. i —� Organizer -.- -... __._.......... __._......—---------- -----.—._ ...-- ---- ---- ..._..._._....—_._.. _..._._....__._....._.. - 'The name and, address of the organizer are set forth below. PAUL B MOORE CPA 8821 DAVIS BLVD #510 KELLER, TX 76248-0336 _._..._......... ... __.._..__-._-.__._..._.__._....__... Effectiveness of Filing A. This document_ becomes effective when the document is filed by the secretary of state. _. OR B. This document becomes effective at a later date, which is not more than ninety (90) days from the date of its— p igning. The delayed effective date is: January 1, 2022� Execution he undersigned affirms that the person designated as registered agent has consented to the appointment. The a '•.undersigned signs this document subject to the penalties imposed by law for the submission of a materially false or Fraudulent instrument and certifies under penalty of perjury that the undersigned is authorized under the provisions of 111 flaw governing the entity to execute the filing instrument. �f _ .... ....... ..... ..............._ .. _�..._ ......:__._..� ?PAUL B MOORE, CPAT�__.__� [Signature of Organizer ;+ FILING OFFICE COPY