HomeMy WebLinkAboutContract 59181-CA1CSC No. 59181-CAl
C I TY OF FORT WORTH
ASSIGNMENT
For value received Mosaic Strategy Partners ("Assignor"), hereby assigns to Mosaic
SKM Collaborative LLC ("Assignee"), all of its right, title and interest in and to any and all
slums of money now due or to become due from the City of Fort Worth to Assignor under PSK
19119/CSCO 59181 (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( � ��� 2023.
Mosaic Strategy Partners
(Assignor)
By:
Print*!S:
Title: Chief Operating Officer
Mosaic SKM Collaborative LLC
(Assignee)
By:
Print: v
Title: Chief Financial Officer
Assignment Page 1 oF3
NOTARY ACKNOWLEDGEMENT
On the 1 L4 day of r A 2023, personally appeared
6rea1-C: 6041d..s , who acknowledged to me that (s)he is the Chief Operating Officer of
Mosaic Strafegy Partners ("Assignor"), and that (s)he executed this document for the purposes
and consideration contained herein.
Mosai tr ers
By:
Print: T
Title: Chief Operating Officer
SUBSCRIBED TO before me on this ILI day of —Ti n c , 2023.
{PRY r a RAJAL AMI
NOTARY PUBLIC Oil
Public a and for the State of 7I
PUBLIC �
* ,t STATE OF TEXAS My commission Expires: 0
OF'LE+�y My Comm E pi os 06 28-2026 � I
r ,: f"�.s .,=r +►a,-..n.,rrvv-r.►�rrr�o.
NOTARY ACKNOWLEDGEMENT
On the l y day of -,T—u r%e_ 2023, personally appeared
}Z (- o1L.- (—,Qc ss, who acknowledged to me that (s)he is the Chief Financial Officer of
Mosaic SKM Collaborative LLC ("Assignee"), and that (s)he executed this document for the
purposes and consideration contained herein.
■
SUBSCRIBED TO before me on this 14 day nc. , 2023.
NARY P RAJAN L DORASAMI
NOTARY PUBLIC ota Pubic zt al nd for the State of_ $o �n
* * STATE OF TEXAS My commission Expires: o L-?—I.
ID # 12425762-3 f
My Comm. Expires 06-28-2026
Assignment Page 2 of3
CONSENT TO ASSIGNMENT
The City of Fort Worth consents to the assignment of Mosaic Strategy Partners
("Assignor") to Mosaic SKM Collaborative LLC ("Assignee"), of all its rights, title, and
obligation owing and all funds due or to become due to Assignor under PSK 19119/CSCO 59181
as long as all terms required of Assignor in said contracts are met by Assignee.
CITY OF FORT WORTH
Jul 5, 2023
Department Director Date
7�C-L- Jul 5, 2023
Assistant City Manager Date
ATTT^ESSTTED BY:
U
Jul 7, 2023
Jannette Goodall, City Secretary Date
APPROVED AS TO FORM AND LEGALITY:
City of Fort Worth 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.
Jul 5, 2023
Employee Signature/Date
NS Manager
Title
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 ► Go to wwwJrs.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.
Mosaic SKM Collaborative LLC
2 Business name/disregarded entity name, if different from above
a�
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
Ca
following seven boxes.
certain entities, not individuals; see
a
instructions on page 3):
o
ElIndividual/sole proprietor or ElC Corporation ElS Corporation ❑✓ Partnership ❑ Trust/estate
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single -member LLC
Exempt payee code (if any)
ao
❑ 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
«�L
+' rn
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 any)
IL °
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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.
d
❑ Other (see instructions) ►
(Applies to accounts maintained outside the U.S.)
y
5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional)
c n
PO Box 470959
6 City, state, and ZIP code
Fort Worth, TX 76147
7 List account number(s) here (optional)
JUM 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 Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
8 7 - 1 1 6 1 5 1 1 1 0 1 2 1 0
JiM Certification
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
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.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)
Date Do -
• 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)
Corporations Section r l) . John B. Scott
PA.Boa 13697 Secretary of State
Austin, Texas 7871. 1-3697
x IT
Office of the Secretary of State
Certificate of Fact
The undersigned, as Secretary of State of Texas, does hereby certify that the document, Certificate of
Formation for Mosaic SKM Collaborative, LLC (file number 804145858), a Domestic Limited
Liability Company (LLC), was filed in this office on July 07, 2021.
It is further certified that the entity status in Texas is in existence.
In testimony whereof, I have hereunto signed my name
officially and caused to be impressed hereon the Seal of
State at my office in Austin, Texas on January 24, 2022.
f John B. Scott
` Secretary of State
Come visit us on the internet at h1tps:iA4wiv.s0s.texas.gov%
Phone: (512) 463-5555 Fax: (5l2) 463-5709 Dial: 7-1-1 for Relay Services
Prepared by: SOS -WEB TID: 10264 document: 11136766800 02
S I
MOSAIC + SKM COLLABORATIVE
Memo: Merger of Mosaic Strategy Partners: Mosaic SKM Collaborative
Date: February 2020
Let this memo serve as confirmation Mosaic Strategy Partners has undergone a name change and is
now the Mosaic SKM Collaborative.
aic + SKM Collaborative