Grobowsky Drainage Easement-CN 2021-06-15AFTER RECORDING RETURN
TO _City of Coppell
Attn: City Secretary
255 E. Parkway Blvd.
Coppell, Texas 75019
NOTICE OF CONFIDENTIALITY RIGHTS: IF YOU ARE A NATURAL PERSON,
YOU MAY REMOVE OR STRIKE ANY OR ALL OF THE FOLLOWING
INFORMATION FROM ANY INSTRUMENT THAT TRANSFERS AN INTEREST IN
REAL PROPERTY BEFORE IT IS FILED FOR RECORD IN THE PUBLIC RECORDS:
YOUR SOCIAL SECURITY NUMBER OR YOUR DRIVER'S LICENSE NUMBER
STATE OF TEXAS §
COUNTY OF DALLAS §
DRAINAGE EASEMENT
THAT the term Grantor used herein shall be construed in the singular or plural number as
such term respectively represents one or more than one person.
THAT, Paula S Grobowsky, a single female, known herein as GRANTOR, in
consideration of the sum of Nine Thousand Ninety -Three and 32/100 Dollars ($9,093.32) and other
good and valuable consideration in hand paid by City of Coppell, Texas, receipt of which is hereby
acknowledged, does by these presents grant, bargain, sell and convey unto City of Coppell, Texas,
("GRANTEE"), a non-exclusive free and uninterrupted use, liberty and privilege of passage in,
along, upon and across real property ("Easement") on approximately a 0.0571 acres (2,489 sf) of
Lot 7, Block 1 of Northlake Woodlands East, Phase 1, an addition to the City of Coppell Texas
owned by Grantor the following described property owned by Grantor (the "Easement") for the
purpose of constructing and maintaining drainage improvements upon Grantor's real property with
the right and privilege at all times, of the GRANTEE herein, its agents, employees, workmen and
representatives having ingress, egress, and regress in, along, upon and across said Drainage
Easement for the purpose of making additions to, improvements on and repairs to said drainage
improvements or any part thereof.
Said Drainage Easement being more particularly described in Exhibit "A" attached hereto
and made a part hereof for all purposes.
Easement Property: Lot 7, Block 1 of Northlake Woodlands East, Phase 1 an Addition to the
City of Coppell, Dallas County, Texas, according to the plat recorded in Dallas County, Texas,
Plat Records of Dallas County, Texas and more particularly described by metes and bounds and
depicted in Exhibit "A" attached hereto and incorporated herein by reference.
Easement Purpose: To provide Grantee, for the benefit of the public, the right of ingress,
egress, and regress therein, to erect, construct, reconstruct, install, replace, repair, operate, use,
inspect, modify, remove and maintain certain drainage improvements and collect and direct
Page 1 I DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITY OF COPPELL
(TM 122603)
storm water over the Easement Property from the adjacent tracts, together with all lines, pipes,
conduits and other equipment, improvements, and appurtenances, if any, used in the collection
and direction of storm water, deemed necessary thereto by Grantee over, along, across, under,
into and through the Easement Property (hereafter called "the Easement Improvements").
Consideration: The sum of NINE THOUSAND NINETY-THREE AND 32/100 DOLLARS
($9,093.32) and other good and valuable consideration, the receipt and sufficiency of which are
hereby acknowledged by Grantor.
Reservations from Conveyance: Grantor reserves all rights, titles, interests, and estates in and
to the Easement Property, subject to and except for the rights of Grantee hereunder. Without
limitation, Grantor reserves the nonexclusive right to use the Easement Property for any and all
purposes that do not unreasonably interfere with Grantee's rights hereunder.
Exceptions to Warranty: This Easement is subject to any and all matters of record or otherwise
affecting the Easement Property.
Grant of Easement: Grantor, as the owner of the Easement Property and the other land
currently owned by Grantor that is adjacent to the Easement Property, for the Consideration, and
subject to the terms and conditions of this Drainage Easement ("Easement Agreement"), the
Reservations from Conveyance and the Exceptions to Warranty, grants, sells, and conveys to
Grantee a nonexclusive easement over, on, and across the Easement Property for the Easement
Purpose and for the benefit of the public (the "Easement"), to have and to hold the Easement.
Subject to and except as to the terms and conditions of this Easement Agreement, the
Reservations from Conveyance, and the Exceptions to Warranty, Grantor binds Grantor and
Grantor's heirs, administrators, successors and assigns to warrant and defend the title to the
Easement in Grantee against every person whomsoever lawfully claiming or to claim the
Easement or any part thereof by, through, or under Grantor but not otherwise.
Terms and Conditions: The following terms and conditions apply to the Easement granted by
this Easement Agreement:
1. Character of Easement. The Easement is nonexclusive and irrevocable, except as
otherwise provided in the terms and conditions of this Easement Agreement.
2. Duration of Easement. The duration of the Easement is perpetual, except as otherwise
provided in the terms and conditions of this Easement Agreement.
3. Reservation of Rights. Grantor reserves for Grantor and Grantor's successors and assigns
the right to continue to use and enjoy the Easement Property for all purposes that do not
unreasonably interfere with or unreasonably interrupt the use or enjoyment of the Easement by
Grantee and the public for the Easement Purposes. Grantor further reserves for Grantor and
Grantor's successors and assigns the right to use all or part of the Easement Property in
conjunction with Grantee and the right to convey to others the right to use all or part of the
Easement Property in conjunction with Grantee, as long as such further conveyance is subject to
the terms and conditions of this Easement Agreement.
Page 2 1 DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITV OF COPPELL
(TM 122603)
4. Equitable Rights of Enforcement. In addition to any other rights or remedies which a
party may have at law or in equity, this Easement may be enforced by restraining orders and
injunctions (temporary or permanent) prohibiting interference and commanding compliance.
Restraining orders and injunctions will be obtainable on proof of the existence of interference or
threatened interference, without the necessity of proof of inadequacy of legal remedies or
irreparable harm, and will be obtainable only by (i) Grantor or (ii) Grantee on behalf of the
public (but not directly by any members(s) of the public); provided, however, that the act of
obtaining an injunction or restraining order will not be deemed to be an election of remedies or a
waiver of any other rights or remedies available at law or in equity.
5. Attorney's Fees. If any party retains an attorney to enforce this Easement Agreement, the
parry prevailing in litigation is entitled to recover reasonable attorney's fees and court and other
costs.
6. Binding Effect; Release. This Easement Agreement binds and inures to the benefit of
Grantee, and of Grantor and Grantor's heirs, administrators, successors and assigns in the
ownership of the Easement Property. If this Easement Agreement terminates, the parties shall
execute, acknowledge and cause to be recorded against the Easement Property a release of this
Easement Agreement in form and substance sufficient to remove this Easement Agreement from
title to the Easement Property and otherwise reasonably satisfactory to Grantor and Grantee. The
provisions in the immediately preceding sentence shall survive the termination of this Easement
Agreement.
7. Choice of Law; Venue. This Easement Agreement will be construed under the laws of
the State of Texas, without regard to choice -of -law rules of any jurisdiction. Venue for any
disputes arising from or related to this Easement Agreement shall be in a state court in Dallas
County, Texas.
8. Counterparts. This Easement Agreement may be executed in any number of counterparts
with the same effect as if all signatory parties had signed the same document. All counterparts
will be construed together and will constitute one and the same instrument.
9. Waiver of Default. It is not a waiver of or consent to default if the non -defaulting party
fails to declare immediately a default or delays in taking any action. Pursuit of any remedies set
forth in this Easement Agreement does not preclude pursuit of other remedies in this Easement
Agreement or provided by law or in equity.
10. Integration. This Easement Agreement contains the complete agreement of the parties
and cannot be varied except by written agreement of the parties. The parties agree that there are
no oral agreements, representations, or warranties that are not expressly set forth in this
Easement Agreement.
11. Notices. Any notice required or permitted under this Easement Agreement must be in
writing. Any notice required by this Easement Agreement will be deemed to be delivered upon
actual delivery or refusal to accept such delivery, as indicated by the return receipt, following
deposit with the United States Postal Service, postage prepaid, certified mail, return receipt
Page 3 1 DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITY OF COPPELL
JM 122603)
requested, and addressed to the intended recipient at the address shown in this Easement
Agreement. Notice may also be given by regular mail, personal delivery or courier delivery and
will be effective when actually received. Any address for notice may be changed by written
notice delivered as provided herein.
12. Legal Construction. If any provision in this Easement Agreement is for any reason
unenforceable, to the extent the unenforceability does not destroy the basis of the bargain among
the parties, the unenforceability will not affect any other provision hereof, and this Easement
Agreement will be construed as if the unenforceable provision had never been a part of the
Easement Agreement. Whenever context requires, the singular will include the plural and neuter
include the masculine or feminine gender, and vice versa. Article and section headings in this
Easement Agreement are for reference only and are not intended to restrict or define the text of
any section. This Easement Agreement will not be construed more or less favorably between the
parties by reason of authorship or origin of language.
SIGNED AND AGREED this � day of JG�ijt�J 2021.
G TOR:
Paula S Grobowsky, a single female
GRANTOR'S ACKNOWLEDGMENT
STATE OF TEXAS §
COUNTY OF DALLAS §
This in trument was acknowledged before me, the
day of t, , 2021, by
CHRISTEL R P:EExpires
NOS
=
Notary ID x1205!
r. My CommissioMay 10,
authority, on the
exas
My Commission expires.
Page 4 1 DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITY OF COPPELL
(TM 122603)
SIGNED AND ACCEPTED on theday of dog, '2021.
CITY OF C
GRANTEE
USA
Land, City Manager
ATTEST:
Ashley Owens, Cicretary
APPROVED,Af TO FORM AND LEGALITY:
Robert E. Hager, City Oditorney
STATE OF TEXAS §
COUNTY OF DALLAS §
This instrument was acknowledged before me on the ,/� day of
June, , 2021, by Mike Land, City Manager of the City of Coppell, Texas, a
Texas home rule municipality, for and on behalf of said municipality.
ASHLEY M. 0 W E N S
ii�P
' enc Notary Public, State of Texas
v:+Pc Comm. Expires 02-24-2023
i%lF •�f •SQL\��
Notary ID 130128128
Notary Public, S4Ce of Texas
V-2 2 2I923
My Commission expires:
Page 5 DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITY OF COPPELL
(TM 122603)
Exhibit "A"
Description of Easement Property
Page 6 1 EXHIBIT "A" TO DRAINAGE EASEMENT: PAULA S. GROBOWSKY TO THE CITY OF COPPELL
EXHIBIT "A"
DRAINAGE EASEMENT
LOT 7, BLOCK 1, NORTHLAKE WOODLANDS EAST, PHASE 1,
CITY OF COPPELL, DALLAS COUNTY, TEXAS
BEING a 0.0571 acre tract of land located in the James Parrish Survey, Abstract Number 1139, City of Coppell, Dallas County, Texas,
said 0.0571 acre tract being a portion of LOT 7, BLOCK 1, NORTHLAKE WOODLANDS EAST, PHASE 1, being an Addition to the City
of Coppell, Dallas County, Texas, according to the plat thereof filed for record in Volume 82116, Page 1956, Map Records, Dallas
County, Texas, said 0.0571 acre tract also being a portion of a tract of land conveyed to PAULA S. GROBOWSKY, by deed thereof
filed for record in Volume 86131, Page 1761, Deed Records, Dallas County, Texas, said 0.0571 acre tract being more particularly
described by the metes and bounds as follows:
COMMENCING from an "X" scribed in concrete found at the northwest lot corner of said Lot 7, same being the northeast lot
corner of Lot 6 of said Block 1, said commencing point being on the south right-of-way line of Villawood Lane (being a 50 feet wide
public right-of-way at this point);
THENCE South 04°16'53" East, departing the said right-of-way line, along the west lot line of said Lot 7 and along the east lot line
of said Lot 6, 88.38 feet;
THENCE North 85°43'07" East, departing the said lot lines and over and across said Lot 7, 5.00 feet to the POINT OF BEGINNING of
the herein described tract of land, said beginning point being on the east line of an existing 10 feet Drainage and Utility Easement,
being shown on and dedicated by said plat of Northlake Woodlands East, Phase 1, said beginning point also having a NAD83 Texas
North Central Zone (4202) grid coordinate of N: 7,036,637.31 and E: 2,436,342.80;
THENCE departing the said easement line and continuing over and across said Lot 7 the following courses and distances:
South 88°02'17" East, 53.80 feet;
South 24°05'16" East, 36.12 feet to the southerly lot line of said Lot 7;
THENCE along the said southerly lot line the following courses and distances:
South 66°35'33" West, 40.29 feet;
North 55°18'27" West, 35.57 feet to the intersection of the said southerly lot line with the said east easement line;
THENCE North 04°16'53" West, departing the said southerly lot line and along the said east easement line, 30.66 feet to the POINT
OF BEGINNING.
The herein above described tract of land contains a computed area of 0.0571 acres (2,489 square feet) of land, more or less.
The bearings recited herein above are based on a local coordinate system based on NAD83 Texas North Central Zone 4202, derived
from GPS RTK observations using the North Texas VRS Network (maintained by Allterra Central, Inc.)
I Eric S. Spooner, a Registered Professional Land Surveyor in the State of Texas, do hereby state that the foregoing description
accurately sets out the metes and bounds description of the easement tract described herein.
Eric S. Spooner, RPLS
Spooner & Associates, Inc.
Texas Registration No. 5922
TBPLS Firm No. 10054900
04-29-21
OF ` T
G\STER �+
4 ERIC S. SPOONER
\� 5922
r o�Is OQ /
i
Parcel 3 — Exhibit "A" — Drainage Easement — Grobowsky — Page 1 of 2
Spooner & Associates, Inc., 309 Byers Street, Suite 100, Euless, Texas 76039 - PH. 817-685-8449 - espooner@spoonersurveyors.com - S&A 20014
PARCEL 3 - D.E.
MAP OF EXHIBIT "A" _-- ------
SEE ATTACHED METES & BOUNDS
DESCRIPTION ON PAGE 1 HEREIN
XCF
0' 15' 30'
-
I
GRAPHIC SCALE IN FEET
DIST.
1"=30'
IcI
C)
A
EX. 10' DRAINAGE
L2
& UTILITY EASEMENT
53.80'
VOL. 82116, PG. 1956,m
lao
M.R.D.C.T.
Iw
S66°35'33"W
I0�
LOT 6, BLOCK 1
N55°18'27"W
NORTHLAKE WOODLANDS
L6
EAST, PHASE 1
30.66'
VOL. 82116, PG. 1956
POINT OF
COMMENCING
M.R.D.C.T.
EX. 5' TP&L EASEMENT
VOL. 82116, PG. 1956,
M.R.D.C.T. L 1-
---- -_--LOT LINE
AREAOF UNKNOWN OWNERSHIP
(GAP BETWEEN PLATS
- OD LAW E
VILLA�OC,o31.OF
(50 W\DE Pubo
OWNER
PAULA S. GROBOWSKY
VOLUME 86131, PAGE 1761
D.R.D.C.T. 01
LOT 7, BLOCK 1
fr NORTHLAKE WOODLANDS
EAST, PHASE 1
VOL. 82116, PG. 1956 LOT 8, BLOCK 1
M.R.D.C.T. NORTHLAKE WOODLANDS
EAST, PHASE 1
POINT OF EXHIBIT "A„ VOL. 82116, PG. 1956
M.R.D.C.T.
BEGINNING' 0.0571 ACRES
N: 7,036,637.31 (2,489 S.F.)
E: 2,436,342.80
(NAD83 - GRID)
EX. 5' TP&L EASEMENT
L2 VOL. 82116, PG. 1956,
M.R.D.C.T.
i
LINE TABLE
NO.
DIRECTION
DIST.
L1
N85°43'07"E
5.00'
L2
S88°02'17" E
53.80'
L3
S24°05'16"E
36.12'
L4
S66°35'33"W
40.29'
L5
N55°18'27"W
35.57'
L6
N04°16'53"W
30.66'
r
' VA i
�S OWN PLP�S)
\ EPOF
SOT PR SGP LOT 4, BLOCK 3
NORTHLAKE WOODLANDS
EAST, PHASE 4
LOT 6, BLOCK 2
NORTHLAKE WOODLANDS
EAST, PHASE 3
LOT 7, BLOCK 2
VOL. 83205, PG. 3713
NORTHLAKE WOODLANDS
M.R.D.C.T.
EAST, PHASE 3
VOL. 83205, PG. 3713
M.R.D.C.T.
EX. UTILITY &
DRAINAGE EASEMENT -
VOL. 83205, PG. 3713,
- - - - - - - - -
M.R.D.C.T.
EXHIBIT "A"
DRAINAGE EASEMENT
LOT 7, BLOCK 1, NORTHLAKE
WOODLANDS EAST, PHASE 1,
CITY OF COPPELL, DALLAS COUNTY, TEXAS
VOL. 83205, PG. 3705
. 2o.� \
M.R.D.C.T.
VO4 Rql,,
M32?o oFFq \ \
Ro 07.
T 3 oSM ,,v
11
THE BEARINGS SHOWN HEREON ARE BASED ON A LOCAL
COORDINATE SYSTEM BASED ON NAD83, TEXAS NORTH CENTRAL
ZONE 4202, DERIVED FROM GPS RTK OBSERVATIONS USING THE
NORTH TEXAS VRS NETWORK (ALLTERRA CENTRAL, INC.)
SPOONER&
A§,,,ls,TER0EDP,.cF1ATES
S
PROPERTY: LOT 7, BLOCK 1, NORTHLAKE WOODLANDS EAST, PHASE 1 309 BYERS STREET, SUITE 100, EULESS, TEXAS 76039
VOLUME 82116, PAGE 1956, M.R.D.C.T. (817) 685-8448 WWW.SPOONERSURVEYORS.COM
20014 PAR 3 EXH A.dwg TBPLS FIRM NO. 10054900
DATE: 04-21-2021 ICHECKED'ev: E.S.S. I PARCEL 3 - EXHIBIT "A" - GROBOWSKY - PAGE 2 OF 2
.e A,%. 04-29-21
E OF ` 1
S T
ERIC S. SPOONER >'-
\� 5922
ocEs OQ
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T H E C 1 T Y O F
COPPELL
M1 II 1
Company Information
%X
/7
Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
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Request for Taxpayer
Identification Number and Certification
► Go to wwwJmgov/FormW9 for instructions and the latest information.
(as shown on your income tax
Paula S. Grobowsky
2 Business name/disregarded entity name,
is required on this line; do not leave this line blank.
trom above
Give Form to the
requester. Do not
send to the IRS.
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
following seven boxes. certain entities, not individuals; see
❑✓ Individual/sole proprietor or Corporation instructions on page 3):
p p ❑ C Cor ❑ S Corporation EI ❑ Trust/estate
single -member LLC Exempt payee code (if any)
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
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 (if 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.
LJ Other (see instructions) 11-
5
5 Address (number, street, and apt. or suite no.) See instructions.
629 Villawood Lane
B City, state, and ZIP code
Coppell, TX 75019
7 List account number(s) here (optional)
(Applies to -Cc Ms memWmd outside the U.S.)
Requester's name and address (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
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other 4 5 1 -
entities, it is your employer identification number (EI N). 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 Requester for guidelines on whose number to enter. F-7-7
lj� 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 seoperty, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends o e not requirgd"fo sign the Wcation, but you must provide your correct TIN. See the instructions for Part 11, later.
Sign signature of
Here I U.S. person ► ��` � �/J( 41/ S' i ft --- Date ► /AV 14
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)
(dividends, ir(cluding those from stocks or mutual
• 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)
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY
This questionnaire is being filed in accordance with Chapter 176. Local Government Code, by a vendor who Date Received
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the
vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental entity not later
than the 7th business day after the date the vendor becomes aware of facts that require the statement to be
filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this section is a misdemeanor.
11 Name of vendor who has a business relationship with local governmental entity.
Atdo 57, (�Iz bo /::� kA I
2
Check this box if you are filing an update to a previo ly filed questionnaire. (The law requires that you file an updated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government officer about whom the information is being disclosed.
i
e
Name of ficer
AJ Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIQ as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
F] Yes 0 No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
El Yes No
5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
6
EJCheck this box if the vendor has given the local government officer or a family member of the officer one or more gifts
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
7
02
Signature of vendor doing business with the governme entity 15ate
Form provided by Texas Ethics Commission rwww.ethics.state.tx.us Revised 11130/2015
NEW VENDOR Electronic Funds Transfer (EFT) Payment Authorization
Vendor Name:
Paula S. Grobowsky
Vendor Address:
629 VIIIawood Ln.
Coppell, TX 75019
Vendor Contact:
Paula S. Grobowsky
Vendor Phone Number:
972-462-8889
Vendor Email for ACH
payment notification:
psg370@yahoo.conl
Please fill in the checking
account information below for EFT payment:
Local Depository Bank:
First Lockhart National Bank
Bank City/State:
Lockhart, TX
Bank Telephone Number:
877-398-3416
Bank Routing Number (9 digits:
114903213
Bank Account Number:
341008
Authority is hereby given to the City of Coppell (Coppell) to initiate credit entries to the account shown above
for any payments the Vendor authorizes Coppell to credit through electronic funds transfer.
The person executing this Agreement on behalf of Vendor represents that he or she has the authority to
authorize the credit to the above account on behalf of Vendor and that all necessary administrative
procedures, policies, and laws prerequisite have been complied with. This authority shall remain in full force
and effect until the City of Coppell receives written notification of a change.
Paula S. Grobowsky 972-462-8889
Nam f uthorized Re e=tted) Telephone Number
06/04/2021
Signature of Authorized Representative Date
ALL FIELDS MUST BE COMPLETED FOR THIS DOCUMENT TO BE VALID
REV. 6/2017