The URL can be used to link to this page

Tax2014D-CS130111 Bid Certification Form Bid No. 2013-33-A Miscellaneous Concrete Replacement Services Company Information The following information must be provided in its entirety for your bid/ Company Name: � C [ Oh ci¢ ie. .� C Principal Place of Business Address: /g 2 no")t om. i • Principal Place of Business City,State,Zip: �9r/.pr/D, X. '75-octc Principal Place of Business Phone Number: Q'a- 26,2 — 95002- Principal Place of Business Fax Number: 917x—7x922 to7!03 Remittance Address(if different from above): Remittance City,State,Zip: Tax Identification No: - Se 37 34- Addendums If an addendum to this bid is issued,acknowledge addendum by initialing beside the addendum number: Add.No. 1 r P/C Add,No.2 �/ Add.No.3 06 Add.No.4 Add. No.5 Certification The undersigned hereby certifies that he/she understands the specifications, has read the document in its entirety and that the prices contained in this bid have been carefully reviewed and are submitted as correct and final. Vendor further certifies and agrees to furnish any or all products/services upon which prices are extended at the price offered, in accordance with the terms and conditions contained herein. Vendor agrees that acceptance of any or all items by the Town of Flower Mound,Texas,within the time frame indicated in this proposal constitutes a contract. The individual signing this bid certifies that he/she is a legal agent of the company, authorized to submit on behalf of the company,and is legally responsible for the decisions as to the prices and supporting documentation provided. Authorized Representative: freVie Sco f9k /— //—/3 Signature Date 4?-0&2fto .4)0h Printed Name /11 Title .0rhe/aA IA 6,"4,? c LO/. A007 Email Mdress 19 ATTACHMENT A—REVISED 1-8-13 TOWN OF FLOWER MOUND MISCELLANEOUS CONCRETE REPLACEMENT SERVICES BID NO.2013-33-A BID PRICING WORKSHEET No. Description Unit Unit Price 1 Remove 6"-8"Reinforced Concrete Pavement 0-50 SY SY $A, So 2 Remove 6"-8"Reinforced Concrete Pavement 51-250 SY SY $ ov ,co 3 Remove 6"-8" Reinforced Concrete Pavement 251-500 SY SY $ A0,00 4 Remove 6"-8"Reinforced Concrete Pavement 501+SY SY $ /' 00 5 Install 6"Reinforced Concrete Pavement,0-50 SY SY $ .57. 7.5'- 6 Install 6"Reinforced Concrete Pavement, 51-250 SY SY $ _Si ,2 S 7 Install 6"Reinforced Concrete Pavement, 251-500 SY SY $ /74. "4,- 8 7s8 Install 6"Reinforced Concrete Pavement,501+SY SY $ zi9. .25- 9 2S9 Install 8"Reinforced Concrete Pavement, 0-50 SY SY $ sit. 00 10 Install 8" Reinforced Concrete Pavement, 51-250 SY SY $ s s0 11 Install 8"Reinforced Concrete Pavement, 251-500 SY SY $ ,5-g, o0 12 Install 8"Reinforced Concrete Pavement,501+SY Sy $ Soy so 13 Remove 4"-5"Concrete Sidewalk, 0-50 SY SY $ /S, 75 14 Install 5"Concrete Sidewalk, 0-50 SY SY $ ,. _co 15 Remove 6"Reinforced Integral Curb, 0-50 LF LF $ g,,s 16 Remove 6"Reinforced Integral Curb, 51-250 LF LF $ �, oa 17 Remove 6"Reinforced Integral Curb, 251-500 LF LF $ /, 73-- 18 s18 Remove 6"Reinforced Integral Curb, 500+LF LF $ J, '75- 19 S19 Install 6"Reinforced Integral Curb, 0-50 LF LF $ oc 20 Install 6"Reinforced Integral Curb, 51-250 LF LF $ <75- 21 Install 6"Reinforced Integral Curb,251-500 LF LF $ S so 22 Install 6"Reinforced Integral Curb, 500+LF _ LF $ 5 00 23 Install 6"Reinforced Concrete Drive Approach (3600psi) SY $ vi sa 24 Install 6"Reinforced Concrete Drive Approach (4000psi) Sy $ ,i9 sO 25 Remove 24"Reinforced Concrete Curb&Gutter, 0-50 LF LF $ (d. oo 26 Remove 24"Reinforced Concrete Curb&Gutter, 51+ LF LF $ S- So 27 Install 24"Reinforced Concrete Curb&Gutter, 0-50 LF LF $ /7,25- 28 Install 24" Reinforced Concrete Curb&Gutter, 51+LF LF $ /7. o0 29- Remove 30"Reinforced Concrete Curb&Gutter, 0-50 LF LF $ 6,. 00 30 Remove 30"Reinforced Concrete Curb&Gutter, 51+ LF LF $ S ,j"o 31 Install 30"Reinforced Concrete Curb&Gutter,0-50 LF LF $ /cp. oo 32 Install 30"Reinforced Concrete Curb&Gutter, 51+LF LF $ // 00 33 Remove 36"Reinforced Concrete Curb&Gutter, 0-50 LF LF $ 6. 00 34 Remove 36"Reinforced Concrete Curb&Gutter,51+LF LF $ s- Si) 35 Install 36"Reinforced Concrete Curb&Gutter, 0-50 LF LF $ /,ov 36 Install 36"Reinforced Concrete Curb&Gutter, 51+LF LF $ if. o0 37 Remove 18"Reinforced Concrete Mountable Curb&Gutter, 0-50 LF LF $ c. o0 38 Remove 18"Reinforced Concrete Mountable Curb&Gutter,51+ LF LF $ S .so 39 Install 18"Reinforced Concrete Mountable Curb&Gutter, 0-50 LF _ LF $ /r,0 0 40 Install 18"Reinforced Concrete Mountable Curb&Gutter,51+LF LF $ /too 41 SDHPT(Grade 2)Type'A' Flex Base-Supplied, Place&Compacted CY $ yc4 oo 1 No. Description Unit Unit Price 42 SDHPT(Grade 2)Type'A'Flex Base-Placed&Compacted Only CY $ .-y,00 43 5"-6"Stamped Patterned Median Pavement, 10-50 SY(Min. 10SY), Color to be applied to surface of wet concrete; Color and stamped pattern to match existing and approved by Town Representative SY $ Ty. 0" 44 8"Stamped Patterned Median Pavement, 10-50 SY(Min.10SY), Color to be applied to surface of wet concrete; Color and stamped pattern to match existing and approved by Town Representative SY $ 63. °° 45 Remove HMAC and Sub Base Material CY $ a-p.oo 46 Saw Cut Full Depth Asphalt LF $ ,,,?, s0 47 Saw Cut Full Depth Concrete Pavement LF $ 0 48 Saw Cut Full Depth Concrete Sidewalk LF $ .!,00 49 Install Sod, 1"-2"Bermuda SY $ f. 00 50 Install Sod, 1"-2"St.Augustine SY $ gyp.00 51 Unclassified Excavation,0-50 CY CY $ ,c0.00 52 Unclassified Excavation,51-100 CY CY $ /S' ao 53 Unclassified Excavation, 101+CY CY $ /g.o., 54 3'x 3' Junction Box(NCTCOG 6010) EA $ /334. Co 55 4'x 4'Junction Box(NCTCOG 6010) EA $ /17d.,0o 56 5'x 5' Junction Box(NCTCOG 6010) EA $ 09-/3k.o0 57 6'x 6'Junction Box(NCTCOG 6010) EA $ .96 5-A,. 00 58 7'x 7'Junction Box(NCTCOG 6010) EA $ 3aap, 00 63 18"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ pi3 4'o 64 18"(TxDOT CH-FW-0) Headwall, Complete in Place EA $ 3,,iS p0 66 21"(TxDOT CH-PW-0) Headwall,Complete in Place EA $ 6ga:,ao 67 21"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ yoo.00 69 24" (TxDOT CH-PW-0) Headwall, Complete in Place EA $ 7y/00 70 24"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ 5.00. 00 72 27"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ r4v. O0 73 27"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ s7s o0 75 30"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ 9 ty.0 a 76 30"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ to 75-.0 0 78 33"(TxDOT CH-PW-0) Headwall, Complete in Place EA $ //34.a0 79 33"(TxDOT CH-FW-0) Headwall, Complete in Place EA $ 17S 00 82 36" (TxDOT CH-PW-0) Headwall, Complete in Place EA $ ivoq 90 83 36" (TxDOT CH-FW-0) Headwall, Complete in Place EA $ r 7 00 85 39"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ /sgo_oo 86 39"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ /duo. oo 88 42"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ /753. 70 89 42"(TxDOT CH-FW-0)Headwall, Complete in Place J EA $ /d,c 00 91 45"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ /9,76.06 92 45"(TxDOT CH-FW-0) Headwall, Complete in Place EA $ /504• co 94 48" (TxDOT CH-PW-0)Headwall, Complete in Place EA $ 5„, 7_0, 540 95 48" (TxDOT CH-FW-0) Headwall, Complete in Place EA $ /,s-,s 00 97 51" (TxDOT CH-PW-0)Headwall, Complete in Place _ EA $ _av?o,oa 98 51"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ /6 S-0 o 0 100 54" (TxDOT CH-PW-0)Headwall, Complete in Place EA $ 017iq,0 o 101 54"(TxDOT CH-FW-0)Headwall, Complete in Place EA $/PaS. 00 103 60"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ 5/4_30 104 60"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ ,/7,5-. oa 106 66"(TxDOT CH-PW-0)Headwall, Complete in Place EA $ 36170_3o 107 66"(TxDOT CH-FW-0)Headwall, Complete in Place EA $ ,5„9,5: 00 No. Description Unit Unit Price 109 72" (TxDOT CH-PW-0) Headwall, Complete in Place EA $ 7 110 72"(TxDOT CH-FW-0) Headwall, Complete in Place EA $ ,2c1,25: o° 642/t236, i° During the term of the contract, the successful vendor will be required to provide an itemize written quote for each miscellaneous concrete replacement job requested by Public Works, utilizing the descriptions as stated herein, and the unit prices submitted on this Bid Pricing Worksheet. Invoices will be submitted in the same manner. ATTACHMENT B REFERENCES WORKSHEET 1. COMPANY NAME: /00,4, I Eie.m>u- ` btaidd CONTACT NAME: c� / PHONE NUMBER: 97� -1#c/- 647/ EFFECTIVE DATES: DESCRIPTION OF SERVICES: Li-4,y , epn/c,&e., ��/l�c�,a� SYLP PLS — /e-h2dla /-6/al l,rl '-['7-, �e/ems✓ fj /41-du - /�ff-, — 71441.,i6 e_ , /462/‘,_e‘ �il �.e5 ado. 2. COMPANY NAME: ce//-9 //-0,;, CONTACT NAME: C4//IT o�� ,t PHONE NUMBER: y79 ��/ "/,9 EFFECTIVE DATES: DESCRIPTION OF SERVICES: 5-/-777P /1-//ey,5 ��u ��.�s /Ye.A.4e! fj o�/G�e�_ G zc q.K5 ' f C�GnerC i.�fi,u7 3. COMPANY NAME: (9' ", u Abny CONTACT NAME: /j)-2 PHONE NUMBER: q r -Z a;---(PG 4A./ EFFECTIVE DATES: �} DESCRIPTION OF SERVICES: ��' - 6—ice /'1 /, //2L/ 5/ > e4 /ffi'/a-C w -/ J:s a . �rY1/,, GLrGrIL /7Q_eld�l�� J e �'/t � .t� Ate,0-1,4/ bA_J/S. 15 ACCORD D CERTIFICATE OF LIABILITY INSURANCE _ DATE i E(M(MM/DD/YY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 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 CONTNAME: Linda Nichols Keystone Southwest Insurance Agency I °PHONE Fall: (972)771-3861 (ac.No):(972)772'1021 P O Box 1747 aooRess:lnichols@kswins.com INSURER(S)AFFORDING COVERAGE NMCIO Rockwall TX 75087 INSURER A Bi tum i no u s Casualty Corp 20095 INSURED INSURER B: F & F Concrete, LLC INSURERC: 1222 Montclair - INSURERD: INSURER E: Garland TX 75040 INSURERF: COVERAGES CERTIFICATE NUMBER:12/13 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSR MD POLICY NUMBER (MM/DD/YYYY)_(MMIDD/YYYY) LIMITS GENERAL UABIUTY Y Y EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 10,000 A CLAIMS-MADE I X I OCCUR CLP3576711 9/17/2012 9/17/2013 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —I POLICY I X 78T- ri LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) _ $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILYINJURY(Per $ AUTOS _AUTOSaccident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS (Per accident) $ _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION Y X WC STATU- OTH- AND EMPLOYERS'UABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) WC3576712 9/17/2012 9/17/2013 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 - DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Town of Flower Mound and its Officers, Employees and elected representatives are listed as additional insureds as to all applicable coverages. Waiver of subrogation is provided in favor of same for all applicable coverages. CERTIFICATEHOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Flower Mound Purchasing Agent 2121 Cross Timbers Rd. AUTHORIZED REPRESENTATIVE Flower Mound, TX 75028 James Leeker/LINDA � � l---?. ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r7n1 nnsl 01 Tha ar'r1Rf nama a nrl Innn aro ranictararl marlre of A(:l1Rrl f �CV ® DATE(MIvtY]D/YY YY) 4.... ----- , • CERTIFICATE OF LIABILITY INSURANCE 1/10/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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(les)Must 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 certMcate does not confer rights to the certificate holder In lieu oT such endorsement(s). RODIJCER CONTACT LarryBradleyInsurance Agency NAME g Y (NC,No, (972)276-6266 FAX 1409 Forest Ln (MAIL ,Elf) (.✓C,No} (972)216-9954 Garland, TX 75042 ADDRESS larry@dfwins.com INSURER(S)AFFORDING COVERAGE NAIC3 INSURER A. Farmers Insurance Company ISURED F & F Concrete LLC INSURER B INSURER C 1222 Montclair INSURER.D Garland, TX 75040 INSURER 972-202-9202 INSURER.F :OVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. 3R ADDL SUER POLICY EFF POLICY EXP 'R TYPE'OF INSURANCE INER MD POLICor HUMBER (MM/DD/YY'fY) (WADE/MOO) LIMITS GENERAL LIABILITf EACH OCCURRENCE $ DAMAGE IU HEN ILL. COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MACE OCCUR MED EXP(Ace one person) 5 PERSONAL$ADO INJURY 5 GENERAL AGGREGATE $ GEI,rL AG,RELATE LIME APPLIES PER PRODUCTS-COMP/OP AGOG $ POLICY n JECT n LOC $ AUTOMOBILE LIABILITY (talaccident) E $ 1,000,000 X ANY/LEG 6936-65-22 11/25/12 11/25/13 BODILY INJURY(Per person) $ ALL'. ' SCHEDULED A. ALEOS AUTOS BODILY INJURY(Per accident) $ — NON-OWNED PROPERTY DAMAGE HIRED AUTOS' AUTOS (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ E..CESS LIAR CLAIMS-MADE - AGGREGATE 5 DED RE rEIJTIC.N S WORT ERS COMPENSATION WC-TATA 011-I- /G40 EMPLOYERS LIABILITYY..N TORY LIMITS ER ANY FROPRIETOFVFARINER/EXECUTME OFFICEP.rMEMCER DICUJOED? IT N/A E L EACH ACCIDENT 5 (Mandatory In NH) E L DISEASE-EA EMPLOYEE 5 If yes.describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIME' 5 _ECRIRTION OF OPERATIONS I LOCATIONS r VEHICLES(Attach ACORD 101.Add banal ReITIafas.ScheOde,If more space is requo ed3 ertificate holder listed as additional insured with Waiver of Subrogation ERTIFICATE HOLDER CANCELLATION Town of Flower Mound SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Purchasing Agent THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN 2121 Cross Timbers Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Flower Mound, Texas 75028 AUTHORIZED REPRESENTATIVE I ©1988-20 0 ACOA D COR P TION. All rights reserved. CORD25(2010/05) The ACORD name and logo are registered marks of ACORD CONFLICT OF INTEREST QUEST ON WIRE, FORM C1Q Far vendor orother*Own doling Mails with usesgcwegtmental entity Tb quisettoanetro reflects changes made to the tatty tits 101, Lag_ti flier Settoton.. OMCEUSEONLY Tisa estiannair being filed-in accortiarrme with Chapter 178,Local Government Code Rc1,4,0 byr"apersonwh has buSinessrelationstgpasd bySe tion17ti: oiti }tulle a local gOvernmentalentity and Me rsansweetscequirementsunderSection 71L000na1_ • Byt it/is questionnairen edbef rf Watt ftlereoadsactministalnrofibelocal gavemmerital erdlsrnot laterthar he 7th businessday'atterthe date the person becxunes aware&facis that require-the stalementabefiled_SeeSecfitarl7fLOpa,.localGWern tCode_ 7i:person ocrnmfis an.offense if the krmwingly,v°iolates Se nn 1701106,Local Gvvemmerd:Code.:Anoffense undihussectfonisa:Class C en eanar_ u tilanworpersonwhohesabusinessietatianstripwit Intafgavernmentatentity_ ❑ Checirthisboalfyos arefffing an updatetoaprev oustyfaed o re. (The law requires that you file en updated completed quesfionnaire with the appropriate filing authority not later than the 7th business day atter the tie the originally fled questionnaire becomes:urt err ple oriaoa;aaa } n Name,oftacal narerYta over withw*Intferhas ea lOYmehtgr sblessretabbns1i1 11Jameoif( r This section(item 3 including subparts A,8.KM&0) mast be completed for each officer with whom the filer has an einployment'Minttrerhismess nelaticinstipip asi!ed by&Mien 178.661(1-a),Leal OgiverrinentCode.Attachhadditioa i pages to Mit.foram OIQ as essay. A, Es the focal gi erri ientiiffl a named in this section teeing or likely to recent'a tame income,other than investment income Gam the peeofthe guestiocwa re?. =Yes ErNo t3 tsthe ll afore lwljritsn iue }e". afhetif fri r t i ��,. tn�. rat at the (keel*of itre Ioc oi-ner named in iii .•Altll}the bumble'income.is not received from the local g`. G. is the filer of this questionnaire'employed byre or other business entity with nom.to WW1 the local government racer serves as an of6oer ar di-Motor.or bads an onnerstio of 1n pmt or more? FlYes r9ril° D.DesuThe each employment or business relatiansl ip with the local government racer named in tlts section. I' 4WC/J 9 f9'�d)0 2 Signature 00 pawl Wing Gra a wtm gee-gems trieeat Ai leo C.5.i29}2l®1 18