0129-K.pdf

RFP 0129-K, Page 1 of 18

BOILERPLATE

REVISED SEPTEMBER 2022

STATE OF WYOMING

DEPARTMENT OF ADMINISTRATION & INFORMATION

GENERAL SERVICES DIVISION, PROCUREMENT SECTION

2323 CAREY AVENUE

CHEYENNE, WY 82002

REQUEST FOR PROPOSAL NUMBER 0129-K

WYOMING GAMING COMMISSION

RACETRACK SAFETY INSPECTOR

PROPOSAL DUE DATE AND TIME

February 10, 2025 – 2:00:00 P.M. MOUNTAIN TIME

AGENCY REPRESENTATIVE:

Nicholas A. Larramendy

PROCUREMENT REPRESENTATIVE:

Jordan Tompkins

Jordan.tompkins@wyo.gov

307-777-6799 mailto:Jordan.tompkins@wyo.gov

RFP 0129-K, Page 2 of 18

Table of Contents

SECTION 1: REQUEST FOR PROPOSAL 3

SECTION 2: GENERAL PROVISIONS 5

SECTION 3: SPECIAL PROVISIONS INFORMATION 7

SECTION 4: KEY DATES 10

SECTION 5: ADMINISTRATIVE BACKGROUND 11

SECTION 6: REQUIREMENTS/SPECIFICATIONS 12

SECTION 7: PROPOSAL SUBMISSION REQUIREMENTS 18

SECTION 8: EVALUATION METHODOLOGY 21

SECTION 9: PROPOSAL PRICE SHEET AND SIGNATURE PAGE 24

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK.

RFP 0129-K, Page 3 of 18

SECTION 1: REQUEST FOR PROPOSAL

1. SUBMISSION OF PROPOSALS:

The A&I Procurement Office will receive proposals for providing safety inspections of all horse racing tracks for the State of Wyoming, Gaming Commission (Agency) through the Public Purchase online bidding system. Proposals are due no later than 2:00:00 P.M. (Mountain Time) on February 10, 2025.

1.1. Proposals should be accompanied by the attached Proposal Price Sheet and signed by the proper official of the firm. All proposals should be uploaded on the Public Purchase online bidding system. Proposals sent by facsimile, email or paper copy may be rejected.

1.2. Proposals should be submitted through the Public Purchase online bidding system on or before the date and time specified. Proposals received after the date and time specified may be rejected.

1.3. The State of Wyoming reserves the right to withdraw this Request for Proposal, without cause, at any time before a contract has been fully signed and submitted to the A&I Procurement Office.

2. MODIFICATIONS OR WITHDRAWAL OF PROPOSALS:

2.1. A proposal may be altered through the Public Purchase online bidding system before the proposal due date and time contained in this document.

2.2. The proposer may withdraw its proposal through the Public Purchase online bidding system up to the proposal due date and time contained in this document. If a proposal is accepted and the proposer fails to furnish the service agreed upon in the proposal, that proposer may be eliminated from future consideration.

3. PREPARATION OF PROPOSALS:

3.1. A proposal may be rejected if it modifies any of the provisions, specifications or minimum requirements of the Request for Proposal.

3.2. In case of error in the extension of prices in the proposal, unit prices will govern.

4. AWARD AND CONTRACT INFORMATION:

4.1. The State of Wyoming will ensure that minority business enterprises will be afforded full opportunity to submit proposals. The State of Wyoming will not discriminate on the grounds of age, race, color, sex, creed, national origin, or disability status.

4.2. The proposer also, agrees that should their firm be awarded a contract, it will not discriminate against any person who performs work there under because of age, race, color, sex, creed, national origin or disability. In addition, the successful proposer shall comply with the Americans with

Disability Act and the Wyoming Fair Employment Practices Act.

4.3. The proposer expressly warrants to the State that it has the ability and expertise to perform the contract if awarded. In doing so, it shall use the highest standards of professional workmanship.

4.4. The State of Wyoming reserves the right to reject any or all proposals, to waive any informality or technical defect in the proposals, or to award the contract in whole or in part, if deemed to be in the best interest of the State to do so. The A&I Procurement Office will award the contract to the firm, determined to have the most responsive and responsible proposal by the Wyoming

Gaming Commission.

RFP 0129-K, Page 4 of 18

4.5. The successful proposer will be required to agree to and execute a formal contract with the State containing terms required by the Attorney General with reasonable adjustments acceptable to the

State.

4.6. If applicable, the State will negotiate payment terms based upon a schedule to be determined by the proposer and the State. Paying invoices will be based upon the proposer successfully completing the deliverables within the stated deadlines, and upon the Agency’s written acceptance of the deliverables or services.

DATED: January 8, 2025

State of Wyoming

Procurement Section

Buyer: Jordan Tompkins

RFP 0129-K, Page 5 of 18

SECTION 2: GENERAL PROVISIONS

1. INSURANCE:

1.1. The contract between the successful proposer and the State shall require the successful proposer to carry certain insurance policies. All such insurance policies, except workers’ compensation and unemployment compensation policies, shall contain a waiver of subrogation against the Agency and the State, its agents and employees.

2. LAWS TO BE OBSERVED:

2.1. The proposer shall keep fully informed of, and comply with, all applicable federal and state laws or rules, all local bylaws, regulations and all orders and decrees of bodies or tribunals having any jurisdiction or authority. The proposer shall protect and indemnify the State and its representatives against any claim or liability arising from or based on the violation of any law, bylaw, ordinance, regulation, order or decree whether by himself or its employees.

3. ASSIGNMENT:

3.1. The proposal shall not be assigned by the proposer. Third party participation is authorized only as a joint venture that shall be clearly stated in detail in the original proposal and signed by all parties participating.

3.2. The proposer shall not enter into any subcontracts for any of the work contemplated under this

Request for Proposal without the State’s prior written authorization.

4. EXTENSION AND AMENDMENT:

4.1. The proposer and the State covenant and agree that this proposal or subsequent contract may, with the mutual approval of the proposer and the State, be extended one year at a time, for a total contract period not to exceed three (3) years. (Agency may modify reasonably to suit project needs)

5. AUDIT AND ACCESS TO RECORDS:

5.1. The State or any of its duly authorized representatives shall have access to the proposer’s books, documents, papers, electronic data and records that are directly pertinent to this Request for

Proposal.

6. CONFLICT OF INTEREST:

6.1. The proposer warrants that no kickbacks, gratuities, or contingency fees have been paid in connection with this Request for Proposal and none have been promised. The proposer warrants that no one being paid pursuant to the proposal is engaged in any activity that would constitute a conflict of interest with respect to the purchases of the proposal.

7. NO FINDER’S FEE:

7.1. The proposer warrants that no finder’s fee, employment agency fee, or any such fee related to the proposal shall be paid.

8. SOVEREIGN IMMUNITY:

8.1. Pursuant to Wyoming Statute § 1-39-104(a), the State of Wyoming and the Agency expressly reserve sovereign immunity and specifically retain all immunities and defenses available to them as sovereigns. The proposer acknowledges that the State of Wyoming has sovereign immunity and only the Wyoming Legislature has the power to waive sovereign immunity. Designation of

RFP 0129-K, Page 6 of 18 venue, choice of law, enforcement actions, and similar provisions shall not be construed as a waiver of sovereign immunity. The parties agree that any ambiguity in this Request for Proposal shall not be strictly construed, either against or for either party, except that any ambiguity as to sovereign immunity shall be construed in favor of sovereign immunity.

9. INDEMNIFICATION:

9.1. The proposer shall release, indemnify, and hold harmless the State, the Agency and its officers, agents, and employees from any and all claims, suits, liabilities, court awards, damages, costs, attorneys’ fees, and expenses arising out of the proposer’s failure to perform any of the proposer’s duties and obligations hereunder or in connection with the negligent performance of proposer’s duties and obligations, including, but not limited to, any claims, suits, liabilities, court awards, damages, costs, attorneys’ fees, and expenses arising out of proposer’s negligence or other tortious conduct.

10. APPLICABLE LAW/VENUE:

10.1. The construction, interpretation, and enforcement of this Request for Proposal shall be governed by the laws of the State of Wyoming, without regard to conflicts of law principles. The terms

“hereof,” “hereunder,” “herein,” and words of similar import, are intended to refer to this Request for Proposal as a whole and not to any particular provision or part.

11. RIGHT OF OWNERSHIP AND MARKETING OF INTELLECTUAL PROPERTY

AND INTELLECTUAL ASSETS SUBMITTED FOR THE RFP (IF APPLICABLE):

11.1. It is acknowledged and agreed that the only party with a right to market, trademark, patent, copyright, or any like right to any intellectual property or intellectual assets submitted in relation to the Request for Proposal shall be and is solely vested in the State. This includes all intellectual property and intellectual assets related to both the written proposal and the oral presentation and any and all documents, pitches, products, media pitches, web screens, layouts, etc. produced for the written proposal and the oral presentation, and any updates, changes, alterations, or modifications to or derivative works.

RFP 0129-K, Page 7 of 18

SECTION 3: SPECIAL PROVISIONS INFORMATION

PROPOSALS SHOULD BE SUBMITTED THROUGH THE PUBLIC PURCHASE ONLINE BIDDING

SYSTEM BY 2:00:00 P.M. MOUNTAIN TIME ON FEBRUARY 10, 2025. PROPOSALS RECEIVED

AFTER THE DATE AND TIME SPECIFIED MAY BE REJECTED.

It is the responsibility of the proposer to clearly identify all information that is considered confidential in accordance with the Wyoming Public Records Act, Wyoming Statute §16-4-201 through §16-4-205. Please identify each confidential page with the word “CONFIDENTIAL” in capital, bold letters centered at the bottom of each page. Information not clearly marked may be considered public. If the proposer submits information that it believes is confidential, it should include a statement justifying its basis for that belief.

1. STATE PARTIES:

1.1. This Request for Proposal is issued by the Wyoming Department of Administration and

Information, General Services Division, Procurement Section (Procurement) on behalf of the

Wyoming Gaming Commission (Agency).

1.2. Throughout this document and others in connection with this project, various references are made, or will be made to the “State.” Generally, whenever this reference appears, the term “State” incorporates all state agencies working on this project.

1.3. It should be understood that the Director of Wyoming Gaming Commission is empowered to be the signatory on all contracts, agreements, or modifications pertaining to this project. Any contracts, agreements, or modifications not bearing this signature or that of a designee are invalid.

2. CONTENT AND PROCUREMENT POINTS OF CONTACT:

2.1. Procurement is the primary point of contact from the date of release of the Request for Proposal until a proposer is selected and the selection is announced.

2.2. Written questions about the procurement should be submitted through the Public Purchase online bidding system until 2:00:00 P.M. Mountain Time on January 24, 2025. Any questions received after that deadline may not be accepted or considered. Each question should be submitted individually. It is the proposer’s responsibility to check the Public Purchase online bidding system for answers to questions, addenda, or bid tabulations. Telephone calls, emails or faxes may not be accepted.

2.3. Written responses will be available through the Public Purchase online bidding system. Responses will not identify the firm that submitted the question. Only the written answers issued by the

Agency are the official position on an issue, and these answers shall become part of the Request for Proposal.

3. RESTRICTIONS ON COMMUNICATIONS WITH AGENCY STAFF:

3.1. Until a proposer is selected and the selection is announced, proposers shall not communicate with

Agency staff except via written questions through the Public Purchase online bidding system.

3.2. If a proposer violates this restriction, the State reserves the right to reject the proposal.

4. EFFECTIVE DATES OF PROPOSAL:

4.1. All terms, conditions and costs quoted in the proposer’s response will be binding on the proposer for one-hundred eighty (180) days from the effective date of the proposal.

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5. ADVERTISING AWARD CONDITIONS:

5.1. A fully executed contract should be completed with the State before the successful proposer may advertise the award of the contract or the services being performed. The proposer should agree not to refer to awards in commercial advertising in such a manner that states or implies that the firm or its services are endorsed or preferred by the State of Wyoming.

6. CONTRACT NEGOTIATIONS:

6.1. The State will notify the most qualified/successful proposer and negotiate a contract in accordance with the Wyoming Attorney General’s contract guidelines. The successful proposer will be required to enter into and sign a formal contract with the Agency.

6.2. In the event the Agency determines contract negotiations are making no forward progress, negotiations will be terminated, and at the State’s sole discretion, negotiations may be initiated with the next most qualified/successful proposer, or the RFP may be withdrawn or reissued. This process will be followed until an agreement is reached, or until the State determines that the RFP will be withdrawn or reissued. The State assumes no obligation to a selected proposer until an agreement is reached and a contract is fully executed. The State will not negotiate concurrently with more than one proposer for the same award.

7. BEGINNING WORK:

7.1. The successful proposer may not perform any work that could be billed until a contract has been executed. The State will not pay for any work by the proposer before a contract is executed.

8. COPYRIGHT INFRINGEMENT:

8.1. The proposer warrants that no materials, products, and services proposed will infringe upon or violate any patent, copyright, trade secret, or other proprietary right of any third party. In the event of a claim by any third party against the State, the State shall promptly notify the proposer, and the proposer shall defend the claim. The defense will be at the proposer’s expense.

9. COST OF PREPARING PROPOSALS:

9.1. All costs incurred for preparing the proposal and for other procurement related activities are solely the proposer’s responsibility. The State of Wyoming will not provide reimbursement of these costs.

10. RISKS AND LIABILITIES:

10.1. By submitting a proposal, a proposer assumes any and all risks and liability associated with information in the proposal and its release.

11. AMENDMENTS:

11.1. The State reserves the right to amend this Request for Proposal before the proposal submission date. Amendments shall be uploaded to the Public Purchase online bidding system.

It is the proposer’s responsibility to check the Public Purchase online bidding system for amendments.

12. PROPERTY DAMAGE AND LIABILITY INSURANCE:

12.1. The proposer may be required to furnish proof of property damage liability insurance in the amount deemed necessary by the Agency for this project, if applicable.

RFP 0129-K, Page 9 of 18

12.2. Questions regarding required insurance coverage and limits for this project should be submitted in writing, in accordance with instructions outlined in the special provisions.

13. MISREPRESENTATION OF INFORMATION:

13.1. Misrepresentation of a proposer’s status, experience, or capability in the proposal may result in disqualification of that proposer from the selection process. Discovery of litigation or investigations in a similar area of endeavor may, at the discretion of the Agency and after consultation with Procurement, preclude the proposer from the selection process.

14. DISPOSITION OF PROPOSALS:

14.1. All material submitted becomes property of the State of Wyoming, which is under no obligation to return any of the material submitted.

15. LEGAL CONSIDERATIONS:

15.1. This Request for Proposal is issued under Wyoming Statute §9-2-3204.

16. PROPOSER RELATIONS WITH STATE:

16.1. The proposer and its staff will have an ongoing relationship with the State that is based on trust, confidentiality, objectivity and integrity. The proposer will operate at all times in the State’s best interests and in a straightforward, trustworthy and professional manner. The proposer shall:

16.1.1. Work cooperatively with the State’s staff and business partners whenever required.

16.1.2. Work cooperatively with the staff of other proposers whenever required.

RFP 0129-K, Page 10 of 18

SECTION 4: KEY DATES

Event Description Date Time (Mountain Time)

RFP Release Date January 8, 2025 N/A

Closing Date for Questions January 24, 2025 2:00 P.M.

Response to Questions Returned February 3, 2025 2:00 P.M.

RFP Submission Due Date February 10, 2025 2:00:00 P.M.

Tentative Award Date March, 2025 N/A

Tentative Work Begins Date May, 2025 N/A

RFP 0129-K, Page 11 of 18

SECTION 5: ADMINISTRATIVE BACKGROUND

1. INTRODUCTION AND BACKGROUND:

1.1. The Wyoming Gaming Commission provides a safety inspection of all four live horse racing tracks each season prior to the beginning of their race meets to ensure the tracks are in proper condition for the safety of the equine and human athletes.

2. PURPOSE AND INTENT:

2.1. The purpose of this Request for Proposal (RFP) is to solicit competitive proposals from proposers who can offer horse racing racetrack safety inspections to meet the Agency’s needs and expectations, as described within this RFP.

RFP 0129-K, Page 12 of 18

SECTION 6: REQUIREMENTS/SPECIFICATIONS

1. SCOPE OF PROJECT:

The State of Wyoming, in coordination with the Wyoming Gaming Commission, is requesting proposals for the contract position of Racetrack Safety Inspector.

The Racetrack Safety Inspector will conduct a thorough inspection of all 4 Wyoming horse racing tracks prior to the start of their respective race meets to ensure the racetracks are safe for both the equine and the human athletes. Any deficiencies found during the inspections will be communicated to the

Wyoming Gaming Commission as well as the Management of the racetrack so that corrective actions can be taken. After corrective actions have been taken, the Safety Inspector will re-inspect the deficient area to ensure the corrections were made to standard.

The Racetrack Safety Inspector shall be considered a representative of the State of Wyoming and should conduct him/herself in a professional and courteous manner.

The Wyoming Gaming Commission will make one award and enter into one Contract with one

Racetrack Safety Inspection Company to service all four race tracks. Multiple awards will NOT be considered.

2. GENERAL REQUIREMENTS:

The Racetrack Safety Inspector will conduct thorough safety inspections in 2025 at Energy Downs in

Gillette, Wyoming; Wyoming Downs in Evanston, Wyoming, Sweetwater Downs in Rock Springs, Wyoming and Thunder Plains in Cheyenne, Wyoming. These inspections must be completed prior to the opening day of the race meet, and with enough time for the management of the respective racetracks to correct any potential found deficiencies. Energy Downs will start their race meet on May 16, 2025.

Wyoming Downs will start their race meet on June 28, 2025. Thunder Plains will start their race meet on August 1, 2025. Sweetwater Downs will start their race meet on August 16, 2025.

The thorough inspection will include all safety related aspects of the racetrack including but not limited to the following:

Track surface: The condition, depth, composition, width, and moisture levels.

Safety rails: Type, condition, height, markings

Starting gates: Condition

Paddock: Saddling stall condition, ground condition, overall layout and condition.

Veterinarian Test Barn: Adequately equipped, overall condition.

Barns: Material type, condition.

Track Maintenance Equipment: Overall condition and amount.

Security: Overall track security for participants.

Safety Policies: Adequate policies in place.

RFP 0129-K, Page 13 of 18

3. REPORTING:

3.1. The Racetrack Safety Inspector will be required to make a verbal report to the Wyoming Gaming

Commission, and the racetrack Management team at the conclusion of each inspection with any deficiencies found during the inspection so corrective action can be made prior to opening day.

3.2. The Racetrack Safety Inspector will also be required to submit a detailed written report to the

Wyoming Gaming Commission after receiving back any laboratory submissions for the dirt samples taken during inspections for each racetrack.

RFP 0129-K, Page 14 of 18

SECTION 7: PROPOSAL SUBMISSION REQUIREMENTS

1. PRE-PROPOSAL CONFERENCE:

1.1. A pre-proposal conference will not be held in connection with this RFP.

2. TECHNICAL PROPOSAL, FORMAT AND CONTENTS:

2.1. Proposals should be submitted in two major sections: the Technical Proposal and the Cost

Proposal. Omission of this section or any item within this section may result in the proposal being eliminated. The proposer should, at a minimum, address the following points:

2.1.1. Resumes: The proposer should include brief resume detailing past experience in the horseracing industry and specifically in inspecting horseracing tracks.

3. COST PROPOSAL FORMAT AND CONTENT:

3.1. Cost Proposal Price Sheets: These pages are required by the A&I Procurement Section and are the

State’s official pricing documents. Each applicable proposer should upload the Technical Proposal and the Cost Proposal Sheets as separate documents, and identify them as such, using the Public

Purchase online bidding system. The price to be entered on this page is the total fixed price. In case of error in the extension of prices in the proposal, unit prices will govern. Cost breakdowns are not included on this page. The proposer should ensure all signatures and identifying numbers are properly affixed to this page in order for the Cost Proposal to be accepted.

4. ORAL PRESENTATIONS / INTERVIEWS:

4.1. Oral Presentations will not be held in connection with this RFP.

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SECTION 8: EVALUATION METHODOLOGY

1. OVERVIEW:

1.1. The Agency will conduct a comprehensive, fair, objective and impartial evaluation of proposals received in response to this Request for Proposal. Proposals will be evaluated independently by the evaluation committee members. The evaluation committee shall be made up of members representing the project subject expertise. The evaluation committee will review and score all proposals independently and consolidate the scores in order to determine the award.

2. COMPLIANCE WITH MANDATORY REQUIREMENTS:

2.1. To be considered responsive, a submitted proposal should meet the minimum requirements defined in this RFP. The minimum requirements are intended to ensure that evaluation of the Technical

Proposal can proceed and that the Contractor agrees to perform all responsibilities within the RFP.

3. TECHNICAL SCORING AND RANKING:

3.1. EXPERIENCE IN THE HORSERACING INDUSTRY: 30 Points. Proposer should present information and materials describing his/her experience in the horseracing industry.

3.1.1. Details of the number of years of experience in the horseracing industry and in what capacity.

3.2. EXPERIENCE IN CONDUCTING SAFETY INSPECTIONS ON RACETRACKS: 50 Points.

The proposer should provide information describing his/her experience conducting safety inspections on horseracing racetracks.

3.2.1. The proposer should include the number of years he/she has been conducting safety inspections on racetracks.

3.3. RESPONSIVENESS TO REQUEST for PROPOSAL: 10 Points. The proposers level of interest in the position as indicated by the responsiveness to the posting.

4. COST SCORING AND RANKING:

4.1. COST ANALYSIS: 10 Points. The cost shall be presented as key deliverables in the form of individual cost and a project total (sum of the deliverables). The State of Wyoming reserves the right to conduct a cost analysis of the proposer’s budget proposal. The analysis will include a review of all the associated costs based on the technical content of their submission. The total project cost should include all of the items listed in the scope of work. If any of the scope of work services cannot be provided in the proposal or the requirement cannot be met, this is to be clearly explained as to why and what alternative approach will be and its associated cost. If there are no exclusions or exceptions, it will be determined that all of the criteria have been met for the price quotes, inclusive of all personnel, overhead, travel, equipment usage, and other miscellaneous costs for the specified contract period.

5. EVALUATION POINT SUMMARY:

Experience in the horseracing industry 30 Points

Experience in conducting safety inspections on racetracks 50 Points

Responsiveness to request for proposal 10 Points

Cost Analysis 10 Points

Total 100 Points

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6. FINAL RANKING OF PROPOSALS:

6.1 The State of Wyoming will be the sole authority of evaluating proposals. The firm that best meets the conditions of each of the criterion will be awarded the highest (not necessarily maximum) points for that criterion. The balance of the proposals will be rated based on their evaluated points. After each criterion is evaluated, the proposer with the highest number of points will be notified. The State of

Wyoming reserves the right to reject any or all proposals, to waive any informality of technical defect in the proposals, or to award the contract in whole or in part, if deemed in the best interest of the State to do so.

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SECTION 9: PROPOSAL PRICE SHEET AND SIGNATURE PAGE

The undersigned agrees to provide Racetrack Safety Inspections to the Wyoming Gaming Commission in accordance with the Request for Proposal, General Provisions, Special Provisions and Proposal Price Sheet for Request for Proposal Number 0129-K.

Total Evaluated all-inclusive price for contract

1. BY SUBMISSION OF A PROPOSAL, THE PROPOSER CERTIFIES:

1.1. Prices in this proposal have been arrived at independently, without consultation, communication or agreement for the purpose of restricting competition.

1.2. The Proposer has not and will not attempt to induce any other person or firm to submit a proposal for the purpose of restricting competition.

1.3. The person signing this proposal certifies they are authorized to represent the company and are legally responsible for the price and supporting documentation provided as a result of this advertisement.

1.4. Proposer will comply with all applicable state and federal regulations, policies, guidelines and requirements.

Prices in this proposal have not been knowingly disclosed by the proposer nor will they be disclosed prior to award.

2. GENERAL INFORMATION:

Proposer Name: Phone:

Email Address:

Mailing Address:

City: State: Zip:

Employer Identification Number (EIN):

3. OWNERSHIP AND CONTROL:

Proposer’s Legal Structure

Sole Proprietorship General Partnership Corporation

Limited Partnership Other

The proposer shall provide to the Agency a certificate of good standing from the Wyoming Secretary of

State or other proof that proposer is authorized to conduct business in the State of Wyoming before performing work under this Contract. The proposer shall ensure all annual filing and corporate taxes due and owing to the Wyoming Secretary of State’s office are up-to-date before signing the contract. Proposers may contact the Wyoming Secretary of State’s office, Corporate Division at (307) 777-7311 for assistance.

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4. VENDOR VERIFICATION

I certify under penalty of perjury, that I am a responsible official (as identified above) for the business entity described above as the proposer, that I have personally examined and am familiar with the information submitted in this disclosure and all attachments, and that the information is true, accurate and complete. I may be charged significant penalties for submitting false information, including criminal sanctions, which can lead to fines and/or imprisonment.

Signature Date

Name Title