Rail Replacement for Starr_s Mill High School.pdf

Rail Replacement for Starr’s Mill High School Football Stadium

Request for Proposals No. 25-005-075 Georgia Procurement Registry Event No. PE-65615-NONST-2025-000000041

Objective

Fayette County Public Schools (hereinafter FCPS or the District) is soliciting proposals via this Request for Proposals (hereinafter RFP) from interested and qualified respondents to provide steel handrail replacement, as specified within this solicitation, throughout Starr’s Mill High School Football Stadium.

As is more fully explained in this RFP, an award, if made, will be made to the responsible and responsive respondent who provides the best solution to the described need, taking into consideration multiple evaluation factors as determined by the FCPS and defined herein.

It is the respondent’s responsibility to address all elements of this RFP. Any respondent failing to meet the terms and conditions herein may suffer a reduction in their evaluation score up to a complete rejection of their proposal.

Responses Due

Responses to this request for proposals are due no later than the date and time specified in the timeline of events either physically or electronically to the FCPS Purchasing Department located at Facilities Services, 939 Goza Road, Fayetteville, Georgia 30215. Proposals received after the specified date and time will not be considered.

Section A: Instructions to Respondents

1. Designated Representative

1.1. The FCPS Purchasing Department has designated the following staff member as the representative of the Department and District during the solicitation process:

Jamie Marrero ( marrero.jamie@fcboe.org )

2. Respondent Registration

2.1. Respondents are encouraged to register with the designated representative listed above via email after reviewing this solicitation.

2.2. Respondents who register will automatically receive an email update with additional documents such as addenda and be notified of award issuance, even if they choose not to submit a proposal.

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Rail Replacement for Starr’s Mill High School Football Stadium (RFP 25-005-075)

3. Schedule of Events

3.1. RFP Released: Thursday, September 12, 2024

3.2. Respondent Questions Due: Wednesday, October 2, 2024

3.3. Addenda Issued (if applicable): Friday, October 4, 2024

3.4. Respondent Proposals Due: Before 10:00AM (EST), Friday, October 11, 2024

3.5. Anticipated Project Start: December 2024

4. Georgia Open Records Act Compliance (O.C.G.A. § 50-18-70)

4.1. This solicitation and any resulting responses, evaluations, contracts, agreement, or purchase orders are subject to the Georgia Open Records Act and may be released publicly.

4.2. Pursuant to the act, for any records or documents marked as “confidential” or “trade secrets” the respondent must submit and attach to the records an affidavit affirmatively declaring that specific information in the records constitutes trade secrets according to O.C.G.A. § 10-1-761.

4.2.1. Failure to attach such an affidavit will result in the record being considered public and subject to release under the Georgia Open Records Act.

4.2.2. If FCPS determines that the specifically identified information does not constitute a trade secret, it shall notify the entity submitting the affidavit of its intent to disclose the information within ten days unless prohibited from doing so by an appropriate court order.

4.2.3. In the event the entity wishes to prevent disclosure of the requested records, the entity may file an action in superior court to obtain an order that the requested records are trade secrets exempt from disclosure. The entity filing such action shall serve the requestor with a copy of its court filing.

4.2.4. If the agency determines that the specifically identified information does constitute a trade secret, the agency shall withhold the records, and the requester may file an action in superior court to obtain an order that the requested records are not trade secrets and are subject to disclosure.

-2-https://advance.lexis.com/api/document/collection/statutes-legislation/id/61XD-TBX1-JN6B-S0Y8-00008-00?cite=O.C.G.A.%20%C2%A7%2050-18-70&context=1000516 http://www.open.georgia.gov/ https://advance.lexis.com/api/document/collection/statutes-legislation/id/61XD-TBV1-F06F-244V-00008-00?cite=O.C.G.A.%20%C2%A7%2010-1-761&context=1000516

5. Solicitation Documents and Forms

5.1. Documents and forms required for submission as part of this RFP can be found on the FCPS Purchasing Department website.

5.2. Failure to include required submissions listed herein may result in a rejection of the proposal.

5.3. A list of required forms is contained herein and additional submissions may be required per the specifications contained herein.

6. Proposal Delivery

6.1. Proposals should be sent to the FCPS Purchasing Department and must be received before the proposal due date and time specified in the solicitation.

6.2. Proposals may be submitted electronically, by mail, or hand-delivered to Facilities Service, 939 Goza Road, Fayetteville, Georgia 30215, Attention: Purchasing Department.

6.3. No faxed or telephone proposals will be accepted or considered.

6.4. Proposals may be emailed to the designated representative if meeting the following guidelines:

6.4.1. Emailed proposals must be in a consistent, clear, and readable format and complete. (Adobe PDF format is preferred unless specified otherwise)

6.4.2. All proposal documents should be bound in one document. Multiple separate documents may result in evaluation score reductions.

7. Attachments

7.1. Any specification listed with “Must Include Attachment” should include a document within the proposal conforming to standards set forth.

7.2. All attachments must be clearly marked and labeled using the following format:

Attachment #, Solicitation Reference, Respondent Name, Solicitation Title, and Number.

8. Proposal Format Requirements

8.1. The proposal should be typed and legible as well as formatted to comply with accessibility standards (refer to ADA and Section 508 compliance).

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8.2. The solicitation document has been carefully organized. All sections, specifications/requirements, and appendices are numbered; therefore proposals should be organized in the same manner referencing the solicitation document when necessary.

8.3. Proposals must be submitted with the following sections clearly identified and delineated:

8.3.1. Letter of Interest

8.3.2. Technical Proposal

8.3.3. Qualifications and Experience

8.3.4. References

8.3.5. Price/Cost

9. Multiple Proposals from the Same Respondent

9.1. Respondents may submit more than one proposal when offering multiple alternatives.

9.2. Proposals must be separate and each should conform to all terms and conditions within the solicitation.

9.3. Proposals must be labeled separately so as to easily identify different proposals from the same respondent.

Section B: Scope of Work and Specifications

10. Background and Project Overview

10.1. The purpose of this Request for Proposal is to secure firm pricing to replace the steel handrails throughout the Starr’s Mill Football Stadium concrete bleachers.

This project will include, but is not limited to; removal of existing handrails, fabrication and installation of new steel handrails, concrete repairs, rub chip corners, and glass bead blasting/sand blasting to clean welding and writing of handrails. Site visits are required to bid on this project and collect the necessary information, measurements, and extent of concrete repairs. This project is turn-key.

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10.2. Site Visits (REQUIRED)

10.2.1. A site visit is required for your company to bid on this project. Site visits must be scheduled by contacting Beria Orr, Maintenance Coordinator, via email orr.robert@fcboe.org or by telephone 770-460-3522.

10.2.2. Site visits will not be scheduled within 72 hours of the solicitation due date. All site visits must be scheduled beforehand.

11. Design/Technical Requirements and Specifications

11.1. Handrail Fabrication Specifications (minimum):

11.1.1. Option #1: 1 ¼” Schedule 40 Stainless Steel Pipe

11.1.1.1. Glass bead blasted (cleaning all welds/writing off handrails)

11.1.2. Option #2: 1 ¼” Schedule 40 Steel Pipe

11.1.2.1. Sand-blasted and powder coated

11.2. All bidding contractors must be licensed and/or certified to complete this project.

11.3. Fabrication and installation must meet all codes and regulations.

11.4. Contractor will be responsible for providing all equipment required to complete this project.

12. Performance and Service Requirements

12.1. Project schedule must be presented and approved by Mike Satterfield, Director of Facilities Services.

12.1.1. All proposed scheduling must be approved at least 72 hours in advance.

12.1.2. Contractor can work during school hours, as long as the school administration approves the proposed dates and times.

12.1.3. If the contractor chooses to work before school, after school, during holiday breaks, or on the weekends they may do so with prior approval

12.1.3.1. Fayette County Public Schools will not be responsible for additional funding for overtime.

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12.2. Contractor is responsible for all materials, shipping/freight, labor, equipment, installation, and project completion to the satisfaction of Fayette County Public Schools.

12.3. Contractor is responsible for the removal and disposal of all job related debris, with the exception of the existing handrails, and disposed of within the EPA guidelines.

12.3.1. Existing handrails, once removed, will be picked up by Facilities Services and scraped.

12.3.2. Contractor must not use any containers on the property (to dispose of project debris) that are in the possession of Fayette County Public Schools.

12.3.3. Contractor must provide their own container for disposal.

12.4. Contractor is responsible for cleaning the project area at the end of each day.

12.4.1. No screws, metal scrap/shavings, tools, trash, or other job related debris should be left onsite between project working days.

12.5. Contractor is responsible for roping/caution taping off areas that should not permit individuals to have access or enter during construction.

12.5.1. Any areas prohibited (roped/caution taped off) must be clearly marked with direction.

12.5.2. Mike Satterfield (Director of Facilities Services) and the school administration must be notified of these prohibited areas at the end of each working day.

Section C: Evaluation of Proposals

13. Evaluation Committee

13.1. All proposals deemed responsive will be evaluated by a review committee composed of project administrators and end-users.

13.2. Criterions based on qualifications and experience, a submitted proposal, and price/cost will be used in the evaluation process.

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14. Evaluation Methodology

14.1. The committee will perform a complete evaluation and verification process on a rating system of required proposal components contained herein based on an “Excellent”, “Good”, “Fair”, or “Poor” rating.

14.1.1. Excellent ratings will be issued four (4) points.

14.1.2. Good ratings will be issued three (3) points.

14.1.3. Fair ratings will be issued two (2) points.

14.1.4. Poor ratings will be issued zero (0) points.

15. Interviews and Presentations

15.1. Post-proposal interviews and presentations may be required, in person at the committee’s direction or desire.

15.2. Submission of a proposal does not guarantee an interview or presentation.

15.3. Selection for interviews and presentations is at the sole discretion of the evaluation committee.

16. Contract Award and Negotiations

16.1. The evaluation committee will issue a recommendation to award following the outcome of its evaluation process.

16.2. The committee reserves the right to reject any or all bids.

16.3. A recommendation to award does not guarantee a contract. Final approval from the Superintendent and/or Board of Education may be required.

16.4. Following a recommendation to award, the Superintendent or their designee may engage in final negotiations with the selected respondent.

Section D: General Terms and Conditions

The FCPS General Terms and Conditions are posted on the Purchasing Department website under the heading of Vendor Terms, Conditions, and Forms and attached to this solicitation. By submission of a proposal, the respondent acknowledges they have read and understood these General Terms and Conditions as well as any terms and conditions contained herein.

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Section E: Special Terms and Conditions

17. Contract Incorporation

17.1. This solicitation will be incorporated into any resulting contract.

17.2. When this solicitation and any resulting contract are in conflict, Fayette County Public Schools will determine the controlling method.

17.3. Only the Superintendent or his direct designee may sign or enter into a contract on behalf of Fayette County Public Schools.

18. Term

18.1. The proposal term will begin from the time of award through June 30, 2025, with no option to renew.

19. Cooperative Purchasing

19.1. This solicitation allows for other Fayette County, Georgia government entities, including local municipalities, to purchase from the awarded contract at the same prices quoted during the effective term pending an agreement between the awarded respondent(s) and the government entity.

20. Substitutions and Alternates

20.1. Products similar to or other than specified may be acceptable if in compliance with all requirements of these specifications and are of the same or better quality.

20.2. The respondent must provide substantiation that proposed substitution or alternate does not violate any other manufacturer's patents, patents allowed, or patents pending and that the alternate proposed meets the same specifications contained herein.

20.3. The FCPS shall be the sole determiner of specification compliance and alternate acceptability.

20.4. No pre-proposal approval will be given for a proposed alternative.

21. Insurance Requirements

21.1. Respondents are required to submit a current and valid Certificate of Insurance (COI) per the General Terms and Conditions and any specification contained herein.

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21.2. Should the respondent choose to utilize subcontractors for installation or other matters, the respondent must provide a valid COI for the subcontractor per the requirements of the General Terms and Conditions.

Section F: Required Forms and Submissions

22. Required Respondent Submissions

22.1. Product Data: Fayette County School District must receive all product data that pertains to solicitations work scope, this includes but is not limited to;

22.2. Product Data Sheet: Manufacturers Specification Sheets

22.3. Product Certification: Submit manufacturer’s certification that products and materials comply with the requirements of the specifications.

22.4. Submit manufacturer's catalog cuts, material safety data sheets (MSDS), brochures, specifications;

22.5. Preparation, maintenance, and installation instructions and recommendations;

22.6. Storage, handling requirements, and recommendations.

22.7. Warranties: Submit warranty documents according to specifications (if applicable).

22.7.1. Include any and all manufacturer’s warranties for each item.

23. Cost Proposal

23.1. All respondents must include a separate cost proposal.

23.2. Pricing not entered in the cost proposal form will not be considered.

23.3. If pricing variations exist for different finishes/materials/options the respondent must include an attachment describing variations and associated costs.

23.4. Costs should be in line-item format detailing all costs applicable to the proposed solution and a grand total cost to execute the proposed solution fully.

24. Letters of Recommendation

24.1. The respondent must include a minimum of three (3) letters of recommendation dated within the previous two (2) calendar years.

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24.2. Letters must be from clients/customers who have engaged the respondent in previous services and must include details such as a description/scope of work, timeline and budget parameters, and assessment of the respondent’s ability to complete work/service as specified.

24.3. Each letter must contain contact information including organization/firm, contact name, telephone, and email.

24.4. Letters from organizations and projects similar to the scope and size of Fayette County Public Schools are preferred.

25. Solicitation Response Form

25.1. Respondents must complete a Solicitation Response Form attached hereto and available online at the Purchasing Department website.

25.2. This form must be placed on top, or as the first page of your proposal.

25.3. Failure to attach could result in a reduction in score or a rejection of your proposal.

26. Business Capability Information Questionnaire

26.1. Respondents must complete a Business Capability Form attached hereto and available online at the Purchasing Department website.

26.2. Failure to attach could result in a reduction in score or a rejection of your proposal.

27. Certificate of Insurance

27.1. The respondent must submit a current certificate of insurance detailing coverage limits as defined in this RFP and the FCPS General Terms and Conditions.

27.2. Failure to attach could result in a reduction in score or rejection of your proposal.

27.3. The selected respondent will be required to submit a COI naming Fayette County Public Schools as an additional insured party.

28. W-9 Form

28.1. The respondent must submit a current Internal Revenue Service W-9 Form complete with proper signature.

28.2. Failure to attach could result in a reduction in score or rejection of your proposal.

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29. E-Verify Documentation

29.1. The respondent must submit a completed E-Verify Compliance Form and Affidavit as attached below.

29.2. Failure to attach could result in a reduction in score or rejection of your proposal.

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Cost Proposal

Starr’s Mill High School Football Stadium Handrail Replacement Cost

**Total project cost must include all materials, shipping/freight, equipment, labor, and installation of handrails and concrete repair**

Option #1: 1 ¼” Schedule 40 Stainless Pipe Steel Handrails

Total Project Cost: ______________________

Option #2: 1 ¼” Schedule 40 Steel Pipe Handrails

Total Project Cost: ______________________

Company Name Date

Signature Printed Name

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Respondent Information Form Place this form on top of your response.

Rail Replacement at Starr’s Mill High School Football Stadium (RFP 25-005-075)

Company Name:

Point of Contact:

Street Address:

City:

State:

Zip Code:

Telephone:

Email:

Website:

Authority to Act The undersigned states that he/she has the requisite authority to act on behalf of his/her employer in these matters and has offered to provide the products/services in accordance with the terms and conditions herein.

Terms, Conditions, and Specifications Through the submission of response and signature below, the respondent verifies that their solution, if applicable, complies fully, or complies with an exception, to all stated general and special terms, conditions, and specifications. See the FCPS General Terms and Conditions for further information and directions on notating exceptions to stated specifications.

Addenda Through the submission of response and signature below the respondent verifies that they have read and understood any addenda issued for this solicitation if issued.

Signature: _____________________________________ Date: _______________________

Business Capability and Respondent Qualification Questionnaire

Please answer all questions fully. Additional pages for responses must be clearly marked to identify the respondent’s name and solicitation number.

1) How long has your company been in business?

2) What was your annual gross revenue in 2023?

3) Please indicate current contracts in hand similar to the scope of this project and attach a separate document indicating the name, telephone, and email of each owner/controlling firm; and the status and completion date of each. (Must Include Attachment).

4) Does your company have experience in public school services? List all public school projects completed in Georgia since 2015.

5) Has your company ever completed a project more than one month behind schedule? If so, please identify the project and explain the circumstances. (If applicable, must include an attachment.)

6) Has your company ever failed to complete any work awarded to it? If so, please explain.

(If applicable, must include an attachment.)

7) Has your company ever defaulted on a contract? If so, please explain. (If applicable, must include an attachment.)

8) Please indicate your company’s bonding capacity.

9) Please indicate your company’s insurance carrier.

10) Please indicate whether any insurance claim has been made against or by your company in the past seven (7) years, the circumstances surrounding such claims, and the outcome.

(If applicable, must include an attachment.)

11) Please indicate whether any legal claim, administrative hearings and/or procedings has been made against your company in the past seven (7) years (including starte and federal Department of Labor as well as OSHA), the circumstances surrounding such claims, and the adjudicated outcome. (If applicable, must include an attachment.)

12) Please list bank reference:

13)Has your company ever had a bankruptcy petition, arbitration demand, or lien filed against it in the previous seven (7) years? If so, please explain. (If applicable, must include an attachment.)

14)Has your company, any principal officers, or project managers had any criminal investigations or proceedings brought against them in the previous ten (10) years? If so, please explain. (If applicable, must include an attachment.)

15) Please attach a separate list of all employees who will be assigned to work on the project described herein and include any professional licenses or certifications they hold. (Must Include Attachment)

The respondent attests that the information included as attachments and responses are true and accurate as of the date of submission. Respondent also agrees by submission to allow Fayette County Public Schools to review or investigate any response contained herein. Respondent may be required to submit recent financial statements/reports and should indicate any objection herein. Failure to indicate or answer questions may deem the proposal non-responsive.

Notarized

FAYETTE COUNTY PUBLIC SCHOOLS - PURCHASING DEPARTMENT

GEORGIA SECURITY & IMMIGRATION COMPLIANCE ACT FORM

GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT OF 2006, AS AMENDED BY

THE ILLEGAL IMMIGRATION REFORM ACT OF 2011, OCGA 13-10-90, ET SEQ.

TO ALL PROSPECTIVE CONTRACTORS:

If you are providing services to Fayette County Public Schools, this completed document, as well as the applicable Georgia Security and Immigration Compliance forms and affidavits referenced herein must be completed, signed, notarized and submitted with your bid, proposal or contract.

Fayette County Public Schools shall comply with the Georgia Security and Immigration Compliance Act, as amended, O.C.G.A.,~13-10-90 et seq. In order to ensure compliance with the Immigration Reform and Control Act of 1986 (IRCA,P.L.99-603 and the Georgia Security and Immigration Compliance Act of 2006, as amended by the Illegal Immigration Reform Act of 2011,O.C.G.A ~ 13-10-90 et seq. (collectively the “Act”) the contractor (“Contractor”) MUST INITIAL the statement applicable to Contractor below:

INITIAL ONLY ONE CHOICE BELOW

____ (Initial here) Contractor represents and warrants that Contractor has registered at https://e-verify.uscis.gov/enroll/ to verify information of all new employees in order to comply with the Act; Is authorized to use and uses the federal authorization program; and will continue to use the authorization program throughout the contract period. Contractor further represents, warrants and agrees that it shall execute and return any and all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-01 et.seq. In accordance with the terms thereof; (Complete and submit the Contractor Affidavit and Agreement); OR

____ (Initial here) Contractor represents and warrants that it has no employees and does not intend to hire employees to perform contractual services, and that Contractor has therefore provided a U.S. state-issued Driver’s license or ID card in lieu of an affidavit and that such license or ID card was issued by a State that verifies lawful Immigration status before issuing the license or ID card. If my status changes I will, before hiring any employees, immediately notify the School District in writing and provide all affidavits required under the Act; OR

____ (Initial here) Contractor represents and warrants that it does not physically perform any service within the State of Georgia as defined in the Act and thus does not have to comply with foregoing Georgia law; OR

_____(Initial here) Contractor is a foreign company and therefore not required to provide the affidavit as required by the Act. The Contractor must comply with any other laws required to perform services in the United States, including but not limited to having an appropriate visa.

USE OF SUBCONTRACTOR(S) and COMPLIANCE AS ABOVE

___(Initial here) Contractor will not employ or contract with any subcontractor in connection with a covered contract unless the subcontractor is registered, Is authorized to use, and uses the Federal Work Authorization Program and provides Contractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of labor as set forth at Rule 300-10-01 et seq.

____(Initial here) Contractor covenants and agrees that, if Contractor employs or contracts with any Subcontractor in connection with the covered contract under the Act and DOL Rule 300-10-1-02, then in such event Contractor will secure from each subcontractor at the time of the subcontract, the subcontractor’s name and address, the employer identification number/taxpayer identification number applicable to the subcontractor; the date the authorization to use the Federal Work Authorization Program was granted to subcontractor; the subcontractor’s attestation of the subcontractor’s compliance with the Act and Georgia Department of Labor Rule 300-10-1-.2.; and the subcontractor’s agreement not to contract with subcontractors unless the subcontractor is registered, authorized to use, and uses the Federal Work Authorization Program; and provides subcontractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-01 et seq. (Complete and submit the Subcontractor Affidavit and Agreement)

_____(Initial here) Contractor agrees to provide Fayette County Public Schools with all affidavits of compliance as required by the Act and Georgia Department of Labor Rule 300-10-1-02, 300-10-1-03, 300-10-1-07 and 300-10-1-08 within five (5) business days of its receipt of any such documents.

Company Name: _____________________________________________________________

SIGNATURE: __________________________________________________________________

DATE: __________________________________________

CONTRACTOR AFFIDAVIT PROVIDED PURSUANT TO O.C.G.A. § 13-10-91(b)(2)

(Rev. 4/18/2019)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91 stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with Fayette County Public Schools, has registered with, is authorized to use, and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned contractor covenants that it will continue to use the federal work authorization program throughout the contract period, that the undersigned contractor will contract for the physical performance of services in the performance of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b), and that the contractor shall forward any subcontractor’s affidavit to the School District within five (5) days of its receipt of the same.

Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

EEV User Identification Number (4 to 6 Digit Number)

Date of Authorization

Contractor/Company

Email Address

Telephone Number

Name of Project

Project Number

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent

Printed Name of Authorized Officer or Agent Title of Authorized Officer or Agent

NOTARY INFORMATION

Sworn to before me this day of , 20 .

Notary Public Signature

My Commission Expires: ____________________________

SUBCONTRACTOR AFFIDAVIT PURSUANT TO O.C.G.A. § 13-10-91(b)(3)

(Rev. 4/18/2019)

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. § 13-10-91 stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract with ___________________, which has a contract with Fayette County Public Schools, has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-91. Furthermore, the undersigned subcontractor covenants that it will continue to use the federal work authorization program throughout the contract period, that the undersigned subcontractor will contract for the physical performance of services in the performance of such contract only with sub-subcontractors who present an affidavit to the subcontractor with the information required by O.C.G.A. § 13-10-91(b), and that the subcontractor shall forward any sub-subcontractors affidavit to the contractor and School District within five (5) days of its receipt of the same.

Subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

EEV User Identification Number (4 to 6 Digit Number)

Date of Authorization

Subcontractor/Company

Email Address

Telephone Number

Name of Project

Project Number

Name of Public Employer

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on , 20 in (city), (state).

Signature of Authorized Officer or Agent

Printed Name of Authorized Officer or Agent Title of Authorized Officer or Agent

NOTARY INFORMATION

Sworn to before me this day of , 20 .

Notary Public Signature

My Commission Expires: ____________________________