Revised Attachment A - Special Terms and Conditions - Pages 1-11.pdf

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Attached to
Elevator Maintenance DOC - LA State Pen. - Addendum NO. 1 - Attachment Revision. Date Issued: July 14, 2025 Your
Solicitation number
3000025030
Issued by
Webster Parish, Baton Rouge City, Louisiana

About this file

This document is a Revised Attachment A - Special Terms and Conditions for a state procurement opportunity involving the Louisiana Department of Corrections (DOC), specifically for elevator maintenance and repair services at the Louisiana State Penitentiary in Angola. The solicitation, identified as RFx 3000025030, seeks a contractor to provide comprehensive maintenance for vertical transportation systems, with a mandatory job site visit required prior to bidding. The bid is scheduled to open on August 5, 2025, at 10:00 A.M. Central Time, with an initial contract period not to exceed 12 months and potential renewal options for two additional 12-month periods, bringing the total contract time to a maximum of 36 months.

The procurement includes detailed insurance requirements, with contractors needing to maintain workers' compensation, commercial general liability, and automobile liability insurance. Payment will be processed electronically through the LaCarte Procurement Card (for purchases under $5,000) or Electronic Funds Transfer (EFT), and the contract is contingent upon legislative fund appropriation. Bidders must be registered in the LaGov vendor system and possess a Louisiana Revised Statutes Specialty License for Elevators and Dumbwaiters. The contract requires the winning vendor to maintain comprehensive elevator maintenance records and submit monthly reports, with services covering four specific elevators across different buildings at the Angola facility. The state reserves the right to award on an all-or-none basis to the lowest responsive, responsible bidder meeting the specifications.

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Revised Attachment A – Special Terms and Conditions RFx 3000025030

Bid Delivery Instructions for State Procurement:

Bidders are hereby advised that the Office of State Procurement (OSP) must receive bids at its physical location by the date and time specified on page 1 of the Invitation to Bid.

Bids may be mailed or delivered by hand or courier service to the Office of State Procurement’s physical location as follows:

Office of State Procurement Claiborne Building, Suite 2-160 1201 North Third Street Baton Rouge, LA 70802

Or bids may be submitted online by accessing the link on page 1 of the Invitation to Bid.

Bidders should be aware of security requirements for the Claiborne Building and allow time to be photographed and presented with a temporary identification badge.

Bidder is solely responsible for ensuring that its courier service provider makes inside deliveries to the Office of State Procurement’s physical location. The Office of State Procurement is not responsible for any delays caused by the bidder's chosen means of bid delivery. Bidder is solely responsible for the timely delivery of its bid. Failure to meet the bid opening date & time shall result in rejection of the bid.

Note: Bidders who choose to respond to this bid online via the vendor portal are encouraged to not submit a written bid as well.

Bidders are hereby advised that due to the nature of the internet, the State of Louisiana cannot guarantee that access to the LaGov or LaPAC websites will be uninterrupted or that e-mails or other electronic transmissions will be sent to you or received by us. The Office of State Procurement is not responsible for any delays caused by the bidder’s choice to submit their bid online. Bidder is solely responsible for the timely delivery of its bid. Failure to meet the bid opening date and time shall result in rejection of the bid.

**Attention**

Receipt of a solicitation or award cannot be relied upon as an assurance of receiving future solicitations. In order to receive notifications of future solicitations from this office, you must register and enroll in the proper category in LaGov at the following website:

https://lagoverpvendor.doa.louisiana.gov/irj/portal/anonymous?guest_user=self_reg

Enrollment in LaGov provides LaPAC email notification of bid opportunities based upon commodities that you select.

Calendar of Events:

Deadline to receive written inquiries: July 21, 2025

Deadline to answer written inquiries: July 30, 2025

Bid Opening Date and Time: August 5, 2025_@ 10:00 A.M. (Central Time)

NOTE: The State of Louisiana reserves the right to revise this calendar. Revisions before the bid opening date and time, if any, will be formalized by the issuance of an addendum to this ITB.

Attachment A – Special Terms and Conditions RFx 3000025030

Bidder Inquiries:

The State shall not and cannot permit an open-ended inquiry period, as this creates an unwarranted delay in the procurement cycle and operations of our Agency customers. The State reasonably expects and requires responsible and interested bidders to conduct their in-depth bid review and submit inquiries in a timely manner.

An inquiry period is hereby firmly set for all interested bidders to perform a detailed review of the bid documents and to submit any written inquiries relative thereto. Without exception, all inquiries MUST be submitted in writing by an authorized representative of the bidder, clearly cross-referenced to the relevant bid section. All inquiries must be received by the Inquiry Deadline date set forth in the Calendar of Events section of this bid. Only those inquiries received by the established deadline shall be considered by the State. Inquiries received after the established deadline shall not be entertained.

Inquiries concerning this bid may be delivered by mail, express courier, e-mail, hand, or fax to:

Office of State Procurement Attention: Kim Mulder 1201 North Third St.

Claiborne Bldg., Suite 2-160 Baton Rouge, LA 70802

E-Mail: kim.mulder@la.gov Phone: (225) 342-6808 Fax: (225) 342-9756

Only the person identified above or their designee has the authority to officially respond to bidder’s questions on behalf of the State. Any communications from any other individuals are not binding to the State.

An addendum will be issued and posted at the Office of State Procurement’s LaPAC* website, to address all inquiries received and any other changes or clarifications to the bid. Thereafter, all bid documents, including but not limited to the specifications, terms, conditions, plans, etc., will stand as written and/or amended by any addendum. No negotiations, decisions, or actions shall be executed by any bidder as a result of any oral discussions with any state employee or state consultant. It is the Bidder’s responsibility to check the LaPAC website frequently for any possible addenda that may be issued. The Office of State Procurement is not responsible for a bidder’s failure to download any addenda documents required to complete the bid.

*Note: LaPAC is the State’s online electronic bid posting and notification system resident on State Procurement’s website https://www.doa.la.gov/doa/osp/. In that LaPAC provides an immediate e-mail notification to subscribing bidders that a solicitation and any subsequent addenda have been let and posted, notice and receipt thereof is considered formally given as of their respective dates of posting.

To receive the email notification, vendors must register in the LaGov portal. Registration is intuitive at the following link:

https://lagoverpvendor.doa.louisiana.gov/irj/portal/anonymous?guest_user=self_reg

Help scripts are available on the Office of State Procurement’s website under Vendor Resources at:

https://www.doa.la.gov/doa/osp/vendor-resources/

Terms and Conditions:

This solicitation contains all terms and conditions with respect to the commodities herein. Any vendor contracts, forms, terms, or other materials submitted with bid may cause bid to be rejected.

Vendor's Forms:

The purchase order is the only binding document to be issued against the contract. Signing of vendor's forms is not allowed.

Acceptance:

Unless otherwise specified, bids on the contract will be assumed to be firm for acceptance for a minimum of 60 days. If accepted, prices must be firm for the specified contract period.

Prices:

Prices shall be complete, including transportation/freight charges prepaid by bidder to the destination, inside delivery, unpacking, assembly of all components and removal of all associated debris from premises.

Prices should be quoted in the unit (each, box, case, hour, flat, mile, etc.) as specified in the solicitation.

Payment:

Payment will be made on the basis of unit price as listed in the contract; such price and payment will constitute full compensation for furnishing and delivering the contract commodities. In no case will the State Agency refuse to make partial payments to the Contractor although all items have not been delivered.

This payment in no way relieves the Contractor of his responsibility to effect shipment of the balance of the order. Payment will be to the Contractor and address as shown on order.

Late Payment:

Interest due by the State Agency for late payments shall be in accordance with La. R.S. 39:1695 at the rates established in La. R.S. 13:4202.

Invoices:

Invoices will be submitted by the Contractor to the Using Agency and the invoice shall refer to the delivery ticket number, delivery date, purchase order number, quantity, unit price, and delivery point. A separate invoice for each order delivered and accepted shall be submitted by the Contractor in duplicate directly to the accounting department of the Using Agency. Invoices shall show the amount of any cash discount and shall be submitted on the Contractor's own invoice form.

Contractual Period:

The State of Louisiana intends to award all items for an initial period, not to exceed 12 months. Delays in awarding, beyond the anticipated starting date, may result in a change in the contract period. If the situation occurs, an award may be made for less than 12 months.

Contract Renewal:

At the option of the State of Louisiana and acceptance by the Contractor, the contract may be extended for two additional 12 month periods at the same prices, terms and conditions. Total contract time may not exceed 36 months.

Electronic Vendor Payment Solution:

In an effort to increase efficiencies and effectiveness as well as be strategic in utilizing technology and resources for the State and the Contractor, the State intends to make all payments to Contractors electronically. The LaCarte Procurement Card will be used for purchases of $5,000 and under, and where feasible, over $5,000. Contractors will have a choice of receiving electronic payment for all other payments by selecting the Electronic Funds Transfer (EFT). If you receive an award and do not currently accept the

LaCarte card or have not already enrolled in EFT, you will be asked to comply with this request by choosing either the LaCarte Procurement Card and/or EFT. You may indicate your acceptance below.

The LaCarte Procurement Card uses a Visa card platform. Contractors receive payment from State Agencies using the card in the same manner as other Visa card purchases. Contractors cannot process payment transactions through the credit card clearinghouse until the purchased products have been shipped or received or the services performed.

EFT payments are sent from the State’s bank directly to the payee’s bank each weekday. The only requirement is that you have an active checking or savings account at a financial institution that can accept Automated Clearing House (ACH) credit files and remittance information electronically. Additional information and an enrollment form is available by contacting the Office of Statewide Reporting & Accounting Policy at DOA-OSRAP-EFT@la.gov.

To facilitate this payment process, you will need to complete and return the EFT enrollment form.

If an award is made to your company, please check which option you will accept or indicate if you are already enrolled.

Payment Type Will Accept Already Enrolled

LaCarte ______ ______

EFT ______ ______

Printed Name of Individual Authorized

Authorized Signature for payment type chosen Date

Email address and phone number of authorized individual

Increase/Decrease Clause:

The quantities listed herein are estimated to be the amount needed. In the event a greater or lesser quantity is needed, the right is reserved by the State of Louisiana to increase or decrease the amount, at the unit price stated in the bid.

Insurance Requirements for Contractors:

The Contractor shall purchase and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder by the Contractor, its agents, representatives, employees or subcontractors. The cost of such insurance shall be included in the bidder’s pricing.

A. Minimum Scope and Limits of Insurance

1. Workers Compensation Workers Compensation insurance shall be in compliance with the Workers Compensation law of the State of the Contractor’s headquarters. Employers Liability is included with a minimum limit of $1,000,000 per accident/per disease/per employee. If work is to be performed over water and involves maritime exposure, applicable LHWCA, Jones Act, or other maritime law coverage shall be included. A.M. Best's insurance company rating requirement may be waived for workers compensation coverage only.

2. Commercial General Liability

Commercial General Liability insurance, including Personal and Advertising Injury Liability and Products and Completed Operations, shall have a minimum limit per occurrence of $1,000,000 and a minimum general aggregate of $2,000,000. The Insurance Services Office (ISO) Commercial General Liability occurrence coverage form CG 00 01 (current form approved for use in Louisiana), or equivalent, is to be used in the policy. Claims-made form is unacceptable.

3. Automobile Liability

Automobile Liability Insurance shall have a minimum combined single limit per occurrence of $1,000,000. ISO form number CA 00 01 (current form approved for use in Louisiana), or equivalent, is to be used in the policy. This insurance shall include third-party bodily injury and property damage liability for owned, hired and non-owned automobiles.

B. Deductibles and Self-Insured Retentions

Any deductibles or self-insured retentions must be declared to and accepted by the Agency. The Contractor shall be responsible for all deductibles and self-insured retentions.

C. Other Insurance Provisions

The policies are to contain, or be endorsed to contain, the following provisions:

1. Commercial General Liability and Automobile Liability Coverages

a. The Agency, its officers, agents, employees and volunteers shall be named as an additional insured as regards negligence by the Contractor. ISO Form CG 20 10 (for ongoing work) AND CG 20 37 (for completed work) (current forms approved for use in Louisiana), or equivalent, are to be used when applicable. The coverage shall contain no special limitations on the scope of protection afforded to the Agency.

b. The Contractor’s insurance shall be primary as respects the Agency, its officers, agents, employees and volunteers for any and all losses that occur under the contract. Any insurance or self-insurance maintained by the Agency shall be excess and non-contributory of the Contractor’s insurance.

2. Workers Compensation and Employers Liability Coverages

To the fullest extent allowed by law, the insurer shall agree to waive all rights of subrogation against the Agency, its officers, agents, employees and volunteers for losses arising from work performed by the Contractor for the Agency.

3. All Coverages

a. All policies must be endorsed to require 30 day written notice of cancellation to the Agency.

10 day written notice of cancellation is acceptable for non-payment of premium. Notifications shall comply with the standard cancellation provisions in the Contractor’s policy. In addition, the Contractor is required to notify the Agency of policy cancellations or reductions in limits.

b. The acceptance of the completed work, payment, failure of the Agency to require proof of compliance, or the Agency’s acceptance of a non-compliant Certificate of Insurance shall not release the Contractor from the obligations of the insurance requirements or indemnification agreement.

c. The insurance companies issuing the policies shall have no recourse against the Agency for payment of premiums or for assessments under any form of the policies.

d. Any failure of the Contractor to comply with reporting provisions of the policy shall not affect coverage provided to the Agency, its officers, agents, employees and volunteers.

D. Acceptability of Insurers

1. All required insurance shall be provided by a company or companies lawfully authorized to do business in the jurisdiction in which the Project is located. Insurance shall be placed with insurers with an A.M. Best's rating of A-:VI or higher. This rating requirement may be waived for workers compensation coverage only.

2. If at any time an insurer issuing any such policy does not meet the minimum A.M. Best rating, the Contractor shall obtain a policy with an insurer that meets the A.M. Best rating and shall submit another Certificate of Insurance within 30 days.

E. Verification of Coverage

1. The Contractor shall furnish the Agency with Certificates of Insurance reflecting proof of required coverage. The Certificates for each insurance policy are to be signed by a person authorized by that insurer to bind coverage on its behalf. The Certificates are to be received and approved by the Agency before work commences and upon any contract renewal or insurance policy renewal thereafter.

2. The Certificate Holder shall be listed as follows:

State of Louisiana 1201 North Third St.

Claiborne Bldg., Suite 2-160 Baton Rouge, LA 70802

3. In addition to the Certificates, the Contractor shall submit the declarations page and the cancellation provision for each insurance policy. The Agency reserves the right to request complete certified copies of all required insurance policies at any time.

4. Upon failure of the Contractor to furnish, deliver and maintain such insurance, the contract, at the election of the Agency, may be suspended, discontinued or terminated. Failure of the Contractor to purchase and/or maintain any required insurance shall not relieve the Contractor from any liability or indemnification under the contract.

F. Subcontractors

The Contractor shall include all subcontractors as insureds under its policies OR shall be responsible for verifying and maintaining the Certificates provided by each subcontractor. Subcontractors shall be subject to all of the requirements stated herein. The Agency reserves the right to request copies of subcontractors’ Certificates at any time.

G. Workers Compensation Indemnity

In the event the Contractor is not required to provide or elects not to provide workers compensation coverage, the parties hereby agree that the Contractor, its owners, agents and employees will have no cause of action against, and will not assert a claim against, the State of Louisiana, its Departments, Agencies, agents and employees as an employer, whether pursuant to the Louisiana Workers Compensation Act or otherwise, under any circumstance. The parties also hereby agree that the State of Louisiana, its Departments, Agencies, agents and employees shall in no circumstance be, or considered as, the employer or statutory employer of the Contractor, its owners, agents and employees.

The parties further agree that the Contractor is a wholly independent Contractor and is exclusively responsible for its employees, owners, and agents. The Contractor hereby agrees to protect, defend, indemnify and hold the State of Louisiana, its Departments, Agencies, agents and employees harmless from any such assertion or claim that may arise from the performance of the contract.

H. Indemnification/Hold Harmless Agreement

1. The Contractor agrees to protect, defend, indemnify, save, and hold harmless, the State of Louisiana, all State Departments, Agencies, Boards and Commissions, its officers, agents, servants, employees, and volunteers, from and against any and all claims, damages, expenses, and liability arising out of injury or death to any person or the damage, loss or destruction of any property which may occur, or in any way grow out of, any act or omission of the Contractor, its agents, servants, and employees, or any and all costs, expenses and/or attorney fees incurred by the Contractor as a result of any claims, demands, suits or causes of action, except those claims, demands, suits, or causes of action arising out of the negligence of the State of Louisiana, all State Departments, Agencies, Boards, Commissions, its officers, agents, servants, employees and volunteers.

2. The Contractor agrees to investigate, handle, respond to, provide defense for and defend any such claims, demands, suits, or causes of action at its sole expense and agrees to bear all other costs and expenses related thereto, even if the claims, demands, suits, or causes of action are groundless, false or fraudulent. The State of Louisiana may, but is not required to, consult with the Contractor in the defense of claims, but this shall not affect the Contractor’s responsibility for the handling of and expenses for all claims.

Termination for Cause:

The State may terminate the contract for cause based upon the failure of the Contractor to comply with the terms and/or conditions of the contract; provided that the State shall give the Contractor written notice specifying the Contractor's failure. If within fifteen 15 days after receipt of such notice, the Contractor shall not have either corrected such failure and thereafter proceeded diligently to complete such correction, then the State, may at its option, place the Contractor in default and the contract shall terminate on the date specified in such notice. The Contractor may exercise any rights available to it under Louisiana law to terminate for cause upon the failure of the State to comply with the terms and conditions of the contract;

provided that the Contractor shall give the State written notice specifying the State's failure.

Termination for Convenience:

The State may terminate any contract entered into as a result of this bid at any time by giving 30 days written notice to the Contractor. The Contractor shall be entitled to payment for deliverables in progress, to the extent work has been performed satisfactorily.

Termination for Non-Appropriations of Funds:

The continuation of the contract is contingent upon the appropriation of funds to fulfill the requirements of the contract by the legislature. If the legislature fails to appropriate sufficient monies to provide for the continuation of a contract or if such appropriation is reduced by the veto of the Governor or by any means provided in the Appropriations Act or Title 39 of the Louisiana Revised Statutes of 1950 to prevent the total appropriations for the year from exceeding revenues for that year or for any other lawful purpose and the effect of such reduction is to provide insufficient monies for the continuation of the contract, the contract shall terminate on the date of the beginning of the first fiscal year for which funds are not appropriated.

Vendor Security Clearance Process:

Any vendor or vendor personnel visiting or working in an institution is required to receive security clearance prior to entering the institution grounds. Vendor must furnish the full name, driver’s license number, social security number, date of birth, race and sex of each employee who will be entering the compound. This information must be furnished in writing to the site visit coordinator prior to commencing work on the awarded project. A criminal background check will be conducted on each employee, and upon arrival, ID cards will be issued to each employee. No vendor personnel will be allowed to work on the institution grounds until the above clearance approval process is completed. The successful vendor is also required to provide a written inventory of tools, vehicles and/or trailers prior to entering the institution grounds.

PREA: Prison Rape Elimination Act:

In accordance with DPS & Department Regulation No. C-01-022 "Sexual Assault and Sexual Misconduct", the vendor agrees to report allegations of sexual misconduct, respond to investigation inquiries and participate in training as directed by the Department of Public Safety and Corrections. The sexual assault and sexual misconduct with inmates acknowledgement form and the Louisiana Criminal Code: La. R.S. 14:134 Malfeasance in Office form will be signed by the vendor and kept on file at the facility. Should the regulation be modified or amended, the vendor will be notified and shall comply with the regulation as modified or amended.

Instructions to Bidders

1. Project

Maintenance and repair of vertical transportation systems for the Department of Corrections (DOC) located at 17544 Tunica Trace, Highway 66, Angola, LA 70712.

2. Bids

Bids must be in accordance with these instructions in order to receive consideration.

3. Documents

Documents include the bidding requirement; general supplementary conditions, technical section, plus addenda which may be issued by the Division of Administration - Office of State Procurement during the bidding period. See specifications for elevator/escalator maintenance page.

4. Examination of Documents and Site

Bidders shall carefully examine the bidding documents and the sites to obtain first-hand knowledge of the scope and the conditions of the work. Each Contractor, by submitting a bid to perform any portion of the work, represents and warrants that he has examined the specifications and site of the work, and from his own investigation, has satisfied himself as to the scope, accessibility, nature and location of the work; character of the equipment and other facilities needed for the performance of the work; the character and extent of other work to be performed; the local conditions; labor availability, practices and jurisdictions and other circumstances that may affect the performance of the work. No additional compensation will be allowed by the owner for failure of such Contractor or subcontractor to inform himself as to the conditions affecting the work.

5. Interpretation of Documents

If any person contemplating submitting a bid for the proposed contract is in doubt as to the meaning of any part of the specifications (project manual), or other proposed contract documents, he may submit to the Division of Administration - Office of State Procurement, no later than 7 working days prior to the date set for opening of bids, a written request for an interpretation or clarification.

Bidders should act promptly and allow sufficient time for a reply to reach them before preparing their bids. Any interpretation or clarification will be in the form of an addendum duly issued. No alleged verbal interpretation or rulings will be held binding upon the owner.

6. Substitutions

Conditions governing the submission of substitutions for specific materials, products, equipment, and processes are in the general conditions. Requests for substitutions must be received by the Division of Administration - Office of State Procurement 7 days prior to the established bid date.

7. Addenda

Interpretations, clarifications, additions, deletions, and modifications to the documents during the bidding period will be issued in the form of addenda and a copy of such addenda will be mailed or delivered to each person who has been issued a set of the bidding documents. Addenda will be a part of the bidding documents and contract documents, and receipt of them should be acknowledged in the bid form. Addenda will not be issued within 3 working days of the established bid date.

8. Preparation of Bids

Prices quoted shall include all items of cost, expense, fees and charges incurred or arising out of, the performance of the work to be performed under the contract. Any bid on other than the required form will be considered informal and may be rejected. Erasure or changes in the bid should be explained or noted over the initials of the bidder. Bids containing any conditions, omissions, unexplained erasures, alterations, or irregularities of any kind may be rejected. Failure to submit all requested information will make the bid irregular and subject to rejection.

9. Submittal of Bids

The "Non-Collusion Affidavit" should be completed and signed by each bidder and submitted with the bid by mail or in person prior to the time for receiving bids set forth in the "Invitation to Bid" to the Division of Administration-Office of State Procurement, 1201 N. Third St., Claiborne Building, Ste. 2-160, Baton Rouge, LA 70802.

Method of Award:

The award to be made on an all-or-none basis to the overall lowest responsive, responsible bidder meeting the specifications. The State of Louisiana reserves the right to reject individual line items from the award.

Claims or Controversies:

Any claim or controversies arising out of the contact shall be resolved by the provisions of La. R.S. 39:1671- 1673.

Non-Exclusivity Clause:

This agreement is non-exclusive and shall not in any way preclude State Agencies from entering into similar agreements and/or arrangements with other vendors or from acquiring similar, equal, or like goods and/or services from other entities or sources.

Mandatory Job Site Visit:

Vendor must inspect jobsite to verify measurements and/or amount of supplies needed prior to bidding. If vendor finds conditions that disagree with the physical layout as described in the solicitation, or other features of the specifications that appear to be in error, same shall be brought to the attention of the Office of State Procurement personnel immediately and no later than 7 working days prior to the bid opening.

Vendor shall contact Danielle Matherne at (225) 655-2589 to schedule a jobsite visit.

MANDATORYJOBSITE VISIT CERTIFICATION

ELEVATOR MAINTENANCE & REPAIR – DOC - LSP

Jobsite Location: Department of Corrections (DOC) located at 17544 Tunica Trace, Highway 66, Angola, LA 70712

DOC- LSP Contact: Danielle Matherne at (225) 655-2589 RFx No.: 3000025030 Opening Date/Time: August 5,2025 at 10:00 A.M. CT

Vendor must call the DOC – LSP contact listed above to schedule an appointment for the inspection.

Jobsite visit must be completed prior to bid opening date and time.

Certificate should be signed by the vendor or vendor’s representative and the DOC – LSP representative or their designee and submitted with the vendors bid response. A signed letter from the DOC – LSP representative stating that the vendor did visit the jobsite and the date of inspection may be substituted.

NOTE: Certification or letter from the DOC – LSP representative must be submitted to the DOC

– LSP Procurement office prior to award. Failure to supply the required documentation will cause the vendor’s bid to be rejected.

I _________________________________ on behalf of ______________________________________ (Vendor Representative’s Name – Please Print) (Vendor’s Company Name – Please Print) certify that I have inspected the referenced jobsite location on ____________________, 20____ and I am familiar with all conditions surrounding fulfillment of the specifications for the bid.

(Vendor Representative’s Signature) (Date)

(DOC – LSP Representative’s Signature) (Date)

(DOC – LSP Representative’s Name & Title – Please Print)

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