RFQ2024-08_Quotation_Request.pdf

Superior Court of California, County of Kern

Request for Quote No. RFQ2024-08

The Superior Court of California, County of Kern (the “Court”) is considering the purchase of certain IT and IT goods and services. If Vendor is interested in selling these goods to the Court, it must complete and sign the quote below and submit it to the Court.

RFQ Issue Date: September 23, 2024

Quote Due Date and Time: No later than 3:00 p.m. on Tuesday, October 8, 2024. The Court must receive the quote before the Quote Due Date and Time.

Submit Quote Via:

☐ E-Mail to: purchasing@kern.courts.ca.gov OR

☐ Deliver to 1430 Truxtun Ave., 5th floor, Bakersfield, CA 93301

Court Contact: Marelle Williams at Marelle.Williams@kern.courts.ca.gov interested bidders must submit any questions regarding this quote or the items listed in writing to the buyer at the email listed above.

Delivery:

☒ Goods must be delivered to the Court’s within 30 days from receipt of order.

Award Basis:

☒ Lowest Responsive Quote that meets minimum specifications listed.

Instructions to Bidder:

1. Review description of each required item. Provide quote/unit and calculate the extended cost. Unit Cost quoted is used to calculate extension costs.

2. Review Rules Governing Non-IT and IT Goods and Services RFQs (available at https://www.courts.ca.gov/documents/jbcl-manual.pdf).

Notes:

1. Vendor must submit a copy of its California Sellers’s Permit with its quote (see the Rules Governing Non-IT and IT Goods and Services RFQ (available at https://www.courts.ca.gov/documents/jbcl-manual.pdf) for additional details.

2. Vendor must submit completed Payee Data Record.

mailto:purchasing@kern.courts.ca.gov mailto:Marelle.Williams@kern.courts.ca.gov https://www.courts.ca.gov/documents/jbcl-manual.pdf https://www.courts.ca.gov/documents/jbcl-manual.pdf

3. All items must be in new and unused condition.

4. The Court reserves the right to not award if bids received exceed budget amount.

Project Background:

Looking to purchase 2 boxes as a pilot program. If project goes well and funds are available, we will need to purchase 10 more boxes in the coming fiscal year.

The keys that are being stored are vehicle keys with key fobs and normal household key sizes. No Folger Adam or any detention style keys will be stored.

We will have approximately 10-20 users in the system upon full deployment that will need access to manage the system. Users who will need badge access to the system to take keys in in the hundreds but no more than 600 at this time.

Our badge cards are DSX HID1386LGGMN. Cards can be provided for configuration upon purchase.

List of Goods and Price Quote (not including tax)

Item No. Description Quantity Unit Unit Cost Extension

1 Smart Key Lock Box System – 40 Keys with Badge Access 1 Each

2 Smart Key Lock Box System – 100 Keys with Badge Access 1 Each

Subscription License Fee (if any):

If there is a cost for subscriptions/licenses please quote the following cost

3 1 Year 1 Each

4 3 Year 1 Each

5 5 Year 1 Each

6 Perpetual 1 Each

Will your pricing stay firm for additional purchases after pilot program is completed? Yes_______ No_______

MINIMUM SPECIFICATIONS

COMPLY

(YES/NO)

EXCEPTION TAKEN?

(YES/NO) provide detail on exception taken to spec.

A Bid must come with all key rings and fobs for the size of box being bid.

B Each key fob must be a smart key fob (RFID or technology equivalent) that knows who and when a key is taken or returned.

C Software must be able to restrict who has access to what key in the box.

D Each key box must be networkable and be configured/controlled with either on premise software or cloud based software. On premise software is preferred.

Please specify if your product is cloud based or on premise: ___________________________

Note: If software is on premise, we have a virtual environment where it can be housed.

Hardware and software specifications are no issue.

E Each key box should have the ability to be plugged into power and not hardwired directly. It is acceptable to have the option to be hardwired or have a standard plug but standard plug must be an option. POE is acceptable.

F Key box must have badge access and pin code access.

G Key fobs should be tamper proof or offer tamper proof key rings.

H Key fobs and key rings should be metal or high durable material.

I Pricing shall include training on software.

J No installation needed. Do not quote any installation cost in your pricing.

QUOTE TERMS – TO BE COMPLETED/SIGNED BY VENDOR

COOPERATIVE AGREEMENTS: The Superior Court of California, County of Kern participates in cooperative agreements such as NASPO-Value Point; U.S. Communities, NJPA, NPP and others. Please provide the best pricing available to the Courts.

FREIGHT/SHIPPING/HANDLING COSTS:

If you are not quoting F.O.B. Destination in the unit cost, please indicate the freight, or a freight not-to-exceed amount. This cost will be considered in the award basis

LS

CALIFORNIA TAXES:

Is this taxable? Yes_______ No ________ Include the current sales tax amount, if applicable. The County pays sales tax at the rate of 8.25 % for items delivered in Kern County. Identify items that are taxable.

LS

PAYMENT TERMS:

Please provide your payment terms (i.e.

“Net”, “Net 30”, etc.):

DELIVERY DAYS:

Delivery will be made in _______days after receipt of purchase order

_________ days

VENDOR QUOTE NOTES:

Please provide any notes or details regarding your quote that the Court needs to be aware of.

Warranty:

Please define any warranties that are included with each manufacturer product

Make/Model Quoted

If selected by the Court, Vendor agrees (i) to sell the requested goods to the Court at the prices specified above, (ii) to deliver the goods to the Court by the dated specified above, and (iii) that the purchase will be governed solely by the Courts Purchase Order Terms and Conditions (attached) without regard to any additional or other terms and conditions proposed by Vendor. Vendor acknowledges that this RFQ is governed by the Court’s Rules Governing Non-IT and IT Goods and Services RFQs (attached).

Submitted by: ____________________________ Vendor Name: _________________________________

____________________________ Address: ______________________________________ (Print or type name and title)

Signature: __________________________________ Email: _____________________________________

Phone: _____________________________________

Fax: _____________________________________

TAX ID: _____________________________________

Rules Governing IT Goods and Services RFQs

Submission of Quotes. Vendor must sign and submit its quote using the Court’s form. Quotes may be submitted by mail (to the address specified on the quote) or by fax (to the fax number specified on the quote). Quotes sent to any other address or fax number will not be considered. The Court must receive the quote on or before the Quote Due Date and Time. Late quotes will not be accepted.

Faxed Quotes. All pages of a faxed quote received before the Quote Due Date and Time will be considered the complete quote.

Please be advised that there may be a heavy demand placed on the fax machine receiving quotes and the Court assumes no responsibility if Vendor cannot transmit its quote via fax, or if the entire quote is not received before the Quote Due Date and Time.

Process. Before the Quote Due Date and Time, the Court may cancel the RFQ for any or no reason. After the Quote Due Date and Time, the Court may reject all quotes and cancel the RFQ if the Court determines that: (i) the quotes received are not really competitive; (ii) the cost is not reasonable; (iii) the cost exceeds the amount expected; or (iv) awarding the contract is not in the best interest of the Court. The Court reserves the right to accept or reject any or all of the items in the quote, to award the contract in whole or in part and/or negotiate any or all items with a vendor if it is deemed in the Court’s best interest. The RFQ is not an order, agreement, or obligation on behalf of the Court, and in no way is the Court responsible for the cost of preparing the quote.

Offer Period. Vendor may withdraw its quote at any time before the Quote Due Date and Time by notifying the Court in writing of its withdrawal. The notice must be signed by Vendor. Quotes cannot be changed or withdrawn after the Quote Due Date and Time;

Vendor's quote is an irrevocable offer for ninety (90) days following the Quote Due Date and Time.

Terms. Upon award of the contract, the Court will issue a purchase order (including the Court’s Purchase Order Terms and Conditions) to the selected vendor. Quotes that reference other terms and conditions or propose changes to the Court’s Purchase Order Terms and Conditions, may be rejected. If the selected vendor rejects or attempts to amend or supplement the Court’s purchase order, the Court may cancel the award and award the contract to the next qualified vendor.

Award Basis. If the “lowest responsive quote” box is checked, the contract will be awarded (if at all) to the responsible Vendor that submitted the lowest responsive quote. If the “highest scored quote” box is checked, the contract will be awarded (if at all) to the responsible Vendor that submitted the highest scored quote. In the event of a tie, the contract will be awarded to the winner of a single coin toss. The coin toss will be witnessed by two Court employees. The Court will provide notice of the date and time of the coin toss to the affected vendors, who may attend the coin toss at their own expense. During the evaluation process, the Court may require Vendor to answer questions or provide clarifications regarding Vendor’s quote. Failure to answer such questions or provide the requested clarifications may result in the quote being deemed non-responsive.

Seller’s Permit and Payee Data Record. Vendor must submit with its quote, for itself and each of its affiliates that make sales for delivery into California, a copy of either (a) a California seller's permit issued under Revenue and Taxation Code (“RTC”) 6066 et seq.

or (b) a certificate of registration issued under RTC 6226. If awarded the contract, Vendor must complete and submit to the Court a Payee Data Record form.

Certifications. Vendor certifies: (i) [Darfur Contracting Act] it is not a “scrutinized company” as defined in Public Contract Code (“PCC”) 10476 (applicable if Vendor currently or within the previous three years has had business activities or other operations outside of the United States); (ii) [Congolese Conflict minerals] it is not a “scrutinized company” as defined in PCC 10490(b), or the goods or services Vendor would provide to the Court are not related to products or services that are the reason Vendor must comply with Section 13(p) of the Securities Exchange Act of 1934; (iii) [DVBE Violation] Vendor is not on the Department of General Services’ (“DGS”) list of firms and persons that have been suspended or debarred from contracting with the state because of a violation of PCC 10115.10, regarding disabled veteran business enterprises (“DVBEs”); and (iv) [Tax delinquency] it is not on the Franchise Tax Board’s list of 500 largest state income tax delinquencies, or the Board of Equalization’s list of 500 largest delinquent sales and use tax accounts.

DVBE Incentive. Eligibility for and application of the DVBE incentive are governed by the Court’s DVBE Rules and Procedures.

Vendor will receive a DVBE incentive if, in the Court’s sole determination, Vendor has met all applicable requirements.

DVBE incentive qualification is optional. Failure to qualify for the DVBE incentive will not render a quote non-responsive.

For lowest responsive quote RFQs: if Vendor receives the DVBE incentive, the dollar amount of its quote will be reduced (for evaluation purposes only) by an amount equal to 3% of the lowest responsive quote. For highest scored quote RFQs: if Vendor receives the DVBE incentive, a specified number of points will be added to the score assigned to Vendor’s quote.

To receive the DVBE incentive, at least 3% of the contract goods and/or services must be provided by a DVBE performing a commercially useful function. Or, Vendor may have an approved Business Utilization Plan (“BUP”) on file with DGS.

If Vendor wishes to seek the DVBE incentive:

1. Vendor must complete and submit with its quote the “Bidder Declaration” document (available from the Court upon request). Vendor must submit with the Bidder Declaration all materials required in the Bidder Declaration.

2. Vendor must submit with its quote a “DVBE Declaration” document (available from the Court upon request) completed and signed by each DVBE that will provide goods and/or services in connection with the contract. If Vendor is itself a DVBE, it must complete and sign the DVBE Declaration. If Vendor will use DVBE subcontractors, each DVBE subcontractor must complete and sign a DVBE Declaration. NOTE: The DVBE Declaration is not required if Vendor will qualify for the DVBE incentive using a BUP on file with DGS.

Failure to complete and submit these forms as required will result in Vendor not receiving the DVBE incentive. In addition, the Court may request additional written clarifying information. Failure to provide this information as requested will result in Vendor not receiving the DVBE incentive. If Vendor receives the DVBE incentive: (i) Vendor will be required to complete a post-contract DVBE certification if DVBE subcontractors are used; (ii) Vendor must use any DVBE subcontractor(s) identified in its quote unless the Court approves in writing the substitution of another DVBE; and (iii) failure to meet the DVBE commitment set forth in its quote will constitute a breach of contract. FRAUDULENT MISREPRESENTATION IN CONNECTION WITH THE DVBE INCENTIVE IS A MISDEMEANOR AND IS PUNISHABLE BY IMPRISONMENT OR FINE, AND VIOLATORS ARE LIABLE FOR CIVIL PENALTIES. SEE MILITARY

AND VETERANS CODE 999.9.

Errors. If errors are found in a quote, the Court may reject the quote. The Court may, at its sole option, correct arithmetic or transposition errors or both. The Court may or may not waive an immaterial deviation or defect in a quote. The Court’s waiver of an immaterial deviation or defect shall in no way modify the RFQ or excuse a Vendor from full compliance with RFQ specifications.

Protests. Any protests will be handled in accordance with Chapter 7 of the Judicial Branch Contract Manual (see www.courts.ca.gov/documents/jbcl-manual.pdf). Failure to comply with the protest procedures set forth in that chapter will render a protest inadequate and non-responsive and will result in rejection of the protest. The deadline for the Court to receive a solicitation specifications protest is Quote Due Date and Time. Protests should be sent to the Court Contact on the page 1 of the

RFQ.

Confidential information. Quotes are subject to disclosure pursuant to applicable provisions of the PCC and Rule 10.500 of the California Rules of Court. Disclosure will be made regardless of whether the quote (or portions thereof) is marked “confidential,” “proprietary,” or otherwise, and regardless of any statement in the quote (a) purporting to limit the Court’s right to disclose information in the quote, or (b) requiring the Court to inform or obtain the consent of Vendor prior to the disclosure of the quote (or portions thereof). Accordingly, Vendor should not include confidential or proprietary information in its quote.

Miscellaneous. It is unlawful for any person engaged in business within this state to sell or use any article or product as a “loss leader” as defined in Business and Professions Code 17030. It is unlawful to prohibit a printer or copier cartridge that is sold to a judicial branch entity from being recycled or remanufactured.

PAYEE DATA RECORD

Required in lieu of IRS W-9 form when receiving payments from the Judicial Council of California (JCC) on behalf of the Superior Courts of California

Instructions

See page two for additional instructional information and Privacy Statement. Complete all information on this form, sign, and date. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used to prepare Information Returns (1099). Return this form to your court representative who will forward it to the Judicial Council of California.

SECTIONS 2 THRU 5 – VENDOR COMPLETE

Legal

Name

PAYEE'S LEGAL NAME - AS SHOWN ON FEDERAL INCOME TAX RETURN

BUSINESS NAME - IF DIFFERENT FROM ABOVE E-MAIL ADDRESS

REMITTANCE MAILING ADDRESS

CITY, STATE, ZIP CODE

PHONE NUMBER

Payee

Entity

Type

Complete

One Box

Only

NOTE:

A taxpayer identification number is required

ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)

PARTNERSHIP CORPORATION EXEMPT (NON-PROFIT)

LIMITED LIABILITY COMPANY CORPORATION – LEGAL GOVERNMENT (FEDERAL, STATE, LOCAL)

INDIVIDUAL/SOLE PROPRIETOR CORPORATION – MEDICAL ESTATE OR TRUST

ENTER SOCIAL SECURITY NUMBER (SSN)

Note: If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN; however, the IRS prefers that you use your

SSN. For trial court employee vendor number, the SSN is not required

Resident

Status check the appropriate box

California Resident - Qualified to do business in California or maintains place of business

California Nonresident (see page 2) – Payment(s) to non-resident for services may be subject to State Income Tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of State Withholding attached

Certification

NOTE:

See instructions on

Vendor

Contact

Information and

Signature

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person, as defined by the IRS.

I hereby certify under the penalty of perjury that the information provided on this document is true and correct.

Should my information change, I will promptly notify the JCC at the address listed in Section 1.

VENDOR REPRESENTATIVE’S NAME (Type or Print) TITLE E-MAIL

AUTHORIZED VENDOR SIGNATURE DATE TELEPHONE

SECTION 6 – COURT COMPLETE

Vendor

Category

Court

Contact

Please choose from the JCC Vendor Category below

ARBITRATOR

BENEFIT PROVIDER

CONTRACTOR

COURT APPT. COUNSEL

COURT INTERPRETER

COURT REPORTER

DECEASED FINAL PAYMENT

EMPLOYEE

GARNISHMENT TRUSTEE

GRAND JURY

MEDIATOR

RENT

SETTLEMENT/ AWARDS

VOLUNTEER

RETIREE – (description required)

COURT CONTACT NAME PHONE NUMBER EMAIL

Requirement to Complete Payee Data Record A completed Payee Data Record (in lieu of the IRS W-9) is required for payments and will be kept on file at the Judicial Council of California, Trial Court Administrative Services Office. Since each state agency with which you do business must have a separate Payee Data Record on file, it is possible for a payee to receive a similar form from various state agencies.

SECTIONS 2 THRU 5 – VENDOR COMPLETE

Enter the payee’s legal name. Sole proprietorships must also include the owner’s full name.

An individual must list his/her legal name as it appears on his/her Federal Income tax return. If a different name is used, that name should also be entered, beneath the legal name.

The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the physical location of business, if different than mailing address. The phone number, e-mail address, and facsimile number should also be provided.

Check the box that corresponds to the payee business type. Check only one box. Corporations must check the box that identifies the type of corporation.

The State of California requires that all parties entering into business transactions that may lead to payment(s) from the

State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and

Taxation Code Section 18646 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the Internal Revenue Code Section 6109(a).

The TIN for individuals is their Social Security Number (SSN). A sole proprietor may have both a Federal Employer

Identification Number (FEIN) and a SSN, the IRS prefers that sole proprietors user their SSN. Only partnerships, estates, trusts, and corporations will enter their FEIN.

Are you a California resident or non-resident?

A corporation will be defined as a “resident” if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at the time of death.

A trust is a resident if at least one trustee is a California resident.

For individuals and sole proprietors, the term “resident” includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a non-resident.

Payments to all non-residents may be subject to withholding. Non-resident payees performing services in California or receiving rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for State income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.

For information on Non-resident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov

For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

This form must be signed. Provide the name, title, e-mail, and telephone number of the individual completing this form. Also, provide the date the form was completed.

Certification Instructions: You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. If you are not a U.S. Citizen or U.S. person, as defined by the Internal Revenue Service, a different form may be required and tax withholdings may apply. See IRS website http://www.irs.gov/businesses/international/index.html for additional information.

SECTION 6 – COURT COMPLETE

Please check the box that best describes the type of business/work the vendor provides. This will assist us in processing payment and tax withholdings. If the court is sending the request, please include contact information to assist with processing your request. Not including court contact information may delay processing the request.

Privacy Statement: Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it.

It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and State law imposes non-compliance penalties of up to $20,000.

You have the right to access records containing your personal information, such as your SSN. To exercise the right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

mailto:wscs.gen@ftb.ca.gov http://www.ftb.ca.gov/ http://www.irs.gov/businesses/international/index.html

Electronic Funds Transfer Authorization

(Automated Clearing House - ACH)

Revised 02/08/2023

SECTION 1. Enrollment Type

Please select the box that indicates the enrollment action.

New Change Certification Cancel

If this is a change or a request to add to an existing vendor, please indicate the vendor number:

SECTION 2. Remittance E-Mail Notification

Please provide one or more Accounts Receivable e-mail addresses where ACH remittance information should be sent:

E-mail 1:

E-mail 2:

SECTION 3. Account Information

Name of Individual/Business:

Name of Financial Institution:

Branch Number or Name: Branch Phone:

Financial Institution Address (Number and Street):

City: State: Zip Code:

Type of Account: Checking Savings

Nine-Digit Routing Number: Depositor Account Number:

Re-enter Routing Number: Re-enter Account Number:

SECTION 4. Authorization

1. Select the appropriate action:

Authorize direct deposit of payments due the entity named in Section 3

Cancel direct deposit for the entity named in Section 3

2. Provide certification information:

I certify that the entire amounts authorized to be received by this account are not subject to be transferred to a foreign bank account. I acknowledge that if this box is not selected, the Judicial Council of California (JCC) will issue all payments by check only.

If I transfer money from this account to an offshore bank, I will cancel this authorization and notify the JCC. This authorization remains in full force and effect until the JCC receives written notification from the entity of its termination in such manner as to afford the JCC and financial institution a reasonable opportunity to act on it, or until the JCC terminates the agreement. This authorization and any future notifications must be sent to one of the contacts listed in Section 5.

Authorized Signature of Entity Named in Section 3:

Signature

Provide the last 4-digits the taxpayer identification number associated with this vendor:

Date:

Phone:

SECTION 5. General Instructions

1. To enroll for direct deposit payments from the Superior Courts of California or change, certify, or cancel your existing direct deposit, complete sections 1, 2, 3 and 4 of this form (all information must be legible).

2. Contact your financial institution to obtain routing and account number information.

3. Your direct deposit will continue to be deposited into your designated account at your financial institution until the JCC is notified that you wish to re-designate your account and/or your financial institution. To re-designate, complete and submit a new form with the new information. Do not close your old account until your first payment is deposited into your newly designated account and/or financial institution.

4. Submit this form to your court representative who will forward it to the Judicial Council of California.

rev Nov. 2018

DARFUR CONTRACTING ACT CERTIFICATION

Pursuant to Public Contract Code (PCC) section 10478, if a proposer currently or within the previous three years has had business activities or other operations outside of the United States, it must either (i) certify that it is not a “scrutinized company” as defined in PCC 10476, or (ii) receive written permission from the JBE to submit a proposal.

To submit a proposal to the JBE, the proposer must insert its company name and Federal ID Number below and complete ONLY ONE of the following three paragraphs. To complete paragraph 1 or 2, simply check the corresponding box. To complete paragraph 3, check the corresponding box and complete the certification for paragraph 3.

Company Name (Printed) Federal ID Number

Printed Name and Title of Person Checking Box (for paragraph 1 or 2 below)

1. We do not currently have, and we have not had within the previous three years, business activities or other operations outside of the United States.

OR

2. We are a “scrutinized company” as defined in PCC 10476, but we have received written permission from the JBE to submit a proposal pursuant to PCC 10477(b).

A copy of the written permission from the JBE is included with our proposal.

OR

3. We currently have, or we have had within the previous three years, business activities or other operations outside of the United States, but we certify below that we are not a “scrutinized company” as defined in PCC 10476.

CERTIFICATION FOR PARAGRAPH 3:

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY, that I am duly authorized to legally bind the proposer to the clause in paragraph 3. This certification is made under the laws of the State of California.

Company Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County of _________ in the

State of ____________