Project Information

Bid Title

26-021 RFP ERATE CABLE REMEDIATION

Issuing Agency

Houston County Board of Education

Location

Georgia

Published Date

Dec 9, 2025

Closing Date

Jan 8, 2026

Government Level

State & Local

Status

Closed

Original Source

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Bid Documents

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Project Description

26-021 RFP ERATE CABLE REMEDIATION

• 26-021 ERATE CABLE REMEDIATION.docx
• 26-021 ERATE CABLE REMEDIATION Q&A01.docx

Attachment Preview

HOUSTON COUNTY SCHOOL DISTRICT

REQUEST FOR PROPOSALS

For

Cable Plant Infrastructure Remediation

RFP NUMBER 26-021

For all questions about this RFP contact:

L. Renee Langston, CPPB, Issuing Officer

Renee.langston@hcbe.net

478-988-6211 ext. 3735

RELEASED ON:

December 09, 2026

DUE ON:

January 08, 2026 2:00 P.M. Eastern Time

1.0
INTRODUCTION

1.1 Purpose of Procurement

The purpose of this RFP is to solicit proposals for remediation of existing network cabling infrastructure. The district is seeking a qualified vendor for the removal of unused cabling, implementation of effective cable management, and ensuring all cables are correctly connected. The goal of the remediation is enhance the network’s performance and longevity.

1.2 Proposal Certification

The Houston County School District certifies the use of competitive sealed bidding will not be practical or advantageous to the District in completing the acquisition described in this RFP.  Competitive sealed proposals will be submitted in response to this RFP. All proposals submitted pursuant to this request will be made in accordance with the provisions of this RFP in 3.0.

1.3 Schedule of Events

This Request for Proposals will be governed by the following schedule:

December 09, 2025 Release of RFP

January 08, 2026 Proposals Due – no later than 2:00 p.m. EST

Remediation must be coordinated with the Director of Technology and may begin after April 01, 2026 after award. A project timeline must be submitted reflecting milestones and the duration of each task necessary for the successful implementation of the proposed solution.

1.4 Restrictions on Communications with Staff

All questions about this RFP must be submitted in the following format:

Company Name

1. Question

Citation of relevant section of the RFP

2. Question

Citation of relevant section of the RFP

Questions must be directed in writing to the Issuing Officer:

renee.langston@hcbe.net

Fax: 478-988-6212

Questions must include the company name and the referenced RFP section.

From the issue date of this RFP until a contractor is selected and the selection is announced, Offerors are not allowed to communicate for any reason with any District staff except through the Issuing Officer named herein, or during the Offeror's conference, or as provided by existing work agreement(s). The District reserves the right to reject the proposal of any Offeror violating this provision. All questions concerning this RFP must be submitted in writing (fax or email may be used) to the Issuing Officer. No questions other than written will be accepted. No response other than written will be binding upon the District. Questions and answers will be posted to the HCSD website and as an addendum in the USAC portal (EPC). Website address is http://www.hcbe.net , click on Departments, Purchasing, Bids/Proposals.

1.5 Definition of Terms

HCSD – Houston County School District

District – Houston County School District

OCGA - Official Code of Georgia Annotated (State Statute)

Offeror Vendor/Contractor – Respondent to this Request for Proposals

RFP - Request for Proposals

1.6 Contract Term

Code section 20-2-506 of the laws of the State of Georgia as of this date and as may be amended apply to this agreement. If it is determined that a contract is established for this project, for the duration of the contract term established through this RFP, contracts will automatically renew on July 1 of each year unless notified in writing by HCSD. The initial contract term is one (1) year, or less, from April 1, 2026 through June 30, 2027, with annual renewals for a maximum of (2) years or (24) months.

1.7 Background

For information on the Houston County School District, please go to www.hcbe.net .

2.0 MANDATORY REQUIREMENTS

This section identifies all mandatory requirements which must be addressed in the proposal before further consideration will be given. Each response must reference the item number it is in reference to (i.e., 2.1.a, 2.1.b, etc.).

Proposals should include pricing per drop removed.

2.1 Remediation Requirements

a. The District and vendor will review existing cable layout for each targeted facility.

b. Service provider will confirm identified drop for remediation has no connected equipment, reporting any to district contact.

c. Service provider will locate all wall jacks, patch panels, and cable termination points where cables identified for remediation are connected.

d. Service provider will loosen any cable ties or cable management fixtures holding cables in place.

e. Service Provider will disconnect cable from wall jack and patch panel.

f. Service provider will remove cable from pathway, ensuring not to damage walls of the pathway or other cables utilizing the pathway.

g. The service provider will consolidate patch panels and relabel the moved drops on the wall plate.

h. Service provider will dispose of removed cable according to the agreed upon recycling plan.

i. Service provider will report total drops remediated for each targeted facility.

j. The District will allow for brief pre-arranged outages during off-hours or facility closure days when required to complete remediation.

2.1.1 Contract Term

a. The initial term of the contract shall be for one (1) year from the starting date listed with the contract. The contract shall automatically renewal annually for an additional one year up to one (1) additional year without any additional agreements. However, HCSD reserves the right to not renew the annual contract for the remaining year, renew the contract monthly, annually or terminate the contract at any point during the entire term of the contract. Additionally, HCSD reserves the right to terminate the contract anytime during the entire term of the contract if the Service Level Agreement (SLA) and Service Guaranty Commitment is not met by the provider.

2.1.2 Performance

a. Service disruptions must be minimized if cutover processes are required and must be performed after normal HCSD business hours.

2.1.3 Nonperformance

a. Nonperformance by a contractor or subcontractor (representative) may result in:

i. Cancellation of the contract by the District.

ii. The assessment of actual costs against the contractor. The contractor shall supervise and exercise control over any subcontractors employed and shall be held responsible for the actions and activities of both employees and subcontractors.

2.2 Qualifications, Service Provider

a. The Service Provider shall be experienced in all aspects of this work and shall be required to demonstrate direct experience on recent systems of similar type and size.

b. The Service Provider selected to provide the service shall have been in business of providing low voltage cabling services a minimum of three (3) years with experience on similar systems.

c. The Service Provider selected for this project must adhere to the engineering, installation and testing procedures of the manufacturers and the municipality.

d. The Service Provider shall have a service call number that is answered 24 hours a day, 365 days per year for maintenance and trouble calls.

e. The Service Provider shall provide references of at least three (3) School Districts with a minimum of twenty (20) schools where they have performed large scale low voltage cabling project.

f. The Service Provider must possess a valid, unencumbered SPIN for the Universal Service Administration Company (USAC), as well as an FCC registration number. Vendors must be able to provide a copy of the most recent USAC Form 473 (SPAC).

g. The Service Provider must be financially stable and responsible. HCSD reserves the right to request proof of financial stability.

h. The Service Provider must be fully licensed to do business in the State of Georgia and remain in compliance with all legal requirements set forth by the Georgia Public Service Commission and the Federal Communications commission of the United States.

i. The E-Rate program requires that all records must be retained for at least ten (10) Years from the last date of service provided on a funding request. Respondent hereby agrees to retain all books, records, and other documents relative to any Agreement resulting from this RFP for ten (10) years after final payment. The District, its authorized agents, and/or auditors reserves the right to perform or have performed an audit of the records of the Respondent and therefore shall have full access to and the right to examine any of said materials within a reasonable period of time during said period.

2.3 Permits, Codes and Inspections

The Service Provider shall obtain and pay for all permits and inspections necessary for the execution of all work pertaining to the remediation service (if required).

2.4 Company Background and Experience

Offeror will describe their background, relevant experience and qualifications including, but not limited to the following:

a. Company Structure

The Offeror will include in the proposal the legal form of their business organization, the state in which incorporated (if a corporation), the types of business ventures in which the organization is involved, the office location that will be the point of contact during the term of any resulting contract, and a chart of the organization structure, including the reporting relationships, as they relate to this RFP.

b. Experience

The Offeror must include the total number of full consecutive years experience as current business.

The Offeror will provide a list of all clients for whom similar services, as detailed in this RFP, have been provided during the past three years.  The list must include:

• dates of service

• name of contact person

• title of contact person

• phone number of contact person

The Offeror will also disclose any services terminated by the client(s) and the reason(s) for termination.

2.5 Submission Requirements

a. Proposals shall be submitted in two separate parts, Technical Proposal and Financial Proposal.

b. The Offeror must submit the Certification Letter with original signature (Appendix A).

c. The Offeror must submit a completed and notarized Certificate Regarding Debarment, Suspension, Ineligibility Form (Appendix B).

d. The Offeror must submit a completed E-Rate Certification Form (Appendix C).

e. The Offeror must submit a completed Vendor Affidavit Form (Appendix D).

f. Any exceptions to the District’s Sample Contract (Appendix E) must be clearly identified and submitted with the Offeror’s Technical Proposal. Proposed exceptions must not conflict with or attempt to preempt mandatory requirements specified in Section 2.0.

g. The Offeror must submit a Technical Proposal detailing the proposed approach to performing all of the services requested under Section 2.0 and providing company information as detailed. The Offeror will submit one hard copy of the Technical Proposal with original signatures and one copy of the Financial Proposal.

h. Each item included in sections 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7 must be addressed and appropriately labeled to reflect the item number addressed. The Offeror must submit a Guide to Mandatory Requirements referencing the page(s) of the Technical Response where satisfaction of the Mandatory Requirements is substantiated.

i. Each submission must include a thumb drive (flash drive, USB drive) of their entire proposal, Technical and Financial. Drive will not be returned to the vendor.

3.0 PROPOSAL SUBMISSION AND EVALUATION

3.1 Process for Submitting Proposals

3.1.1 Preparation of Proposal

Each proposal should be prepared simply and economically, avoiding the use of elaborate promotional materials beyond those sufficient to provide a complete presentation. If supplemental materials are a necessary part of the technical proposal, the Offeror should reference these materials in the technical proposal, identifying the document(s) and citing the appropriate section and page(s) to be reviewed.

3.1.2 Packaging of Proposal

The Offeror's proposal in response to this RFP must be divided into two appropriately labeled and sealed packages - a Technical Submission and a Financial Proposal.

The contents of each package will include:

1. Technical Submission

• Certification Letter (Appendix A)

• Certificate Regarding Debarment, Suspension, Ineligibility (Appendix B)

• E-Rate Certification (Appendix C)

• Vendor Affidavit (Appendix D)

• Any Contract Exceptions (Appendix E)

• Technical Proposal, addressing all requirements in Section 2.0

• Do not include cost information in the Technical Proposal

2. Financial Proposal

• The Offeror must use the Financial Proposal form (Appendix F).

Mark the outside of shipping package as follows:

Name of Company

Phone Number and Point of Contact for Company

RFP # 26-021

Due no later than January 08, 2026 2:00 P.M. Eastern Time

3.1.3 Submission of Proposals

Proposals must be submitted to:

HCSD – Purchasing Dept.

L. Renee Langston, CPPB

200 Jerry Barker Drive

Warner Robins, Georgia 31088

Any proposal received after the due date and time will not be evaluated.

3.2 Evaluation Process

The evaluation of proposals received on or before the due date and time will be conducted in the following phases.

3.2.1 Administrative Review

The proposals will be reviewed by the Issuing Officer for the following administrative requirements:

1. Submitted by deadline

2. Separately sealed Technical Submission and Financial Proposal

3. All required documents have been completed and submitted

4. Technical Submission does not include any information from the Financial Proposal

5. All documents requiring an original signature have been signed and are included

3.2.2 Mandatory Requirements Review

Proposals which pass the administrative review will then be reviewed by the Technical Evaluation Team to ensure all requirements identified in Section 2.0 are addressed satisfactorily.

3.2.3 Proposal Evaluation

Proposals which pass the Mandatory Requirements Review will be reviewed by the Technical Evaluation Team for quality and completeness.

The following are the maximum possible points of each category:

Point Category Points Allotted

Eligible Cost 45

Proposed Solution 35

Business Qualifications 10

Demonstrated “E‐Rate” experience 10

Total Possible Points 100

3.2.4 Oral Presentations

The District reserves the right to choose and invite Offerors to present their technical solution to the Technical Evaluation Team. The Financial Proposal must not be discussed during the oral presentation. All Offerors submitting proposals may not be asked to make a presentation.

3.2.5 Financial Proposal Evaluation

Offerors will use only the Financial Proposal Forms provided with the RFP (Appendix F).

3.2.6 Identification of Apparent Successful Offeror

The resulting Financial Proposal scores will be combined with the Technical Proposal score. The Offeror with the highest combined technical and financial score will be identified as the apparent successful Offeror.

3.3 Rejection of Proposals/Cancellation of RFP

The District reserves the right to reject any or all proposals, to waive any irregularity or informality in a proposal, and to accept or reject any item or combination of items, when to do so would be to the advantage of the District. It is also within the rights of the District to reject proposals that do not contain all elements and information requested in this document. The District reserves the right to cancel this RFP at any time. The District will not be liable for any cost/losses incurred by the Offerors throughout this process.

4.0 TERMS AND CONDITIONS

4.1 RFP Amendments

The District reserves the right to amend this RFP prior to the proposal due date. All amendments and additional information will be posted to the HCSD Purchasing website, located at: https://www.hcbe.net/purchasing/openbids. Offerors are encouraged to check this website frequently.

4.2 Proposal Withdrawal

A submitted proposal may be withdrawn prior to the due date by a written request to the Issuing Officer. A request to withdraw a proposal must be signed by an authorized individual.

4.3 Cost for Preparing Proposals

The cost for developing the proposal is the sole responsibility of the Offeror. The District will not provide reimbursement for such costs.

4.4 Sample Contract

The Sample Contract, which the District intends to use with the successful Offeror, is attached to this RFP and identified as Appendix E. Exceptions to the Contract should be identified and submitted with the Offeror's proposal. Proposed exceptions must not conflict with or attempt to preempt mandatory requirements specified in Section 2.0.

Prior to award, the apparent winning Offeror will be required to enter discussions with the District to resolve any contractual differences before an award is made. The District is a political subdivision of the State of Georgia. Be advised that State Entities are unable to agree to certain terms and conditions that are not in accordance with the laws of Georgia. These discussions are to be finalized, and all exceptions resolved within one (1) week of notification. Failure to resolve contractual differences will lead to rejection of the Offeror's proposal.

The District reserves the right to modify the Contract to be consistent with the successful offer and to negotiate with the successful Offeror other modifications, provided that no such modifications affect the evaluation criteria set forth herein or give the successful Offeror a competitive advantage.

4.5 Conflict of Interest

If an Offeror has any existing client relationship that involves the Houston County School District, the Offeror must disclose each relationship.

4.6 Compliance with Laws

The Contractor will comply with all State and Federal laws, rules, and regulations.

ATTACHMENT A

Primary Locations

School / Admin sites	Street	City	State	Zip	Latitude, Longitude
BoE Annex	1600 Macon Rd	Perry	GA	31069	32.467638, -83.727885
Purchasing Warehouse	200 Jerry Barker Drive	Warner Robins	GA	31088	32.549701, -83.674287
Bonaire Elementary School	101 Elm Street	Bonaire	GA	31005	32.547261, -83.600122
Bonaire Middle School	125 Hwy 96 East	Bonaire	GA	31005	32.547012, -83.589207
Bonaire Primary School	535 Thompson Mill Rd	Bonaire	GA	31005	32.538242, -83.570681
C.B Watson Primary School	401 Dover Dr	Warner Robins	GA	31088	32.60872357767607, -83.6112039601746
Centerville Elementary School	450 N Houston Lake Blvd	Centerville	GA	31028	32.629238, -83.688099
Transportation	311 Bear Country Blvd	Warner Robins	GA	31088	32.546599, -83.678713
Central Registration	410 Bear Country Blvd	Warner Robins	GA	31088	32.553180, -83.678784
David A. Perdue Primary School	150 Bear Country Blvd	Warner Robins	GA	31088	32.54799, -83.674147
Eagle Springs Elementary School	3591 Us Hwy 41 N	Byron	GA	31008	32.630184, -83.710225
Feagin Mill Middle School	1200 Feagin Mill Rd	Warner Robins	GA	31088	32.569479, -83.676140
Hilltop Elementary School	301 Robert Bryson Smith Pkwy	Bonaire	GA	31005	32.543006, -83.621289
Houston Career & Technical Center	1311 Corder Rd.	Warner Robins	GA	31088	32.595320, -83.653682
Houston County WIN Academy	215 Scott Blvd	Warner Robins	GA	31088	32.600762, -83.615827
Houston County High School	920 Highway 96	Warner Robins	GA	31088	32.554535, -83.676254
Huntington Middle School	206 Wellborn Rd	Warner Robins	GA	31088	32.599694, -83.600794
Kings Chapel Elementary School	460 Arena Rd	Perry	GA	31069	32.454782, -83.653590
Lake Joy Elementary School	985 Lake Joy Rd	Warner Robins	GA	31088	32.575307, -83.694916
Lake Joy Primary School	995 Lake Joy Rd	Warner Robins	GA	31088	32.577526, -83.695388
Langston Road Elementary	315 Langston Rd	Perry	GA	31069	32.498716, -83.701722
Langston Road Primary	325 Langston Rd	Perry	GA	31069	32.500638, -83.705780
Lindsey Student Support Center	81 Tabor Dr	Warner Robins	GA	31093	32.639447, -83.615973
Matt Arthur Elementary School	2500 Ga Hwy 127	Kathleen	GA	31047	32.506188, -83.652291
Matt Arthur Primary	150 Talton Rd	Kathleen	GA	31047	32.50142026151707, -83.63687881893611
Miller Elementary School	101 Pine Valley Dr	Warner Robins	GA	31088	32.615256, -83.638720
Morningside Elementary	1206 Morningside Dr	Perry	GA	31069	32.464187, -83.710185
Mossy Creek Middle School	200 Danny Carpenter Dr	Kathleen	GA	31047	32.533881, -83.700962
Northside Elementary School	305 Sullivan Rd	Warner Robins	GA	31093	32.655269, -83.657153
Northside High School	926 Green St	Warner Robins	GA	31093	32.626985, -83.630798
Northside Middle School	500 Johnson Rd	Warner Robins	GA	31093	32.636866, -83.645471
Parkwood Elementary School	503 Parkwood Dr	Warner Robins	GA	31088	32.624900, -83.630274
Pearl Stephens Elementary School	420 Pearl Stephens Way	Warner Robins	GA	31088	32.602827, -83.616405
David A. Perdue Elementary School	115 Sutherlin Dr	Warner Robins	GA	31088	32.549429, -83.670828
Perry Warehouse and Cannery Plant	1701 Houston Lake Rd	Perry	GA	31069	32.467885, -83.718531
Perry High School	1307 North Ave	Perry	GA	31069	32.467273, -83.725873
Perry Middle School	495 Perry pkwy	Perry	GA	31069	32.485409, -83.726817
Quail Run Elementary School	250 Smithville Church Rd	Warner Robins	GA	31088	32.608491, -83.688552
Russell Elementary School	101 Patriot Way	Warner Robins	GA	31088	32.596699, -83.635346
Shirley Hills Elementary	300 Mary Lane	Warner Robins	GA	31088	32.602848, -83.650969
Thomson Middle School	301 Thomson St	Centerville	GA	31028	32.633442, -83.694364
Tucker Elementary School	1300 Tucker Rd	Perry	GA	31069	32.448809, -83.721868
Veterans Middle School (NEW)	345 Piney Grove Rd	Kathleen	GA	31047	32.51550377372506, -83.60936000250578
Veterans High School	340 Piney Grove Rd	Kathleen	GA	31047	32.513935, -83.613003
Warner Robins High School	401 S Davis Dr	Warner Robins	GA	31088	32.610820, -83.614411
Warner Robins Maintenance	601 S. Davis Dr.	Warner Robins	GA	31088	32.608575, -83.614229
Warner Robins Middle School	425 Mary Lane	Warner Robins	GA	31088	32.597330, -83.654143
Westside Elementary School	201 N Pleasant Hill Rd	Warner Robins	GA	31093	32.621436, -83.624168

Appendix A

Certification Letter

(Form must be completed and returned with bid.)

I certify that I have read and understand the terms and conditions herein. I further state that I am and/or my company is capable, able to, and will provide the requested product(s) and/or service(s) described herein. I am the owner or agent of the company stated below and am authorized and empowered to contract. By my signature on this ITB, I/we guarantee and certify that all items included in my bid meet or exceed specifications.

I certify that this bid is made without prior understanding, agreement, or connection with any corporation, firm or person submitting a bid for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I understand collusive bidding is a violation of State and Federal Law and can result in fines, prison sentences, and civil damage awards. I agree to abide by all conditions of this ITB and certify that I am authorized to sign this bid for the Vendor.

I certify and acknowledge that the laws of the State of Georgia, including the Georgia Open Records Act , require procurement records and other records to be made public unless otherwise provided by law.

By signing below I warrant that the bid price(s), terms and conditions stated in my response to this bid shall be firm through the bid process and until the time the award is made at which time prices shall remain firm and fixed for the entire contract period.

I certify and acknowledge that No substitutes will be accepted after the bid is awarded without prior written approval from the Director of Purchasing.

SUBMITTED BY___________________________________ DATE _____________________

TITLE____________________________________EMAIL: ____________________________

COMPANY NAME_____________________________________________________________

ADDRESS_______________________________CITY______________ST_____ZIP________

TELEPHONE NUMBER____________________FAX NUMBER________________________

COMPANY WEBSITE _________________________________________________________

SIGNATURE _________________________________________________________________

DO YOU ACCEPT VISA? ______________

ADDITIONAL FEE IF PAYMENT MADE WITH VISA: _________________

Appendix B

Certificate Regarding Debarment, Suspension, Ineligibility

The Houston County School District is a recipient of Federal monies. As such we require that participating vendors not be debarred, suspended, ineligible or excluded from doing business with the Federal government or any agency thereof.

The prospective participant certifies, by submission of the proposal, that neither it, nor its principals, is presently debarred, suspended, proposed for debarment, declared ineligible, or excluded from participation in this transaction by any Federal department or agency.

Organization Name

Service Provider Identification Number (SPIN)

Name(s) and Title(s) of Authorized Representative(s)

Signature(s) Date

Notary Date

Appendix C

E-RATE CERTIFICATION

I, _______________________________________, certify that___________________________, is a

(Print or Type Name) (Company Name)

Service Provider as defined by the E‐Rate Program and has not been suspended or disbarred from participating by the Federal Communications Commission. Our SPIN # is __________________, and

(Type Service Provider ID)

we have operated under this SPIN for ______years.

(number)

I also certify to the acceptance of the following:

1. All information necessary to respond to any PIA (Program Integrity Assurance), Item 25 Selective Review, or Audit performed by the FCC, the SLD, or their designated authority, will be furnished completely and in a timely manner sufficient to meet the any response deadlines;

2. In the event an appeal is necessary, all the information necessary to complete the appeal will be furnished completely and in a timely manner to the Houston County School District, it’s attorney(s) or authorized agent;

3. Any contract awarded based upon RFP#26-021 is contingent upon the receipt of a Funding Commitment Decision Letter (FCDL) from the SLD that awards the requested discounts in full. In the event that partial funding or no funding is granted, the Houston County School District reserves the right to cancel the contract in whole or in part;

4. The Houston County School District will be invoiced for only the matching funds portion, and it our responsibility, as the E‐Rate Service Provider, to invoice the SLD for the remaining “non‐discount” portion. This billing method is known as the SPI (Service Provider Invoice) method;

5. In the event the Houston County School District wishes to perform a SPIN change, as afforded by the COPAN decision, permission will be granted within the contracted terms, provided 14 days prior written notice is given.

___________________________________________________ _________________________

(Original Signature in Blue or Black Ink) (Today’s Date)

___________________________________________________

(Print or Type Name)

___________________________________________________/

(Title)

Appendix D

Vendor Affidavit under O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned Vendor 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 on behalf of Houston County School District 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 Vendor will continue to use the federal work authorization program throughout the contract period and the undersigned Vendor will contract for services in satisfaction of such contract only with sub-Vendors who present an affidavit to the Vendor with the information required by O.C.G.A. § 13-10-91(b). Vendor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization User Identification Number Date of Authorization

( )
Name of Vendor Name of Project

Houston County School District

Name of Public Employer

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

Executed on ______, ___, 2026 in ____________________(city), ______(state).

__________________________________________
Signature of Authorized Officer or Agent

__________________________________________

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________, 2026.

...

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