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2013-005 RES APPROVING MULTIPLE USE AGREEMENT BY AND BETWEEN STATE OF TX AND COPRESOLUTION NO. 2013-005 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS, TEXAS; APPROVING A MULTIPLE USE AGREEMENT BY AND BETWEEN THE STATE OF TEXAS AND THE CITY OF PARIS, TEXAS; PROVIDING FOR CONSTRUCTION , MAINTENANCE AND OPERATION OF THE ROADSIDE PARK LOCATED ALONG US HIGHWAY 82 AT THE INTERSECTIOIV OF 41sT SW STREET IN THE CITY LIMITS; AUTHORIZING THE CITY MANAGER TO EXECUTE ON BEHALF OF THE CITY, ANY AND ALL DOCUMENTS NECESSARY FOR THE MULTIPLE USE AGREEMEIVT; MAKING OTHER FINDINGS AND PROVISIONS RELATED TO THE SUBjECT; AND DECLARING AN EFFECTIVE DATE. WHEREAS, the Ciry Council desires to enter into a Multiple Use Agreement with the State of Texas to improve the current condition of the roadside park located along US Highway 82 W at the intersection of 41St Street SW in the Paris city limits to provide beautification and practical use for the community; and, WHEREAS, a conceptual site plan for the roadside park improvements is attached to the Agreement further describes the improvements the City would like to provide to the roadside park; and, WHEREAS, the State of Texas has indicated its willingness to approve the Multiple Use Agreement with the City of Paris, Texas for improvements to the roadside park; and, WHEREAS, the City Council hereby finds that it is in the best interest of the City and its citizens to enter into this Multiple Use Agreement with the State of Texas. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, TEXAS, THAT: Section 1. The findings set out in the preamble to this resolution are hereby in all things approved. Section 2. The terms and conditions of the Agreement, attached hereto as Exhibit, "A", having been reviewed by the City Council of the City of Paris and found to be acceptable and in the best interest of the City of Paris and its citizens, is hereby in all things approved. Section 3. That the City Manager is hereby authorized to execute on behalf of the City of Paris, Texas all documents necessary for the Multiple Use Agreement. Section 4. This resolution shall be effective immediately upon passage. DULY PASSED AND APPROVED this 11th day of February, 2013. A.J. Hashmi;�D., Mayo�% �. ATTEST: � , nice Ellis, City Clerk APPROVED AS TO FORM: W. Kent , City Attorney � � � Form 2044 (Rev. 11/11) Page 1 of 9 STATE OF TEXAS § COUNTY OF TRAVIS § MULTIPLE USE AGREEMENT THIS AGREEMENT made by the State of Texas by and between the Texas Department of Transportation, hereinafter referred to as "State", party of the first part, and City of Paris, Texas , hereinafter called the "Local GovernmenY' , party of the second part, is to become effective when fully executed by both parties. WHEREAS, on the body for the into Resolution/Ordinance No. reference, authorizing the this agreement with the State; and WHEREAS, the WITNESSETH day of Local Government Local Government Local Government construction, maintenance and operation of a public Roadside Park right of way, (General description of area) , 20 , the goveming , entered hereinafter identified by 's participation in has requested the State to permit the on the highway Park located along US Highway 82 at the intersection of 41 st Street in the City Limits of Paris shown graphically by the preliminary conceptual site plan in Exhibit "A" and being more specifically described by metes and bounds of Exhibit "B", which are attached and made a part hereof; and WHEREAS, the State has indicated its willingness to approve the establishment of such facilities and other uses conditioned that the Local Government will enter into agreements with the State for the purpose of determining the respective responsibilities of the Local Government and the State with reference thereto, and conditioned that such uses are in the public interest and will not damage the highway facilities, impair safety, impede maintenance or in any way restrict the operation of the highway facility, all as determined from engineering and tra�c investigations conducted by the State. � �� EXHIBIT Form 2044 (Rev. 11/17) Page 2 of 9 AGREEMENT NOW, THEREFORE, in consideration of the premises and of the mutual covenants and agreements of the parties hereto to be by them respectively kept and performed as hereinafter set forth, it is agreed as follows: 1. DESIGN AND CONSTRUCTION Local Government will prepare or provide for the construction plans for the facility, and will provide for the construction work as required by said plans at no cost to the State. Said plans shall include the design of the access control, necessary horizontal and vertical clearances for highway structures, adequate landscape treatment, adequate detail to ensure compliance with applicable structural design standards, sufficient traffic control provisions, and general layout. They shall also delineate and define the construction responsibilities of both parties hereto. Completed plans will be submitted to State for review and approval and when approved shall be attached to the agreement and made a part thereof in all respects. Construction shall not commence until plans have been approved by the State. Any future revisions or additions shall be made after prior written approval of the State. Any sidewalks, curb ramps and other pedestrian elements to be constructed, either on site or off site, by the Local Government shall be in accordance with the requirements of Title II of the Americans With Disabilities Act (ADA) and with the Texas Accessibility Standards (TAS). Elements constructed by the Local Government and found not to comply with ADA or TAS sha�l be corrected at the entire expense of the Local Government 2. INSPECTION Ingress and egress shall be allowed at all times to such facility for Federal Highway Administration personnel and State Forces and equipment when highway maintenance operations are necessary, and for inspection purposes; and upon request, all parking or other activities for periods required for such operations will be prohibited. 3. PARKING REGULATIONS Parking regulations shall be established limiting parking to single unit motor vehicles of size and capacity no greater than prescribed for 1'/2 ton trucks, such vehicles to conform in size and use to governing laws. Parking shall be permitted only in marked spaces. Parking shall be prohibited when a securiry threat, as determined by TxDOT, exists. Form2044 (Rev.11/11) Page 3 of 9 4. PROHIBITION/SIGNS Regulations shall be established prohibiting the parking of vehicles transporting flammable or explosive loads and prohibiting use of the area in any manner for peddling, advertising or other purposes not in keeping with the objective of a public faciliry. The erection of signs other than those required for proper use of the area will be prohibited. All signs shall be approved by the State prior to the actual erection. 5. RESPONSIBILITIES Maintenance and operation of the facility shall be entirely the responsibility of the Local Government . Such responsibility shall not be transferred, assigned or conveyed to a third party without the advanced written approval of the State. Further, such responsibiliry shall include picking up trash, mowing and otherwise keeping the facility in a clean and sanitary condition, and surveillance by police patrol to eliminate the possible creation of a nuisance or hazard to the public. Hazardous or unreasonably objectionable smoke, fumes, vapor or odors shall not be permitted to rise above the grade line of the highway, nor shall the facility subject the highway to hazardous or unreasonably objectionable dripping, droppings or discharge of any kind, inctuding rain or snow. 6. FEES Any fees levied for use of the facilities in the area shall be nominal and no more than are sufficient to defray the cost of construction, maintenance and operations thereof, and shall be subject to State approval. A. Retention Period. The Local Government shall maintain all books, documents, papers, accounting records and other evidence pertaining to fees collected and costs (hereinafter called the Records). The City shall make the records available during the term of the Agreement and for four years from the date the Agreement is terminated, until completion of all audits, or until pending litigation has been completely and fully resolved, whichever occurs last. B. Availability. The State or any of its duly authorized representatives, the Federal Highway Administration, the United States Department of Transportation, Office of Inspector General, and the Comptroller General shall have access to the Local Government �S records that are directly pertinent to this Agreement for the purpose of making audits and examinations. 7. TERMINATION UPON NOTICE This provision is expressly made subject to the rights herein granted to both parties to terminate this agreement upon notice, and upon the exercise of any such right by either party, all obligations herein to make improvements to said facility shall immediately cease and terminate. Form2044 (Rev.11/11) Page 4 of 9 8. MODIFICATION/TERMINATION OF AGREEMENT If in the sole judgment of the State it is found at any future time that traffic conditions have so changed that the existence or use of the facility is impeding maintenance, damaging the highway facility, impairing safety or that the faciliry is not being properly operated, that it constitutes a nuisance, is abandoned, or if for any other reason it is the State's judgment that such facility is not in the public interest, this agreement under which the facility was constructed may be: (1) modified if corrective measures acceptable to both parties can be applied to eliminate the objectionable features of the facility; or (2) terminated and the use of the area as proposed herein discontinued. 9. PROHIBITION OF STORAGE OF FLAMMABLE MATERIALS All structures located or constructed within the area covered by the agreement shall be fire resistant. The storage of flammable, explosive or hazardous materials is prohibited. Operations deemed to be a potential fire hazard shall be subject to regulation by the State. 10. RESTORATION OF AREA The Local Government shall provide written notification to the State that such facility will be discontinued for the purpose defined herein. The Local Government shall, within thirty (30) days from the date of said notification, clear the area of all facilities that were its construction responsibility under this agreement and restore the area to a condition satisfactory to the State. 11. PREVIOUS AGREEMENTS It is understood that this agreement in no way modifies or supersedes the terms and provisions of any existing agreements between the parties hereto. 72. INDEMNIFICATION Each party acknowledges that it is not an agent, servant, or employee of the other party. Each party is responsible for its own acts and deeds and for those of its agents, servants, or employees. Neither party hereto intends to waive, relinquish, limit or condition its right to avoid any such liability by claiming its govemmental immunity. When notified by the State to do so, the other party hereto shall within thirty (30) days from receipt of the State's written notification pay the State for the full cost of repairing any damages to the highway facility which may result from its construction, maintenance or operation of the facility, and shall promptly reimburse the State for costs of construction and/or repair work made necessary by reason of such damages. Form 2044 (Rev. 11/11) Page 5 of 9 Nothing in this agreement shall be construed as creating any liability in favor of any third party against the State and the Local Government . Additionally, this agreement shall not ever be construed as relieving any third party from any liability against the State and the Local Government shall become fully subrogated to the State and shall be entitled to maintain any action over and against the third party which may be liable for having caused the Local Government to pay or disburse any sum of money hereunder. 13. HOLD HARMLESS The Local Government shall indemnify and save harmless the State and its officers and employees from all claims and liability due to its materials or activities of itself, its agents, or employees, performed under this agreement and that are caused by or result from error, omission, or negligent act of the party or of any person employed by the party. The Local Government shall also indemnify and save harmless the State from any and all expense, including but not limited to attorney fees that may be incurred by the State in litigation or otherwise resisting the claim or liabilities that may be imposed on the State as a result of such activities by the Local Government , its agents, or employees authorized under this agreement. The Local Government further agrees to indemnify and save harmless the State from and against all claims, demands, and causes of action of every kind and character brought by any employee of the party against the State due to personal injuries and/or death to such employee resulting from any alleged negligent act by either commission or omission on the part of the Local Government . The indemnification of the State shall extend for a period of three (3) years beyond the date of termination of this agreement. 14. INSURANCE The Local Government , shall provide necessary safeguards to protect the public on State maintained highways including adequate insurance for payment of any damages which might result during the construction, maintenance and operation of the facility occupying such airspace or thereafter, and to save the State harmless from damages, to the extent of said insurance coverage and insofar as it can legally do so. Prior to beginning work on the State's right of way, the Local Government 's construction contractor shall submit to the State a completed insurance form (TxDOT Form No. 1560) and shall maintain the required coverage during the construction of the facility. Form 2044 (Rev. 11/11) Page 6 of 9 15. USE OF RIGHT OF WAY It is understood that the State by execution of this agreement does not impair or relinquish the State's right to use such land for highway purposes when it is required for the construction or re-construction of the traffic facility for which it was acquired, nor shall use of the land under such agreement ever be construed as abandonment by the State of such land acquired for highway purposes, and the State does not purport to grant any interest in the land described herein but merely consents to such use to the extent its authority and title permits. 16. ADDITIONAL CONSENT REQUIRED The State asserts only that it has sufficient title for highway purposes. The Local Government shall be responsible for obtaining such additional consent, permits or agreement as may be necessary due to this agreement. This includes, but is not limited to, appropriate permits and clearances for environmental, ADA and public utilities. 17. FHWA ADDITIONAL REQUIREMENTS If the Facility is located on the Federal-Aid Highway System, "ATTACHMENT A", which states additional requirements as set forth in the Federal Highway Administration's Title 23, Code of Federal Regulations, § 710, shall be attached to and become a part of this agreement. 18. CIVIL RIGHTS ASSURANCES The Local Government , for itself, its personal representatives, successors and interests and assigns, as part of the consideration hereof, does hereby covenant and agree as a covenant running with the land that: (1) no persons, on the grounds of race, color, sex, age, national origin, religion or disabling condition, shall be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination in the use of said facility; (2) that in the construction of any improvements on, over or under such land and the fumishing of services thereon, no person on the ground of race, color, sex, age, national origin, religion or disabling condition, shall be excluded from participation in, denied the benefits of, or otherwise be subjected to discrimination; (3) that the Local Government shall use the premises in compliance with all other require- ments imposed by or pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Non-discrimination in Federally-Assisted programs of the Department of Transportation - Effectuation of Title VI of the Civil Rights Act of 1964, and as said Regulations may be amended. That if in the event of any breach of the above non-discrimination covenants, the State shall have the right to terminate the agreement and reenter and repossess said land and the facilities thereon, and hold the same as if said agreement had never been made or issued. Form 2044 (Rev. 11/11) Page 7 of 9 19. AMENDMENTS Any changes in the time frame, character or responsibilities of the parties hereto shall be enacted by a written amendment executed by both parties hereto. 20. LEGAL CONSTRUCTION In case one or more of the provisions contained in this agreement shall for any reason be held invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any provision hereof and this agreement shall be construed as if such invalid, illegal, or unenforceable provision had never been contained in this agreement. 21. AUDIT The State may conduct an audit or investigation of any aspect of this agreement. The Local Government must provide the State with access to any information the State considers relevant to the investigation or audit. The audit can include, but is not limited to, any contract for construction or maintenance of any facility or structure authorized by this agreement or any contract to provide a service to the Local Government if that service is author- ized by this agreement. 22. AUTHORITY OF STATE AUDITOR The state auditor may conduct an audit or investigation of any entity receiving funds from the state directly under the contract or indirectly through a subcontract under the contract. Acceptance of funds directly under the contract or indirectly through a subcontract under this contract acts as acceptance of the authority of the state auditor, under the direction of the legislative audit committee, to conduct an audit or investigation in connection with those funds. An entity that is the subject of an audit or investigation must provide the state auditor with access to any information the state auditor considers relevant to the investigation or audit. 23. COMPLIANCE OF THE LAW The Local Government shall comply with all federal, state, and local law, statutes, ordinances, rules and regulations and with the orders and decrees of any courts or administrative bodies or tribunals in any manner affecting the performance of this agreement. 24. NOTICES All notices required under this agreement shall be mailed or hand delivered to the following respective addresses: STATE (Name of other party) (Mailing Address) (Mailing Address) Texas Department of Transportation Maintenance Division 125 East 11th Street Austin, Texas 78701-2483 Form 2044 (Rev.11/11) Page 8 of 9 25. WARRANTS The signatories to this agreement warrant that each has the authority to enter into this agreement on behalf of the party represented. List of Attached Exhibits: . Exhibit A - General Layout Exhibit B- Metes and Bounds Description Exhibit C- Approved Construction Plans Exhibit D- Certificate of Insurance (TxDOT Form 1560) Exhibit E- Attachment A(FHWA Additional Requirements) IN WITNESS WHEREOF, the parties have hereunto affixed their signature, the on the day of , 20 , and the State on the day of , 20 STATE OF TEXAS Executed and approved for the Texas (Name of other party) Transportation Commission for the purpose and effect of activating and/or carrying out the orders, and established policies or work programs By� heretofore approved and authorized by the Texas Title Transportation Commission. By: Printed Name Director, Maintenance Division Date Printed Name Date APPROVAL RECOMMENDED: District Engineer Printed Name Date Form 2044 (Rev.11/11) Page 9 of 9 ATTACHMENT A Inasmuch as this project is on the Federal-Aid highway system, the following additional requirements as applicable with the Federal Highway Administration's Title 23, Code of Federal Regulations, § 710. 1. Any significant revision in the design or construction of the facility shall receive prior approval by the Texas Department of Transportation subject to concurrency by the FHWA. 2. Any change in the authorized use of airspace shall receive prior approval by the Texas Department of Transportation subject to concurrence by the FHWA. 3. The airspace shall not be transferred, assigned or conveyed to another party without prior Texas Department of Transportation approval subject to concurrence by the FHWA. 4. This agreement will be revocable in the event that the airspace facility ceases to be used or is abandoned. 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"' � . - Thenee north SD .ia• R. si.tA couth right+ot-*sy �ia� oi HighMa� �0� C4fl ls�t Lo th� plaer _ of Eegianins, oonta�a�ng 1,� �eres. � , Thi♦ prop�rty oonteyed tor uas as right-of-n�y ond pesk tor ASgAwa� aad titl�'to ewce s�- . . .. �er;s to grentors i! ebapEop�E or not naintait+�d fas the�� parpo�es. ; '' � Ind it la fvrtdar o�ela thet ths sa1E in oanslAei�otioa of tAe Deaetlts �Aov�: ;. ; '. � _ s�t oat�,'*!11 remo�a ftom Lhe prop�s'ty aLor� •eot sueh f�naea� DnilQings �uA othtT oD- � .• g '. atzuotion� e�loar be found upoa snid prarerty. � � ,. TO HAYH aHb 70 9D1D ��s abora deaatiDeff premises� togethex sith aii ettd eirigulai� Zhe i1g1�Ls ,� � ,. ' rad L�reEita�oentR thereunto 1n aay�rise Lelongiag aato the snia Steta o1 7exaa, and iie rseiga�i � •1nE we hersby D1ad� oun c�laa, eiseutor� and adsihl�trato=a to forsr�x ■.arrsat aaE daienE . � th� rigtfir �n6 iitl� �o sald premisss unto ths te1Q 9tatt ot Tez�s i6nlnst a�sTy•peraon �Loa• �� • ' �oeter larfUllJ eleimlag or to oisieo tna �nme or oay.p�rt th�r�of. " 1Yitness ou1� handa this.tbe 17 day bf �pril. A, D. 1D36. " '," . - . ' . E. P. l2ay�r . � � . • C.. 2. Sroa4. _ .. ! . . �...� " � STtTE OT TEU3 . ! � - '� ' COIJNI'7 OF L►1'1R f ' � • f!lt::iit2:::2Jtli B�lor� m�. �. H. Y.oCul�tipa, o notar� publie in �nE faa �ald oonatr anQ , ," ; • StEte� on this d�y per�onull� appees�Q H. A. 6'nyes aaQ C. T. �aaA 1maRa to me to D� tha �er- ' � � � �oai rla�s n&m�s as� suDSOrib�d to ths Soregoing inittoment ►ad aclmoMledgeQ to me tDut thq �. ; ` �:eeuteA tbe �ama tos td� puryos�s 6aA eonalA�i6tiom th�r�2A �zprsessd. - � � ; . QStan und�t. ap� hend �ead �eal ot oltiee� thii th� 17 ea� ef dprll 4. D. 1958. • . . . DG. g. kcCul.ston. 8otarr . . ' ' l9B�L) . . . Publio. �+mer Coaaty. Tezar. __ . Tlled tor R�eard thi� th� Il d�y of Jlm�� l: D. 1�56, et �iSO orolaok P. M. - � - 8. tr, gammaok. Clerk Catat� - -� DY A. 6.. Col�m�n, INputT. Court, y�mr= Oouatq� T�zN; . . . � i ` . �` � .. ' 'y ��r� . .. . � ��~ � � . 5 � i S . � • �� �� �,�;.. �•�_:,: .�: � �. 4.: 'Gj� i • . �•` ��. ' . " ��' H�:� �.� �^` ",, .�: _ . '7 i� T. ., Y ' • �:�� :: ., :� � ' . t-`a _ . j � �- _ k . S � � �. . � ~�\ N US HWY 82 W W E S � 1 "=50' . . ,.. . ! .Y �f ' • . � Y �. F � . .` : f , � . ! � � . ♦ �1 . ` , i f I �1 ! *CONCRETE TABLE PADS °� � WILL BE 5" THICK 3,000 PSI "� �� 20' WIDE PAVING CONCRETE WITH #3 REBAR � WITH 8" FLEXIBLE BASE ON 18" CENTERS ` IN 4" COMPACTED LIFTS AND A 2 COURSE CHIP SEAL WEARING � • ' � SURFACE ON COMPACTED NATURAL SUB-GRADE �. . .. . �. � PARKIN < . �. . � � 30X30 � y • .. �. T �1: . � < l • • �. ♦ 14X14 ADA � . ' X10 TABLE PAD* �S TABLE • � PAD* .....; �. � '�. .�<. " �, . . 12X22 �'' �' . PARKING ,' .. X10 '. !' � TABLE , : � �... :c �. PAD* . . • _ ..,� .._� �/ ��� C'I.��'�'� J�' ���� 100 BUSHES 4FT SPACING HWY 82W ROADSIDE PARK PROPOSED ADDITIONS JULY 2012 DRAWN BY: ARE � Texas Department of Transportation (TxDOT) ,,,� CERTIFICATE OF INSURANCE Fortn 1560-CSS Professional Provlder Ir4wrence �o,i,z� Page 2 of 2 This cert�cale of insurance is provided for informationai purposes only. This certificale does nol confer any rights or obligations other than the rights and obligations conveyed by the policies reterenced on this cerlificate. The terms oF the referenced policies conUol over the terms oi this ceAificale. Prior to the beginning of work, the Contractor shall obtain lhe minimum insurance and endorsements specfied. Only the TxDOT certHipte of insurance form is acceptable as proof of insurance fo� department contracts. Agents should complete lhe form providing all requested infwmation lhen either fax or mail this form directly to the address listed on age two of Ihis fortn. Copies of endorsements listed below are not required as attachments to ihis certificsle. . Insured: C: T� n f' 4r. S Street/Mailing Address: . O, �X yo3? City: J'�c.� �� State: Zip Code: 'T.S� / Phone Number: 0 3— 7$ if— J� �� Vendor EIN Number (11 digits): 7,S �p0 � 6 3 S' �� Workers' Compensation Insurance Coverage: Endorsed with a Waiver of Subrogation in favor of TxDOT. Carrier Name: Carrier Phone Number: Address: Cily: State: Zip: Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability Workers' Compensation Not Less Than: Statutory - Texas Commercial General Liability Insurance: Carrier Name: %'c �r; �' .� . a. T l¢ P Carrier Phone Number: .?' ,�, — f—a 3 o p Address: .O. Qo ! p City: vS7'.'e� State: %' ZiP:�%8 / Type of Insurance Policy Number Effective Date Expiration Date Limils of Liability Commercial General Not Less Than: Liabiliry Insurance o-1- !oZ q 3 d-�.3 Bodily Injury ,$" 8 a3 1 I" $500,000 each occurrence Property Damage $100,000 each occurrence OR $100,000 for aggregate Commercial General OR Liability Insurance $600,000 combined single limit Automoblle Liability lnsurance: Carrier Name: � 0.S .,r ,'a: � � ., —„� � Carrier Phone Number. S a �. ... � ° � Address:/� p, G, �f / City: v f�,�r/ State: � Zip: j Type of Insurance Policy Number Effective Date Expiralion Date Limits of Liability Business Automobile Policy Not Less Than: Bodily Injury �—� � 3 lQ ��_ I� f— 3Q— ! 3 $zso,000 each person Property Damage $500,000 each occuRence $100,000 each occuRence Umbrella Policy (if applicable): Carrier Name: Address: Tvae of Insurance Umbrella Policy Number I Effective Date Authorized Agent name, address and zip code: Carrier Phone Number. � State: � Zip: Date T Limits of Li� THIS IS TO CERTIFY to the Texas DepaMient oi Transportation acting on behalf of the State of Texas ihal the insurance policies named are in full torce end effecl ll chis /orm is sent by /acsimile machine (faxj, the sender adopts !he document received by TxDOT as a duplicate aigina/ and adopts the signature produced by !he receiving fax machine as the sender'a original si�atwe. The Texas Department of Transportation maintains lhe informalion collecled lhrough this form. Wfth few exceptions, you are en6tled on request to be informed about the infortnaGon lhat we collect about you. Under seclions 655.021 and 553.U23 of the Texas Govemment Code, you also are enGUed to receive and review the information. Under secGon 559.004 of the Govemment Code, you a e also enli have us correct information about you that is incorrect. Area Code ( 03 ) ,S�f —! � 7 � ��-� ,�' � j3 Authorized Agent's Phone Number Original Signature of Authorized Agent Date