Before me, the undersigned official, on this day, personally appeared _____________________, a person known to me to be the person whose signature appears below, whom after being duly sworn upon his oath deposed and said:

1. My name is _____________________________. I am over the age of 18 and have never been convicted of a crime. I am legally authorized and competent to make this affidavit.

2. I am a legally authorized representative of the following business entity: ____________________________________________________________________________________________________________________________________________________________________________

3. The above named business entity is the sole source of the following product(s) and/or service(s), and no other business entity in the United States of America sells or distributes the product(s) and/or service(s) that are listed below: ____________________________________________________________________________________________________________________________________________________________________________


4. Competition in providing the above named product(s) and/or service(s) is precluded by the existence of a patent, copyright, secret process, or monopoly.

5. There is/are no other like product(s) and/or service(s) available for purchase that would serve the same purpose or function and there is only one price for the above named product(s) and/or service(s) because of exclusive distribution or marketing rights.

6. I am legally authorized to, and do hereby bind the above named business entity to the following:

The business entity named above agrees to indemnify and hold harmless the White Settlement I.S.D. from all claims, damages, expenses, and costs of any nature based upon its reliance on this affidavit of sole source.

7. This affidavit is valid for one year from the date subscribed and sworn below which is the date of execution of this affidavit.







SUBSCRIBED AND SWORN to before me on this __________day of ___________, 20____.

(Seal) ___________________________________

Notary Public Signature

Print Name: __________________________________

My Commission Expires: _______________________

Company: ____________________________________________________________________

Address: ____________________________________________________________________

City, State, and Zip: ____________________________________________________________

Telephone Number: ____________________________ Fax: ____________________________

Contact Person: _________________________________________________________