Form 1295 Draft - Certificate Of Interested Parties printable pdf download

Form 1295 Draft - Certificate Of Interested Parties

1295

CERTIFICATE OF INTERESTED PARTIES

FORM

OFFICE USE ONL

OFFICE USE ONLY Y Y Y Y

OFFICE USE ONL

Complete Nos. 1 - 4 and 6 if there are interested parties.

Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.

Name of business entity filing form, and the city, state and country of the business

entity's place of business.

Name of governmental entity or state agency that is a party to the contract for

which the form is being filed.

Provide the identification number used by the governmental entity or state agency to track or identify the contract,

and provide a description of the services, goods, or other property to be provided under the contract.

Nature of Interest (check applicable)

City, State, Country

Name of Interested Party

(place of business)

Controlling

Intermediary

Check only if there is NO Interested Party.

AFFIDAVIT

I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.

Signature of authorized agent of contracting business entity

AFFIX NOTARY STAMP / SEAL ABOVE

Sworn to and subscribed before me, by the said _______________________________________________, this the ______________ day

of ________________, 20 _______ , to certify which, witness my hand and seal of office.

Printed name of officer administering oath

Title of officer administering oath

Signature of officer administering oath

ADD ADDITIONAL PAGES AS NECESSARY

Form provided by Texas Ethics Commission

Revised 4/8/2016

Form 1295 Draft - Certificate Of Interested Parties