Form 1295 - 2015 Certificate Of Interested Parties printable pdf download

YOU MUST REGISTER AND COMPLETE THIS FORM ONLINE

1295

CERTIFICATE OF INTERESTED PARTIES

FORM

https://

OFFICE USE ONL

OFFICE USE ONLY Y Y Y Y

OFFICE USE ONL

THIS IS A SAMPLE FORM !!

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

THIS FORM MUST BE

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

COMPLETED ONLINE, THEN

PRINTED, NOTARIZED AND

SUBMITTED WITH BID OR

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

PROPOSAL DOCUMENTS.

entity's place of business.

ALVIN I.S.D. MUST THEN

ENTER YOUR BUSINESS NAME, CITY, STATE & COUNTRY HERE

CONFIRM TO THE TEXAS

ETHICS COMMITTEE THAT

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

A NOTARIZED FORM HAS

which the form is being filed.

BEEN RECEIVED FOR EACH

ENTER ALVIN I.S.D. HERE (WE ARE THE GOVERNMENTAL ENTITY)

AWARDED VENDOR.

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

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

ENTER THE PROPOSAL (OR CONTRACT) NAME AND NUMBER HERE

Nature of Interest (check applicable)

City, State, Country

Name of Interested Party

(place of business)

Controlling

Intermediary

ENTER EACH PERSON HAVING INTEREST,

OWNERS ARE THE CONTROLLING PARTIES

SAMPLE DOCUMENT

WORKERS (OR NON-OWNERS) IN YOUR

COMPANY ARE INTERMEDIARY PARTIES

AFTER ONLINE FORM IS COMPLETE, PRINT FORM, HAVE FORM NOTARIZED,

SEND NOTARIZED FORM TO ALVIN I.S.D. - BY EMAIL TO:

jortiz@alvinisd.net

~OR~

pursery@alvinisd.net

OR FAX TO: 281-585-4567

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.

ALVIN I.S.D. MUST KEEP THIS NOTARIZED FORM ON FILE FOR EACH PROPOSAL OR CONTRACT AND EACH

VENDOR RESPONDING TO PROPOSALS OR CONTRACTS.

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.

FAILURE TO COMPLY WITH HB1295 WILL RESULT IN VOIDING YOUR PROPOSAL OR CONTRACT

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

Adopted 10/5/2015

Form 1295 - 2015 Certificate Of Interested Parties

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