FORM 1295 CERTIFICATE OF INTERESTED PARTIES

CERTIFICATE OF INTERESTED PARTIES
FORM
1295
OFFICE USE ONL
Y
ONLY
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.
1 Name of business entity filing form, and the city, state and country of the business
entity's place of business.
2
Name of governmental entity or state agency that is a party to the contract for
which the form is being filed.
3
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.
4
City, State, Country
(place of business)
Name of Interested Party
5
Nature of Interest (check applicable)
Controlling
Intermediary
Check only if there is NO Interested Party.
6 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.
Signature of officer administering oath
Printed name of officer administering oath
Title of officer administering oath
ADD ADDITIONAL PAGES AS NECESSARY
Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Adopted 10/5/2015