10-Form 9 - Disclosure of Interest Form.pdf
PDF 55 KB Posted
- Solicitation number
- 260-25-EPW-IFB
- Issued by
- Cameron County, Texas
About this file
The document is a Disclosure of Interest form from the City of Brownsville, Texas, designed for businesses seeking to do business with the city. The form requires detailed disclosure of any potential conflicts of interest, specifically requesting information about city employees, officials, or board members who may have an ownership interest (10% or more) in the firm or who are employed by the firm. Businesses must identify their type of organization (corporation, partnership, sole owner, association, or other) and provide comprehensive information about any municipal connections.
The form is a transparency mechanism requiring complete disclosure, with provisions for publicly traded corporations to submit a current SEC Form 10-K in lieu of answering specific questions. Firms must certify the accuracy of their disclosures and commit to providing supplemental statements if changes occur. The document includes multiple tables for listing names, titles, departments, and board/commission affiliations, and requires a signature from an authorized representative who attests to the truthfulness of the submitted information.
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Text version
CITY OF BROWNSVILLE
DISCLOSURE OF INTEREST
City of Brownsville, Texas requires all persons or firms seeking to do business with the City to provide the following information. Every question must be answered. If the question is not applicable, answer with “NA.” Corporations whose shares are publicly traded and listed on national or regional stock exchanges or over-the-counter markets may file a current Securities and Exchange Commission Form 10-K with the City in lieu of answering the questions below. See reverse side for definitions.
Date: _____________
FIRM NAME:
ADDRESS_____________________________________________________________
FIRM is: 1. Corporation ( ) 2. Partnership ( ) 3. Sole Owner ( )
4. Association ( ) 5. Other ( ) ______________________________
Disclosure Questions If additional space is necessary, please use the reverse side of this page or attach separate sheet.
1. State the names of each “employee” of the City of Brownsville having an “ownership interest constituting 10% or more of the voting stock or shares of the business entity or ownership of $2,500 or more of the fair market value of the business entity or employed by the above named “firm.”
Name Title Department
2. State the name of each “official” of the City of Brownsville having an “ownership interest” constituting 10% or more of the ownership in the above named “firm”, or employed by the above named “firm.”
Name Title Department
3. State the names of each “board member” of the City of Brownsville having an
“ownership interest” constituting 10% or more of the ownership in the above named “firm”, or employed by the above named “firm.”
Name Board, Commission, or Committee
Certificate I certify that all information provided is true and correct as of the date of this statement, that I have not knowingly withheld disclosure of any information requested; and that supplemental statements will be promptly submitted to the City of Brownsville, Texas as changes occur.
Certifying Person: _____________________________________ Title:_____________
(Type or Print)
Signature of Certifying Person: ___________________________ Date: ____________
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