3-Form 9 - Disclosure of Interest Form.pdf
PDF 55 KB Posted
- Attached to
- Non-Incumbent Rental Car Concession
- Solicitation number
- 333-25-AIR-RFP
- Issued by
- Cameron County, Texas
About this file
This document is a City of Brownsville, Texas Disclosure of Interest form designed to capture potential conflicts of interest for businesses seeking to do business with the city. The form requires firms to disclose any city employees, officials, or board members who have an ownership interest of 10% or more in the business or are employed by the firm. The document provides spaces for listing names, titles, departments, and board/commission affiliations for such individuals.
The form is a standard compliance document that aims to ensure transparency in municipal contracting by requiring businesses to declare any potential financial or employment connections to city personnel. Firms must complete the form, indicating their type of business entity (corporation, partnership, sole owner, etc.), and provide a certification that the information is true and correct. The form allows for alternative submission of a current SEC Form 10-K for publicly traded corporations, and mandates that any changes be promptly reported to the City of Brownsville.
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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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