5-Form 1295.pdf
PDF 128 KB Posted
- Attached to
- HVAC Equipment, Service and Supplies
- Solicitation number
- 1075HVAC
- Issued by
- Victoria County, Texas
About this file
This document is a Certificate of Interested Parties (Form 1295), which is an official state form used to disclose interested parties in a government contract. The form is designed to be completed by a business entity when entering into a contract with a governmental entity or state agency, requiring detailed information about potential interested parties and their nature of interest (either as a controlling entity or intermediary). The form provides spaces for listing the business entity's name, the governmental entity involved, contract identification number, and details about any interested parties.
The form requires an affidavit swearing under penalty of perjury that the disclosed information is true and correct, with provisions for notarization and official certification. It includes instructions for completing the form based on whether there are interested parties present, with options to check a box if no interested parties exist. The document serves as a transparency mechanism to reveal potential conflicts of interest or significant stakeholders in government contracts, with spaces for additional pages to be added if more disclosure is necessary.
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Text version
Attachment e.
CERTIFICATE OF INTERESTED PARTIES FORM 1295
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.
OFFICE USE ONLY
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 services, goods, or other property to be provided under the contract.
Name of Interested Party
City, State, Country (place of business)
Nature of Interest (check applicable)
Controlling Intermediary
5 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
File details come from the government source that posted it. Updated .