6-1002HVAC Form 1295.pdf
PDF 147 KB Posted
- Attached to
- CNS POINT OF SALES DISTRICT WIDE
- Solicitation number
- 1072CNPS
- Issued by
- Victoria County, Texas
About this file
This document is a Certificate of Interested Parties (Form 1295), a standard state-level disclosure form used to document potential conflicts of interest in government contracts. The form provides a template for businesses to list any interested parties associated with a contract, including their name, business location, and nature of interest (either controlling or intermediary). The form requires completion of various sections depending on whether interested parties exist, and includes spaces for the business entity's information, the contracting governmental entity, contract identification number, and an affidavit affirming the truthfulness of the disclosed information. The document is designed to be signed by an authorized agent, notarized, and submitted to provide transparency in government contracting processes.
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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
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