6-1002HVAC Form 1295.pdf
PDF 147 KB Posted
- Attached to
- CNS Disposal Serive State and local contract opportunity
- Solicitation number
- 1074CNDS
- Issued by
- Van Zandt County, Texas
About this file
This document is a Texas Certificate of Interested Parties (Form 1295), which is a standard disclosure form used for state government contracts. The form is designed to transparently list any interested parties who have a controlling interest or serve as an intermediary in a business entity entering into a government contract. While the specific contract details are not filled out in this image, the form provides a template for businesses to disclose their ownership structure and potential conflicts of interest when bidding on or executing state contracts.
The form requires detailed information including the name of the business entity, the governmental entity or state agency involved, and a contract identification number. Parties must list any interested parties with their city, state, and country of business, along with checking whether they have a controlling interest or serve as an intermediary. The document includes an affidavit section where an authorized agent must swear under penalty of perjury that the disclosed information is true and correct, with space for notarization to validate the disclosure.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 1-1002HVAC Bid Sheet.pdf | ||
| 15-1003INSU Specifications.pdf | ||
| 7-1002HVAC Anti-Terrorism Certification.pdf | ||
| 5-1002HVAC Form CIQ.pdf | ||
| 8-1002HVAC Tex Govt Code 2270 Verification.pdf | ||
| 10-1002HVAC Vendor Debarment Statement.pdf | ||
| 14-1003INSU Addendum 1.pdf | ||
| 3-1002HVAC Non-Collusive Certificate.pdf | ||
| 4-1002HVAC Felony Conviction Notification.pdf | ||
| 9-1002HVAC Lobbying Certification.pdf | ||
| 11-1002HVAC Certificate of Residency.pdf | ||
| 12-1002HVAC HUB or Minority Owned Business.pdf | ||
| 13-1002HVAC W-9 Form.pdf | ||
| 16-1003INSU Questionnaire 2022.pdf | ||
| 2-1002HVAC Deviations Form.pdf |
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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
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