ESBD_383080_1731698259405_EXHIBIT I - Form 1295 Certificate of Interested Parties.pdf
PDF 493 KB Posted
- Attached to
- Employee Assistance Program Benefits
- Solicitation number
- 2510-003
- Issued by
- Travis County, Texas
About this file
The document provided is a Form 1295 Certificate of Interested Parties, which is required to be filed with the Texas Ethics Commission for a state or local government contract. The form identifies the business entity filing the form, the governmental entity or state agency that is a party to the contract, and the nature of any interested parties. This form appears to be related to a contract opportunity issued by the Travis County Healthcare District, doing business as Central Health, for an Employee Assistance Program (EAP) to provide consultation, counseling, referrals, training, and critical incident response services to its approximately 1,900 full-time employees. The initial contract term is 2 years with optional 4 one-year renewal periods, and proposals are due by December 30, 2024 at 2:00 PM Central Time.
The evaluation criteria for this contract opportunity include the proposer's ability to perform the required services, quality, service offerings, cost, and innovation. Central Health reserves the right to negotiate pricing and terms, make multiple awards, or not award a contract at all. While the solicitation does not mention a Historically Underutilized Business (HUB) set-aside, it indicates that Central Health has a policy to include HUBs in its procurement process and provide equal opportunities for HUB participation. The solicitation also does not specify a funding source, but suggests that Central Health has ongoing contractual relationships with various healthcare providers, nonprofit organizations, and government entities, and is seeking transparency around any potential conflicts of interest or financial entanglements that consultants may have.
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Text version
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 12/22/2017
FORM 1295CERTIFICATE OF INTERESTED PARTIES
OFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLYYYYY
6 UNSWORN DECLARATION
My name is _______________________________________________________, and my date of birth is _______________________________.
My address is ________________________________________________, ___________________, _______, __________, ______________.
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in ___________________ County, State of ______________ , on the _______ day of _______________, 20______.
(month) (year)
Signature of authorized agent of contracting business entity (Declarant)
ADD ADDITIONAL PAGES AS NECESSARY
Name of Interested Party Nature of Interest (check applicable)City, State, Country
(place of business) Controlling Intermediary
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.
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.
1 Name of business entity filing form, and the city, state and country of the business entity's place of business.
Check only if there is NO Interested Party.
Mus t fi le on lin e a t w ww.et hic s.s tat e.t x.u s/F ile
File details come from the government source that posted it. Updated .