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
This is Form 1295 Certificate of Interested Parties, provided by the Texas Ethics Commission, which is required to be filed online for contracts with Texas governmental entities and state agencies. This form is specifically associated with Central Health's Request for Proposals (RFP) for Employee Assistance Program Benefits, though the form itself is blank and does not contain any filled-in information.
The form requires disclosure of interested parties for business entities contracting with governmental entities or state agencies. It includes sections for identifying the business entity filing the form, the relevant governmental entity, contract identification and description, names of interested parties and their nature of interest (controlling or intermediary), and an unsworn declaration from the authorized agent. The form must be completed and filed online at www.ethics.state.tx.us/File, and additional pages can be added if necessary.
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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 .