ESBD_383080_1731698259405_EXHIBIT I - Form 1295 Certificate of Interested Parties.pdf
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- Attached to
- Employee Assistance Program Benefits
- Solicitation number
- 2510-003
- Issued by
- Travis County, Texas
About this file
This document is Form 1295, Certificate of Interested Parties, provided by the Texas Ethics Commission, which must be filed online for contracts with Texas governmental entities or state agencies. The form is a required disclosure document that must be completed by business entities entering into contracts with Texas government agencies, requiring declaration of interested parties who either have a controlling interest in the business entity or serve as intermediaries in the contract.
The form requires completion of several key sections including the business entity's information, the governmental entity or state agency involved in the contract, contract identification number and description, disclosure of interested parties and their nature of interest (controlling or intermediary), and an unsworn declaration by an authorized agent. The document is dated December 22, 2017, and must be filed online at www.ethics.state.tx.us/File. No specific pricing information or other contract details are included in this form, as it serves purely as a disclosure document.
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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 .