ESBD_508959_1776889571352_Attachment F- 1295 Certificate of Interested Parties Form.pdf
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- Attached to
- OER Grantee Technical Assistant Partner
- Solicitation number
- 781-6-CB-14
- Issued by
- Travis County, Austin City, Texas
About this file
This is a Certificate of Interested Parties Form 1295 issued by the Texas Ethics Commission for use in state and local contract opportunities in Texas. The form requires the filing business entity to provide its name, address, and place of business location, along with identification of the governmental entity or state agency that is party to the contract. The form also requires the filer to provide the identification number used by the governmental entity to track the contract and a description of the services, goods, or other property to be provided under the agreement.
The form includes sections for listing interested parties and their nature of interest in the contract, with options to indicate whether a party is a controlling intermediary. Filers must complete sections 1 through 4 and 6 if interested parties exist, or sections 1, 2, 3, 5, and 6 if no interested parties are present. The form requires an unsworn declaration executed under penalty of perjury, signed by an authorized agent of the contracting business entity, and must be filed online through the designated state ethics filing system. Additional pages may be attached as necessary to accommodate multiple interested parties or supplemental information.
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Text version
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 5/14/2025
Attachment F - CERTIFICATE OF INTERESTED PARTIES FORM 1295
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 .
Mus t fi le on lin e a t h ttp s:/ /pr d.t ec prd .et hic se file .co m/File
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