EXHIBIT I - Form 1295 Certificate of Interested Parties.pdf
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- Attached to
- Medical, Dental, Vision Insurance Services
- Solicitation number
- 2604-002
- Issued by
- Travis County, Austin City, Texas
About this file
This file is a Form 1295 Certificate of Interested Parties, a disclosure form required by the Texas Ethics Commission for entities entering into contracts with Texas governmental entities or state agencies. The form serves as a mandatory filing document to identify all interested parties involved in a contract transaction and to ensure transparency in state procurement processes. The form requires completion of specific sections identifying the contracting business entity, the governmental entity party to the contract, the contract identification number and description of services or goods to be provided, and all interested parties with their respective nature of interest in the transaction.
The form must be completed and filed online through the Texas Ethics Commission website at www.ethics.state.tx.us. Filers are required to provide their name, date of birth, and address, and execute an unsworn declaration under penalty of perjury confirming the accuracy of the information provided. The form accommodates multiple interested parties through the addition of pages as necessary and requires identification of the nature of each party's interest, including designation of controlling intermediaries where applicable. Alternatively, if no interested parties exist, filers may complete only the designated sections and submit accordingly. This filing requirement applies universally to all state and local contract opportunities in Texas regardless of contract value or scope.
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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
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