Contract - Freightliner of Austin - 12/17/2020 CERTIFICAM OF INTERESTED PARTIES, FORM 1295
1,Of 1
Complete Nos:1-4:and 6 if there are ititerestei9 parties. OFF1t3E.USE ONLY
Complete Nos.;1,2 3 5r-and 6;if there are'no interested patties: CERTIFICATION:OF,FILIfdG
1. Name of business entity filing,form,4ti4 the city,state and country oft'he;business entity's place Certificate Nurr er
of busines.'sc. 2020-691069 "
Freightliner of Austin
Austin TX United States, Date Filed:.
2 ANamge of'governtnental entity or state agency thatls a`party.to the contract for'whieh'theform is 11/1812020
. ' Beni filed.
City of Round Rock Date Acknowledged:
3 Prov dethe identification number used.by the governmental entity:or state.agency to track oridentify thei`contract,an l.provide•a
descriptlon of the,seyyices,,goo. P pe
ds,or'6ther ro "tty:tobe:provideti'underthe contact.
000000 TIPS;�200206
CLASS AD MP TRUCK,
4 Nature of interest;
'Name,of Interested Party: C.ity,_ tate,Country(place of4business} (check:appiicabie)
Gontroliing Jnterrmedtary,
Hernpel,Cariton Austin,TX United States: X
5 =Check onlylhhere.is NO,interested Party. �-
LJ
ti UNSWORN D'E_CLARATION.,
My"name is A//�O'7 "` and my'date.ou irth is,
My,address,s
"(
(zip Cade) (country)sheet). (city) {state}`
i declare,tinder.penairy of perjury th6tYthe foregoing is true and correct.
Executed in f .^sue-rt t County;.State of -on the - -day; ��'of e+- 20
'
(mgMh) (year)'
`Stgrature of au oriz agent of contracting business entity
{Declarant)
'Formes providedby Texas:Ethics,Commission vvww:ethics:stateAuts VOsion V1 T,3a6aaf'7d'
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1of1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2020-691069
Freightliner of Austin
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a parry to the contract for which the form is 11/18/2020
being filed.
City of Round Rock Date Acknowledged:
12/03/2020
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.
000000 TIPS 200206
CLASS A DUMP TRUCK
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Hempel, Carlton Austin,TX United States X
I
i
i
I
I
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
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)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d