Contract - Library Interiors - 1/27/2022 (2) 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. 2022-841199
WORKPLACE SOLUTIONS,INC
DALLAS,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form s01/18/2022
being filed.
CITY OF ROUND ROCK ]Date Acknowledged:
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 LIBRARY FURNITURE
PUBLIC LIBRARY FURNITURE FOR CITY OF ROUND ROCK LIBRARY
4 Nature of Interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
WORKPLACE SOLUTIONS,INC. DALLAS,TX United States X
5 Check only if there is NO Interested Party. ❑
5 UNSWORN DECLARATION
My name is GREG ANDERSON and my date of birth is
My address is 1505 HI LINE DR SUITE 100 DALLAS TX 75207 US
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in DALLAS County, State of TEXAS on the 18TH day of JANUARY 20 22
/ (month) (year)
i�L�x4aA1+2",0 i
Sidliature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc
CERTIFICATE 4F INTERESTED PARTIES FORM 1295
101`1
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. 2022-841199
WORKPLACE SOLUTIONS,INC
DALLAS,TX United States Date Filed:
2 Name of governmen en ty or state agency that Is a party to the contract for which the form Is 0111$12022
being filed.
CITY OF ROUND ROCK Date Acknowledged:
01/2112022
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 LIBRARY FURNITURE
PUBLIC LIBRARY FURNITURE FOR CITY OF ROUND ROCK LIBRARY
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
WORKPLACE SOLUTIONS,INC. DALLAS,TX United States X
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
(Dectarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc