Contract - KidZone Play LLC - 3/24/2016CERTIFICATE OF INTERESTED PARTIES FORM 1295
101`1
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 i1 there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-25088
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
KidZone Play Inc, LLC dba Recreation Consultants of Texas
Garland, TX United States
Date Filed:
03/11/2016
2 Name of governmental entity or state agency that is a party to the contract for which the form is
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 goods or services to be provided under the contract.
Old Settlers Park
Commercial Grade Playground equipment and installation
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest (check applicable)
Controlling
Intermediary
Russell, David
Lucas, TX United States
X
5 Check only if there is NO Interested Party.
6 AFFIDAVIT I swear, or affirraunder penalty of perjury, that the above disclosure is true and correct.
iisu,urt -..
���axa� , TIFFANY RITTER
s,:N �t+rNotary Public, State of Texas )
'' Comm. Expires 03-08-2018
a,`m,k`i}+� Notary !D 124128988 Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP ! SEAL ABOVE
/
Swor to and subscribed before me, by the said V �/ S�Q this the day of �G
20. to certify which, witness my hand and seal of office.
Bi.4u,eof
oath Printed name of offic r administering oath Title of officer administering oath
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10f1
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.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-25088
Date Filed:
03/11/2016
Date Acknowledged:
03/11/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
KidZone Play Inc, LLC dba Recreation Consultants of Texas
Garland, TX United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
City of Round Rock
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 goods or services to be provided under the contract.
Old Settlers Park
Commercial Grade Playground equipment and installation
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest (check applicable)
Controlling
Intermediary
Russell, David
Lucas, TX United States
X
5 Check only if there is NO Interested Party. ❑
6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.U.311