Contract - L3 Mobile-Vision, Inc. - 9/8/2016CERTIFICATE OF INTERESTED PARTIES FORM 1295
1 of 1
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:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2016-97388
L-3 Mobile -Vision, Inc.
Rockaway, NJ United States
Date Filed:
08110/2016
2- Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
The 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.
Body Cameras
Body Cameras and Support Equipment
Nature of interest
4
Name of Interested Party
City, State, Country (place of business)
(check applicable)
Controlling
Intermediary
5 Check only if there is NO Interested Party.
X
6 AFFIDAVt,T" '""`'"`:• I swear, or affirm, unde enalty of 'ury, that the above disclosure is true and correct.
John Powers
Vice President of Sales and Marketing
` Signature of t of contracting business entity
AF'( NOTARY,STAM0 f EfAL ABOVE
Sworn to and'sUbtcrib6d before me, by the said John Powers this the 10 dayof August
2016 to certify which, witness my hand and seal of office.
ei\N HOURIHAN
PUBLIC OF NEW JERSEY
# 50038788
sRan Hourihan •' osal Writer
4ig
e of officer administering oath Printed name of officer administering oath Title of officer administering oath
k - - -0 1 A 1ki I . . . 1. -
lterff'is provided by Texas Ethics Commission viww,ethlcs.state.tx.us AYAN vtiaivi l v'",L' 1
O�0NEW 38788
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:
2016-97388
Date Filed:
08/10/2016
Date Acknowledged:
08/18/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
L-3 Mobile -Vision, Inc.
Rockaway, NJ United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
The 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 services, goods, or other property to be provided under the contract.
Body Cameras
Body Cameras and Support Equipment
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
5 Check only if there is NO Interested Party. ❑
X
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 V1.0.277