Contract - Austin Business Furniture - 11/20/2018 CERTIFICATE OF INTERESTED PARTIES FORM 1295
10f1
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. 2018-417411
Austin Business Furniture
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 10/22/2018
being filed.
City of Round Rock Date Acknowledged:
g 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.
LUTHER PETERSON SERVICE CENTER
OFFICE FURNTIURE FOR NEW SITE
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Panty.
X
6 UNSWORN DECLARATION
M name is.,,,,
Y �41J '; Vt- , and my date of birth is
My address is &/e \ TX .
(street) (city) (st e) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in i .��a ► county, State of f.��L on the ��. da of20
(Mont (year)
Signature of authorized agent of contracling-business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state,tx.us Version V1.0.6711
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1 of 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. 2018-417411
Austin Business Furniture
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 10/22/2018
being filed.
City of Round Rock Date Acknowledged:
10/24/2018
g 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.
LUTHER PETERSON SERVICE CENTER
OFFICE FURNTIURE FOR NEW SITE
4 Nature of interest
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 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)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711