Laserfiche WebLink
CERTIFICATE OF INTERESTED PARTIES <br />FORM 1295 <br />101`1 <br />m. .. ,m. <br />Complete Nos. 1- 4 and 6 if there are interested parties. <br />, ._ <br />��,.. <br />OFFICE USE ONLY <br />Complete Nos. 1, 2, 3, S. and 6 it there are no Interested parties. <br />CERTIFICATION OF FILING <br />_....A,r, ... .. <br />1 Name of business entity filing form, and the city, state and country of the business entity's place <br />Certificate Number: <br />of business. <br />2022-872388 <br />Richard Drake Construction Company LP <br />POWDERLY, TX United States <br />date Filed: <br />2__ dame o"gaverrimentai entity ir'state agency that is par4y''to tine contract'fur vuiitct"tirenrm is <br />""" <br />0411212022 <br />being filed. <br />City of Paris <br />Date Acknowledged: <br />_.. ............ ._.... .... ........... ...... --------____ ........ _.----- _____.wwm <br />3 Provide the identification number used by the governmental entity or state agency to tract[ or identify the contract, and provide a <br />description of the services, goods, or other property to be provided under the contract. <br />Sealed Bid: City Of Paris <br />Sealed Bid: Concrete Demolition and Construction <br />.......... <br />. ............... -- _.___.... <br />.............. ��„m <br />Nature oflnt erest <br />Namc of fnietested Party <br />City, State, Country (place of business) <br />(check applicable) <br />................ _ <br />___ ..__ ........ <br />..... .......... ......... .._. <br />... <br />Controlii ng <br />.. <br />intermediary <br />. <br />M r„ _... . ..... ....................................... ­ _,_,_. . .000. <br />.,.,..... <br />5 Check only if there is NO Interested Party. n <br />I <br />_... .__ ... .__ _ <br />6 UNSWORN DECLARATION <br />.......................... , <br />M name is � ..y ��, . 4 A.A .. _ . r ' ” r + � and my date of birth Is t� � <br />�t )� t� �.,.. � lbs, i � <br />� <br />�..__ <br />My address is ti m 1� f.-"I, � „ <br />...... _ �-ahAdr <br />(street) (CRY) <br />(state) (zip code) (country) <br />I declare under penalty of perjury that the foregoing is true and correct. <br />Executed in --County, State of on the a of t" r t r1� <br />��� ��� � � �� y �iy�i 20ys�,. <br />(month) (year) <br />i <br />Signatnr. J autharized agent of contracting business entity <br />(Dedarant) <br />Forms provided by Texas Ethics Commission www.ethics.state,tx.us <br />�,r,.. Version V1.1.191b5cdc <br />