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(To be completed by awarded vendor) <br />LM:3:41112 IYN��� <br />Complete Nos- 1 - 4 and 6 it there are interested -parties- <br />Comp!eta Nos- 1. 2 3, 5. and 6 it there are no intsmasted parlies. <br />76M ., � <br />...... ........ .. ............ <br />N no <br />a e of bu!5inerss entigy filing form, and the rity, state and country of the business e ntity's P I a Ge M busirtes S <br />NaM–`eofgovemmental entityorstate agency that is a party to the contract 4P 'r <br />which the rorm is being Tiled. <br />3 Provide the identification number used by the governmental entity or state af;Pneylo -kR identify the contract, <br />and provide a description of the services. goods. or other Property io be provided e 00 ntir-a cf- <br />ahjre or Inleffest (check_pp <br />City, State, Country <br />Narriti-of Interested Party <br />4plaGe of business) On Cout-olling Iriterrnediary <br />Form prided by Texas Eth�s Corivnis5ion <br />A <br />" and rrry "e offbrdi is <br />day of , , -- 2�-- <br />(rronN ir-no <br />sign of WAt W coniiil—lrig WS -35 entry <br />(00daran!) <br />ADD ADDITIONAL PAGES AS NECESSARY <br />. ...... ..... .... -- - I .. .. . ...... <br />WWW Revised MM"2017 <br />