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(1a) he cotnplc(cd 1)1 ;ave , ardcd � cndor) <br />CERTIFICATE OF INTERESTED PARTIES FORM 12915 <br />01FIFICEUSEONLY <br />Complipte Nos. 1 - 4 and 6 if there ,Are, interestrad pates. <br />Complete Nos 1, 2, 3, 5, 'and 16 if there are no interested parties. <br />'I Narn e, of Iounsiniess entity fiti ng forrn, andl the cily, state and caltin try of thie busli nves s. <br />einfity's ptare-of business. <br />2 Name Dfgovernme,ntal entity a,r state agency that is a, pairty to the co,ntract for <br />which the form is being file,d. <br />t t ko1*i,denqif.y the conitr3ct, <br />3 Prov ild e the ildlenti ficatian n urnber usedl by the govern men la I en ti ty or state, a glen c;y 0 <br />andl provicle, a descriptlion of the services, goods, or other property to be piravid,ed econtract. <br />0 <br />&IX <br />xg <br />4 <br />( <br />City, State, Country <br />w <br />�Kafixre of [niterestfolaeGlk a(pipfiGablie)i <br />Name, of Interested Party <br />(plaze of business• <br />Controlling Intermediary <br />sk <br />5, <br />Cheolk only il'theireInherested'Party. El <br />UNS4 ORNDEC11 FI&I N <br />ply hairs as and my dzle of b,)Ih is <br />My addr <br />(sireet) jclttr (slate) 6,zup codoe") )country"r <br />d nder penafty of pe -P) that rhe knegoing s tame and correct. <br />Executed un CoLvrtv. State of On the. clay d, 2D <br />AMDnth,li (year) <br />3gnalure. & authorizedago--ml rad contrarfiRg buslness entry <br />(lea arank) <br />ADD ADDITIONAL PAGES AS NECESSARY <br />Form pfr-,Mded by Texas Edik-s Cownisslan waweth,,L- slate.tx us Rewlsed 111221'20f,7 <br />GRANTWORKS, INC. I PROPRIETARY & CONFIDENTIAL AI IACHMEN 1 2 REQUIRED FORMS I PAGE 79 <br />