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Contract # <br /> <br />FirndCompany Name <br /> <br />BU$fl~ES$ OWNEP~HIP .. <br />Section 231.006, Family Code, ~cquires the Department to oollcot the nam~ and social seoudty number of <br />individuals owning 25% or more of the.businems entity awarded this contract. <br /> In the spaOCS below please provide thc names and social s¢cUmty number of mdtwduals owning 25% <br /> <br />· more of the busings <br /> <br /> .. NAME <br /> <br /> Dale C. Sellers <br /> <br />SOCLAL sECUR1TY <br /> 451-15-6895 <br /> <br />OF <br /> <br />2, Ple~e chock the box below if no individual ownz 9.5% or more of tho business. <br /> [ I 1go individual owns 25% or more of tho business' <br /> Except as provide~, by Section 231.302(d), Family Code, a social scc .ufitYnumber is confidential, amd may be <br /> disclosed only for thc purpose ofrespon~h~g to a rcquc~t for infonnation fi~am tn agency opcratmg under the <br /> provisionS of parts A and D to Title IV of thc fedcr~l Social Sccutlty Act (42 USC Section 601-617 ired .65 l- <br /> Under section 231.00d, Family Code, the Vendor or ;qaplicant certifies that the individual or business entity <br /> named in this contract, bid, or application is eligible to receive the spcoified grant, loan, or p,~ym~mt and <br /> aclcnowled~c$ that'this contract may be terminated and payment may bc withhold if this c¢ffdficafion is <br /> · ~ ,--,i~,wlded and t'etumed with th¢ exeouted conira.ot <br /> The informatton mu.~..u~ r.:- ~-_--L... ~..:.. d~lared in default and forfeiture <br /> <br /> ~~.~~~ August 28,2001. <br /> ~ Da~e C. sellers ' ' · <br /> <br />Print lqamc <br /> <br /> If this project Is a ~[otnt Venture, all parties to the ]olnt ve~turc must provide a completed form. <br /> <br /> <br />