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Contract # <br /> <br />Firm/Company Name <br /> <br />BU$INES$ 0 ['frNERSHIP <br /> <br />Section 231.006, Family Code, requires the Department to collect the names and social securiW number of <br />individuals e~/ng 25% ur mor~ of the business cntiW ~warded thi~ con,ct. <br /> <br />I. In th~ sp~ces b~low pl~se previd~ the names and social sceufiW number of individuals o~ing 25% or <br />more of~ business <br /> <br /> NAME SOC~L SB~ ~ER <br /> <br />2. Please cheek the box below if no individual owns 25% or more of the business. <br /> <br /> [ I 1'4o individual owns 25% or more of the business. <br /> <br />Except as provided by Section 231.302(d), Family Code, a social security number is confidential and mai, be <br />disclosed only for the purpose of responding to a request for information fi:om an agency operating under the <br />provisions of Parts A Ired D to Title IV of the federal Social Se. ourity Act (42 USC Section 601-617 and ~$1- <br /> <br />Under section 231.006, Family Code, the Vendor or applicant certifies that the individual or business entity <br />named in this contract, bid, or application is eligible to receive the specified grant, loan, or payment and <br />aoknowledges that~his contract may be terminated and payment may be withheld if this certification is <br />inaccurate. <br /> <br />The information must be Provided and returned with the executed contract documents. Failure to furnish this <br />information will result in the contract being declared in default and forfeiture of the proposal guaranty. <br /> <br />Signature Date <br /> <br />Print Name <br /> <br /> If this project is a Joint Venture, all parties to the joint venture must provide a completed form. <br /> <br /> <br />