HomeMy WebLinkAbout2017.01.24 DFW Infrastructure 1295 Cert 2017-157890Controlling
Name of Interested Party4 Nature of interest
City, State, Country (place of business)
Intermediary
(check applicable)
CERTIFICATE OF INTERESTED PARTIES 1295FORM
1 of 1
1
OFFICE USE ONLY
2 01/24/2017
Complete Nos. 1 - 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
DFW Infrastructure, Inc.
Burleson, TX United States
Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
3
City of Colleyville
Manhole Rehabilitation
FY 2016 Manhole Rehab Project
2017-157890
01/30/2017
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
Signature of officer administering oath
6
AFFIX NOTARY STAMP / SEAL ABOVE
Signature of authorized agent of contracting business entity
Title of officer administering oath
I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Sworn to and subscribed before me, by the said _____________________________________, this the ____________ day of ______________,
20________, to certify which, witness my hand and seal of office.
AFFIDAVIT
Printed name of officer administering oath
Check only if there is NO Interested Party.5
X
Version V1.0.277www.ethics.state.tx.usForms provided by Texas Ethics Commission