HomeMy WebLinkAbout2017.11.01 MSA Cert 2017-279128 Form 1295Controlling
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 11/01/2017
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.
MSA Professional Services, Inc
Dallas, 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, TX
Professional Engineering Services, licensed survey work, and landscape architecture
ENG2018-001
2017-279128
11/03/2017
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
Laue, Mike XBeaver Dam, WI United States
Bongard, Chuck XBaraboo, WI United States
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
Version V1.0.3337www.ethics.state.tx.usForms provided by Texas Ethics Commission