HomeMy WebLinkAbout2017.11.28 TNP Form 1295 Cert 2017-287629Controlling
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 11/28/2017
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.
Teague Nall and Perkins, Inc.
Fort Worth, 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
Right of Way Services
Project #1833A
2017-287629
11/28/2017
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
Berry, Mark XFort Worth, TX United States
Hilton, C. Ty XFort Worth, TX United States
Jones, Michael XFort Worth, TX United States
Dryden, David XFort Worth, TX United States
Saunders, Greg XFort Worth, TX United States
Turner, Todd XDenton, TX 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
CERTIFICATE OF INTERESTED PARTIES 1295FORM
1 of 1
Complete Nos.1 -4 and 6 if there are interested parties.OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties.CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business.2017-287629
Teague Nail and Perkins,Inc.
Fort Worth,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 11/28/2017
being filed.
City of Colleyville Date Acknowledged:
3 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.
Project #1833A
Right of Way Services
4
Nature of interest
Name of Interested Party City,State,Country (place of business)(check applicable)
Controlling Intermediary
Berry,Mark Fort Worth,TX United States X
Hilton,C.Ty Fort Worth,TX United States X
Jones,Michael Fort Worth,TX United States X
Dryden,David Fort Worth,TX United States X
Saunders,Greg Fort Worth,TX United States X
Turner,Todd Denton,TX United States X
5 Check only if there is NO Interested Party.D
6 AFFIDAVIT I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct.
\\1111111/11 SHANNON MARIE PERKINS"~"yP(I<t"
D'ktJAA..ifJJ J
g'i:":~i:ti":Notary Public,State of Texas
E"':,,:':'~Comm Expires 08-15·20200:.-:;,••••I·~':-.
';;:'~6f'\~'"Notary 10 130778657'11111\
Sir~ure of ~thorlzed adent of contracting business entity
AFFIX NOTARY STAMP I SEAL ABOVE U
Sworn to and subscribed before me,by the said :J.Q.hV'\~~~{/,this the ;)~..rv day of NOV~~
20 ",to certify which,witness my hand and seal of office.
~~~~~5(S II "fJ jJ (HJ !-AtLIG P fYlt(J f.lS N7)1f1l2.Y
SignattJreof officer ad'ministeringoath Printed name of officer administeringoath Title of officer administeringoat~
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337