HomeMy WebLinkAboutForm 1295 - BlueCross BlueShield of TexasControlling
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 04/27/2020
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.
Blue Cross and Blue Shield of Texas, a Division of HCSC, a Mutual Legal Reserve Company
Richardson, 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
Health and Welfare Request for Proposal
RFP #HR-2020-01
2020-612075
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
6
Signature of authorized agent of contracting business entity
My name is _______________________________________________________________,
UNSWORN DECLARATION
Check only if there is NO Interested Party.5
X
My address is _______________________________________________, _______________________,
and my date of birth is _______________________.
Executed in ________________________________________County,
I declare under penalty of perjury that the foregoing is true and correct.
(street)(state) (zip code) (country)
(year)(month)
_______, ______________, _________.
State of ________________, on the _____day of ___________, 20_____.
(city)
(Declarant)
Version V1.1.3a6aaf7dwww.ethics.state.tx.usForms provided by Texas Ethics Commission
Jason Motter February 10, 1970
1001 East Lookout Drive Richardson TX 75082 USA
Collin Texas 6 May 20
Per Ali Becerra, on Monday, April 27th, we have provided an electronic signature; however, we would be happy to provide hard copies with original
signatures, if requested.