HomeMy WebLinkAboutForm 1295 - Superior VisionControlling
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 06/26/2020
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.
Block Vision of Texas, Inc. dba Superior Vision of Texas
Ft. 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
Vision Plan Services
#HR-2020-01
2020-637378
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
Versant Health Holdco, Inc.XLinthicum, MD United States
HUB International Dallas, TX United States X
Richards, (CCO), Lula XLinthicum, MD United States
Luchetta, (SVP, Commercial Group Sales), Thomas XFt. Worth, TX United States
Tavel, (Sr. VP & Secretary), Bruce XLinthicum, MD United States
Bicknell, (CFO & Treasurer), Jonathan XLinthicum, MD United States
Osnoss, (Director), Daniel XNew York, NY United States
Kabaker, (Director), Matthew XNew York, NY United States
Rothrock, (President, CEO & Director), Kirk XLinthicum, MD United States
6
Signature of authorized agent of contracting business entity
My name is _______________________________________________________________,
UNSWORN DECLARATION
Check only if there is NO Interested Party.5
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
Thomas Luchetta 03/04/59
6300 Ridglea Place, #312 Ft. Worth TX 76116 USA
Tarrant Texas 26 June 20