HomeMy WebLinkAboutC2020-336 - 10/13/2020 - Approved (2)CERTIFICATE OF INTERESTED PARTIES FORM 1295
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. 2020-664961
Southern Tire Mart, LLC
Columbia, MS United States Date Filed :
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/08/2020
being filed.
City of Corpus Christi 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.
3164
Tire Repair , Replacement , and Alignment Services for CCFD
Nature of interest
4
Name of Interested Party City, State, Country {place of business) {check applicable)
Controlling Intermediary
Duff , Thomas Columbia , MS United States X
Duff, James Columbia , MS United States X
5 Check only if there is NO Interested Party.
6 UNSWORN DECLARATION
My name is Richard Conwill and my date of birth is 9/10/1950
My address is 800 Highway 98 Columbia -~-39429 USA
(street) (city) (sta te ) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Marion County , State of Miss iss ipp i , on the ~day of September ,20~.
(mo nth) (yea r)
--±:::==7 c-:
\ Signature OT authorized agent of contracting business entity
(De clarant)
Forms provided by Texas Ethics Comm1ss1on www.ethics .state.tx .us Version Vl.1.3a6aaf7d
DocuSign Envelope ID: 1453DC22-0913-4F15-8FB8-5132E52F4A0B
10/13/2020