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CERTIFICATE OF INTERESTED PARTIES <br />FORM 1295 <br />1 of 1 <br />Complete Nos. 1- 4 and 6 9 there are interested parties. <br />OFFICE USE ONLY <br />Complete Nos.1, 2, 3, 5, and 6 if there are no interested parties. <br />CERTIFICATION OF FILING <br />Certificate Number: <br />2016-39374 <br />1 Name of business entity filing form, and the city, state and country of the business entity's place <br />of business. <br />CorWorth / Restroom Facilities Ltd. <br />Marble Falls, TX United States <br />Date Filed: <br />04/3.3/2016 <br />2 Name of governmental entity or state agency that is a party to the contract for which the form is <br />being filed. <br />City of La Porte, TX <br />Date Acknowledged: <br />4 - a � - I U <br />3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a <br />description of the goods or services to be provided under the contract. <br />4112016 <br />Design / Build <br />4 <br />Name of Interested Party <br />City, State, Country (place of business) <br />Nature of interest (check applicable) <br />Controlling <br />Intermediary <br />Putman, John <br />Marble Falls, TX United States <br />X <br />5 Check only if there is NO Interested Party. ❑ <br />6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. <br />=TAMMYMILLER <br />r �f-- <br />/\ a, �(2 "11� Sig nat a of authorized'agent of contracting business entity <br />1f <br />AFFIX NOTARY STAMP / SEAL ABOVE <br />Sworn to and subscribed before me, by the said c JQ)p4, i t.c:kYY-,cu-, - C61 'Jil nl , this the 6;� JQ 1 ` day of AI yL , <br />20to certify which, witness my hand and seal of office. <br />MILLER <br />ID #11748987 <br />aTAMMY <br />My Commission Expires <br />March 28, 2020 k <br />.�kw.C,M, ^^ ereS��n _ <br />Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath <br />Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.645 <br />