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Complete Nos. 1 - 4 and 6 if there are interested parties. <br />Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. <br />I Name of business entity filing form, and the city, state and country of the business entity's place <br />of business. <br />W.W. Payton Corporation <br />Katy, TX United States I <br />or state agency that is a party to the contract <br />being filed. <br />City of La Porte <br />Ter—N MZON <br />I of 1 <br />OFFICE USE ONLY <br />CERTIFICATION OF FILING <br />Certificate Number: <br />2019-464392 <br />Date Filed: <br />03/18/2019 <br />Date Acknowledged: <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 services, goods, or other property to be provided under the contract. <br />BID#19011 <br />HILLRIDGE WATER PLANT IMPROVEMENTS PHASE 11 <br />4 <br />Name of Interested Party <br />City, State, Country (place of business) <br />Nature of interest <br />(check applicable) <br />Controlling <br />I intermediary <br />Payton, Wesley and Marilyn <br />Katy, TX United States <br />X <br />5 Check only if there is NO Interested Party. 1:1 <br />6 UNSWORN DECLARATION <br />My name is Wesley W. Payton , and my date of birth is <br />My address is P.O. BOX 1056 <br />(street) <br />I declare under penalty of perjury that the foregoing is true and correct <br />3-22-19 <br />Katy TX , 77492 -Harris <br />(city) (state) (zip code) (country) <br />Executed in Waller County, State of Texas on the 18tbday of March 20 19. <br />(month) (year) <br />nature of authorized age contracting business entity <br />(Declarant) <br />Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.39f8039c <br />