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ru mb piuvwcu uy i exas crrnus tummission www.etnics.state.tx.us Version V1.0.3337 <br />CERTIFICATE OF INTERESTED PARTIES <br />FORM 1295 <br />10f1 <br />Complete Nos. 1- 4 and 6 if 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 />2017-276907 <br />1 Name of business entity filing form, and the city, state and country of the business entity's place <br />of business. <br />Scheibe Consulting, LLC <br />Austin, TX United States <br />Date Filed: <br />10/26/2017 <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 San Marcos, Texas <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 />13028132-56252 <br />Civil Engineering Services <br />4 <br />Name of Interested Party <br />City, State, Country (place of business) <br />Nature of interest <br />(check applicable) <br />Controlling <br />Intermediary <br />Scheibe, Eric <br />Austin, 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 />•`":n"'�., CANDICE NGUYEN <br />Notary Public, State of Texas <br />„ Comm. Expires 10-042or <br />'�n��°;���••` Notary ID 13180392-6 Signature of authorized agent of contracting business entity <br />AFFIX NOTARY STAMP / SEAL ABOVE <br />Sworn to and subscribed before me, by the said F_i"i C ��f�PlUf this the <br />day of 'C V��✓ , <br />20to certify which, witness my hand and seal of office. <br />C64 74 <br />Signature of officer administering oath Printed name of officer administering oath <br />Title of officer administering oath <br />ru mb piuvwcu uy i exas crrnus tummission www.etnics.state.tx.us Version V1.0.3337 <br />