1295 HuntsvilleControlling
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 11/29/2022
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.
Korein Tillery, LLC
Saint Louis, MO 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 Huntsville
To provide legal representation to the city in connection with litigation seeking damages, declaratory relief, attorneys' fees, interest
& other appropriate relief.
2022-29
2022-959366
Date Filed:
Date Acknowledged:
Certificate Number:
CERTIFICATION OF FILING
Tillery, Stephen XSt. Louis, MO 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 V3.5.1.eb87ef42www.ethics.state.tx.usForms provided by Texas Ethics Commission