CMS-07-021/023 - Los Angeles County Department of Children and ...

REQUIRED FORMS – FORM 14
CERTIFICATION OF OWNERSHIP AND FINANCIAL INTEREST
Prospective Contractor must declare if it holds a controlling interest in any other
organization, or is owned or controlled by any other person or organization.
Yes_____No_____
If yes, provide name of organization or person and the following information:
Print Name and Title Address
Telephone Number Contact Person
I declare under penalty of perjury that that the foregoing Firm/Organization information is
true and correct.
Print Name and Title of Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with the
County.
Authorized Signature of Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with the
County.
Date
Prospective Contractor must declare whether it has Financial Interest in any other
business.
Yes_____No_____
If yes, provide name of business:
Print Legal Name of Business Address
Telephone Number Contact Person
I declare under penalty of perjury that the foregoing Firm/Organization information is true
and correct.
Print Name and Title of Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with
the County.
Authorized Signature of Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with
the County.
Date