HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-2/10/2006
TM
INTERMEDIX
Intermedix, Inc.
Dear Provider;
Recently the Texas Ethics Commission (TEC) and the Texas Legislature enacted a law to
help preclude conflicts of interest between governmental agencies and vendors. This law
(HB 914) requires vendors to inform the agency of any affiliations between the agency
and the vendor as outlined within HB 914. The TEC has created form #CIQ (Conflict of
Interest Questionnaire) for this purpose.
As you appear to meet the definition of a "Local Government Entity" as defined within
HB 914, the attached Conflict ofInterest Questionnaire is forwarded to you for filing in
accordance with the requirements ofHB914.
To assist you with this process, we are including a copy ofHB914 along with our
required filing ofthe CIQ Form.
Intermedix appreciates the opportunity to serve you and looks forward to a continued
successful business relationship.
Please do not hesitate to contact me at 866-398-8999 x4994 or via email at
rklemme(2V,intermedix.com should you have any questions.
Sincerely;
~
Richard C. Klemme
Director of Corporate Development
Physical Address
16225 Park Ten Place Drive, Suite 805
Houston, Texas 77084-5152
(866) 398-8999
(866) 724-5995 Fax
www.intermedix.org
Mailing Address
PO Box 940249
Houston, Texas 77094-7249
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
This questionnaire is being filed in accordance with chapter 176 of the Local
Government Code by a person doing business with the governmental entity.
By law this questionnaire must be filed with the records administrator of the
local government not later than the 7th business day after the date the
person becomes aware of facts that require the statement to be filed. See
Section 176.006, Local Government Code.
A person com mitts an offense if the person violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
OFFICE USE ONLY
Date Received
1 Name of person doing business with local governmental entity.
Intermedix, Inc.
20
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than
September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and
not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
3 Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who
makes recommendations to a local government officer of the local governmental entity with respect to expenditure of
money.
No affiliations
4 Describe each affiliation or business relationship with a person who is a local government officer and who appoints or
employs a local government officer of the local governmental entity that is the subject of this questionnaire.
No affiliations
Adopted 01/1312006
CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
Page 2
For vendor or other person doing business with local governmental entity
5 Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if
the answer to A, B, or C is YES.)
This section, item 5, including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or
business relationship. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the
questionnaire?
o
Yes
[g] No
B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government
officer named in this section AND the taxable income is not from the local governmental entity?
o Yes
[g] No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves
as an officer or director, or holds an ownership of 10 percent or more?
o Yes
[g] No
D. Describe each affiliation or business relationship.
6 Describe any other affiliation or business relationship that might cause a conflict of interest.
None
7 Intermedix, Inc.; P. O. Box 941608; Houston, Texas 77094-8608
Date
Adopted 01/13/2006