HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016 (6)CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing business with local governmental entity
This questionnalre reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFlCEUSEONLY
This questionnaire Is being filed in accordance wi�h Chapter 176, Local Govemment Code, by a vendor who oate Received. ' � .
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the �
vendor meets requiremenis under Sedion 176.006(a). �
By law this questionnaire must be filed with ihe records administrator oi fhe local governmental entity not later
than the 7th business day (fter) he date the vendor becomes aware oi tacts that require the statement to be ' 2l l`j I Zv �(p
filed. See Section 176.006 a-1 , Local Government Code.
A vendor commits an oflense if the vendor knowingly violates Section� 176.006, Local Government Code. An
oflense under this section is a misdemeanor. � � -
y Name of vendor who has a business relationship with local governmental entily.
Info-Tech Research Group Ina
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� Checklhisboxifyouarefilinganupdatetoapreviouslyfiledquestionnaire.(Thelawrequiresthatyoutileanupdated
completed questionnaire with the appropriate filing authority not later than the 7th 6usiness day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government officer about whom the information is being disclosed.
N/A
� Name of Officer
4- Describe each employment ar other business relationship with the local governmenf officer, or a family member of the
officer, as described by Sectlon 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationshlp described. Attach additional pages to this Form
CIQ as necessary. �
N/A
A. Is the local government officer or a family member of the officer receiving or likely to receive tauable income,�
other than investment income, from the vendor?
� Yes � No
B. Is the vendor receiving or likely to receive ta�cable income, other than investment income, from or aY the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity? �
� Yes � No
5 Describe each employment or business relationship that the vendor named in Section 1 mainfains with a corporation or
other business entity with respect to which the local government officer serves as an officer or directar, or holds an
ownership interest of one percent or more. � �
N/A
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❑Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
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Ryan Huggett : �m�;:�:�;�,,�o�,�a oe�. �, 2016
Signature of vendor doing businesszwith the governmental entity � Date
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 77/30/2015