HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-01/16/2017 (2)CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing business with locai governmental entity
This questionnaire reflects changes made to [he law by H.B. 23, 84th Leg., Regular Session. OFFICEUSEONLY
This questionnaire is being filed in accordance with Chapter n6, Local Government Cotle, by a vendor who Date Received
has a business relationship as defined by Section 176.001(1-a) with a local governmen[al entiry and the
vendor meets requirements under Section 176.006(a).
By law this questionnaire must be fiied wiih the records administrator of the local governmental entity not later
than the 7th business day after ihe date the vendor becomes aware of facts that require ihe statement to be
filed. See Section 176.006(a-1), Local Govemment Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this section is a misdemeanor.
� Name of vendor who has a business relationship with Iocal governmenWl entity.
2
❑ Check this box if you are filing an update to a previously tiled questionnaire. (The law requires that you file an updated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government o icer abo t w he intormation is being disclosed.
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Nar� of Officer
4 Describe each employment or other business relationship with the local government officer, or a family member of ihe
officer, as described by Section 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 relationship described. Attach additional pages to this Form
CI� as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
� Yes �No
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B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direciion
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 maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
6
❑ 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).
7 �
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