HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-01/18/2017CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
FORM CIQ
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg-, Regular Session.OFFICE USE ONLY
lhls questionnaire is being tiled in accordance with Chapter 176, Local Government Code, by a vendor who
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the
vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental entity not later
than the 7th business day after the date the vendor becomes aware of facts that require the statement to be
filed. SeeSection 176.006(a-1), Local Government 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.
Date Received
rl Name of vendor who has a business relationship with local governmental entity.
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u Gheck 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 the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
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9J Name of local government officer about whom the information is being disclosed.
NA
Name of Officer
4l Describe each employment or other business relationship with the local government officer, or a family member of lhe
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 lor each employment or business relationship described. Atlach additional pages to this Form
CIQ as necessary.
A. ls 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?
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B. ls the vendor receiving or likely to receive taxable income, other than investment income, f rom or at 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?
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NA
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.
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AN
6lJ Check this box if the vendor has given the local government officer or a family member of the officer one or more giftsl-J as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
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Date
Form provided by Texas Ethics Commission www. eth ics.state.tx. us Revised 11/30/20 15
1/18/2017