HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-01/31/2017CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFlCEUSEONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Cotle, by a vendor who Date Recei�ed
has a business relationship as definetl by Section 176.001(1-a) with a local govemmental entity and the
ventlor meets requirements under Section 176.006(a).
By law Ihis questionnaire must be filed with the records administrator of ihe local governmental entity not later
than the 7th business day afler the date the vendor becomes aware of facts that require the 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
oKense under ihis section is a misdemeanor.
� Name of vendor who has a business relationship with local governmental entity.
N/A
2
� Checkthisboxifyouarefilinganupdatetoapreviouslyfiledquestionnaire.(Thelawrequiresthatyoufileanupdated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware lhat the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government officer about whom the information is being disclosed.
Name of Officer
4 Describe each employment or other business relationship with the local government officer, or a family member of the
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 foreach employment or business relationship described. Attach additional pages to this Form
CIQ 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
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from 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?
� Yes � No
5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporetion 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
1/24/2017
S at re of vendor doing business with the governmemal entiry Date
rorm providea ny iexas ttnics Gommisslon www.ethics.state.tx.us Revised 11l30/2015