HomeMy WebLinkAboutBlackerby CIQCONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
Page 2
J Name of local govemment officerwith 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?
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 govemmental entity?
ri7(es
No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local govemment officer serves
as an officer or director, or holds an ownership of 10 percent or more?
Yes
D. Describe each affiliation or business relationship.
o
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J Describe any other affiliation or business relationship that might cause a conflict of interest.
Si. • •tureof person doing business with the govemmellitai entity Date
Amended 01/13/2008
LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This is the notice to the appropriate local governmental entity that the following local
govemment officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176, Local Government Code.
OFFICE USE ONLY
Date Received
J Name of Local Government Officer
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J Office Held
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2i Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
R4)- C�0 n/ Ty .T(/l/N'/ C ,,,a6,4 Ti r A/
LI Description of the nature and extent of employment or other business relationship with vendor named in item 3
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11 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
that the disclosure applies to each family member (as defined by Section 176.001(2). Local
Govemment Code) of this local government officer. I also acknowledge that this statement
covers the 12-month period described by /tion 176.003(a)(2)(B), Local Government Code.
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Signature of. / vernment Offi -r /
AFFIX NOTARY STAMP / SEAL ABOVE faSa
/_{yam,, /ASwom
n Z Si ia'�/ ' this the V �+' Y day
to and subscribed before me, by the said .
of /7 20/ , to certify which, witness my hand and seal of office.
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Title of.of administering oath
iceriicer
Signa ure of office ad inistering oath Printed name of offadministering oath
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Notary ID 4t 6444261
My Commission Expires
April 28, 2017
LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
Section 176.003 of the Local Government Code requires certain local government officers to file this form. A
"local government officer" is defined as a member of the governing body of a local governmental entity; a
director, superintendent, administrator, president, or other person designated as the executive officer of a
local governmental entity; or an agent of a local governmental entity who exercises discretion in the planning,
recommending, selecting, or contracting of a vendor. This form is required to be filed with the records
administrator of the local governmental entity not later than 5 p.m. on the seventh business day after the date
on which the officer becomes aware of the facts that require the filing of this statement.
A local government officer commits an offense if the officer knowingly violates Section 176.003, Local
Government Code. An offense under this section is a misdemeanor.
Please refer to chapter 176 of the Local Government Code for detailed information regarding the requirement
to file this form.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of the local government officer filing this statement.
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code. Enter
the name of the vendor described by Section 176.001(7), Local Government Code, with whom the officer has
an employment or other business relationship as described by Section 176.003(a)(2)(A), Local Government
Code.
4. Description of the nature and extent of employment or business relationship with vendor named
in item 3. Describe the nature and extent of the employment or other business relationship with the vendor
in item 3 as described by Section 176.003(a)(2)(A), Local Government Code.
5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3
exceeds $100. List gifts accepted during the 12 -month period (described by Section 176.003(a)(2)(B).
Local Government Code) by the local government officer or family member of the officer from the vendor
named in item 3 that in the aggregate exceed $100 in value.
6. Affidavit. Signature of local government officer.
Adopted 8/7/2015