HomeMy WebLinkAboutKing CIQCONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
This questionnaire reflects chanmadeio
ges to the law by H.B. 23, 84th Leg., Regular Sessn.
This questionnaire is being filed in accordance with Chapter 176. i.cI Government Code, by a vendor who
has a business relationship as delined 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 roiiirds administrator ol the local governmental entity not later
than the 71h business day alter the dale the vendor becomes aware of facts that require the statement to be
iled. See Section 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.
Name of vendor who has a business relationship with local governmental entity.
0.4
FORM CIQ
OFFICE USE ONLY
Dale Received
11-- Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updaled
completed questionnaire with 1he appropriate filing authority not later Than the 7th business day after the date on which
you became aware thal the originally filed questionnaire was incomplele or inaccurate.)
Name of local government officer about whom the information Is being disclosed.
YQ
it
Name of Offic
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 for each employment or business relationship described. Attach additional pages lo this Form
CIO as necessary.
A. Is Ihe local government officer or a family member of the officer receiving or likely to receive taxable income,
other than inveslment income, from the vendor?
Yes
No
B. Is the vendor receiving or likely to receive taxable income, other than investmenl 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
* I governmental enlity?
Yes
v
No
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
ownersh InIere5I of one percent or more.
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 gills described in Section 176.003(a-1).
51. ature at vendor doing busir ss with
Form provided -by Texas Ethics Commission
he go rnmental entity Dale
.ethics.slate.lx.us
Revised 11/30/2015