HomeMy WebLinkAboutAldape CIQCONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.R. 23, 84th Leg., Regular Session.
This questionnaire is being filed 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 arid the
vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental ent ly nol later
than the 7th business day alter the dale the vendor becomes aware of facts Mal require the statement to be
filed. See Section 176,006(a.1), Local Government Code.
A vendor commits an oltense If the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this section is a misdemeanor,
LI Name of vendor who has a business relationship with local governmental entity.
5prod r1C
FORM CIQ
OFFICE USE ONLY
Dais Received
Check 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 dale on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
LI Name of local government officer about whom the Informauion Is being disclosed.
Name ot Officer
al Describe each employment or other business relalionship with the local government officer, or a family member of the
officer, as described by Section 175.003(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
CIO 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 i
Yes
the vendor?
No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or al the direction
of the local govemment officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
Yes
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 govemment officer serves as an officer or director, or holds an
ownership interest of one percent or more.
,
Check this box if the vendor has given the local government officer or a family member of the oflicer one or more gifts
as described in Section 176.003(a)(2)(6), excluding gifts described in Section 176.003(a-1).
q-- It- 15K
SigIure ot vridor doing business ilh the govemmontal enl ty Dale
Form provided by Texas Ethics Comm.ssion
vwww.ethics.statelx.us Revised 11/3012015