HomeMy WebLinkAboutFranklin CIQ79072
:'-! re;a. iiZed;i~there haS,been some ~nfu~ion:a's to:Wl~ether o~* not' c t es are requ red
t,,o,.~btain the bonflibt 0f)qte(~t qL~e~tiOnn~i[e from a[:geridO~;rs, ihave take~ the"
I!berty-°f,c~plefi~iglthe form arid;have ,encLosed a CoPY for,,y°u'r records, i. hope
this,will be o~Som'e a~sistance M,yoU, ' - ' :--
ny:thing,W~ cat do for.you.
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at;Law.
2435
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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of the Local OFFICE USE ONLY
Government Code by a person doing business with the governmental entity, cate
By law this questionnaire must be filed with the records administrator of the
local government not later than the 7th business day after the date the person
becomes aware of facts that require the statement to be filed. See Section
176.006, Local Government Code.
A person commits an offense if the person violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
t~ Name of person doing business with local governmental entity.
~ 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
September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and
not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
recommendations to a local government officer of the local governmental entity with respect to expenditure of money.
Describe each affiliation or business relationship with a person who is a local government officer and who appoints or
employs a local government officer of the local governmental entity that is the subject of this questionnaire,
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM ClQ
Page 2
Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the
answer toA. B, crc is YES.)
This section item 5 inclu(]mg subparts A B C & D. must be comBleted for each officer with whom the filer has affiliation or
business retatlonshre Attach additional pages to this Form ClQ as necessary.
A. Is the Ioca~ government officer named Jn ibis section receiwng or likely to recewe taxable income from the filer of the
c~uesdonnaire?
J-~ Yes j~ No
B is [ne filer of the questionnaire receiving or likely to receive taxable income from or at the direction Of the iota[ government
officer name(] in this section AND the TaxaBle qcome is not from the Ioca govemmenfal entity?
~---'~ Yes ~ No
as an officer or aJrector, or ho ds an ownership of 10 Percent or more?
~--~ Yes ~ No
D. Describe each affiliation or business relationship.
~J Describeany~thera~i~iati~n~rbusinessre~a~~nshipthatmightcauseac~n~ict~flnterest~
Signature of person doing business with the governmental entity
Date