HomeMy WebLinkAboutForm CIQ King Carpet Plus 06-06-2014CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
OFFICEUSEONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Code
Date Received
by a person who has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the person meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental
entity 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 176.008, Local Government Code.
A person commits an offense if the person knowingly violates Section 176.006, Local
Government Code.An offense under this section is a Class C misdemeanor.
1 Name of person who has a business relationship with local governmental entity.
K� n 0 -NC_
2
Check tdwbox 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 date the originally filed questionnaire becomes incomplete or inaccurate.)
3
Name of local government officer with whom filer has ern I yment or business relationship.
`
Name of Officer
This -section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has;an
employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional
pages to this Form CIO as necessary.
A; Is the local government officer named in this section receiving or likely to receive taxable income, other than investment
Income, from the filer of the questionnaire?
nYes F7No
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the
direction of the local government officer named in this section AND the taxable income is not received from the local
governmental entity?
® Yes LEI No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Ez Yes F� No
D. Describe each employment or business relationship with the local government officer named in this section.
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4
Sig lure of person doing busin s with the governmental entity Date
Adopted 06/2912007