HomeMy WebLinkAboutWilliams Meriwether Smith CIQCONFLICT 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 OFFICEUSEONLY
Government Code by a person doing business with the governmental entity. Date Received
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.
1 Name of person doing business with local governmental entity.
~~'//~a..t.r ~t~fari~./~~~t,.-rsi~.~~,. d- Lv,
L. L-./~
~
z
Check this box If you are filing an update to a previouslyflled 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.)
3 Describe each afflllatlon or business relationship with an employee or contractor of the local govemmental entity who makes
recommendations to a local government officer of the local govemmental entity with respect to expenditure of money.
4 Describe each affiliation or business relatlonship with a person who is a local government officer and who appoints or
employs a
l
ocal government officer otthe loca
l
govemm
ental entity that is the subject of this questionnaire.
//
,,_
/
~
)
~~~-: r ~srt~i Lty ~+o Q /ac in.t .~i~a. ~~
/p~r"~~i~s~ i iv O wr ~i iri~vr
,
~
/
2 v.~l ~iivLL ~ ~i.r-G
Amended 01/13/?006
CONFLICT OF INTEREST QUESTIONNANRE FORM CIQ
For vendor or other person doing business with local governmental entity Page 2
5 Name of local govemmentotflcerwlth whom filer has affiliation or business relationship. (Complete this section only if the
answer to A, B,orCIsYES.) /Qn~rt~-~ NaS~~ G~ GK~~u%,,`
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 govemment officer named in this section receiving or likely to receive taxable income from the filer of the
questionnaire?
Yes ~ No
B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local govemment
officer named in this section AND the taxable income is not from the kcal governmental entity?
Yes ~ No
C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves
as an officer or director, or holds an ownership of 10 percent or more?
Q Yes ~ No
D. Describe each affiliation or business relationship.
~j-~pwa ~i~.G~f~o ~ ~i~~ /~/y~~ ~y ~'~~`/H~v I-~~.~ /~~Ow,.r .r°Y~9 2t4~
B~Mh.C~ .~~t..~, ~J~lYt// /:v ~i.c. T7 rYS~f ~~ l.~~i /~. ~~'r.'r'y
6 Describe any other affiliation or business relationship that might cause a conflict of interest
~0~'1 G .
7
,fC~~C ~ 7 /v-0,6
Signature of person doing business v~h the governmental entity Date
.amended 01/13/?006