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HomeMy WebLinkAboutMartin CIQCONFLICT 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. OFFICE USE ONLY 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). Bylaw this questionnaire must be filed with the records administratorofthe local govemmental entity not laterthan 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 knowingly violates Section 176.006, Local Government Code An offense under this sPCtion is a Class ~, r±isde,ne.~n.,r 1 Name of person who has a business relationship with local govemmental entity. 2 ^ 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 date the originally filed questionnaire becomes incomplete or inaccurate.) 3 Name of local government officer with whom filer has employment 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 Govemment Code. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely ~~ receive taxable income, other than investment income, from the filer of the questionnaire? Yes ~No t3. Is the tiler of the questionnaire receiving or likely to receive taxable income, other than investment income from or at the I , direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? Yes ~ 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? Yes ©No D. Describe each employment or business relationship with the local govemment officer named in this section. ,_ 7 .~ . _ Fi,eL .. T ~~ S9~L~ ~ s~e.r~~ee, E _. __ 4 ~-/1-09 gna of person doing business with the govemmental entity Date Adopted 06129!2007