FORM CIQ
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
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FOR OFFICE USE ONLY
DATE RECEIVED: Dec 11, 2016 |
style="font-weight:bold;">This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session
This questionnaire is being filed in accordance with chapter 176, Local Government Code 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 176.006, Local Government Code.
A person committs 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.
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 Government Code. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investement income, from the filer of the questionnaire?
YES X NO
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 from the local governmental entity?
YES X 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 X NO
D. Describe each affiliation or business relationship.
X By Checking this box, you certify that you are the person who has filed this form. (electronic signature)