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CONFLICT OF INTEREST QUESTIONNAIRE <br />For vendor or other person doing business Wth lo"I governmental entity <br />This questionnaire reflects changes made to the law by 1-1.13, 1491, 80th Leg., Regular Session, <br />This questionnaire is being filed in accordance with Chapter 176, Local Government Code <br />by a person who has a business relationship as defined by Section 176.001 (1-a)with a local <br />governmental entity and the person meets requirements under Section 176.006(a), <br />By law this questionnaire must be filed vAth the reoords administrator of the local governmental <br />entity not later than the 7th business day after the date the person becomes aware of facts <br />that require the statement to be filed. See Section 176.006, Local Government Code - <br />A person commits an offense if the person knowingly violates Section 176.006, Local <br />Government Code. An offense under this section is a Class C misdemeanor. <br />Name of person who has a business relationship with local governmental entity. <br />1:1 Check this box If you are filing an update to a previously filed questionnaire. <br />OFFICIEUSEONLY <br />Date Raceved <br />(The law requires that you file an updated completed questionnaire with the appropriate filing authority not <br />later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) <br />Name of local government officer with whom filer has employment or business relationship, <br />Name of Officer <br />This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an <br />employment or other business relationship as defined by Section 176.001(1--a), Local Government Code. Attach additional <br />pages to this Form CIQ as necessary, <br />A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment <br />income, from the filer of the questionnaire? <br />ED Yes El No <br />B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the <br />direction of the local government officer named in this section AND the taxable income is not received from the local <br />governmental entity? <br />E:1 Yes E] No <br />C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local <br />government officer serves as an officer or director, or holds an ownership of 10 percent or more? <br />E:1 Yes El No <br />D. Describe each employment or business relationship with the local government officer named in this section. <br />Signature of person <br />E12 -1 -L - <br />entity Date <br />Adopted 0612912007 <br />