07-22-19 Regular Meeting of the La Porte City Council

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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doina business with local aovernmental entity This auestionnaire reflects chanaes made to the law by H.B. 23, 84th Lea.. Reaular Session. OFFICE USE ONLY This auestionnaire is beina filed in accordance with Chaoter 176. Local Government Code. by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local aovernmental entitv and the vendor meets reouirements under Section 176.006(a). By law this auestionnaire must be filed with the records administrator of the local aovernmental entitv not later than the 7th business day after the date the vendor becomes aware of facts that reauire the statement to be filed. See Section 176.006(a-1). Local Government Code, A vendor commits an offense if the vendor knowinalv violates Section 176.006. Local Government Code. An offense under this section is a misdemeanor. !J Name of vendor who has a business relationship with local aovernmental entitv. Wesley W. Payton 21 - E] Check this box if vou are filina an update to a oreviousiv filed auestionnaire. (The law reauires that vou file an updated completed auestionnaire with the armrooriate filina authority not later than the 7th business day after the date on which vou became aware that the oriainaliv filed auestionnaire was incomplete or inaccurate.) 3:1 Name of local ciovernment officer about whom the information is beino disclosed. N/A Name of Officer 4 J Describe each emDlovment or other business relationship with the local aovernment officer, or a family member of the officer, as described by Section 176.003(a)(2)(A), Also describe anv familv relationship with the local aovernment officer. Complete subparts A and B for each err Dlovm ent or business relationship described. Attach additional Daaes to this Form CIQ as necessarv. A. Is the local aovernment officer or a familv member of the officer receivina or likely to receive taxable income, other than investment income, from the vendor? ElYes a No B. Is the vendor receiving or likelv to receive taxable income. other than investment income. from or at the direction of the local aovernment officer or a familv member of the officer AND the taxable income is not received from the local aovernmental entitv? E:1 Fv-1 Yes L�j No Describe each ernDlovment or business relationship that the vendor named in Section 1 maintains with a conaoration or other business entitv with respect to which the local aovernment officer serves as an officer or director, or holds an ownership interest of one oercent or more. ±j Check this box if the vendor has aiven the local aovernment officer or a familv member of the officer one or more aifts EJ as described in Section 176.003(a)(2)(8). excludina aifts described in Section 176.003(a-1). :7] 6-25-19 Signature of vendor doina business with the aovernmental entitv Date XAjasleNj X V P;iNitnn - Prt=qirjpnt Form orovided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015