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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ <br />For vendor doing business with local governmental entity <br />This questionnaire reflects changes made to the law by K& 23, 84th Leg., Regular Se log. FICE USE ONLY <br />This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vender who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Date Received <br />vendor meets requirements under Section 176.006(a). <br />By law this questionnaire must be filed with the records administrator of the local governmental entity not later <br />than the An business day after the date the vendor becomes aware of facts that require the statement to be <br />filed. See Section 176.006(a-1), Local Government Code, <br />A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Govemment Code. An <br />offense under this section is a misdemeanor. <br />Chen It thin box if �rou at° fiilr� are €tpdat l a rev lc�lsly fled rf€tetlrsrtrta3re. (The 4avr requires that you fide an <br />updated <br />fetedquestionnaire with the appropriate filing authority not later than the 7th business day after the date on which you <br />became aware that the originally filed questionnaire was incomplete or inaccurate.) <br />� dame of 3cal gs�vernrrtent e�fficer about wham site arsfos°matiors''' is being discloser. <br />NONE <br />Name of Office <br />hip With the local government officer, or a family member of The <br />officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. <br />Complete subparts A and 8 for each employment or business relationship described. Attach additional pages to this Form <br />CIO as necessary. <br />A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, <br />other than investment income, from the vendor? <br />r—'-1 <br />L—J Yes No <br />B. Is the vendor receiving or likely to recei,(e taxable income, other than investment income, from or at the direction <br />of the local government officer or a family member of the officer AND the taxable income is not received from the <br />local governmental entity? <br />ED <br />�D I business ­rel lon -lip <br />soc a that h d d in nagntain �'Ih a Corp ra !Ono <br />ao en 0 an or 8 so af Ven 8me Section 1 a V <br />1p' Ym <br />'Ib <br />t e a re pe tt t I I gove M r as a a cer 0 <br />r bu iness entity with swhichrn not"M serves <br />n r f, r director, or ohoilds act <br />C h 0 0 he 008 officer <br />se es, <br />W r hl� I t t f p r t , <br />no s 0 n eres 0 one e cen 0, more. <br />Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts <br />Li as described in Section 176MS(a)(2)(B), excluding gifts described in Section 176.003(a-1). <br />7 <br />A <br />'§Tg`nat�" of venoor doing Wshe <br />s with the governmental entity <br />Form provided by Texas Ethics Commission www. ethics. state. tx,u s Revised 11/30/2015 <br />