10-14-19 Regular Meeting of the La Porte City Council

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0 CONFLICT OF INTEREST QUESTIONNAIRE, FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICEUSEONLY This questionnaire is being filed in accordance with Chapter 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 governmental entity and the vendor 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 vendor becomes aware of facts that require the statement to be filed. See Section 176,006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Cod An offense under this section is a misdemeanor, El Name of vendor who has a business relationship with local glovernmentall, entity. 21 F-1 Check this box if you are filing an update to a previously filed questio, sire. (The lawnrequires that you file an updated completed questionnaire with the appropriate filing authority not later t n the 7th business day after the date on which t you became aware that the originally filed questionnaire was into lete or inaccurate.) 31 Name of local government officer about whom the information 7 g disclosed. Name of Off i r AJ Describe each employment or other business relation ip with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Als escribe any family relationship with the local government officer. Complete subparts A and B for each emplo siness relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local rnm t officer or a family member of the officer receiving or likely to receive taxabie income, other t n inv t ' come, from the vendor? Yes F-1 No B. Ishe ven r receiving or likely to receive taxable income, other than investment income, from or at the direction , o h 10cal ; vernment officer or a family member of the officer AND the taxable income is not received from the f the local gov nme ntal entity? F7yes E:1 No -5J Describe ch employment or business, relationship that the vendor named in Section 1 maintains with as corporation or otherbu ness entity with respect to which the local government officer, serves as an officer or director, or holds an I owners ip interest of one percent or more. Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). Signature of vendor doing business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015