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Conflict of Interest Questionnaire for Vendors

For vendor or other person doing business with local governmental entity

This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity.

By law this questionnaire must be filed with the records administrator of the local government 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.

*= Required Information

CIQ Form for Vendors

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Name of person doing business with local governmental entity. *

(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

Check this box if you are filing an update to a previously filed questionnaire.

• Yes, this is an update.

Name each employee or contractor of the local governmental entity who makes recommendations to a local government officer of the governmental entity with respect to expenditures of money AND describe the affiliation or business relationship.

Name each local government officer who appoints or employs local government officers of the governmental entity for which this questionnaire is filed AND describe the affiliation or business relationship.

Name of local government officer with whom filer has affiliation or business relationship.

Complete this section only if the answer to A, B, or C is YES.

the the government

A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire?

• Yes

B. Is the filer of the questionnaire receiving or likely to receive taxable 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

C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more?

• Yes

Describe each affiliation or business relationship.

Describe any other affiliation or business relationship that might cause a conflict of interest.

By Checking this box, you certify that you are the person who has filed this form. (electronic signature) *

• Confirmed

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