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Cuestionario de conflicto de intereses para proveedores

Para proveedores u otras personas que hagan negocios con entidades gubernamentales locales

Este cuestionario se presenta de acuerdo con el capítulo 176 del Código de Gobierno Local por una persona que hace negocios con la entidad gubernamental.

Por ley, este cuestionario debe presentarse al administrador de registros del gobierno local a más tardar el séptimo día hábil después de la fecha en que la persona tenga conocimiento de los hechos que requieren que se presente la declaración. Consulte la Sección 176.006 del Código de Gobierno Local. Una persona comete un delito si viola la Sección 176.006 del Código de Gobierno Local. Un delito en virtud de esta sección es un delito menor de Clase C.

*= información obligatoria

Formulario CIQ para proveedores

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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.

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.

local has with

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

• Confirmed

Submit