CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
For vendor or other person doing business with local governmental entity
this questionnaire reflects changes made to the law by H B 1491 80th Leg Regular Session
OFFICE USE ONLY
This questionnaire is being filed in accordance with Chapter 176 Local Govemment Code
Date Received
byaperson who has a business relationship as defined by Section 176 001 1 a with a local
govemmental entity and the person meets requirements underSection 176 006 a
By law thisquestionnaire must be filedwith the records administratorofthe local govemmental
0
entity not later thanthe 7th businessday after thedate the person becomes aware offaets
J
that require the statementto be filed See Section 176 006 Local Govemment Code
Q
A person commits an offense if the person knowingly violates Section 176 006 Local
Govemment Code An offense underthis section is aClass C misdemeanor
J Name of person who has a business relationshipwith local governmental entity
1ttT E1aD
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rlEllT s Rlc6C
IJ C
D Check this box lfyou are filing an updateto a previously filed questionnaire
The law requires that you file an updated completed questionnaire with the appropriate filing authority not
later than the 7th business day aller the date the originally filed questionnaire becomes
incomplete or inaccurate
lJ Name of local government officer with whom filer has employment or business relationship
J JO
F
Name of Officer
This seotlon
Item 3 including subparts A S C
D must be completed for each offioer with whom the filer has an
employment or other business relationship as defined by Section 176 001 1 a Local Govemment Code Attach additional
pages to this Form CIQ as necessary
A Is the local govemment officer named in this section receiving or likely to receive taxable income other than investment
income
from the filer of the questionnaire
D Ves
DNO
B
Is the filer ofthe questionnaire receiving or likely to receive taxable income otherthan investment income from or at the
direction of the local govemment officer named in