HomeMy WebLinkAboutT Bar Fence and Tennis Courts 2022CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 134th Leg., Regular Session.
OFFICE USE ONLY
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 requh-e 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 Code. An
offense under this section Is a misdemeanor.
1J Name of vendor who has a business relationship with local governmental entity.
2
Check this box if you are filing an update to 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 after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 Name of local government officer about whom the information is being disclosed.
Name of Officer
AJ Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
Yes E-1 No
B. Is the vendor receiving or likely to receive taxable income, other than investment income. from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
71 Yes F-1 No
5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business entity with respect to which the local govern nt officer serves as an officer or director, or holds an
ownership interest of one percent or more.
6
171 Check this box if the .ndor has given tl I cal go ernment officer or a family member of the officer one of more gifts
as described in con 1 6.003(a)( ( , excl ing gifts described in Section 176 03(a -1).
7
4Da
Signature o/v0doV6iiTg MiAss wi hag o mental entity
Form provided by Texas Elhics Commission J www.ethics.State.tx.us l ' Revised 11130,!2015
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