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CONFLICT OF INTEREST QUESTIONNAIRE FORM ClU
For vendor doing business with local governmental entity
This questionnaire reflects changes made to the taw by H.S. 23, 84th Log., Regular Session. OFF4CE USE ONLY
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received
has a business relati(xisHp 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 riled with the records administrator of ft local governmental entry 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 Code, An
offense under this section Is a misdemeanor.
9 Name of vendor who hasia business relationship with local governmental entity.
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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.)
IF-14--a- rn eo-flocal government officer about whom the Information is being disclosed.
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Name of Off loer
ij-Describe each employment or other business relationship with the local government officer, or a farrilly menriber of the
officer, as described by Section 176,003(a)(2)(A). Also describe any family relationship with ft 100W governinent officer.
Complete subparts Aand B for each employment or busine" retationshiptlesictibed. Attach additional pages to this Form
C40 as nacessary.
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 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?
0 Yes No
Describe each employment or business relationship that the vendor named in Section I maintains with a corporation or
other business entity with respect to which the local govenvirant officer serves as an officer or director, or holds an
ownership Interest of one percent or more.
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Check this box if the vendor has given the local government officer or afamily 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).
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V') - 7
nature
��4 of vendor doing business with die governmental entity Date
Form provided by Texas Ethics Commission www.ethics.stata.txms Revised 11/3012015
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