HomeMy WebLinkAboutDurable Specialties Inc 9/01/2021CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor doing buisiness, with local governmental entity,
This questionnaire reflects changes made to the law by H-B. 23, 84th Log., Regular Session. ORICE USE ONLY
This cr,wstdrjrvaire is b6nm g filed in accordance witi Gh@Ptejr 176, Local Govern mew Code, by a Yandw who Date Rer,;,*941
has a bUSiness reialion ship as defined by Section 176,010 1 � I -ali wlih a 1%,al ppvwnrnental: entity and the
vandar meats requirenvanIS resider 176006(a),
By law Mis questions cilre must be filed with the records administrator opt the local govinimental entity not later
than the '7th business day after die date the vaindor becarnes awye of farts that i equire die statement to be
Red See Section 176.M(a- 1), Local Government Code
A vondw ecmmits an offense if the vandar knowingify viciates Section 176.006, Local Government Code An
OHOIISO Under this &90i0ll is , imisderneanor,.
Name of vendor who has a business rel lionship with local governmental entity.
77
Check this box it you sre'fillng n update to a previously filed questionnaire. (The law requires that yotA file all updated
Gorn:pieted questionnaire with the appropriate filling authority nol later than the 7th business day alter the date on which
you became aware that the originally filed questionnalre was incorni or inaccurate.)
:31 Name of local government officer about whom the i formation is being disclosed..
7 "A
- Xameofofficer
41 Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section i 76,003(a)(2)(A). Mae describe any family relationship with the local government officer.
complete subparts A and 8 for each employment or business relailionshiledesciritted. Attatchaddittionall pages tolthis Form
CIO as necessary.
A, is the local government officer or a family member of the officer receiving or likely to receive taxable inoome,
oVier than investment income, from the vendor?
Yes No
e is the vendor receiving or likeJy to receive taxable income, other than investment income, from or at the direction
of the local governl-rent officer or a family member of the officer AND the taxable lnccrne is not received from the
local governmental entity?
F-1 Yes El 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 locall government officer serves as an officer or director, or holds ain
ownef,shlip interest of one percent or more,
,sj
Check this box if the vendor has given the local government officer or a family mornber of the officer one or rnore gilts
as described in 5'ection 171: 003(a)(2)(e), excluding gifts describer) in Seonon 176 003(a- 1).
zi A
qldl ijX
Signature, I vendor doing ❑UttireSS 'with the governmental entity Date
Form provided by Texas Ethics Commission WWW athics'state tx us Revised I 1111W1015
1 -23
NR.H Purchasing Guidance