HomeMy WebLinkAboutXIT Paving & Construction, Inc.CONFLICT 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, 84th Leg., Regular Session. OFFICE USE ONLY
This.:quesdonnaire 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 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.
IJ Name of vendor who has a business relationship with local governmental entity.
��r r '
2 .
Check this box if you are filing an update to a previously filed qu" - onttafre: (The law requires that you file an updated
completed questionna re 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.)
lj Name of local government officer about whom the information is being disclosed.
ame of Officer
4 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 8 for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
I'
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 No A/4
191 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation p or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership Interest of one _percent .or more. P'
s
EJCheck 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). :7] �"
Signature of van or d Ing bu iness wit e g immental entity Da
Form provided by Texas Ethics Commission www:ethics.stateAx . us Revised 11/30/2015
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