HomeMy WebLinkAboutDouble D Contracting 1/26/2023CONFLICT OF INTEREST QUESTIONNAIRE FORM C101
For vendor doings business with local governmental entity
This questionnaire reflects changes made to the taw by H.S. 23, gain Log., Regular Session. OFFIC
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lKs questionnaire is being Wed In accordance Will Chapter 176, Local Government Code, by a vendor
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has a I)LIS111995 relationship as defined by Section 178.001 (1 a) wilt a local governmental entity and Session.
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vendor meets requirements Linder Section 176,0106(a).
By law fts questionl1kro must be filed with the records acirltnistriLior of die locaY governmainal entry not later
than the 791 business day after 010 date tile vendor becomes aware of facts that r0qtiffe file statement to be
filed. %e Section IM006(a- 1), Local Government Code,
A vendor commits an offense V the vendor knowingly violates Section 176.0106, Local Government Code, An
offense Under this saclon is a miscistilaanor.
Name, of vendor who has a bustler relationship with local governmentai entity
Check this box if You are filing an update to a previously filed questionnaire, (The taw 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,)
Name of local government officer about whom the Information is being disclosed'.
Narne of Officer
Describe each employment or other business relationship with the localgovernment officer, or a fe"Y member of the
Officer, as deacribed by Sectlon'IM003(a)(2XA), Also describe any family relationship Willy the local government offlom
Complete subparts A and B for each employment or business relationship described. Attach additional Pages to this Form
CIO as necessary.
A. is the Be government officer or a family member of the officer receiving of likely to rocorve, taxable Income,
other than Investment Income, from the vendor?
EJ Yes M No
e. is the vendor receiving or likely to receive Wable Income, other than investment incorne, from or at the difftlion
of the lOcal government officer or a family member of the officer AND the taxable Income Is not received from the
local governmental entity?
Describe each employment or business relationship that the vendor named in Section J! maintains wMa corporation or
other business entity with realtact to which the local, government officer serves as an officer or director, or holds an
ownership interest of one percent or more,
Check this box if the vendor has giv n the 'r )
cal goy4millent officer or a family member of the officer one or more gifts
as do cl In Socilon 176, excluding gifts described ln Section 176,003(a-1),
nature o vend doing bu'P Go$ writ die gova--m.777n-F-y
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