10-Conflict of Interest Questionnaire.pdf
PDF 12 KB Posted
- Solicitation number
- 25/0236
- Issued by
- Harris County, Texas
About this file
This document is a Conflict of Interest Questionnaire (Form CIQ) adopted on 06/29/2007, which is a legal form used by local governmental entities in Texas under Chapter 176 of the Local Government Code. The form requires individuals or vendors with a business relationship with a local governmental entity to disclose potential conflicts of interest. The questionnaire must be filed within 7 business days of becoming aware of facts necessitating the disclosure, and failure to do so can result in a Class C misdemeanor.
The form requires the filer to provide their name and details about any business or employment relationships with local government officers. Specifically, the filer must answer whether the local government officer is receiving or likely to receive taxable income from the filer, if the filer is receiving taxable income from the officer, and whether the filer is employed by a corporation where the officer serves in a leadership or significant ownership role. The form provides space to describe each employment or business relationship and requires the signature of the person doing business with the governmental entity.
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Text version
Adopted 06/29/2007
FORM CIQ
OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code by a person who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person 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 person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code.
A person commits an offense if the person knowingly violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
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 the originally filed questionnaire becomes incomplete or inaccurate.)
Name of person who has a business relationship with local governmental entity.1
Date Received
Name of local government officer with whom filer has employment or business relationship.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the filer of the questionnaire?
Yes No
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity?
Yes No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes No
D. Describe each employment or business relationship with the local government officer named in this section.
Signature of person doing business with the governmental entity Date
File details come from the government source that posted it. Updated .