11-Conflict of Interest Questionnaire.pdf
PDF 12 KB Posted
- Solicitation number
- 25/0223
- Issued by
- Harris County, Texas
About this file
This is a Conflict of Interest Questionnaire (Form CIQ) required by the State of Texas under Chapter 176 of the Local Government Code, applicable to vendors and other persons conducting business with Harris County Juvenile Probation Department in connection with a Request for Sealed Quotations for Residential Services. The questionnaire must be completed and filed with the local governmental entity's records administrator no later than the seventh business day after a person becomes aware of facts requiring disclosure. The form applies to vendors or contractors who have a business relationship with the local governmental entity as defined by Section 176.001(1-a) of the Local Government Code and meet the requirements under Section 176.006(a). Filers must identify any local government officers with whom they have an employment or other business relationship and provide detailed information regarding all such relationships.
The questionnaire requires filers to disclose whether any local government officer is receiving or likely to receive taxable income from the filer; whether the filer is receiving taxable income from the officer outside of the governmental entity; whether the filer is employed by a corporation or business entity in which the officer serves as an officer, director, or holds ownership of 10 percent or more; and a detailed description of each employment or business relationship. Failure to file or knowingly violating the disclosure requirements constitutes a Class C misdemeanor offense under Texas law. This form serves as a critical compliance document to ensure transparency and prevent conflicts of interest in the procurement process for residential services contracts with Harris County.
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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 .