OPS-07 2/14/2020

Rev. 0 - 02/14/2020 Page 1 of 1

OFFICE OF PROCUREMENT SERVICES

CONFLICT OF INTEREST POLICY

It is the City of Dallas' practice to obtain a conflict of interest form from every individual or business entity that is currently doing business with the City or before being considered for award.

This practice is intended to comply with the requirements under chapter 176 of Texas Local Government Code:

Conflict of Interest

During the 79th Legislative Session, House Bill 914 was approved, which added chapter 176 to the Texas Local Government Code. Chapter 176 mandates the public disclosure of certain information concerning persons doing business or seeking to do business with the City of Dallas, including affiliations and business and financial relationships such persons may have with City of Dallas officers. An explanation of the requirements of chapter 176, applicable forms and a complete text of the new law are available at: http://www.ethics.state.tx.us/whatsnew/conflict forms.htm.

The vendor acknowledges by doing business or seeking to do business with the City of Dallas that he/she has been notified of the requirements under chapter 176 of the Texas Local Government Code and that he/she is solely responsible for complying with the terms and conditions therein. Furthermore, any individual or business entity seeking to do business with the City of Dallas who does not comply with this practice may risk award consideration of any City contract.

Revised 11/30/2015Form provided by Texas Ethics Commission www.ethics.state.tx.us

FORM CIQ

OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who 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.

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

Date Received

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 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?

Yes No

Check this box if the vendor has given the local government officer or a family 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).

Signature of vendor doing business with the governmental entity Date

Name of vendor who has a business relationship with local governmental entity.1

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 on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)

3 Name of local government officer about whom the information is being disclosed.

Name of Officer

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 B for each employment or business relationship described. Attach additional pages to this Form CIQ as necessary.

Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation 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.