4-Conflict Of Interest.pdf

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

FORM CIQ

OFFICE USE ONLY

This queslionnaire reflects changes made to the law by H.8.23,84th Leg., Regular Session.

Th s quesl onnarre is being liled in accordance with Chapter 176, Local Governmenl Code, by a vendor who has a business relationship as defined by Section 176 001(1-a) wilh a local governmental entity and the vendor meels requkements under Section 176.006(a).

By law this quesllonnaire must be filed wilh the records administralor o, the local governmenlal entiiy nol later than the 7th buslness day atter the date the vendor becomes aware ol Jacts that require the statemenl lo be liled. See Section 176.006(a-1), Local Governmenl Code.

A vendor commits an otfense if the vendor knowingly violates Section 176.006, Local Govemment Code' An otfense under lhis seclion is a misdemeanor.

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

checkthis box if you are liling an updateto a previously tiled questionnaire. (The law requires that you lile an updated completed questionnaire with the appropriate filing authority not laler than the 7th business day after the date on which you became aware thal the originally liled questionnaire was incomplete or inaccurate )

Name of Officer

4 hip with the local government olficer, or a family member ol the escribe any family relalionship with the local government otticer' ness relationship described. Attach additional pages to this Form

A,lsthelocalgovernmentotficerorafamilymemberoflheoflicerreceivingorlikelyloreceivetaxableincome' other than investment income, trom the vendor?

CIO as necessarY.

Yes

Describe each employment or other business relations ollicer, as described by Section 176.003(a)(2XA). Also d Complete subparts A and B lor each employment or busi

5 Describe each employment or business relationship that the vendor named other business enlity with respect lo which the local government oflicer s ownership interest ol one percent or more.

in Section 1 maintains wlth a corporation or erves as an olficer or director, or holds an check lhis box if the vendor has given the local governmenl officer or a lamily member of lhe ofticer one or more gifts as described in Section 1 76.004(a)(2X B)' excluding gifts described ln Section 176003(a-1)'

DaleSignalure ol vendor doing business with tIre governmental entitY

Form provided by Texas Ethics Commission www.elhics.slale.tx.us Revised l/1/2021

Name of locat government otlicer about whom the inlormalion is being disclosed'

B' lS the vendor receiving or likely to receive taxable income' other than investment income, |rom or at the direction ot the tocat government 6flicer oi a family member of the officer AND the taxable income is not received trom the local governmenlal entity?

I--l ves [--l lro

NoE

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

A complete copy of Chapter 1 76 of the Local Government Code may be Iound at http://wwwstatutes.legis.state tx us/

Docs/Lc/htmi LG.176.htm. For easy relerence, below are some of the sections cited on this form.

Local Government Code 6 176.001 1-a : "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The lerm does not include a connection

(A) a transaction that is subject to rate or lee regulation by a federal, state, or local g based on:

overnmental entitY or an agency of a federal, state, or local governmental enlity;

1B; a transaction conducted at a price and subiect to terms available to the public; or igi a purcrrase or tease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency.

Local Government Code 176 003(aX2XA) and (B):

1a1 A local government off icer shall file a conflicts disclosure statement with respect to a vendor if or

(ii) the local governmental entity is considering entering into a contract with the

(2) the vendor:

(A)hasanemploymentorotherbUsinessrelationshipwiththelocalgovernmenlolficeror.a iamily membei oithe officer that results in the oflicer or lamily member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that.(DacontractbetweenthelocalgovernmentalentityandVendorhasbeenexecuted;

vendori (B)haSgiventothelocalgovernmentofficerorafamilymemberoftheotficeroneormoregifts ih"t hruJ un ,ggr"gate value ol more than $1oo in the 12-month period preceding the date the olficer becomes aware that:

(i) a contract belween the local governmental entity and vendor has been execuled;or ii0 it to""t governmental entity is considering entering into a contract with the vendor'

Local Government code s 176.006(a) and (a'1)

@ofinterestquestionnaireittheVendorhaSabUSineSsrelationship with a local governmental entity and:

(1)hasanemploymentorotherbusinessrelationshipWithalocalgovernmentofficeroflhatlocal governmental entiiy, or a family member of the ofticer, described by section 176.003(a)(2)(A);

iz; has given a local governmlnt otticer of that local governmental entity' or a {amily member of the otii"",., o-n" o,. *o,.e gifts with the aggregate value specilied by section 176.003(a)(2)(B), excluding any gift described by Section 176 003(a-1 ); or ie1 nas a tamity relationship with a local government otficer of that local governmental entily.

(a-1) The completed conllict ot interest questionniire must be filed with the appropriate records administrator not later than the seventh business day after the later of:

(1) the date that the vendor:

(A)beginsdiscussionsornegotiationstoenterintoacontractWiththelocalgovernmental entity; or

(B) ;ubmits to the local governmental entity an application, response to a request for proposals or bids, correspondenie, or another writing related to a potential contract with the local governmental entity; or

(2) the date the vendor becomes aware:

(A)olanemploymentorotherbusinessrelationshipwitha|ocalgovernmentotficer,ora family member of the oliicer, described by Subsection (a);

(B) that the vendor has given one or more gilts described by Subsection (a); or

(C) of a family relationship wilh a local government officer'

Form provided by Texas Ethics Commission www.elhics.slale.lx.us Revised 1/1/2021