5-1002HVAC Form CIQ.pdf
PDF 212 KB Posted
- Attached to
- CNS Disposal Serive State and local contract opportunity
- Solicitation number
- 1074CNDS
- Issued by
- Van Zandt County, Texas
About this file
The document is a Conflict of Interest Questionnaire (Form CIQ) for vendors or persons doing business with a local governmental entity, as mandated by Chapter 176 of the Local Government Code. The form is designed to disclose potential conflicts of interest when a person has a business relationship with a local governmental entity, with specific requirements for filing the questionnaire within 7 business days of becoming aware of facts necessitating the statement.
The questionnaire requires the filer to provide details about their business relationship with a local government officer, including whether the officer is receiving or likely to receive taxable income from the filer, if the filer is receiving taxable income from the officer, and if the filer is employed by a corporation where the officer serves in a leadership or significant ownership role. Failure to file or knowingly violating the disclosure requirements can result in a Class C misdemeanor. The form must be filed with the records administrator of the local governmental entity and includes sections for updating previously filed questionnaires.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 1-1002HVAC Bid Sheet.pdf | ||
| 15-1003INSU Specifications.pdf | ||
| 7-1002HVAC Anti-Terrorism Certification.pdf | ||
| 8-1002HVAC Tex Govt Code 2270 Verification.pdf | ||
| 10-1002HVAC Vendor Debarment Statement.pdf | ||
| 14-1003INSU Addendum 1.pdf | ||
| 3-1002HVAC Non-Collusive Certificate.pdf | ||
| 4-1002HVAC Felony Conviction Notification.pdf | ||
| 6-1002HVAC Form 1295.pdf | ||
| 9-1002HVAC Lobbying Certification.pdf | ||
| 11-1002HVAC Certificate of Residency.pdf | ||
| 12-1002HVAC HUB or Minority Owned Business.pdf | ||
| 13-1002HVAC W-9 Form.pdf | ||
| 16-1003INSU Questionnaire 2022.pdf | ||
| 2-1002HVAC Deviations Form.pdf |
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Text version
Attachment d.
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
This 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.
OFFICE USE ONLY
Date Received
Name of person who has a business relationship 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 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 .