CJA Enterprises LLPCONFLICT OF INTEREST OUESTIONNAIRE
For vendor doing business with local governmental entity
FORM CIQ
This questionnaire reflecls changes made to the law by H.B" 23, B4th Leg., Regular Session.OFFICE USE ONLY
Thts questionnaire is being filed in accordance with Chapter 176. Local Governmenl Code, by a vendor who
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and thevendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental entity not laler
than the 7th business day after the date the vendor becomes aware of facts that require the stalement to befiled. See Section 176.006(a-1). Locai Government Code.
A vendor commits an offense if lhe vendor knowingiy violates Section 176.006. Local Government Code. An
offense under this section is a misdemeanor.
Date Received
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Check this box if you are filin! 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.)
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gl Name ol local government officer about whom the information is being disclosed.
lJ Describe each employment or other business relationship with the local government officer, or a family member ol the
officer, as described by Section 176.003(a)(2)(A). Also describe any lamily relationship with the local government officer.
Complete subparts A and B tor each employment or business relationship described. Attach additional pages to this Form
CIQ as necessary.
A. ls the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than lnvestment income. from the vendor?
J lves I lNo
B. ls 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 lhe officer AND the taxable income is not received from the
local governmental entity?
[-l v". l-l ruo
Describe each employment or business relationship thal the vendor named in Section 'l 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.
-!l
Check this box if the vendor has given the local government officer or a family member of the officer one or more giftsI I as describgd-rq Section 176.003(a)(2)(B). excluding gifts described in Seclion 176.003(a-1).
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Form provided by Texas Ethics Commission www. elh ics. slate.tx. u s Hevised 1113012A15