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Cardio Partners
CONFLICTOFINTERESTQUESTIONNAIRE-FORMCIQForvendororotherpersondoingbusinesswithlocalgovernmentalentityThisquestionnairereflectschangesmadetothelawbyH.B.23,84thLeg.,RegularSession.ThisquestionnaireisbeingfiledinaccordancewithChapter176,LocalGovernmentCode,byavendorwhohasabusinessrelationshipasdefinedbySection176.001(1-a)withalocalgovernmentalentityandthevendormeetsrequirementsunderSection176.006(a).Bylawthisquestionnairemustbefiledwiththerecordsadministratorofthelocalgovernmententitynotlaterthanthe7thbusinessdayafterthedatethevendorbecomesawareoffactsthatrequirethestatementtobefiled.SeeSection176.006(a-1),LocalGovernmentCode.AvendorcommitsanoffenseifthevendorknowinglyviolatesSection176.006,LocalGovernmentCode.Anoffenseunderthissectionisamisdemeanor.Nameofvendorwhohasabusinessrelationshipwithlocalgovernmentalentity.1CARDIOPARTNERS,INC.JDCheckthisboxifyouarefilinganupdatetoapreviouslyfiledquestionnaire.(Thelawrequiresthatyoufileanupdatedcompletedquestionnairewiththeappropriatefilingauthoritynotlaterthanthe7thbusinessdayafterthedateonwhichyoubecameawarethattheoriginallyfiledquestionnairewasincompleteorinaccurate.)NameoflocalgovernincutorfieerahoulwhomIheinformaIioninthissectioiiisbeingdisclosed.N/ANameofOfficerDescribeeachemploymentorotherbusinessrelationslupwiththelocalgovernmentofficer,oratbmilymemberoftImofficer,asdescribedbySection176.003(a)(2)(A).Alsodescribeanyfamilyrelationshipwith(helocalgovernmenLofficer.Thissection,(item3includingsubpartsA,B.C&D),musthecompletedforeachofficerwithwhomthevendorhasanemploymentorotherbusinessrelationshipasdefinedbySection176.001(1-a),LocalGovernmentCode.AttachadditionalpagestothisFormCIQasnecessary.A.Isthelocalgovernmentofficernamedinthissectionreceivingorlikelytoreceivetaxableincome,otherthaninvestmentincome,fromthevendor?YesNoB.Isthevendorreceivingorlikelytoreceivetaxableincome,otherthaninvestmentincome,fromoratthedirectionofthelocalgovernmentofficernamedinthissectionAND(hetaxableincomeisnotreceivedfromthelocalgovernmentalentity?YesNoC.Isthefilerofthisquestionnaireemployedbyacorporationorotherbusinessentitywithrespecttowhichthelocalgovernmentofficerservesasanofficerordirector,orholdsanownershipofonepercentormore?YesNoD.Describeeachemploymentorbusinessandfamilyrelationshipwiththelocalgovernmentofficernamedinthissection.IhavenoConflictofInteresttodisclose.__ __ ___ ___ ___1v11oSignalureofvendordoingbusinesswiththegovernmentalentityDate