FS.com IncCONFLICT 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. 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 government 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.
1 Name of vendor who has a business relationship with local governmental entity.
FS.com INC
2 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 7
thbusiness 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 in this section is being disclosed.
N/A
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 relations hip with the local government officer. This section, (item 3 including subparts A, B, C & D), must be
completed for each officer with whom the vendor 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, fromthe 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 named in
this section AND the taxable income is not received from the local governmentalentity?
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 one percent or more?
Yes No
D.Describe each employment or business and family relationship with the local government officer named in thissection.
4 I have no Conflict of Interest to disclose.
5
Signature of vendor doing business with the governmental entity Date
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
Acomplete copyof Chapter 176 of the Local Government Code maybe found at http://www.statutes.legis.state.tx.us/
Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.
Local Government Code § 176.001(1-a):"Business relationship" means a connection between two or more parties
based on commercial activity of one of the parties. The term does not include a connection based on:
(A)a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(B)a transaction conducted at a price and subject to terms available to the public; or
(C)a purchase or lease 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(a)(2)(A) and (B):
(a)Alocal government officer shall file a conflicts disclosure statement with respect to a vendor if:
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(2)the vendor:
(A)has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family 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
(i)a contract between the local governmental entity and vendor has been executed;
or
(ii)the local governmental entity is considering entering into a contract with the
vendor;
(B)hasgiventothelocalgovernmentofficerorafamilymemberoftheofficeroneormoregifts
thathave an aggregate valueof morethan $100 in the 12-monthperiodprecedingthe date the
officer becomes awarethat:
(i)a contract between the local governmental entity and vendor has been executed;or
(ii)the local governmental entity is considering entering into a contract with the vendor.
Local Government Code § 176.006(a) and (a-1)
(a)A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local governmental entity and:
(1)has an employment or other business relationship with a local government officer of that local
governmental entity, or a family member of the officer,described by Section 176.003(a)(2)(A);
(2)has given a local government officer of that local governmental entity, or a family member of the
officer,oneormoregiftswiththeaggregatevaluespecifiedbySection176.003(a)(2)(B), excludingany
gift described bySection 176.003(a-1); or
(3)has a family relationship with a local government officer of that local governmentalentity.
(a-1) The completed conflict of interest questionnaire 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)begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(B)submitsto the localgovernmentalentityan application,responseto a requestforproposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity;or
(2)the date the vendor becomes aware:
(A)of an employment or other business relationship with a local government officer, or a
family member of the officer, described by Subsection (a);
(B)that the vendor has given one or more gifts described by Subsection (a); or
(C)of a family relationship with a local government officer.
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015