Prosource Specialties LLCCONFLICT OF INTEREST QUESTIONNAIRE -
vendor or other
questionnaire refle
business with local gi
changes made to the law by H.B. 23,
FORM CIQ
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defines
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 IN
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 t
misdemeanor.
name or venip wno nas lousiness relationsnlp witn local governmental entity.
l�o0Ua2Ct St��r /- LTA LLC
❑ 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 T" business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
Name of local government officer about whom the information in this seetipnf being disclosed.
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 s on receiving or likely to receive taxable income, other than investment income, from the vendor?
ElYes 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 mcci d from the local governmental entity'?
❑ Yes No
C. Is the, tiler 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 u No
D. Describe each employment or business and family relationship with the local government officer rained in this section.
MI have no
to disclose.
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SignaNre of or doing business with the governmental entity Date