Catalyst Agency COIQ 6.10.20FOR M C IQCONFLICT OF INTEREST QUESTIONNAIRE -
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 fiied in accordance with Chapter 176, Locai Government Code, by avendor who has abusiness reiationship as defined
by Section 176.001(1-a) with aiocal governmentai entity and the vendor meets requirements under Section 176.006(a).
By law this questionnaire must be fiied 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.
Avendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
misdemeanor.
Name of vendor who has abusiness relationship with local governmental entity.
g-iAJ^v-/
1
2
Check this box if you are filing an update to apreviously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7*^ business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3Name of local government officer about whom the information in this section is being disclosed.
S»-or7~
Name of Officer
Describe each employment or other business relationship with the local government officer, or afamily 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 3including 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 176.00 l(l-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 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 governmental entity?
Yes No
C.Is the filer of this questionnaire employed by acorporation 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 this section.
4
Ihave no Conflict of Interest to disclose.
?!5
(D' 2 - ^ ®
^^^^ignature'S
vendor doing bi^e the governmental entity Date'll