OES NA COIQ 2020GONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local qovernmental entitv
FORM GIQ
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 definedby 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 thedate 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.
Name of vendor who has a business relationship with local governmental entity.ES -/1,
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 7th business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
Name of Officer
Describe each emplol,rnent or other business relationship with the Iocal govemment 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 emplo;nnent or other business relationship as defined by Section 176.001(1-a), Local Covernment Code.
Attach additional pages to this Form CIQ as necessary-
A. Is the loca1 government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?I "".El *"
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?
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C. Is the filer ofthis questionnaire employed by a corporation or other business entity with respect to which the 1oca1 govemment of{icer serves as an officer
or director, or holds an o'lvnership of one percent or more?
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D. Describe each employment or business and family relationship with the local government officer named in this section
X , n"r" no Conflict of lnterest to disclose.
Signature ofvendor doing business with the