7109-016 - Contract Executed
Docusign Transmittal Coversheet
File Name
Purchasing Contact
Contract Expiration
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ATTACHMENT A
CONFLICT 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.
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 7th business 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.
Name of 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, 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 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 this section.
4
I have no Conflict of Interest to disclose.
5
Signature of vendor doing business with the governmental entity Date
Certificate Of Completion
Envelope Id: D2A4937EF5BF44A7B23EB4DD2C44DE95 Status: Completed
Subject: ***Purchasing Approval*** 7109-016 Landfill Permit Testimony-Geology and Groundwater
Source Envelope:
Document Pages: 26 Signatures: 4 Envelope Originator:
Certificate Pages: 5 Initials: 0 Crystal Westbrook
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
901B Texas Street
Denton, TX 76209
crystal.westbrook@cityofdenton.com
IP Address: 198.49.140.104
Record Tracking
Status: Original
10/28/2020 9:08:01 AM
Holder: Crystal Westbrook
crystal.westbrook@cityofdenton.com
Location: DocuSign
Signer Events Signature Timestamp
Crystal Westbrook
crystal.westbrook@cityofdenton.com
Senior Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Completed
Using IP Address: 198.49.140.104
Sent: 10/28/2020 9:20:23 AM
Viewed: 10/28/2020 9:20:33 AM
Signed: 10/28/2020 9:23:42 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Gregory Adams
gadams@biggsandmathews.com
Managing Partner
Security Level: Email, Account Authentication
(None)Signature Adoption: Pre-selected Style
Using IP Address: 97.94.222.146
Sent: 10/28/2020 9:23:43 AM
Viewed: 10/29/2020 9:18:54 AM
Signed: 10/29/2020 9:23:27 AM
Electronic Record and Signature Disclosure:
Accepted: 10/29/2020 9:18:54 AM
ID: 5b750d5b-c48a-498a-bfbc-bc0f2e6118ae
Brian Boerner
brian.boerner@cityofdenton.com
Director of Solid Waste
Security Level: Email, Account Authentication
(None)Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.10
Sent: 10/29/2020 9:23:29 AM
Viewed: 10/30/2020 8:52:08 AM
Signed: 10/30/2020 8:53:03 AM
Electronic Record and Signature Disclosure:
Accepted: 10/30/2020 8:52:08 AM
ID: 2a03e59b-e078-4860-b977-d0323280e168
Crystal Westbrook
crystal.westbrook@cityofdenton.com
Senior Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.104
Sent: 10/30/2020 8:53:06 AM
Viewed: 10/30/2020 9:10:48 AM
Signed: 10/30/2020 9:11:00 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
ygent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Caryon Copy Events Status Timestamp
Cheyenne Defee
cheyenne.defee@cityofdenton.com
Contract Administrator
City of Denton
Security Level: Email, Account Authentication
(None)
Sent: 10/30/2020 9:11:01 AM
Viewed: 10/30/2020 12:55:14 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
yitness Events Signature Timestamp
yotary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 10/28/2020 9:20:23 AM
Certified Delivered Security Checked 10/30/2020 9:10:48 AM
Signing Complete Security Checked 10/30/2020 9:11:00 AM
Completed Security Checked 10/30/2020 9:11:01 AM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
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