Child's Play, Inc.CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with rocal governmental entity
FORM CIQ
This questionnaire reflects changes made to the law by H.B. 23, g4th Leg., Regular session.
This questionnaire is being filed in accordance with chapter 176, Local Government code, by a vendor whohas a business relationship as defined by Section 176.001(1-a) *iil'r " ilcar governmentat entity and thevendor meets requirements under Section 176.006(a).
By law this questionnaire must be liled with the records administrator of the local governmentat entity not laterllal th: 7th business day after the date the vendor becomes aware of lacts that require the statement to befiled. See Section i76.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. Anoffense under this section is a misdemeanor.
siness relationship with local governmental entity.*rt W.
Name of vendor who
Gheck this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updatedcompleted questionnaire with the appropriate filing authoiity not iater than the 7ih business day after the date on whichyou became aware that the originally filed questionnaire was incomplete or inaccurate.)
Name of local government officer about whom the information is being disclosed.,-N/A
Name of Officer
D.escribeeachemp|oymentorotherbusinessre|ationshipwiitrtrretocalgoue,nm
Itjf?I:?j j?i1'::11r:"-"jl"_i]1.9 993(a)(2)(A). Also describe any family retarionship wirh rhe tocal sovernmenr officer.complete subparts A and B for each employment or business rer"tionsr.rip'o;'";;ffi:'riili6 ;ff;;Yil:," ililii:';';rTCIQ as necessary.
A' ls the local government officer or a family member of the officer receiving or likely to receive taxable income,other than investment income, from the vendor?
B' ls the vendor receiving or likely to receive taxable income, other than investment income, from or at the directionof the local government officer or a family member of the officer AND the taxable income is not received from thelocal governmental entitv?
ownership interest of one percent or more.
t/ on,t /fr/ /A/H
Describe each employment or business relationship that the vendor named in section 1 maintains with a corporationlrother business entity with respect to which the loial government officer serves as an officer or director, or holds an
check this box if the vendor has 9iu91lh-e local government officer or a family member of the officer one or more giftsas described in Section 176.003(a)(2)(B), excluding gifts. described in Seition 176.003(a-1).
Form provided by Texas Ethics Commission www.eth ics.state.tx. us Revised 1113012015