Advanced One Legal CIQ 6.25.21CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
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 govemment 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 Governrnent Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Govemment Code. An offense under this section is a
misdemeanor.
2 n
who has a business Iocal govemmental entity.
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Check thls 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 7h 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 ls being disclosed,
Describe each e'mFloyment or other business relatimship with the local government ofEcer, or a family member of the of8cer, as described by Section
176.003(a)(2)(A). Also describe any family relations hip with the local government offrcer. This section, (item 3 including subparts A, B, C & D), must be
completed for each of{icer 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 govemment officer named in this section receiving or likely to receive taxable income, other lhan investment income, from the vendor?
Yes n No
B. Is the ve.ndor receiving or likely to receive taxable income, othpr than inveshent income, from or at the direction of the local goverrment officer named in
this sectioa AND the taxable income is uot recEived from the local govemmental entity?
l-_l ,o I--l *o
C. Is the filer ofthis questioauaire employed by a corporation or other business entity with respect to which the local governmoat o{Iicer serves as an oIficer
or director, or holds an ownership of oue perce,nt or more?
Yes No
D. Describe each employment or business and family relationship with the local government officer named in this section.
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5
I have no Conflict of lnterest to disclose.
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sigou*. of *odofioing business with the governmedal entity
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Date
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Name of Officer