Wells Fargo Merchant Services, LLC COIQ 11-17-2021Document Number: 21897286
Contract # 7436
Exhibit H
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
Not Applicable
Corby Gordon Wells Fargo Merchant Services, L.L.C.
DocuSign Envelope ID: 1794C129-3C78-4313-B375-DF031986612C
DocuSign Envelope ID: 1794C129-3C78-4313-B375-DF031986612C