Painters Poetree CIQ 3.1.22CONFLICT OF INTEREST QUESTIONNAIRE .FORM GIQ
For vendor or other person doing business lvjh !oS4lgoye!!entity
This questionnaire reflects changes made to the law by H,B,23, 84th Leg., Regular Session.
This questionnaire is being Illed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as delined
by Section 176.001(1-a) with a local governmenlal 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 Government Code.
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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 7h business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
Name ollocal government officer about rIhom the information in this section is being disclosed.
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Name of Orficer
Describe each employment or other business relationship with the local govemment officer, or a family member ofthe officer, as described by Section
176-003(a)(2XA). Also describe any family relations hip with the local govemment officer- This section, (item 3 including subparts A. B, C&D), mustbe
completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.001( 1-a), Local Govemment Code.
Attach additionalpages to this Form CIQ as necessary.
A. Is the local govemment officer named in this section receiving or likely to receive taxable income, other than investment income. from the vendor?
No
B ls the vendor receiving or likely to receive taxable income, other than investment inconre, from or at the direction oftle Iocal govemnent officer named in
this section AND the taxable income is not received from the local govemmental entity?
Yes No
C ls tle filer ofthis questionnaire employed by a corporation or other business entity witl respect to which thc local govemment officer serves as an officer
or director, or holds an ownership ofone percent or more?
No
D. Dcscribc cach employment or business and lalrily relationship with the local govcmment officer named in this section
4 M I have no Conflict ot lnterest to disclose.
Signa of vendor doing business with the govemmental entity Date
Name of vendor who has a business relationship with local governmental enlity
THE
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
misdemeanor.
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