JJS Technical Services CIQ 3.17.22CONFLICT OF INTEREST QUESTIONNAIRE . FORM CIQ
For vendor or other person doing business with Iocal governmenta! 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 1 76.006(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
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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 7th business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
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9l N".. of local government oflicer about whom the information in this section is being disclosed.
Name of Officer
Describe each anployment or other business relationship with the local government officer, or a family member of the officer, as described by Section
176.003(aX2XA). Aiso describe any family relations hip with the local government officer. This section, (item 3 including subparts A, B, C & D), must be
completed for each offrcer with whom the vendor has an employment or other business relationship as defined by Section I 76.00 I ( l -a), l,ocal Government Code.
Attach additional pages to this Form CIQ as necessary.
A. Is the local govemment offrcer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?i r., fi*"
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local govemment oflicer named in
this section AND the taxable income is not received from the local governmental entity?
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves zrs an officer
or director, or holds an ownership ofone percent or more?
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D. Describe each employment or business and family relationship with the local govemment officer named in this section.
!ff , n"".no Gonflict of lnterest to disclose.
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with the governmental entity Date