Brave Combo CIQ 5.8.22CONFLICT OF INTEREST QUESTIONNAIRE -
erson doinFor vendor or other business with local overnmental enti
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) and by City of Denton
Ethics Code, Ordinance 18-757.
By law this questionnaire must be filed with the records administrator of the local government entity not later than the 7th business day after th
date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Goifernment 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.
Name of vendor who has a business relationship with local governmental entity.
Check this box if you are filing an update to a previously filed questionnaire. i
(The law requires that you file an updated completed questionnaire with the.approp{iate filing authority not later than the 7th business day_ I _I_ __. :____..__I._ \questionnaire was incomplete or inaccurate.)after the date on which you became aware that the originally filed
Name of local government officer about wliom the information in this section is being disclosed.
\
Name of Officer
Descritieeachemploymentorotherbusinessrelationshipwiththelocalgoverrmentofficer,orafamilymemberoftheofficer,asdescribedbySection
176.003(a)(2)(A). Also describe any fahily relations hip with the local government officer. This section, (item 3 including subparts A, 8, C & D), must be
completedforeachofficerwithwhomthevendorhasanemploymentorotherbusinessrelationshipasdefinedbySection176.001(1-a),LocalGovemmentCode.
Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
I yes ENo
8. Is the vendor receiving or likely to receive taxable income, other than investment \ffifrcc;'me, from or at the direction of the local government officer named in
this section AND the taxable income is not received from the local governmental entity?
I yes ENo
C. Is the fller of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer
or director, or holds an ownership of one' percent or more?
/
I yes ENo
D. Describe each employment or business and family relationship with the local government officer named in this section.
nterest to disclose.
with the governmental entity
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