Durable Specialties Inc CIQ 6.28.22CONFLICT OF INTEREST QUESTIONNAIRE
CONFLICT OF INTEREST QUESTIONNAIRE -FORM CTQ
lql vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.8.23, E4th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Covemment Code, by a vendor who has a business relationship as
defined by Section 176.001(l-a) with a local govemmental entity and the vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator ofthe 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-l), Local Govemment Code.
A vendor commits an offense ifthe vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
misdemeanor.
Name ofvendor $ho hrs a business relrlionship rvith locsl govcrnmcntal cntitj.
tr Check this box ifyou are liling an update to a previously fil.d questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7s business day aller the
date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3 N_ame of locrl govemment olficer rbout whom the information in this section is being disclosed.
Name ofOfficer
This section, (item 3 including subpans A, B, C & D), must be completed for each oflicer with whom the vendor has an employment or other business
relationship as defined by Section 176.001( l-a). Local Covemment Codc, Attach additional pages to this Form CIQ as neoessary.
A. Is the local govemment officer named in this section receiving or likely to receive taxable income, other than investment iflcome, from thc vendor?
Yes No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction ofthe local govemment oflicer
named in this section AND the taxable incomc is not received from the local govemmental entity?
Ycs No
C. Is the filer ofthis questiormaire employed by a corporation or other business entity with respect to which the local govemment officer serves as an
officer or director, or holds an ownership of one percelt o. more?
No
D- Describe each employment or business and family relationship with the local govemment officer named in $is s€ction.
F I have no Conflict of lnterest to disclose,
Signature ofvendordoing business with the govemmental entity Datc
adka/aaee