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McCoy, Richard D CIQ 2.22.23CONFLiCTOFiNTERESTQUEST10NNAIRE-　　　　　　　　　　　　　　FORMCiQ Fo「vendoro「otherpersondoingbusinesswithlocalgove「nmentalentitY ThisquestionnairerefIectschangeSmadetotheIawbyH.B.23.84thLeg..RegularSession. Thisquestiomai「eisbeing刷edinacco「dancewithChapte「176,LocalGove「nmentCode,byavendorwhohasabusinessre!ationshipasdefined bySection176・001(1-a)withaIocaIgove「nmentalentityandthevendormeets「equi「ementsunde「Section176・OO6(a)" Bylawthisquestiomairemustbe凧edv面hthereco「dsadmjnist「ato「Ofthel∝aIgove「nmententitynotlaterthanthe7thbusinessdayafte「th datethevendo「becomesawareoffactsthatrequj「ethestatementtobefiled.SeeSection176・006(a-1),しOCalGove「nmentCode・ AvendorcommitsanoffenseiftheverldorknowingIyviolatesSection176.006,LooalGovernmentCode・Anoffenseunder輔ssectionisa misdemeanor, 1 Na続窃聾eSS;施㌫噂mme吋 2 □C剛SbatyouarefillnganuPdateto(aprev10uSIyfitedquest-Onna-re. IThelaw「equi「esthatyoufiIeanupdatedcompletedquestiorlnai「ewith肌eapp「op「iate踊れgauthorityno=ate「thanthe7thbusinessday afterthedateonwhichyoubecameawa「ethattheoriglnallyfiledquestionnai「ewasincompleteorinaccurate・) 3Nameoflocalgovemmento縦ceraboutwhomtheinformationinthisseetionisbeingdiscIosed. 　　　　　NameofOffice「 DescribeeachenlPIoymentOrOtherbusinessrelationshipwit掴helocalgovemmento捕cer,Orafalrilymemberoftheo餓ceI‘.aSdescribedbySection 176.003(a)(2)(A)・AIsodescribeanyfamllyrela櫨0nShipwiththelocalgovemmentofficer.Thissection,6tem3includingsubpartsA,B,C&D),muS[be COmPletedfocacho綿しCerWithwhomthevendorhasa皿emPIoymentoro血erbusinessrela瞳onshipasdefinedbySection176.001(l-a),LocalGovemmentCode. AttachadditionalpagestothisFormCIQasnecessary. A.Isthelocalgovemmentofficernamedinthissectionreeeivingo「likelytoreceivetaxableincome,Otherthaninvestmentincome,fromthevendor? □滝　　　　口N。 B・tsthevendorreceivingorlikelytoreceivetaxableincome.otherthaninvestmentincome,fromoratthedirectionofthelocalgovemmentofficermmedin thissectionANDthetaxableincomeisnotreceivedfromthelocalgovemmentalentity? □Y鎧　　　　□N。 C・Isthe組erofthisques[iormaireempIoyedbyacorporationorothe「businessentitywithrespecttowhichthelocalgovemmento締cerservesasano餓cer Ordirector,Orholdsanownershipofonepercentormore? □Y∞　　　　□N。 D.DescribeeachempIoymentOrbusine縫andfamilyrelationshipwiththelocalgovemmenlo揮icernamedinthisection. 4 鴫f±v。n。。。n,,i。,。冊。r。S,,。dis。,。S。. //、　　　　　　　　　　　　　　　　ノブ〇人三　∴∴-∵　　　　二十二二∴二二二 S鮒ureofvendordoingbusinesswi岨egorre皿en午ty　　　　　　　Date