Cloudcompli CIQ 1-14-19CONFLICT OF INTEREST QUESTIONNAIRE - FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by F.B. 23, 84th Leg., Regular Session.
This questionnaire is being Bled 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 176.006(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.
Name ofvendorwho has a business relationship with local governmental entity. / v / /
❑ Check this box if you are riling an update to a previously riled questionnaire. C
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 76 business day after the
date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.
Name of local government officer about whom the information in this section is being disclosed.
Name of Officer
This section, (item 3 including subparts A, B, C & D), must be completed for each officer with whom the vendor has an employment or other business relationship
as defined by Section 176.001(1-a), Local Government Code. 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 invesbment income, from die vendor?
Yes ® No
B. is the vendor receiving or likely to receive taxable income, other than investment income, 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?
0 Yes .omp2F No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which die local government officer serves as an
officer or director, or holds an ownership of one percent or mom?
E] Yes J, _. No
D. Describe each employment or business and family relationship with the local government officer named in this section.
Ihaveno Coanictorinleresttodisclose.
Signathre or vendor doing business Date
with the governmental entil