Cloninger, DC CIQ 3.16.237
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local govqfnlqenlg!,gqtty
fhis questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
fhis questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined
:y Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a).
3y law this questionnaire must be filed with the records administrator of the local govemment entity not later than the 7th business day after the
late the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code.
\ vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
risdemeanor.
Name of vendor who has a business relationship with local governmental entity.
D,C. C/on|n
Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an r.lpdated completed questionnaire with the appropriate filing authority not later than the 7th business day
after the date on which you became aware ihat the originally filed questionnaire was incomplete or inaccurate.)
Name of local government officer about whom the information in this section is being disclosed.
ta*< Ri dd le
Name of Offlcer
Describe each employment or other business relationship with the local government ofhcer, or a family member of the officer, as described by Section
176,003(aX2XA), Also Oes.rite any family relations trip witl ttre local government officer. This section, (itern 3 hcluding subparB A' B, C & D)' must be
completedforeachofficerwith wbomthe vendorhas arerploymetrt or-otherbusinessrelationshipas definedbySection 176.00l(l-a), Local Government Code'
Attach additional pages to this Form CIQ as necessary-
A. Is the of6cer named in this seclion receiving or likely to receive taxable incorne, other than investment income, from the vendor?
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B. Is the vendor receiving or likely to receive taxable iacoms, other than irvestment income, &om or at the directior of the local government officer named in
this section AND the taxable income is not received from the local govemmental eofitf
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C. Is the filer of this questionnaire etqloyed by a corporation or other busircss mtity with respect to which the local government ofEcer serves as 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 itr this section
tt/c-n <
local governmentil ,".
I have no Gonflict of lnterest to disclose.
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Sipature of vendor doing business with fle govemmental entity Date