JWC Environmental CIQ 5.16.23CONFLICT OF INTEREST QUESTIONNAIRE -
For vendor or other person doing business with local governmental entity
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).
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.
1 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.
5-
I Date
20-
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7thbusiness day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
..!J Name oflocal government officer about whom the information in this section is being disclosed.
Name of Officer
Describe each employment or other business relationship with the local government officer,or a familymember of the officer,as described by Section
176.003(a)(2)(A).Also describe any family relations hip with the local government officer.This section,(item 3 including subparts A,B,C &D),mustbe
completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.00I(I-a),Local Government Code.
Attach additional pagesto this Form CIQ as necessary.
A.Is the local government officer named in this section receiving or likely to receivetaxable income,other than investment income,from the vendor?
DYes DNo
B.Is the vendor receiving or likelyto receive taxable income,other than investment income,from or at the direction ofthe local government officer named in
this section AND the taxable income isnot received from the local governmental entity?
DYes DNo
C.Is the filer of this questionnaire employed by a corporation or other business entitywith respect to which the local government officer serves as anofficer
or director,or holds an ownership of one percent or more?
DYes DNo
D.Describe each employment orbusiness andfamily relationship with the local government officer named in this section.
4-~I have no Conflict of Interest to disclose.
~/;
Signature of vendor doing business with the governmental entity