Verizon Wireless CIQ 10.27.23CONFLICT 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 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
Name of vendor who has a business relationship with local governmental entity.
2 l—l Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the T1” business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate )
A Name of local government officei 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 family member 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), must be
completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176 OOl(l-a), Local Government Code
Attach additional pages to this Form CIQ as necessary
A Is the local government officer named in tins section receiving or likely to receive taxable income, other than investment income, from the vendor1’
B Is the vendor receiving 01 likely to receive taxable income, other than investment income, from or at the direction of the local government officer named m
this section AND the taxable income is not received from the local governmental entity7
C Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer
or director, or holds an ownership of one percent or more7
D Describe each employment or business and family relationship with the local government officer named m this section
I have no Conflict of Interest to disclose.
Signature of vendor doing business with the governmental entity Date