Facility Solutions Group Inc CIQ 8.1.23CONFLICT OF INTEREST QUESTIONNAIRE
CONFLICT OF INTEREST QUESTIONNAIRE -FORMCIQ
For vendor or other person doin2 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 l 76.006(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-l), 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.
w Name of vendor who has a business relationship with local governmental entity.
l:J □ Check this box if you arc 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 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
W 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 176.00l(l�a), Local Government Code. Attach additional pages to this Form CIQ as necessary.
A.
B.
C.
D.
_4J
Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
Yes DNoIs 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? D Yes □Nols the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer sc1vcs as an officer or director, or holds an ownership of one percent or more? D Yes DNoDescribe each employment or business and family relationship with the local government officer named in this section.
,: I have no Conflict oflntcrcst to disclose.
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Signatu?e otJlldcii· doing busineSs with thegi3VeiTihien�I entity Date
August 1, 2023
DocuSign Envelope ID: 937D9D4D-0194-46AB-95B5-5E016BAEE36D
Facility Solutions Group, Inc.
Exhibit G- Form CIQ