Mann Robinson & Son Inc CIQ 11.28.23CONFLICT OF INTEREST QUESTIONNAIRE
CONFLICT OF INTEREST QUESTIONNAIRE -FORMCIQ
For vendor or other person doine: business with local e:overnmental entitv
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-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.
1J Name of vendor who has a business relationship with local governmental entity .
.:J • . 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 7th business day after the
date on which you became aware that the originally filed Questionnaire was incomplete or inaccurate.)
1.J 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), L-Ocal Government Code. Attach additional pages to this Form CIQ as necessary.
A. ls the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
D Yes DNo
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 governinental entity?
D Yes •No
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 more?
D Yes DNo
D. Describe each employment or business and family relationship with the local government officer named in this section.
~ ~ I .have no Conflict of Interest to disclose.
\\-a._'8-~D~3
Signature of vendor doing business with the governmental entity Date
Exhibit G
DocuSign Envelope ID: 3CABF80B-EA8E-4AB7-B56C-AD51A7A0841C
Certificate Of Completion
Envelope Id: 3CABF80BEA8E4AB7B56CAD51A7A0841C Status: Completed
Subject: Please DocuSign: City Council Contract 8393 Drainage Infrastructure Repair
Source Envelope:
Document Pages: 35 Signatures: 5 Envelope Originator:
Certificate Pages: 6 Initials: 1 Christina Dormady
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
901B Texas Street
Denton, TX 76209
christina.dormady@cityofdenton.com
IP Address: 198.49.140.104
Record Tracking
Status: Original
1/11/2024 9:19:37 AM
Holder: Christina Dormady
christina.dormady@cityofdenton.com
Location: DocuSign
Signer Events Signature Timestamp
Christina Dormady
christina.dormady@cityofdenton.com
Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Completed
Using IP Address: 198.49.140.104
Sent: 1/11/2024 9:27:18 AM
Viewed: 1/11/2024 9:27:33 AM
Signed: 1/11/2024 9:28:33 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Lori Hewell
lori.hewell@cityofdenton.com
Purchasing Manager
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.104
Sent: 1/11/2024 9:28:35 AM
Viewed: 1/11/2024 1:26:06 PM
Signed: 1/11/2024 1:30:53 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Marcella Lunn
marcella.lunn@cityofdenton.com
Mack Reinwand City Attorney
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.10
Sent: 1/11/2024 1:30:55 PM
Viewed: 1/12/2024 1:10:52 PM
Signed: 1/12/2024 1:12:48 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Tim Robinson
mrsinc1980@gmail.com
Secretarty/Treasurer
Mann Robinson & Son, Inc
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 38.123.124.239
Sent: 1/12/2024 1:12:50 PM
Resent: 1/31/2024 4:24:09 PM
Viewed: 2/1/2024 10:59:47 AM
Signed: 2/2/2024 3:13:08 PM
Electronic Record and Signature Disclosure:
Accepted: 2/1/2024 10:59:47 AM
ID: f987d652-6f2f-4e02-8aad-75b15833dcee