Ashmore, Suzanne CIQ 9.02.2024CONFLICT OF INTEREST QUESTIONNAIRE • FORM CIQ
For vendor or other erson doin business with local overnmental entit
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 flied 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.
Check thl$ box if you are filing an update to a previously flied questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7tt1 business day
after the date on which you became aware that the originally filed questionnaire was Incomplete or Inaccurate.)
Name of local government olllcer about wllom tlae illformatJon in this sec:tion is being dlsdosed.
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 176.00 1(1-a), Loeal Government Code.
Attach additionnl pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
D Yell 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 governmental entity'!
D Yes D No
C. Is the filer of this questiormaire employed by a corporation or other business entity with respect to wbich the local government officer serves as an officer
or director, or holds an ownership of one percent or more?
DYes DNo
D. Describe each employment or business and family relationship with the local government officer named in this section.