BadgeAndWallet.com CIQ 10.15.2024-------
CONFLICT OF INTEREST QUESTIONNAIRE
CONFLICT OF INTEREST QUESTIONNAIRE -
For vendor or other erson doin business with local overnmental entit
FORMCIQ
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 l 76.006(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.
1 Name of vendor who has a business relationship with local governmental entity.
~"J vre_~~ Y'O~ f y'\(_" GhJ
2 D 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 7• business day after the
date on which ou became aware that the ori inall filed uestionnaire was incom lete or inaccurate.
3 Name oflocal government officer about whom the information in this section is being disclosed.
1 '
Name of Officer/
This section, (item 3 including subparts A, B, C & D), must be completed for eac offic r ~djwhom the vendor bas an employment or other business
relationship as defined by Section 176.001(1-a), Local Government Cod ttach dditi nalt9ages t this Form CIQ as necessary.
A. Is the local government officer named in this sectir>lf"_,.. .. ;
D Yes
B. Is the vendor receiving or like
named in this section AND th
D Yes No
ome, other than investment income, from the vendor?
er than investment income, from or at the direction of the local government officer
from the local governmental entity?
C. Is the filer of this questio e mployed by a corporation or other business entity with respect to which the local government officer serves as an
i:ls an o ership of one percent or more?
□No
D. each employment or business and family relationship with the local government officer named in this section.
4
I have no Conflict of Interest to disclose.
5
I o I S '2-0 2}-\
Signature of vendor doing business with the governmental entity Date