HomeMy WebLinkAboutNorthstar Construction LLC CIQ 07.08.2600 35 14 CONFLICT OF rNTEREST AFFIDAVIT -CSP
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SECTION 00 35 14
2 CONFLICT OF INTEREST AFFIDAVIT -CSP
CONFLICT OF INTEREST QUESTIONNAIRE -FORMCIQ
For vendor or other person doing business with local !!: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 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.
Northstar Construction, LLC
2 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.) liJ Name oflocal 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), Local Government Code. Attach additional pages to this Form CJQ as necessary.
A.
B.
C.
D.
4-
-
Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
D Yes □No
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 0No
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
Describe each employment or business and family relationship with the local government officer named in this section.
[x]I have no Conflict of Interest to disclose.
A f
l _,, ,/
Signature offender d"oing business with the governmental entity
3 END OF SECTION
CITY OF DENTON STANDARD CONSTRUCTION SPECIFICATION DOCUMENTS Revised November 23. 2020
Effective Januan, I 5. 202 I
07/08/2026
Date
CSP# 8507
Docusign Envelope ID: BCB12EEB-B70D-8DD3-8331-BA7879E042F9