HomeMy WebLinkAbout(0025) Conflict of Interest Form - CLS Sewer Equipment Co..pdfCONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing 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 requim nts under Section 176.006(a).
By law this question air must be filed with the records administrator of the local governmental 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 1 6. 06(a-1), Local Government Code.
A vendor commits a o ense if the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this s cti n is a misdemeanor.
Name of vendor v rho has a business relationship with local governmental entity.
01 C I P__ , n _'
FORM CIQ
OFFICE USE ONLY
Date Received
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.)
Name of localo ernment officer about whom the information is being
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Name of Officer
Describe each a ployment or other business relationship with the local
officer, as des ri led by Section 176.003(a)(2)(A). Also describe any family
Complete sub a s A and B for each employment or business relationship c
CIQ as necess r
A. Is the local government officer or a family member of the
of er than investment income, from the vendor?
Yes ®No
it officer, or a family member of the
ip with the local government officer.
Attach additional pages to this Form
receiving or likely to receive taxable income,
B. ils he vendor receiving or likely to receive taxable income, otherthan investment income, from or at the direction
of he local government officer or a family member of the officer AND the taxable income is not received from the
loci I governmental entity?
aYes ® No
Describe eac eployment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business ntity with respect to which the local government officer serves as an officer or director, or holds an
ownership in#er st of one percent or more.
w1
cl
as
as
box if the vendor has given the local government officer or afamily member of the officer one or more gifts
ad in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
/L17/
Date
Form provided by T Ejhics Commission www.ethics.state.tx.0
Revised 1/1/2021