CONFLICT 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 beingf filed in accordance with Chapter 176, Local Government Code, by a vendor who has al business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Date Received By law this questionnaire must be filed withi the records administrator oft 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 Av vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An Name of vendor who has a business relationship with local governmental entity.  FORM CIQ  OFFICEUSEONLY  vendor meets requirements under Section 176.006(a). filed. See Section 176.006(a-1), Local Government Code. offense under this section is a misdemeanor.  Check this boxi ify youaret filing an update toap previously filed questionnaire. (Thel lawr requires thaty youf file an updated completed questionnaire with the appropriate filing authority notl 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 local government officer about whomi thei information is being disclosed.  Name of Officer  4 Describe each employment or other business relationship with the local government officer, or ai family member of the officer, as described by Section 176.003a)2)A). Also describe any family relationship with thel local government officer. Complete subparts Aand Bi for eache employment or business relationship described. Attach additional pages tot this Form  CIQ as necessary.  A. Is the local government officer or ai family member of the officer receiving or likely to receive taxable income,  other than investment income, from the vendor?  Yes  No  B. Is the vendor receiving or likely tor receive taxable income, othert thani investment income, from or att the direction oft the local government officer or a family member of the officer AND the taxable income is not received from the  local governmental entity?  Yes  No  Describe each employment or business relationship that the vendor namedi in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an  ownership interest of one percent or more.  6 7  Check this! boxi ift the vendor has given thel local government officer or ai family member oft the officer one or more gifts as described in Section 176.003(a)2/B), excluding gifts described in Section 176.003(a-1).  Signature of vendor doing business with the governmental entity  Date  Form provided by" Texas Ethics Commission  www.ethicsslate.kus  Revised 11/30/2015    CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity  Acomplete copy of Chapter 1760 oft theLocal Government Coder may bef found ath htp./www.statures.egis.state.Kus DocslGmtm.di78.ntm. For easy reference, below are: some of the sections cited on this form. Local Government Code $176.001(1-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. Thet term does noti include a connection based on: (A) at transaction thati is subject to rate orf fee regulation by af federal, state, orl local governmental entity or an (C) ap purchase orl lease of goods or services from ay person that is chartered by a state or federal agency and (a) Alocal government officer shalli file a conflicts disclosure statement with respect to a vendor if:  agency ofa af federal, state, or local governmental entity;  (B) at transaction conducted at a price and subject to terms available to the public; or that is subject to regular examination by, and reporting to, that agency.  Local Government Code $178009e12MAlande):  *** (2) the vendor:  (A) has ane employment or other business relationship with the local government officer ora family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period (1) acontract between thel local governmental entity and vendor has been executed; (i) the local governmental entity is considering entering into a contract with the (B) has givent tot thel local government officer or af family member oft the officer one or more gifts that! have ana aggregate value of moret than$100 inthe 12-monthp periodp preceding the date the () ac contract between the local governmental entity and vendor has been executed; or () thel local governmental entityi is considering entering into a contract with the vendor.  preceding the date thatt the officer becomes aware that  or vendor;  officer becomes aware that:  Local Government Code S 176.006(a) and (a-1) with al local governmental entity and:  (a) Avendor shall file ac completed conflict ofi interest questionnaire ift the vendor has al business relationship (1) has an employment or other business relationship with al local government officer of that local governmental entity, or at family member ofi the officer, described by Section 176.003a)2)A); (2) has given al local government officer of that! local governmental entity, or af family member of the officer, one or more gifts with the aggregate value specifiedb by Section 176.003(a)2/B), excludingany (3) has at family relationship with al local government officer of that local governmental entity. (a-1) The completed conflict ofi interest questionnaire must! bet filed with the appropriate records administrator  gift described! by Section 176.003(a-1);or notl later thani the seventh business day after the later of:  (1) the date that the vendor: entity; or  (A) begins discussions or negotiations to enter into a contract with the local governmental (B) submits tot thel local governmentals entity an application, response to a request forp proposals or bids, correspondence, or another writing related to a potential contract with the local (A) of an employment or other business relationship with a local government officer, ora (B) that the vendor has given one or more gifts described! by Subsection (a);or  governmental entity;or (2) the date the vendor becomes aware:  family member of the officer, described by Subsection (a); (C) ofat family relationship with al local government officer.  Formp provided by Texas Ethics Commission  www.etncs.siate.kus  Revised 11/30/2015