CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity FORM CIQ 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 Date Received has al business relationship as defined by Section 176.001(1-a) with a local governmental entity and the By law this questionnaire must bef filed with the records administrator ofi the local govemnmental 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 ift the vendor knowingly violates Section 176.006, Local Government Code. An 1] Name of vendor whol has al business relationship with local governmental entity. 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. CLEAMY LAND 2 Check thisl boxi ify you: arei filing an update to a 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.) 3 Name of local government officer abouty whomi the information is being disclosed. -lorcne Harfiel Name Omyahg Describe each employment or other business relationship with the local government officer, or ai family member of the officer, as described by Section 176.003(a)2)A). Also describe any family relationship with the local government officer. Complete subparts A: and Bi for eache employment or business relationship described. Attach additional pages tot this Form CIQ as necessary. A. Is the local government officer or a 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 likelyt to receive taxable income, other thani investment income, from or at the direction of the local government officer or at family member of the officer. AND1 the taxable income is not received from the local governmental entity? Yes ho 5] Describe each employment or business relationship that the vendor named in Section 1r 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. N/A 61 7 Check thisl boxi ift the vendor has givent thel local govemment officer or a family member of the officer one or more gifts as described in Section 176.003a)(2)B), excluding gifts described in Section 176.003(a-1). with the governmental entity htliy llh4 Form provided by Texas Ethics Commission ww.etncs.state.k.s Revised 1/1/2021 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmenta entity FORM CIQ This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is beingf filedi in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the Byl law this questionnaire must! be filed with the records administrator oft the local govemmental entity not later than the 7th business day after the date the vendor becomes aware off facts that require the statement to be Av vendor commits an offense ift the vendor knowingly violates Section 176.006, Local Government Code. An Name of vendor whoh has al business relationship with local governmentalentity,. 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. DAPHNIEY KIRBy 2] Check this boxify you aret filinga an update toap previously filed questionnaire. (Thel lawr requires thaty yout 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 local govemment officer about whom thei information! ist being disclosed. Name of Officer/ AryesleploaH-RA 4 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)2XA). Also describe any family relationship with thel local government officer. Complete subpartsAand! Bf fore each employment or business relationship described. Attach additionai pages to this Form CIQ as necessary. A. Is the local government officer or a 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 orl likely to receive taxable income, other thani investment income, from or at the direction of the local government officer or a family member of the offiçer AND the taxable income is not received from the local govemmental entity? Yes No 5 Describe eache employment or business relationship thatt the vendor namedi in Section 1 maintains with ac 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 Check thist boxi ift the vendor has given the! local government officer or af family member of the officer one or more gifts as described in Section 176.003(a)(2)B), excluding gifts described in Section 176.003(a-1). - governmental entity 1Haaf Form provided by Jéxas Ethics Commission www.ethies.slate.kus 4H46 Revised 1/1/2021