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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO <br />For vendor doing business with local governmental entity <br />This questionnaire reflects changes made to the law by H.B. 23, 84th Leg„ Regular Session. OFFICEUSEONLY <br />This questionnaire Is being filed In accordance with Chapter 178, Local Government Code, by a vendor who Oate Receivedw.�.M <br />has a business relationship as defined by Section 178.001(1-a) with a tote] governmental entily and the <br />vendor meets requirements under Section 176,006(a). <br />By law Ihis questionnaire must be tiled with the records administrator of the local governmental entity not later <br />than the 7th business day after the date the vendor becomes aware of facts that require the statement to be <br />filed. See Section 176.006(a• 1), Local Government Code, <br />A vendor commits an offense if the vendor knowingly violates Section 175-006, Local Government Code. An <br />offense under this section Is a misdemeanor, <br />! Name of <br />en dor has a business relationship with localgovernmental .ity...._ <br />- -- . .���. fp entity. <br />None <br />completed box If you are <br />with then update rsale Rene previously <br />filed <br />questionnaire. <br />the <br />........ ......� m <br />Check this y gp y q . (The taw requires that you lite an updated <br />q appropriate 8 y 7th business day after the date on which <br />you became aware that the originally !Aad questionnaire was Incomplete or Inaccurate.) <br />Name of local government officer about whom the information is being disclose���� <br />S -, d. <br />NONE <br />Name of Officer <br />Describe each emplo meat or other business relationship with the Ioca) government officer or a family member of the <br />Y y e <br />officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. <br />Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form <br />Cid as necessary. <br />N/A <br />A. Is the Ioca! government officer or a family member of the officer receiving or likely to receive taxable Income, <br />other than investment Income, from the vendor? <br />❑ Yes ❑ No <br />8, Is the vendor receiving or likely to receive taxable Income, other than Investment Income, Irom or of the direction <br />of the local government officer or a family member of the officer AND the taxable Income is not received from the <br />local governmental entity? <br />❑ Yes ❑ No <br />$ ,. o rntyir business relationship <br />a�named I Section maintains <br />� corporation or <br />hrbusinesseiywithrespect to which theoval government off Icer serves as an offceor director, o holds <br />an <br />ownership Interest of one percent or more. <br />NONE <br />.,.. mm❑ � _.n „� �.._.. Section ceoom m^^^ <br />^^^^^ <br />Checkthis <br />box <br />fhavador has givent eOvalgovernment <br />aror,fy lrf1air one r more gills <br />as describedoSection 00( giftsdescribed beo (-1) <br />^^^^^ <br />............�.a.._a <br />04/21/21 <br />one urs van r doing business w e governmentalan y Date <br />Fomn provided by _Texas Ethics Commission ..wa-..................w......... „oo,... w R,—evi s.ewd i1/1.3..0_.V12200 <br />16 <br />Page 9 of 25 <br />