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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIO For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Sessiom OFFICELISEONLY This questionnaire is being filed Inaccordance with Chapter 176, Local Government Code, by a vendor who Date Roc&4ed has a business relationship as defined by Section 176.001(1-a) with a loosl governmental entity and the vendor maels requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 71h business day after the date the vendor becomes aware of facts that require the statement to be ffed. See Section 176.006(a-1), Local Govemment 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. e of vendor who has a business relationship with local governmental entity. 2T Check this box it you am- filing on, update to a previously filed questionnaire, (The law requires that you file an updated E] completed questionnaire with the appropriate filing authority not later than the 7th business day of the date on which you became aware that the originally filed questionnaire was Incomplete or inaccurate.) Name of lloc,,W government officer about who the information is being disclosed. Name of Officer :41 Describe each employment or other business relationship with the local government officer, or at 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 B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the l government officer arra family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? 1:1 Yes El No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is riot received from the local governmental entity? El Ye s ED No . . . . ...... !be each employment or business relationship that the ve ndor named in Section I rnamlains with as 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 move Chock this box If the vendor has given fiv:s local government offIcPr or at family member- of the officer one or more gifils, as descrilmd In Section 176-003(a)(2)(13), excluding gifts d=libod In SW.'HOfl 176.01313(a-l). 70—rla.—II-1711-11r,-",�—I'T'Ir-7�,,u-,—iu-%n,-,,, with fl,,e �w.,rnamn Date . . ....................... Forim poylidedby Texas I::.:t1hicsGornrrk�,�sioin ReVised 11,MV2015 Page 9 of 25