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CONFLICT OF INTEREST QUESTIONNAIRE <br />For vendor doing business with local governmental entity <br />This questionnaire reflects changes made to the few by N.B. 23, 041h Leg., Regular Session. <br />This quesdonnehs is being Bad in acaoidanas with ChWer M. local Government Code, by a vendor who <br />has a business relationship w delined by Section 05.00111-11) with a local govemmental entity and Ike <br />vendor meets requiremanta under Section 1 N.008(a). <br />By law this questionnaire must be filled with the records adininlairator of the local governmental anally not later <br />than the 71h bualnass day akar the date the vendor becomes swan of facts MW req*a the statement to be <br />Rod, See Sedbn 176.006(a-1), Local ememmenl Code. <br />A vendor commits an offense ff the vendor knowingly violates Section 17UM Local Government Code. An <br />offense wider this section Is a misdemeanor. <br />µ Name of vendorwho has a business relationship Wilt governmental <br />entity. <br />Richard Drake Construction Company L.P. <br />FORM CIG! <br />OFRCE USE ONLY <br />Doe Paoelved <br />®Check this box It you are flft an update to a previously Ned questionnaire. (The law requires that you Mean updated <br />oornpleted questionnaire with the appropriate ming authority not later than the 7th business day after the date on which <br />you became aware that the originally fled questionnaire was Incomplete or Inaccurate.) <br />Name of focal government officer aboutwhom the Information Is being disclosed. <br />NONE <br />Name of Officer <br />Describe each employment or other business relationship with the local government officer, or a family member of the <br />officer, as described by section 17GAWa)(2XAj Also describe any family relationship with the Want government officer. <br />Complete subparts A and 8 for eachemployment or business relationshlpciescribad. Allach additional papa to this Form <br />Cis as necessary, <br />N/A <br />A. is the local government officer or a family member of the officer receiving or likely to receive taxable income, <br />other than tweatment Income, from the vendor? <br />MYes Q No <br />S. Is the vendor receiving or likely to receive taxable Income, other than Investment fnoome, from or al the direction <br />of the local govemment officer or a family member of the olffcar AND the taxable income Is not received from the <br />local governmental entity? <br />Yes 0 No <br />Describe each employment or business relationship that the vendor named In Section t maintains with a corparatlon or <br />other business entity with respect to which the local government officer serves as an officer or director, or holds an <br />ownership Interest of one percent or more. <br />NONE <br />Check this box it the vendor has given the local government officer or a family member of the officer one or mare gats <br />I ..J as described in Section 17O.D03(a)(2)(B), excluding gine described in Section 176.003(a-1). <br />04/19/2022 <br />Signature of vendor d3ing buskesi WS the governMRSIVIR to <br />iamprovidedbyTexas"EthiaCorrrmission........... ....... . � www.elhica.etate.rx.us � Revised <br />11=2015 <br />