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CONFLICT OF INTEREST� <br />QUESTIONNAIRE FORM CIO <br />For vendor doing business with local governmental entity <br />This de to the law by H.B.3 84th� Leg., Regular Sass n. � ® E <br />q OFFICEUSONLY <br />questionnaire reflects changes ma <br />This questionnaire is being riled in accordance with Chapter 176, Local Government Code, by a vendor who Date Received <br />has a business relationship as defined by Section 176.001(1.8) with a local governmental entity and the <br />vendor meets requirements under Section 176.006(a). <br />By law This questionnaire must be filed with the records administrator of the local governmental entity not later <br />than the 71h 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 176.006. Local Government Code. An <br />offense under this section is a misdemeanor. <br />Name vendrwho has a business relationship with focal governmental entity. <br />_Jffl� <br />2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated <br />completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which <br />you became aware that the originally filed questionnaire was incomplete or inaccurate.) <br />3 Narne of local government officer about whom the information Is being disclosed. <br />Name of Officer <br />f Describe each employment or other business relationship with the local government officer, or a family member of the <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 8 for each employment or business relationship described. Attach additional pages to this Form <br />CIO as necessary. <br />A. Is the local government officer or a family member of the officer receiving or likely to receW taxable income, <br />other than investment inoorne, from the vendor? <br />ED Yes No <br />B. Is the vendor receiving or likely to receive taxable Income, other than investment income, from or at 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 />a <br />Yes ZNo <br />6 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation 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 />_Nont, <br />mo w. as described i Section or has given the l excluding gifts described f 5 the <br />.. r one or _,...� .�... <br />Check This box it the vendor has given the local government officer ,mm <br />� gg�.,n� or a family member of the officer one or more gifts <br />Section 176.003(a-1). <br />IT <br />,k <br />M „�i 1 , , , �/'�9%j ! `� atei,,' irrom ri, i fu7j) —m �� To <br />_ <br />Form provided by Texas Ethics Commission www.ethicsstate.tx.us � Revised iIW2015 <br />Page 9 of 26 <br />