CONFLICT OF
INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity |
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This questionnaire is being filed in accordance
with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person committs an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. |
Date Submitted:
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1. Name of person doing business with
local governmental entity.
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2. | Check this box if you are filing an update to a
previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) |
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3. | Name each employee or contractor of the local governmental
entity who makes recommendations to a local government
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4. | Name each local government officer who appoints or employs
local government officers of the governmental entity for
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5. | Name of local government officer with whom filer
has affilitation or business relationship. (Complete this section only |
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A. Is the local government officer named
in this section receiving or likely to receive taxable income from the
filer of the questionnaire? |
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B. Is the filer of the questionnaire receiving
or likely to receive taxable income from or at the direction of the local
government officer named in this section AND the taxable income is not from the local governmental entity? |
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C. Is the filer of this questionnaire affiliated
with a corporation or other business entity that the local government
officer serves as an officer or director, or holds an ownership of 10 percent or more? |
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D. Describe each affiliation or business relationship.
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By selecting the checkbox to the right, you are electronically signing this questionaire and affirming all the information is accurate to best of your knowledge. Name of person completing questionaire: |
Electronic Signature was performed at time of submission. |