CONFLICT OF
INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity |
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.
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1. Name of person doing business with
local governmental entity.
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2.
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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.) |
3. |
Name each employee or contractor of the local governmental
entity who makes recommendations to a local government
officer of the governmental entity with respect to expenditures of money
AND describe the affiliation or business relationship.
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4. |
Name each local government officer who appoints or employs
local government officers of the governmental entity for
which this questionnaire is filed AND describe the affiliation or business
relationship.
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5. |
Name of local government officer with whom filer
has affilitation or business relationship. (Complete this section only
if the answer to A, B, or C is YES.
This section, item 5 including subparts A, B, C & D, must be completed
for each officer with whom the filer has affiliation or other
relationship. Vendors must complete a separate questionnaire for each
officer that must be reported. |
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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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Yes
No
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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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Yes
No
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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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Yes
No
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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:
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Check this box for Electronic Signature
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