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.

 

 

 

1. Name of person doing business with local governmental entity.

 

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.)
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.

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.

 

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.

  A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the
questionnaire?
 

Yes No

 

 
  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?
 

Yes No

 

 
  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?
 

Yes No

 

 
 

D. Describe each affiliation or business relationship.

 

 

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:

Check this box for Electronic Signature