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CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
For vendor or other person doing butanes with local governmental entity
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The questionnaire k
being filed in2wcordance with Chapter 176 Local Government Code p y a
by a maw whorls ebusineas relationiddp as defined by Secppe 176
1whit a total
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governmental entity arid thoperrec mash requlremenla tnderSeetlon 176
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nnakenib belledWithttrefecotthiedminlahatorolthelocalgovernmental
entry not later than the 7th business dayalterthe date the person becomes aware offade
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that requite the statement tobeMed Soo Strohm 000
176 Loci GOVermnentCode
A person comb an offense if the person
APR 2 12010
006 Local
rtngty violates Section 176
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RECEIVED
Government Code An offense under this sedlon Is a Class C misdenteaner
Name orporno who has bantam rstattonanlpy h Wee gotrotrs watota tiny
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The law requires that you Me an updated completed questionnaire with Ina appropriate filing authority not
hear then the 7th ovalness day after the date the orighheuy riled queetotmeke booms incomplaale or inaccurate
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Name ofloud government officerwith lateen tilerhieeleepttytghpotor
Name of
Th1A badlon Mon 3 including subparts A a C
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b connected for each error with whom the Olor has an
employment or otter business rmladauhtp t defined by 9eaeon 776
1a Local GOVenaneAt Code Attach additional
001
pogae to this Form CIO as theceesary
A Is the iocal govamnlert odeesr named in this section receiving or likely to receive taxable Inaonw other than invesppard
income from the filer of the que
fionwlre
CD Yea
i
EI No
6 Is the filer of the questionnaire receiving or gayly to receive taxable income other than investment income tom or at the
direction of the load gcVaroment officer named in this section AND the loathe income is not maims tom the load
govwrtaletrial entity
L Yea
E No
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C Is the friar of tide questionnaire omploped by a corporation or other business entity with respect to which the local
government doer OM es an officer or director or hotda en ownership of 10 percent or more
Yes
No
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D Macke each employment or business reletopaldp watt the local ilovrmmool oMcer nailed in this section
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