doing business with localgovernmental OntitY
For vendor or
Government Code by a person doing business Mth the governmental entity
Date Received
By law this questionnaire must be filed with the rewrd administrator of the
total government not later than the 7th txminess day after the date the
person becomes swans of facts that require the statement to be filed tee
Section 176
006 Local Government Cade A person commits an offense if
ITY SECRET
the person vlolates Secfian 176
006 Local Government Coale An offense
under this section is a Class G misdemeanor
1
Name of person doing business with local governmental entity
Y
JAN 1 2414
RECEIVED
heck if you are ding an update to a previously filed questionnaire
The law requires that you file an updated completed questionnaire with the appropriate fling
authority not later than September 1 of the year for which an activity described in Section
a Loral Govo
006
176
mment Cade is pending and not later than the 7th business day after the
bate the originally filed questionnaire becomes incomplete or inacmrste
we eaun amuw or ousumss relationship with an employee or contracts
im
vernmental entity who makes recommendations to a local government officer
varnmental entity with respect to expendi of money
I
d
Describe each atfillatio n or business relabonshilp with a person who is a local govi
and who appoints or employs a loo al government offli er of the local governmental
the subject of this questionnaire
is
lf Pe
i
dc
ef
FORM Cld
CONFLICT OF INTEREST QUESTIONNAIRE
Page 2
For vendor or othw person doing business with local govermentat entity
5
whom filer has affiliation or business relatiOnship
Narne of local government officer
Complete this section only if the answer to A l9 or C Is YES
This section item 5 including subpe
ts A fl C
D mi st be completed for each officer with whom the
filer has affiliation or business relationship Attach addWonai pages to this Form CIO as necessary
A Is the local government officer named in this seotioni receiving or likely to receive tame income
from the filer of ft questionnaire
Yes
No
B is the fifer of the questionnaire receiving or timely to receive taxable income from or at the direction
officer the local government officer named in this section AND the table income is not from the local
govemmentai entity
Yes
hIo
C Is the fifer of this questionnaire affiliated with a corporation or other business entity that the x
W
government officer serves as an officer or director or holds an ownership of 10 percent or more
Yes
No
D De
rlbe each alrillat on or business relationship
Date