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HomeMy WebLinkAboutBayer ElectricCONFLICT 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 tiled. 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. I. Name of person doing business with local governmental entity. Michael Bayer-ei...__.,_. FORM CIQ Check this box if you are filing an update to a previously filed questionnaire. t. I he latic requires that you file an updated completed questionnaire with the appropriate tiling authority not later than September I 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. Describe each affiliation or business relationship with an employee or contractor of the local t►overnmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. C Glenn Brown. City Manager Robert Alley. Fire Chief • Pete Cater. Landfill Mgr. C David Gwin. Economic Dev. .0 David Massey. Electric • Lance Simms. Planning & Dev Cheryl Tumey. Purchasing Mgr. O Terry Childers, Deputy City Mgr O Steve Beachy. Parks & Rec O Harvey Cargill. City Attorney O Connie Hooks. City Secretary O Becky Nugent, Public Relations O Mark Smith. Public Works O John Woody. W/WW O Kathy Merrill, Asst. City Mgr. ❑ Olivia Burnside. Inf. Tech. ❑ Michael Clancey, Police Chief O JetT Kersten. Chief Fin.Officer ❑ Julie O'Connell. human Resources ❑ Ed Spillane, Municipal Judge O NONE Describe each aft ion or business relationship with an employee checked in Question 3 abov Attend the same church as David Massey. 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is the subject of this questionnaire. O Ron Silvia, Mayor 0 Ron Gay. Place 3 O David Ruesink. Place 6 City of College Station Elected Officials College Station City Council O Ben White. Place I O Lynn TvicIlhaney, Place 4 M NONE O John Happ, Place 2 CI Chris Scotti. Place 5 City of College Station Committees, Boards, and Commissions O Lam Ringer, Chairman El Mary Fran Troy O Jennifer Bohac E Sarah Adams. Chair E James Batenhorst O David Chester 0 Donald Braune El Dan B. Sears. Chairman 0 Mike Lane C Steve Parker. alternate N NONE B/CS Library Committee 0 Katherine Edwards O Jeanne Mitchell O James Bradford Cemetery Committee O Virginia Reese O Weldon Kruger O RC Slocum El NONE Construction Board of Adjustments and Appeals/Building & Standards Commission O Frank Cox O Larry D. Patton 0 Glenn Thomas. alternate O Don Scherr CI B. Carroll Johnson • NONE O Kevin Myers O Joe Wallace O James Matson O David Hart 0 Charles Thomas, alternate CI Quinn Williams O Hillary Jessup, Chairman O Haskell Monroe 0 Ernie Wright ti -J NONE O Rebecca Eplen O Rusleen Maurice al NONE O Jodi Warner_ Chair O Shawn Rhodes El John Crompton E NONE El John Nichols. Chair Cl Marsha Sanford O Harold Strong O Rick Heanv O Alan King 0 Susie Cox, alternate O Jay Goss, Chair 0 Denise Whisenant [X NONE Historic Preservation Committee O Bill Lancaster O Jane Hughey O Neal Nutall. Jr. Joint Relief Funding Review Committee O J. Kevin Byrne El Charlotte Mikulee Parks and Recreation Board O Kathleen Ireland O Jody Ford O Harry Green Planning and Zoning Commission O Glenn Schroeder 0 Dennis Christiansen lJ NONE Design Review Board 0 Hunter Goodwin O Ward Wells O Robert Rayburn. alternate Zoning Board of Adjustments O Joshua Berm O Donald Braune O Marguerite Anthony O Meredith Waller O Colleen Risinger O Deborah Deitering O Peggy Samson O Joan Perry O Gary Thomas O Gary Erwin O Derek Dictson O Bill Davis O Nancy Sawtelle O John Nichols (311 NONE O John Richards O Thomas Mather O Larry Hodges O Glenn Brown, City Manager O Sharon Colson, Chair O Kenny Mallard O Don Lewis O Gregg Baird O Chad Jones O Stephen Syptak, Chair 1:1 Torn Kirkland I7C1 NONE El Hugh Lindsay, Area I O John Crompton, Area II O Steve Arden, Area III El Hugh Steams. Area IV O Andrew Burleson, Student Resident El Dorthea Robinson, Alternate. ETJ Resident O Chris Scotti. Councilmember 0 Hillary- Jessup, Historic Preservation O Lloyd Wasserman, County Commission Research Valley Partnership Board of Directors O Larry Mariott [21 NONE Wolf Pen Creek TIF Board O Marsha Sanford, Vice Chair O James Massey Outside Agency Funding Review O Charles Taylor O Sheryl Welford a NONE Northgate Tax Increment Finance Board O David Scarmardo O Glenn Thomas Comprehensive Plan Committee O John Richards, Area I O Brian Bochner. Area II O Laurie Corbelli, Area III O Jerry Cooper, Area IV O Kristina Campbell, Alternate, Student Resident O Craig Hall. Resident -At -Large O Lynn Mcllhaney, Alternate. Councilmember O Gary Erwin. Parks & Rec O Larry- Haskins, Northgate District Assoc. O Chris Scotti, Councilman O Marc Chaloupka ll NONE O Roger Reese O Carolyn Berrow O Anne Jackson O Dale O'Riley O David Hart, Alternate. Area I O Dennis Corrington. Alternate. Are II CI Tom Taylor, Alternate, Area III O Adrian Williams, Alternate. Area IV O Douglas Rape', ETJ Resident O Mike Guido, Alternate. Resident -At -Large O Bill Davis, P&Z O Kathleen Ireland. Parks & Rec Alternate O Bo Miles, Building & Land Development O Larry Marriott, Home Builders Assoc. O Tedi Ellison. Intergovernmental Comm/Chamber of Commerce O James Massey, Intergovernmental Comm/TAMU Admin O Dr. Clark Ealy, Intergovernmental Comm/CSISD O Chuck Martinez, Intergovernmental Corm/ Research Valley Patnership O Linda LaSut, Intergovernmental CommIMPO O Lindsey Guindi, Intergovernmental Comm/Chamber of Commerce O Rodney Weis, Intergovernmenta Comm/TAMU Transit O Dr. Colleen Netterville, Intergovernmental Comin/BISD O Margie Lucas, Intergovernmental Comm/ Brazos Transit District O Chad Bohne, Intergovernmental Conun/TxDOT O Michael Parks, Intergovernmental Comm/BVCOG 0 0 EI Gary Arnold, Intergovernmental Comm/Brazos County Sheriff Gary Teston, Intergovernmental Comm/ Easterwood Airport NONE The following individuals are appointed by the City Council to represent the City of College Station on joint committees with other governmental agencies and community groups. Cl Lynn Mcllhanev O Ron Sily Brazos County Health Department ❑ Ben White IN NONE Brazos Valley Council of Governments Mayor &I NONE u Ron Silvia, Mayor ❑ Lynn Mcllhaney ❑ Ron Silvia, Mayor B/CS Metropolitan Planning Organization IJ NONE BVCOG TMPA Regional Park Project Advisory Board ® NONE BVSWMA Policy Advisory Board O Chris Scotti City Center Committee ❑ Ron Silvia 0 Ben White ® NONE ❑ Ron Gay a NONE Intergovernmental Committee O Ben White • NONE ❑ Dave Ruesink ❑ John Hopp O Dave Ruesink i NONE Joint City/School Intergovernmental Committee O Ben White 0 John Happ Sister Cities Association O Dave Ruesink El NONE 01 Ron Gay O Ken Fogle O Michael Parker. BVCOG O Ron Gay Transportation Committee O John Happ O Linda LaSuit, MPO O Bran Woods. TxDOT Wolf Pen Creek Oversight Committee O Lynn Mcllhaney O Dennis Christianson, TTI El NONE O Chris Scotti (i0 NONE Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity 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. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes x 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 x No C. Is the tiler 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 x No D. Describe each affiliation or business relationship. 6. January 31, 2007 Signature of person doing business with governmental entity Date Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ 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. OFFICE USE ONLY Date Received 1. Name of person doing business with local governmental entity. Michael Bayer 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. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. ❑ Robert Alley, Fire Chief O Steve Beachy, Parks & Rec ❑ Glenn Brown, City Manager ❑ Olivia Burnside, Int Tech. ❑ Pete Caler, Landfill Mgr. O Harvey Cargill, City Attorney ® David Massey, Electric ❑ Michael Clancey, Police Chief ❑ Lance Simms, Planning & Dev ❑ John Woody, W/WW ❑ Terry Childers, Asst. City Mgr ❑ Connie Hooks, City Secretary ❑ Jeff Kersten, Chief Fin.Officer ❑ Charles McLemore, Public Works ❑ Charles McLemore, Public Works ❑ Becky Nugent, Public Relations ❑ Julie O'Connell, Human Resources ❑ Mark Smith, Asst. City Mgr ❑ Ed Spillane, Municipal Judge ❑ Cheryl Turney, Purchasing Mgr. ❑ NONE Describe each affiliation or business relationship with an employee checked in Question 3 above: Attend the same church as David Massey. 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is the subject of this questionnaire. ❑ Ron Silvia, Mayor ❑ Ron Gay, Place 3 O David Ruesink, Place 6 City of College Station Elected Officials College Station City Council ❑ Ben White, Place 1 ❑ Lynn Mcllhaney; Place 4 ® NONE ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions ❑ Larry Ringer, Chairman ❑ Eric Miller ❑ Lois Koontz ❑ Sarah Adams, Chair ❑ James Batenhorst ❑ David Chester ❑ Dan B. Sears, Chairman ❑ Mike Lane ❑ Steve Parker, alternate B/CS Library Committee ❑ Katherine Edwards O Jeanne Mitchell O James Bradford Cemetery Committee ❑ Virginia Reese O Mary Lind Bryan 13 NONE Construction Board of Adjustments and Appeals/Building & Standards Commission D George McLean, Vice Chair ❑ Larry D. Patton ❑ David Ruesink, alternate Facade Improvement Program Advisory Committee ❑ Don Scherr ❑ Jo Berg 110 NONE ❑ Kevin Myers O Joe Wallace ❑ Frank Cox D David Hart, alternate al NONE ❑ Karen Kasper, Merchant ❑ Valerian Miranda, Architect 0 Rick Lemmons, Business Owner ❑ Joey Dunn, Dir. Planning & Dev 0 Robert Mosley, City Engineer 0 Eric Barton, CD Coordinator DT NONE ❑ Hillary Jessup, Chairman ❑ Marguerite Anthony ❑ Thomas Taylor ❑ Colleen Risinger O Rebecca Eplen ❑ Rusleen Maurice ® NONE ❑ Kathleen Ireland ❑ Carol Blaschke ❑ John Crompton ® NONE ❑ Scott Shafer, Chairman ❑ Marsha Sanford ❑ Harold Strong ❑ Rick Heany ❑ Alan King O Susie Cox, alternate ❑ Jay Goss, Chair ❑ Graham Sheffy ❑ Denise Whisenant Historic Preservation Committee ❑ Bill Lancaster O David Ruesink O Ernie Wright ® NONE Joint Relief Funding Review Committee ❑ J. Kevin Byrne ❑ Charlotte Mikulee Parks and Recreation Board ❑ Glenn Schroeder ❑ Jeannie McCandless ❑ Harry Green Planning and Zoning Commission ❑ John Nichols O Dennis Christiansen 6d NONE Design Review Board ❑ Hunter Goodwin ❑ Ward Wells ❑ Robert Raybum, alternate Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune ❑ Derek Dictson ❑ Marsha Crenwelge ❑ Dipankar Sen ❑ Neal Nutall, Jr. ❑ Mary Sherwood ❑ Peggy Samson ❑ Jodi Warner ❑ Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds ❑ Bill Davis ❑ Nancy Sawtelle ❑ Scott Shafer 12 NONE ❑ John Richards ❑ Charles Taylor ® NONE ❑ David Hickson ❑ Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard Research Valley Partnership Board of Directors ❑ Larry Marion ® NONE Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ James Massey 0 Chris Scotti, Councilman ❑ Marc Chaloupka El NONE The following individuals are appointed by the City Council to represent the City of College Station on joint committees with other governmental agencies and community groups. ❑ Susan Lancaster ❑ Ron Silvia, Mayor ❑ Ron Silvia, Mayor ❑ Susan Lancaster ❑ Ron Silvia, Mayor Brazos County Health Department O Nancy Beny ® NONE Brazos Valley Council of Governments Board of Directors El NONE B/CS Metropolitan Planning Organization El NONE BVCOG TMPA Regional Park Project Advisory Board ® NONE BVSWMA Policy Advisory Board 0 Susan Lancaster ® NONE ❑ Ron Silvia 1J NONE ❑ Nancy Berry ® NONE ❑ Nancy Berry Cid NONE City Center Committee O Ben White 0 Nancy Berry Intergovernmental Committee O Ben White ❑ John Happ Joint City/School Intergovernmental Committee O Ben White ❑ John Happ Sister Cities Association ❑ Ron Gay 51 NONE ❑ Ron Gay ❑ Linda LaSuit, MPO ❑ Bryan Woods, TxDOT Transportation Committee ❑ John Happ 0 Dennis Christianson, TTI ® NONE O Ken Fogle O Michael Parker, BVCOG Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 Wolf Pen Creek Oversight Committee Ron Gay Chris Scotti NONE • • ►a Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity 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. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. FORM CIQ A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes X 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 I x I 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 X No D. Describe each affiliation or business relationship. ?` 24-04 Signature of person doing busi with the governmental entity Date Adopted 01/13/06 Lemontree Park Field Lighting Bid #06-55 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ 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. OFFICE USE ONLY Date Received 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. • Robert Alley, Fire Chief • Michael Clancey, Police Chief • Charles McLemore, Public Works • Steve Beachy. Parks & Rec IN Joey Dunn, Planning & Dcv • Becky Nugent, Public Relations ❑ Glenn Brown. City Manager • Don Fazzino, Legislative Liason • Julie O'Connell, Human Resources ❑ Olivia Burnside, inf. Tech. 0 Mark Smith, Public Works • Kim Foutz. Economic DCN' • Pete Caler. Landfill Mgr. ■ Connie Hooks. City Secretary • Ed Spillane, Municipal Judge • Harvey Cargill. City Attorney • Jeff Kersten, Finance ■ Cheryl Turney, Purchasing Mgr. CZ NONE • John Woody, Utilities Lemontree Park Field Lighting Bid #06-55 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. City of College Station Elected Officials City of College Station Committees, Boards, and Commissions Cemetery Committee College Station City Council B/CS Library Committee Ron Silvia, Mayor Larry Ringer, Chairman ■ Kevin Myers John Happ, Place 2 • • Ben White, Place 1 • • Ron Gay, Place 3 al NONE Eric Miller Chris Scotti, Place 5 • • Susan Lancaster, Place 4 • • Nancy Berry, Place 6 Xl NONE Lois Koontz • City of College Station Committees, Boards, and Commissions Construction Board of Adjustments and Appeals/Building & Standards Commission El Dan B. Sears, Chairman ❑ Mike Lane ❑ George McLean, Vice Chair ❑ Larry D. Patton ❑ Frank Cox ❑ David Hart, alternate ❑ Steve Parker, alternate ❑ David Ruesink, alternate ® NONE Cemetery Committee B/CS Library Committee • Sarah Adams, Chair Larry Ringer, Chairman ■ Kevin Myers Katherine Edwards Don Scherr • • • al NONE Eric Miller Jeanne Mitchell Jo Berg • IN • Lois Koontz James Bradford III NONE • • Construction Board of Adjustments and Appeals/Building & Standards Commission El Dan B. Sears, Chairman ❑ Mike Lane ❑ George McLean, Vice Chair ❑ Larry D. Patton ❑ Frank Cox ❑ David Hart, alternate ❑ Steve Parker, alternate ❑ David Ruesink, alternate ® NONE Cemetery Committee • Sarah Adams, Chair ■ Virginia Reese ■ Kevin Myers ❑ James Batenhorst ■ Mary Lind Bryan • Joe Wallace ❑ David Chester al NONE Construction Board of Adjustments and Appeals/Building & Standards Commission El Dan B. Sears, Chairman ❑ Mike Lane ❑ George McLean, Vice Chair ❑ Larry D. Patton ❑ Frank Cox ❑ David Hart, alternate ❑ Steve Parker, alternate ❑ David Ruesink, alternate ® NONE Facade Improvement Program Advisory Committee • Karen Kasper, Merchant ■ Valerian Miranda, Architect ■ Rick Lemmons, Business Owner • Joey Dunn, Dir. Planning & Dev ■ Robert Mosley, City Engineer ■ Eric Barton, CD Coordinator 0 NONE Lemontree Park Field Lighting Bid #06-55 Joint Relief Funding Review Committee ❑ Rebecca Eplen ❑ Rusleen Maurice ❑ J. Kevin Byrne ❑ Charlotte Mikulee El NONE ❑ Mary Sherwood ❑ Peggy Samson Parks and Recreation Board ❑ Kathleen Ireland El Glenn Schroeder ❑ Jodi Warner ❑ Carol Blaschke ❑ Jeannie McCandless ❑ John Crompton NONE ❑ Harry Green ❑ Gary Thomas ❑ Gary Erwin Planning and Zoning Commission • Historic Preservation Committee Design Review Board • John Nichols • Hillary Jessup, Chairman • Bill Lancaster Hunter Goodwin Marsha Crenwelge • • ■ ■ ® NONE Marguerite Anthony Alan King David Ruesink Ward Wells Dipankar Sen • • ■ • Thomas Taylor Susie Cox, alternate Robert Rayburn, alternate • Ernie Wright Neal Nutall, Jr. U • Colleen Risinger J NONE Joint Relief Funding Review Committee ❑ Rebecca Eplen ❑ Rusleen Maurice ❑ J. Kevin Byrne ❑ Charlotte Mikulee El NONE ❑ Mary Sherwood ❑ Peggy Samson Parks and Recreation Board ❑ Kathleen Ireland El Glenn Schroeder ❑ Jodi Warner ❑ Carol Blaschke ❑ Jeannie McCandless ❑ John Crompton NONE ❑ Harry Green ❑ Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds ❑ Bill Davis Planning and Zoning Commission • Scott Shafer, Chairman Design Review Board • John Nichols ■ • Marsha Sanford Hunter Goodwin ■ Dennis Christiansen Nancy Sawtelle • Harold Strong ■ ® NONE • ❑ Ken Reynolds ❑ Bill Davis Zoning Board of Adjustments ❑ Jay Goss, Chair ❑ Joshua Benn ❑ John Richards El Graham Sheffy ❑ Donald Braune ❑ Denise Whisenant ❑ Derek Dictson ❑ Charles Taylor ® NONE Design Review Board ■ Rick Heany Hunter Goodwin Nancy Sawtelle • ■ • Alan King Ward Wells Scott Shafer ■ • • Susie Cox, alternate Robert Rayburn, alternate Q NONE ■ Zoning Board of Adjustments ❑ Jay Goss, Chair ❑ Joshua Benn ❑ John Richards El Graham Sheffy ❑ Donald Braune ❑ Denise Whisenant ❑ Derek Dictson ❑ Charles Taylor ® NONE Lemontree Park Field Lighting Bid #06-55 El Sharon Colson, Chair Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ Marc Chaloupka ❑ Kenny Mallard ❑ James Massey ® NONE Research Valley Partnership Board of Directors David Hickson Chris Scotti, Councilman • ■ Larry Mariott ■ Glenn Brown, City Manager 5 NONE • El Sharon Colson, Chair Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ Marc Chaloupka ❑ Kenny Mallard ❑ James Massey ® NONE Lemontree Park Field Lighting Bid #06-55 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity 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. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes X 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 X No C. Is the fifer 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 X D. Describe each affiliation or business relationship. 6. 2- ?-©& Signature of person doing business i ith the governmental entity Date Adopted 11/02/2005