Broach, Donald (Central Texas Properties, LTD)CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code
by a person who has a business relationship as defined by Section 176.001(1-a) with a local
governmental entity and the person meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental
entity 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 commits an offense if the person knowingly violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
OFFICE USE ONLY
Date Received
Name of person who has a business relationship with local governmental entity.
71/0 Nr
2
filing authority not
incomplete or inaccurate.)
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
later than the 7th business day after the date the originally filed questionnaire becomes
3
Name of local government officer with whom filer has employment or business relationship.
NO A/'
with whom the filer has an
Code. Attach additional
other than investment
income, from or at the
not received from the local
respect to which the local
in this section.
Name of Officer
This section (item 3 including subparts A, B, C & D) must be completed for each officer
employment or other business relationship as defined by Section 176.001(1-a), Local Government
pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income,
income, from the filer of the questionnaire?
Yes No
B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment
direction of the local government officer named in this section AND the taxable income is
governmental entity?
Yes No
C. Is the filer of this questionnaire employed by a corporation or other business entity with
government officer serves as an officer or director, or holds an ownership of 10 percent or more?
Yes No
D. Describe each employment or business relationship with the local government officer named
4
1.6...!..111(11110_ 7-7-/-f
Signature of person doing business with the governmental entity Date
Adopted 06/29/2007
CITY OF COLLEGE STATION
City of College Station
Community Development Unit
1207 Texas Ave
P 0 Box 9960
College Station, Tx 77842
(979) 764-3778; Fax (979) 764-3785; Email dbrower(&,,cstx.gov
CERTIFICATION OF RECEIPT OF APPRAISAL INFORMATION BY OWNER/SELLER
Date: 7- 7- / `/
Owner(s)/Seller(s): C_' &V , L p&oP 'T7. LT /)
Address of Property Under Consideration: IC/ Soc,-+L,(Csr Pu'rollege Station, Brazos County, Texas
Because Federal funds may be used in the purchase of your property, we are required to collect the following certification
to comply with the provisions of the Uniform Relocation Assistance and Real Property Acquisition Policies Act as
amended (URA), Section 24.101(b)(2):
Certification:
Owner/Seller hereby certifies that:
A. He or she has received and reviewed an appraisal dated /--/'J"/%showing an indicated Fair Market
Value of $ 5 4/22. The actual sale price may differ from this amount and is indicated on the
Real Estate Contract. AND
B. By signing this certification and initialing each page of the appraisal report, the Owner/Seller certifies that
he or she fully understands the process as to how the appraiser arrived at the Fair Market Value for the
Property.
Certified this ITS day of U L`� , 2014
Seller
Witness