Matcham, Karrie J.Joyce Duda - Conflict Disclosure Statement - Vendor Questionnaire.pdf Pae 1
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'
tJ Name of persondoing business with localgovemmentalentity.
N@NE \4C (W— "S. ClAeck.CCAM
J
Check this box if you are filing an update to a previously filed questionna ire.
(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.)
2.1
Name each employee or contractor of the local governmental entity who makes recommendations to a local government
off icerof the governmenta l entity with respect to expenditures of money AND describe the affiliation or business relationship.
N/A
J Name each local government officer who appoints or employs local government officers of the governmental entity for
whichthis questionnaire is filed AND desc ribe the affiliation orbusiness relationship.
N/A
Mopted 11/02/2005
Joyce Duda - Conflict Disclosure Statement - Vendor Questionnaire.pdf Page 2
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
Page 2
Name of local government officerwith whom filerhas affilitationorbusiness 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. Attach additional pages to this Form CID as necessary.
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 gover nment
officer named in this section AND the taxable income is not from the local governmental entity?
Yes
x
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.
Adopted 11/02/2005