Klotz AssociatesCONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM CIQ
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 7`r' 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 violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
OFFICE USE ONLY
1 Name of person doing business with local governmental entity.
2
Klotz Associates, Inc.
1160 Dairy Ashford, Suite 500
Houston, TX 77079
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 7`h 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 government entity with respect to expenditure of
money.
None
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 governmental entity that is the subject of this questionnaire.
None
Amended 01/13/2006
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
5
Name of local government officer with whom filer has affiliation or business relationship.
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
relationship. Attach additional pages to this Form CIQ as necessary.
FORM CIQ
Page 2
(Complete this
has affiliation or other
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 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.
None
6 Describe any other affiliation or business relationship that might cause a conflict of interest.
None
7
November 9. 2006
Signature of person doingbusiness with the governmental entity Date
Tom S. Ramsey, PE — Sr. Vice President
Amended 01/13/2006