Joe Charol03/18/2008 TUE 15:11 FAX 512-366-7350
171001/003
CONFLICT OF INTEREST QUESTIQNNAIRE FORM C!Q
for vendor or other person doing business with local governmental entity
This questionnaire is being filed in accordance with chapter 176 of the Local OFFICE USE ONLY
G
overnment Code by a person doing business with the governmental entity. Date Received
By law this questionnaire must be filed with fhe records administrator of the
local government no# 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 violates Section 176.006, Local
Governmen# Code. An offense under this section is a Class C misdemeanor.
~ Wame of person doing business with local governmental entity.
~~ ~ 2 C7 r ~ i+.t. IvLW C
2
Check this box ifyou are filing an update to a previously filed questionnaire.
(The law requires that you file an upda#ed completed questionnaire with the appropriate filing authority not later than
September i of the year for which an activity descrllaed in Section 176
006(a)
Lac
l G
.
,
a
overnment Code, is pending and
not later than fhe 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)
3 Describe each affiliation or business relationship with an employee orcontractorofthe local governmental entity who makes
recommendations to a local government officer of the loco! governmental entity with respect to expenditure of mone
y.
~a~~
4
Describe each affiliation or business relatfanshlp with a person who is a local ovemment officer and who a
ppoints or
employs a local government officer of the local
governmental entity that is the subject of this questionnaire.
/ V t~ /~ r~
Amendetl 01/13/2006
03/18/2008 TUE 15:11 FAX 512-366-7350 002/003
CONFLICT OF INTEREST QUESTIONNAIRE FORM CiQ
For vendor or other person doing business. with focal governmental entity Page ~
Name of local government of leer with whom tiler has affiliation or business relationship. (Complete this sectlan 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 tine filer has affiliation os•
business relationship. Attach additional pages to this Form CIQ as necessary.
A. Is the focal government officer named in this section receiving ar likely to receive taxable income from the filer of the ,
questionnaire?
a Yes ~ 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 Warned in this section AND the taxable income is not from the local governmental entity?
Yes ~No
C. Is the f ler of this questionnaire affiliated with a corporation or other business erStity that the local government officer serves
as an officer or director, or Izolds an ownership of 10 percent or more?
Yes Np
~ a a
~s
D. Describe each affiliation or business relationship.
~~~
Describe any other affiliation or business reiatlonahlp that might cause a confttct of interest.
~~~
Sign ure of person doing business wittti the c~ovemmental entity
Date
Amended 0117 3l?.OD6
03/18/2008 TUE 15:11 FAX 512-38fi-7350 0003/003
F~m, W-9
(Rov. November 2005} Request for Taxpayer Giv9 form to tho
Department of the Treasury
Identification Number and Certification requester. Do not
send to tl,e IRS
Intornal Revenue Service .
N Name (as shown on your income tax return) `"'"'
Rz Communications
Inc
° ,
..
'
c Business name, If different from atwve
0
N
C
o
~ ~
~ rvrdual! ~
Check appropriate pox: Sole proprietor ~ Corporation ~ partnership ~ Other - Exempt from backup
~ _ withhotdin8
e Addres3 (number, street, and apf, or suite t,0.) Requesters name and addre9s (optional}
;~ ~ 1400 Smith Road, Suite 101B
u City, state, and ZIP coda
~ Austin TX 78721
List account numbor(s) here (optional)
Enter your TIN in the appropriate box. The TIN provided must match the name given on tine 1 to avoid
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Parf I instructions on page 3. For other entities, it 35
your employer identification number {EIN). If you do not have a number, sae Mow to gat a TtN on page 3.
Note. If the account is in more than one name, see the chart on page 4 #or guidelines on whose
number to enter,
Social security number
or
Employer Identification number
20-18o2sRn
Under penalties of perjury, t certify that:
1. The number shown on this form is my correct taxpayer indentificatian number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b} I have not been notified by the Internal
Revenue Service {IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or {c) the IRS has
notified me that 1 am no longer subject to backup withholding, and
3. I am a U.S. person {including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report ail interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonmen# of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
i°
Sign Signaturo of
Here U. S. person - - .:- '~/~'r~;:_.~~,~i'..,_-~~... ;- is
AN1~Rp!G7 wntur acv Date - ~://.~
DAA _
Form W-9 (Rev. 1?-2005)