HomeMy WebLinkAboutElliott Construction, Ltd. - UpdateCONFLICT 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 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.
Elliott Construction,LTD
2.
FORM CIQ
OFFICE USE ONLY
Date Received
SEP 2 0 2007
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.
❑ Glenn Brown, City Manager
❑ Robert Alley, Fire Chief
❑ Pete Caler, Landfill Mgr.
❑ David Gwin, Economic Dev.
❑ David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
❑ Terry Childers, Deputy City Mgr
O Steve Beachy, Parks & Rec
O Harvey Cargill, City Attorney
O Connie Hooks, City Secretary
❑ Becky Nugent, Public Relations
O Mark Smith, Public Works
O Dave Coleman, W/WW
O Kathy Merrill, Asst. City Mgr.
O Ben Roper, Inf. Tech.
O Michael Clancey, Police Chief
O Jeff Kersten, Chief Fin.Officer
O Julie O'Connell, Human Resources
O Ed Spillane, Municipal Judge
El NONE
Describe each affiliation or business relationship with an employee checked in Question 3 above:
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.
CI Ben White, Mayor
0 Ron Gay, Place 3
0 David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
O John Compton, Place 1
O Lynn Mcllhaney, Place 4
E NONE
0 James Massey, Place 2
O Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
B/CS Library Committee
O Katherine Edwards
0 Larry Ringer, Chairman
O Mary Fran Troy
O Sonio Margarita Gangotena
CI Sarah Adams, Chair
O James Batenhorst
El David Chester
O Donald Braune
Cl Dan B. Sears, Chairman
CI Mike Lane
O Steve Parker, alternate
Di NONE
O Jeanne Mitchell
O James Bradford
Cemetery Committee
O Virginia Reese
O Weldon Kruger
O RC Slocum
n NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
O Frank Cox
0 Larry D. Patton
GI Glenn Thomas, alternate
Cl Don Scherr
O B. Carroll Johnson
Pc1 NONE
0 Kevin Myers
1:1 Joe Wallace
O James Matson
0 David Hart
O Charles Thomas, alternate
O Quinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
❑ NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ Jane Hughey
❑ Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
O Meredith Waller
❑ Colleen Risinger
El Tedi Ellison El J. Kevin Byrne El Deborah Deitering
❑ Rusleen Maurice ❑ Reba Ragdale El
Lel NONE
El Jodi Warner, Chair
E l Shawn Rhodes
❑ John Crompton
® NONE
El John Nichols, Chair
❑ Marsha Sanford
El Harold Strong
E l Rick Heaney
El Alan King
❑ Susie Cox, alternate
❑ Jay Goss, Chair
❑ Denise Whisenant
® NONE
Parks and Recreation Board
El Kathleen Ireland
El Jody Ford
❑ Harry Green
Planning and Zoning
Commission
❑ Glenn Schroeder
El Dennis Christiansen
In NONE
Design Review Board
❑ Hunter Goodwin
❑ Ward Wells
El Robert Rayburn, alternate
Zoning Board of Adjustments
El Joshua Benn
❑ l Donald Braune
❑ Joan Perry
❑ Gary Thomas
❑ Gary Erwin
El Derek Dictson
O Bill Davis
El Nancy Sawtelle
❑ John Nichols
® NONE
❑ John Richards
❑ Thomas Mather
O Larry Hodges
0 Glenn Brown, City Manager
O Sharon Colson, Chair
• Kenny Mallard
O Don Lewis
O Gregg Baird
O Chad Jones
O Stephen Syptak, Chair
O Tom Kirkland
El NONE
O Hugh Lindsay, Area I
O John Crompton, Area II
O Steve Arden, Area HI
O Hugh Stearns, Area IV
O Andrew Burleson, Student Resident
O Dorthea Robinson, Alternate,
ETJ Resident
O Chris Scotti, Councilmember
O Hillary Jessup, Historic
Preservation
O Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
O Larry Mariott
PE NONE
Wolf Pen Creek TIF Board
O Marsha Sanford, Vice Chair
O James Massey
Outside Agency Funding Review
O Charles Taylor
O Sheryl Welford
1 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
DE NONE
O Roger Reese
O Carolyn Berrow
O Anne Jackson
O Dale O'Reiley
O David Hart, Alternate, Area I
O Dennis Corrington, Alternate, Area II
O 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
❑ Larry Marriott, Home Builders
Assoc.
❑ Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
❑ Linda LaSut, Intergovernmental
Comm/MPO
❑ Lindsey Guindi, Intergovernmental
Comm/Chamber of Commerce
❑ Rodney Weis, Intergovernmental
Comm/TAMU Transit
❑ Dr. Colleen Netterville,
Intergovernmental Comm/BISD
❑ Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
Comm/BVCOG
❑ 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.
Brazos County Health
Department
O Lynn Mcllhaney 0 Ben White 4 NONE
Brazos Valley Council of
Governments
O Mayor El NONE
B/CS Metropolitan Planning
Organization
O Mayor G3 NONE
BVCOG TMPA Regional Park
Project Advisory Board
O Lynn Mcllhaney Ill NONE
BVSWMA Policy Advisory
Board
O Mayor 0 Chris Scotti gcl NONE
City Center Committee
O Ron Silvia 0 Ben White 0 Dave Ruesink
21 NONE
Intergovernmental Committee
O Ron Gay 0 Ben White 0 John Happ
CI NONE
❑ Dave Ruesink
® NONE
Joint City/School
Intergovernmental Committee
❑ Ben White ❑ John Happ
Sister Cities Association
❑ Dave Ruesink ® NONE
❑ Ron Gay
O Ken Fogle
O Michael Parker, BVCOG
O Ron Gay
O John Nichols
O Joan Perry
Transportation Committee
O John Happ
O Linda LaSuit, MPO
O Bryan Woods, TxDOT
Wolf Pen Creek Oversight
Committee
❑ Chris Scotti
O Marsha Sanford
❑ Sharon Colson
❑ Lynn Mcllhaney
❑ Dennis Christianson, TTI
NONE
❑ Marc Chaloupka
❑ Jodi Warner
El NONE
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 tiler
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
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.
6.
Signature of person doing business with the governmental entity Date
Adopted 01/13/06
CONFLICT 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 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.
Elliott Construction,LTD
2.
FORM CIQ
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. 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.
❑ Glenn Brown, City Manager
❑ Robert Alley, Fire Chief
❑ Pete Cater, Landfill Mgr.
❑ David Gwin, Economic Dev.
❑ David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
❑ Terry Childers, Deputy City Mgr
❑ Steve Beachy, Parks & Rec
❑ Harvey Cargill, City Attorney
❑ Connie Hooks, City Secretary
❑ Becky Nugent, Public Relations
❑ Mark Smith, Public Works
❑ Dave Coleman, W/WW
❑ Kathy Merrill, Asst. City Mgr.
❑ Ben Roper, Inf. Tech.
❑ Michael Clancey, Police Chief
❑ Jeff Kersten, Chief Fin.Officer
❑ Julie O'Connell, Human Resources
❑ Ed Spillane, Municipal Judge
NONE
Describe each affiliation or business relationship with an employee checked in Question 3 above:
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 Ben White, Mayor
O Ron Gay, Place 3
O David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
O OPEN, Place 1
0 Lynn Mcllhaney, Place 4
NONE
O James Massey, Place 2
El Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
O Larry Ringer, Chairman
O Mary Fran Troy
O Sonio Margarita Gangotena
O Sarah Adams, Chair
O James Batenhorst
O David Chester
O Donald Braune
O Dan B. Sears, Chairman
O Mike Lane
O Steve Parker, alternate
53 NONE
B/CS Library Committee
O 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
0 Larry D. Patton
O Glenn Thomas, alternate
O Don Scherr
O B. Carroll Johnson
El NONE
O Kevin Myers
O Joe Wallace
O James Matson
O David Hart
O Charles Thomas, alternate
O Quinn Williams
O Hillary Jessup, Chairman
O Haskell Monroe
O Ernie Wright
D2 NONE
O Tedi Ellison
O Rusleen Maurice
NONE
O Jodi Warner, Chair
O Shawn Rhodes
O John Crompton
C3 NONE
O John Nichols, Chair
O Marsha Sanford
O Harold Strong
O Rick Heaney
O Alan King
O Susie Cox, alternate
O Jay Goss, Chair
O Denise Whisenant
13 NONE
Historic Preservation Committee
O Bill Lancaster
O Jane Hughey
O Neal Nutall, Jr.
Joint Relief Funding Review
Committee
O Marguerite Anthony
O Meredith Waller
O Colleen Risinger
O J. Kevin Byrne 0 Deborah Deitering
O Reba Ragdale 0
Parks and Recreation Board
O Kathleen Ireland
O Jody Ford
O Harry Green
Planning and Zoning
Commission
O Glenn Schroeder
O Dennis Christiansen
121 NONE
Design Review Board
O Hunter Goodwin
O Ward Wells
O Robert Rayburn, alternate
Zoning Board of Adjustments
O Joshua Benn
O Donald Braune
O Joan Perry
O Gary Thomas
O Gary Erwin
O Derek Dictson
O Bill Davis
O Nancy Sawtelle
O John Nichols
13 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
O Tom Kirkland
EN NONE
O Hugh Lindsay, Area I
O John Crompton, Area II
O Steve Arden, Area III
O Hugh Stearns, Area IV
O Andrew Burleson, Student Resident
O Dorthea Robinson, Alternate,
ETJ Resident
O Chris Scotti, Councilmember
O Hillary Jessup, Historic
Preservation
O Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
O Larry Mariott
13 NONE
Wolf Pen Creek TIF Board
O Marsha Sanford, Vice Chair
O James Massey
Outside Agency Funding Review
O Charles Taylor
O Sheryl Welford
13d 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
• 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
[21 NONE
O Roger Reese
O Carolyn Berrow
O Anne Jackson
O Dale O'Reiley
O David Hart, Alternate, Area I
O Dennis Corrington, Alternate, Area 11
o Tom Taylor, Alternate, Area III
0 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
❑ Larry Marriott, Home Builders
Assoc.
❑ Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
❑ Linda LaSut, Intergovernmental
Comm/MPO
❑ Lindsey Guindi, Intergovernmental
Comm/Chamber of Commerce
❑ Rodney Weis, Intergovernmental
Comm/TAMU Transit
❑ Dr. Colleen Netterville,
Intergovernmental Comm/BISD
❑ Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
Comm/BVCOG
❑ Gary Arnold, Intergovernmental
Comm/Brazos County Sheriff
O Gary Teston, Intergovernmental
Comm/ Easterwood Airport
14
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.
O Lynn Mcllhaney
O Mayor
O Mayor
O Lynn Mcllhaney
O Mayor
O Ron Silvia
E ig NONE
Brazos County Health
Department
0 Ben White IS] NONE
Brazos Valley Council of
Governments
CD NONE
B/CS Metropolitan Planning
Organization
El NONE
BVCOG TMPA Regional Park
Project Advisory Board
al NONE
BVSWMA Policy Advisory
Board
0 Chris Scotti
City Center Committee
0 Ben White
Intergovernmental Committee
0 Ron Gay 0 Ben White
1;1
NONE
[ NONE
0 Dave Ruesink
0 John Happ
O Dave Ruesink
O NONE
Joint City/School
Intergovernmental Committee
O Ben White 0 John Happ
Sister Cities Association
O Dave Ruesink 0 NONE
Transportation Committee
O Ron Gay 0 John Happ 0 Lynn Mcllhaney
O Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI
O Michael Parker, BVCOG 0 Bryan Woods, TxDOT P NONE
O Ron Gay
O John Nichols
O Joan Perry
Wolf Pen Creek Oversight
Committee
O Chris Scotti
O Marsha Sanford
O Sharon Colson
O Marc Chaloupka
O Jodi Warner
EIS 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 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.
6.
Signature of person doing business with the governmental entity
Date
Adopted 01/13/06
CONFLICT 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 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.
Elliott Construction,LTD
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.
❑ Glenn Brown, City Manager
❑ Robert Alley, Fire Chief
El Pete Caler, Landfill Mgr.
❑ David Gwin, Economic Dev.
El David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
❑ Terry Childers, Deputy City Mgr
❑ Steve Beachy, Parks & Rec
❑ Harvey Cargill, City Attorney
❑ Connie Hooks, City Secretary
El Becky Nugent, Public Relations
❑ Mark Smith, Public Works
El John Woody, W/WW
❑ Kathy Merrill, Asst. City Mgr.
❑ Ben Roper, Inf. Tech.
❑ Michael Clancey, Police Chief
❑ Jeff Kersten, Chief Fin.Officer
❑ Julie O'Connell, Human Resources
❑ Ed Spillane, Municipal Judge
❑ NONE
Describe each affiliation or business relationship with an employee checked in Question 3 above:
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.
❑ Ben White, Mayor
❑ Ron Gay, Place 3
❑ David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
❑ OPEN, Place 1
❑ Lynn Mcllhaney, Place 4
Lel NONE
O James Massey, Place 2
❑ Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
❑ Larry Ringer, Chairman
❑ Mary Fran Troy
❑ Sonio Margarita Gangotena
❑ Sarah Adams, Chair
❑ James Batenhorst
❑ David Chester
❑ Donald Braune
❑ Dan B. Sears, Chairman
❑ Mike Lane
❑ Steve Parker, alternate
a NONE
B/CS Library Committee
❑ Katherine Edwards
O Jeanne Mitchell
O James Bradford
Cemetery Committee
❑ Virginia Reese
❑ Weldon Kruger
❑ RC Slocum
® NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ Frank Cox
❑ Larry D. Patton
❑ Glenn Thomas, alternate
❑ Don Scherr
❑ B. Carroll Johnson
tt1 NONE
❑ Kevin Myers
❑ Joe Wallace
❑ James Matson
❑ David Hart
❑ Charles Thomas, alternate
❑ Quinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
® NONE
Historic Preservation Committee
O Bill Lancaster
❑ Jane Hughey
❑ Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Tedi Ellison ❑ J. Kevin Byrne ❑ Deborah Deitering
❑ Rusleen Maurice ❑ Reba Ragdale ❑
® NONE
❑ Jodi Warner, Chair
❑ Shawn Rhodes
❑ John Crompton
i7 NONE
❑ John Nichols, Chair
❑ Marsha Sanford
❑ Harold Strong
❑ Rick Heaney
❑ Alan King
❑ Susie Cox, alternate
❑ Jay Goss, Chair
❑ Denise Whisenant
12c1 NONE
Parks and Recreation Board
❑ Kathleen Ireland
❑ Jody Ford
❑ Harry Green
Planning and Zoning
Commission
❑ Glenn Schroeder
❑ Dennis Christiansen
0 NONE
Design Review Board
❑ Hunter Goodwin
❑ Ward Wells
❑ Robert Rayburn, alternate
Zoning Board of Adjustments
❑ Joshua Benn
❑ Donald Braune
❑ Joan Perry
❑ Gary Thomas
El Gary Erwin
❑ Derek Dictson
❑ Bill Davis
❑ Nancy Sawtelle
❑ John Nichols
tJ NONE
❑ John Richards
❑ Thomas Mather
❑ Larry Hodges
O Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
❑ Don Lewis
❑ Gregg Baird
❑ Chad Jones
❑ Stephen Syptak, Chair
O Tom Kirkland
Li NONE
❑ Hugh Lindsay, Area I
❑ John Crompton, Area II
❑ Steve Arden, Area III
❑ Hugh Stearns, Area IV
❑ Andrew Burleson, Student Resident
❑ Dorthea Robinson, Alternate,
ETJ Resident
❑ Chris Scotti, Councilmember
❑ Hillary Jessup, Historic
Preservation
❑ Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
❑ Larry Mariott
ll NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
Outside Agency Funding Review
❑ Charles Taylor
❑ Sheryl Welford
® NONE
Northgate Tax Increment
Finance Board
❑ David Scarmardo
❑ Glenn Thomas
Comprehensive Plan Committee
O John Richards, Area I
❑ Brian Bochner, Area II
❑ Laurie Corbelli, Area III
❑ Jerry Cooper, Area IV
O Kristina Campbell, Alternate,
Student Resident
❑ Craig Hall, Resident -At -Large
❑ Lynn Mcllhaney, Alternate,
Councilmember
❑ Gary Erwin, Parks & Rec
❑ Larry Haskins, Northgate
District Assoc.
❑ Chris Scotti, Councilman
❑ Marc Chaloupka
® NONE
❑ Roger Reese
❑ Carolyn Berrow
❑ Anne Jackson
❑ Dale O'Reiley
❑ David Hart, Alternate, Area I
❑ Dennis Corrington, Alternate, Area II
❑ Tom Taylor, Alternate, Area III
❑ Adrian Williams, Alternate, Area IV
❑ Douglas Rape', ETJ Resident
❑ Mike Guido, Alternate,
Resident -At -Large
❑ Bill Davis, P&Z
❑ Kathleen Ireland, Parks & Rec
Alternate
❑ Bo Miles, Building & Land
Development
❑ Larry Marriott, Home Builders
Assoc.
❑ Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
❑ Linda LaSut, Intergovernmental
Comm/MPO
❑ Lindsey Guindi, Intergovernmental
Comm/Chamber of Commerce
❑ Rodney Weis, Intergovernmental
Comm/TAMU Transit
❑ Dr. Colleen Netterville,
Intergovernmental Comm/BISD
❑ Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
Comm/BVCOG
❑ Gary Arnold, Intergovernmental
Comm/Brazos County Sheriff
❑ Gary Teston, Intergovernmental
Comm/ Easterwood Airport
LII 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.
❑ Lynn Mcllhaney
❑ Mayor
❑ Mayor
❑ Lynn Mcllhaney
❑ Mayor
❑ Ron Silvia
DI NONE
❑ Ron Gay
Di NONE
Brazos County Health
Department
0 Ben White ® NONE
Brazos Valley Council of
Governments
® NONE
B/CS Metropolitan Planning
Organization
® NONE
BVCOG TMPA Regional Park
Project Advisory Board
I NONE
BVSWMA Policy Advisory
Board
O Chris Scotti
City Center Committee
O Ben White
Intergovernmental Committee
❑ Ben White
® NONE
❑ Dave Ruesink
0 John Happ
❑ Dave Ruesink
12 NONE
Joint City/School
Intergovernmental Committee
0 Ben White 0 John Happ
Sister Cities Association
❑ Dave Ruesink ® NONE
❑ Ron Gay
❑ Ken Fogle
❑ Michael Parker, BVCOG
❑ Ron Gay
❑ John Nichols
O Joan Perry
Transportation Committee
❑ John Happ
❑ Linda LaSuit, MPO
❑ Bryan Woods, TxDOT
Wolf Pen Creek Oversight
Committee
❑ Chris Scotti
❑ Marsha Sanford
❑ Sharon Colson
❑ Lynn Mcllhaney
❑ Dennis Christianson, TTI
❑ NONE
❑ Marc Chaloupka
❑ Jodi Warner
If NONE
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
FORM CIQ
This Section item 5 including subparts A, B, C & D, must be completed for each o
off
with whom the filer
has affiliation or other relationship. Attach additional pages to this Form CIQ as nec
5. Name of local government officer with whom filer has affiliation or business
this section only if the answer to A, B, or C is YES.
essary.
relationship. (Complete
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.
6.
Signature of person doing business with the governmental entity
8-2-07
Date
Adopted 01/13/06
CONFLICT 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 atter 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.
Elliott Construction, LTD
2.
FORM CIQ
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 tiling 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.
❑ Glenn Brown, City Manager ❑ Terry Childers, Deputy City Mgr ❑ Kathy Merrill, Asst. City Mgr.
❑ Robert Alley, Fire Chief ❑ Steve Beachy, Parks & Rec ❑ Ben Roper, Inf. Tech.
❑ Pete Caler, Landfill Mgr. ❑ Harvey Cargill, City Attorney ❑ Michael Clancey, Police Chief
❑ David Gwin, Economic Dev. ❑ Connie Hooks, City Secretary ❑ Jeff Kersten, Chief Fin.Officer
❑ David Massey, Electric ❑ Becky Nugent, Public Relations ❑ Julie O'Connell, Human Resources
❑ Bob Cowell, Planning & Dev ❑ Mark Smith, Public Works ❑ Ed Spillane, Municipal Judge
❑ Cheryl Turney, Purchasing Mgr. ❑ John Woody, W/WW n NONE
Describe each affiliation or business relationship with an employee checked in Question 3 above:
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 Ben White, Mayor
O Ron Gay, Place 3
0 David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
O OPEN, Place 1
O Lynn Mcllhaney, Place 4
54 NONE
O James Massey, Place 2
D Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
B/CS Library Committee
O Katherine Edwards
O Larry Ringer, Chairman
O Mary Fran Troy
• Sonio Margarita Gangotena
O Sarah Adams, Chair
O James Batenhorst
0 David Chester
0 Donald Braune
O Dan B. Sears, Chairman
O Mike Lane
O Steve Parker, alternate
a NONE
O Jeanne Mitchell
O James Bradford
Cemetery Committee
O Virginia Reese
O Weldon Kruger
O RC Slocum
Il NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
O Frank Cox
Larry D. Patton
O Glenn Thomas, alternate
O Don Scherr
O B. Carroll Johnson
ll NONE
O Kevin Myers
O Joe Wallace
O James Matson
O David Hart
O Charles Thomas, alternate
O Quinn Williams
llillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
3� NONE
Historic Preservation Committee
❑ Bill Lancaster
O Jane Hughey
❑ Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Tedi Ellison ❑ J. Kevin Byrne ❑ Deborah Deitering
❑ Rusleen Maurice ❑ Reba Ragdale ❑
Xl NONE
❑ Jodi Warner, Chair
❑ Shawn Rhodes
John Crompton
t�T NONE
❑ John Nichols, Chair
❑ Marsha Sanford
❑ Harold Strong
❑ Rick Heaney
❑ Alan King
❑ Susie Cox, alternate
Jay Goss, Chair
Li Denise Whisenant
❑ NONE
Parks and Recreation Board
❑ Kathleen Ireland
❑ Jody Ford
❑ Harry Green
Planning and Zoning
Commission
❑ Glenn Schroeder
❑ Dennis Christiansen
i NONE
Design Review Board
❑ Hunter Goodwin
❑ Ward Wells
❑ Robert Rayburn, alternate
Zoning Board of Adjustments
❑ Joshua Benn
O Donald Braune
❑ Joan Perry
❑ Gary Thomas
❑ Gary Erwin
❑ Derek Dictson
❑ Bill Davis
❑ Nancy Sawtelle
❑ John Nichols
12 NONE
❑ John Richards
❑ Thomas Mather
Li Larry !lodges
D Glenn Brown, City Manager
CI Sharon Colson, Chair
Li Kenny Mallard
11 Don Lewis
lit L-..] Gregg Baird
-
LI Chad Jones
4..
F.] Stephen Syptak, Chair
111 Tom Kirkland
k1 NONE
O Hugh Lindsay, Area I
El John Crompton, Area II
D Steve Arden, Area III
1 Hugh Stearns, Area IV
Andrew Burleson, Student Resident
LI Dorthea Robinson, Alternate,
ETJ Resident
['I Chris Scotti, Councilmember
LI I lillary Jessup, Historic
Preservation
LI Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
O Larry Mariott
I NONE
Wolf Pen Creek TIF Board
O Marsha Sanford, Vice Chair
O James Massey
Outside Agency Funding Review
O Charles Taylor
CI Sheryl Welford
FM NONE
Northgate Tax Increment
Finance Board
O David Scarmardo
O Glenn Thomas
Comprehensive Plan Committee
CI John Richards, Arca I
ID Brian Bochner, Area 11
O Laurie Corbelli, Area III
0 Jerry Cooper, Area IV
O Kristina Campbell, Alternate,
Student Resident
LI Craig Hall, Resident -At -Large
CI Lynn McIlhaney, Alternate,
Councilmember
O Gary Erwin, Parks & Rec
CI Larry Haskins, Northgate
District Assoc.
0 Chris Scotti, Councilman
CI Marc Chaloupka
EX NONE
0 Roger Reese
CI Carolyn Berrow
CI Anne Jackson
LI Dale O'Reiley
LI David Hart, Alternate, Area I
O Dennis Corrington, Alternate. Area it
Cl Tom Taylor, Alternate, Area III
El Adrian Williams, Alternate. Area IV
O Douglas Rape', ETJ Resident
CI Mike Guido, Alternate,
Resident -At -Large
El Bill Davis, P&Z
O Kathleen Ireland, Parks & Rec
Alternate
0 Bo Miles, Building & Land
Development
Ill Larry Marriott, Home Builders
Assoc.
111 Tcdi Ellison, Intergovernmental
Comm/Chamber of Commerce
0 James Massey, Intergovernmental
Comm/TAMU Admin
111 Dr. Clark Ealy, Intergovernmental
Comm/CS I SD
0 Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
0 Linda LaSut, Intergovernmental
Comm/MPO
0 Lindsey Guindi, Intergoverhmental
Comm/Chamber of Commerce
El Rodney Weis, Intergovernmental
Comm/TAMU Transit
1:1 Dr. Colleen Netterville,
Intergovernmental Comm/BISD
0 Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
0 Chad Bohne, Intergovernmental
Comm/TxDOT
0 Michael Parks, Intergovernmental
Comrn/BVCOG
El Gary Arnold, Intergovernmental
Comm/Brazos County Sheriff
0 Gary Teston, Intergovernmental
Comm/ Easterwood Airport
(56 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.
❑ Lynn Mclihaney
❑ Mayor
❑ Mayor
❑ Lynn Mcllhaney
❑ Mayor
❑ Ron Silvia
1 NONE
❑ Ron Gay
K1 NONE
Brazos County Health
Department
❑ Ben White Il NONE
Brazos Valley Council of
Governments
1 NONE
B/CS Metropolitan Planning
Organization
E NONE
BVCOG TMPA Regional Park
Project Advisory Board
• NONE
BVSWMA Policy Advisory
Board
❑ Chris Scotti
City Center Committee
❑ Ben White
Intergovernmental Committee
❑ Ben White
® NONE
❑ Dave Ruesink
❑ John Happ
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 he 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
tiler of the questionnaire?
Yes
No
N/ A
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
No
N/ A
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
No
D. Describe each affiliation or business relationship.
6.
NIA
N/A
511;7)-7/7/
Signature of person doing business with the governmental entity
Date
Adopted 01/13/06
LI Dave Ruesink
KJ NONE
Joint City/School
Intergovernmental Committee
El BeneWhite 0 John Happ
Sister Cities Association
0 Dave Ruesink I/ NONE
O Ron Gay
O Ken Fogle
D Michael Parker, BVCOG
O Ron Gay
O John Nichols
0 Joan Perry
Transportation Committee
John Happ
LI Linda LaSuit, MPO
0 Bryan Woods, Tx DOT
Wolf Pen Creek Oversight
Committee
O Chris Scotti
O Marsha Sanford
D Sharon Colson
LI Lynn Mcllhaney
El Dennis Christianson, TTI
KJ NONE
0 Marc Chaloupka
0 Jodi Warner
J 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 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.
5csi. /iAzi#4- #
2.
OFFICE USE ONLY
1
Date Received
2-07-06A10:50 RCVD
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
❑ Steve Beachy, Parks & Rec
O Glenn Brown, City Manager
O Olivia Burnside, Inf. Tech.
❑ Pete Caler, Landfill Mgr.
❑ Harvey Cargill, City Attorney
❑ John Woody, Utilities
❑ Michael Clancey, Police Chief
❑ Joey Dunn, Planning & Dev
O Don Fazzino, Legislative Liason
O Kim Foutz, Economic Dev
❑ Connie Hooks, City Secretary
❑ Jeff Kersten, Finance
NONE
❑ Charles McLemore, Public Works
❑ Becky Nugent, Public Relations
❑ Julie O'Connell, Human Resources
❑ Mark Smith, Public Works
❑ Ed Spillane, Municipal Judge
❑ Cheryl Turney, Purchasing Mgr.
Describe each affiliation or business relationship with an employee checked in Question 3 above:
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
O Ron Gay, Place 3
❑ Nancy Berry, Place 6
City of College Station Elected Officials
College Station City Council
❑ Ben White, Place 1 ❑ John Happ, Place 2
❑ Susan Lancaster, Place 4 0 Chris Scotti, Place 5
jX1( NONE
City of College Station Committees, Boards, and Commissions
B/CS Library Committee
❑ Larry Ringer, Chairman ❑ Katherine Edwards 0 Don Scherr
O Eric Miller ❑ Jeanne Mitchell ❑ Jo Berg
❑ Lois Koontz ❑ James Bradford ' NONE
Cemetery Committee
❑ Sarah Adams, Chair ❑ Virginia Reese
❑ James Batenhorst ❑ Mary Lind Bryan
❑ David Chester %NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ Kevin Myers
❑ Joe Wallace
O Dan B. Sears, Chairman 0 George McLean, Vice Chair ❑ Frank Cox
❑ Mike Lane ❑ Larry D. Patton ❑ David Hart, alternate
❑ Steve Parker, alternate ❑ David Ruesink, alternate ,NONE
❑ Karen Kasper, Merchant
❑ Joey Dunn, Dir. Planning & Dev
NONE
Facade Improvement Program
Advisory Committee
❑ Valerian Miranda, Architect ❑ Rick Lemmons, Business Owner
❑ Robert Mosley, City Engineer ❑ Eric Barton, CD Coordinator
❑ Hillary Jessup, Chairman
❑ Marguerite Anthony
❑ Thomas Taylor
❑ Colleen Risinger
❑ Rebecca Eplen
❑ Rusleen Maurice
12( NONE
El Kathleen Ireland
❑ Carol Blaschke
❑ John Crompton
lEr NONE
❑ Scott Shafer, Chairman
❑ Marsha Sanford
❑ Harold Strong
❑ Rick Heany
❑ Alan King
❑ Susie Cox, alternate
❑ Jay Goss, Chair
❑ Graham Sheffy
El Denise Whisenant
Historic Preservation Committee
❑ Bill Lancaster
❑ David Ruesink
❑ Ernie Wright
%NONE
Joint Relief Funding Review
Committee
❑ J. Kevin Byrne
❑ Charlotte Mikulee
Parks and Recreation Board
❑ Glenn Schroeder
❑ Jeannie McCandless
El Harry Green
Planning and Zoning
Commission
El John Nichols
❑ Dennis Christiansen
121: NONE
Design Review Board
El Hunter Goodwin
❑ Ward Wells
El Robert Rayburn, alternate
Zoning Board of Adjustments
❑ Joshua Benn
❑ Donald Braune
❑ Derek Dictson
❑ Marsha Crenwelge
❑ Dipankar Sen
❑ Neal Nutall, Jr
❑ Mary Sherwood
El Peggy Samson
❑ Jodi Warner
❑ Gary Thomas
El Gary Erwin
❑ l Ken Reynolds
❑ Bill Davis
El Nancy Sawtelle
El Scott Shafer
T'S' NONE
❑ John Richards
❑ Charles Taylor
X( NONE
❑ David Hickson
❑ Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
Research Valley Partnership
Board of Directors
❑ Larry Mariott
,181 NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
Cl Chris Scotti, Councilman
❑ Marc Chaloupka
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.
Brazos County Health
Department
❑ Susan Lancaster ❑ Nancy Berry NONE
Brazos Valley Council of
Governments Board of Directors
❑ Ron Silvia, Mayor X NONE
B/CS Metropolitan Planning
Organization
❑ Ron Silvia, Mayor PeNONE
BVCOG TMPA Regional Park
Project Advisory Board
❑ Susan Lancaster NONE
BVSWMA Policy Advisory
Board 1�
O Ron Silvia, Mayor 0 Susan Lancaster ,&] NONE
❑ Ron Silvia
le NONE
❑ Nancy Berry
1J NONE
❑ Nancy Berry
NONE
City Center Committee
❑ Ben White ❑ Nancy Berry
Intergovernmental Committee
0 Ben White 0 John Happ
Joint City/School
Intergovernmental Committee
❑ Ben White 0 John Happ
Sister Cities Association
El Ron Gay NONE
Transportation Committee
Cl Ron Gay ❑ John Happ
❑ Linda LaSuit, MPO ❑ Dennis Christianson, TTI
El Bryan Woods, TxDOT 'NONE
❑ Ken Fogle
❑ 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
•
•
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 C.IQ 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
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
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
No
D. Describe each affiliation or business relationship.
6.
Signature of person doing business with the governmental entity Date
Adopted 01/13/06