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HomeMy WebLinkAboutOffice MaxCONFLICT 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. l 1,4- 1. Name of person doing business with local governmental entity. 2. FORM CIQ OFFICE USE ONLY Date Received H/ 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. LI David Gwin, Economic Dev. ❑ David Massey, Electric ❑ Lance Simms, 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 ❑ John Woody, W/WW ❑ Kathy Merrill, Asst. City Mgr. ❑ Olivia Burnside, 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. ❑ Ron Silvia, Mayor ❑ Ron Gay, Place 3 ❑ David Ruesink, Place 6 City of College Station Elected Officials College Station City Council ❑ Ben White, Place 1 ❑ Lynn Mcllhaney, Place 4 1YNONE ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions ❑ Larry Ringer, Chairman ❑ Mary Fran Troy ❑ Jennifer Bohac ❑ Sarah Adams, Chair ❑ James Batenhorst ❑ David Chester ❑ Donald Braune ❑ Dan B. Sears, Chairman ❑ Mike Lane ❑ Steve Parker, alternate ONE B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell ❑ James Bradford Cemetery Committee ❑ Virginia Reese ❑ Weldon Kruger ❑ RC Slocum P'NONE Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Frank Cox ❑ Larry D. Patton O Glenn Thomas, alternate O Don Scherr O B. Carroll Johnson EI—NONE ❑ Kevin Myers O Joe Wallace ❑ James Matson O David Hart O Charles Thomas, alternate O Quinn Williams ❑ Hillary Jessup, Chairman ❑ Haskell Monroe ❑ Ernie Wright E 1VONE ❑ Rebecca Eplen ❑ Rusleen Maurice kr-NONE ❑ Jodi Warner, Chair O Shawn Rhodes ❑ John Crompton L9� ONE Historic Preservation Committee ❑ Bill Lancaster ❑ Jane Hughey ❑ Neal Nutall, Jr. Joint Relief Funding Review Committee ❑ J. Kevin Byrne ❑ Charlotte Mikulee Parks and Recreation Board ❑ Kathleen Ireland ❑ Jody Ford ❑ Harry Green Planning and Zoning Commission ❑ John Nichols, Chair 0 Glenn Schroeder ❑ Marsha Sanford 0 Dennis Christiansen ❑ Harold Strong P -NONE Design Review Board ❑ Marguerite Anthony ❑ Meredith Waller ❑ Colleen Risinger ❑ Deborah Deitering ❑ Peggy Samson ❑ Joan Perry ❑ Gary Thomas ❑ Gary Erwin ❑ Derek Dictson ❑ Bill Davis O Rick Heany 0 Hunter Goodwin 0 Nancy Sawtelle ❑ Alan King ❑ Ward Wells ❑ John Nichols ❑ Susie Cox, alternate 0 Robert Rayburn, alternate -NGNE ❑ Jay Goss, Chair ❑ Denise Whisenant E NONE Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune ❑ John Richards ❑ Thomas Mather { ❑ Larry Hodges O Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard ❑ Don Lewis ❑ Gregg Baird ❑ Chad Jones O Stephen Syptak, Chair ❑ Tomh�Kirkland IidlNONE ❑ Hugh Lindsay, Area I ❑ John Crompton, Area II O Steve Arden, Area III ❑ Hugh Stearns, Area IV ❑ 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 VNONE 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 O David Scarmardo O Glenn Thomas Comprehensive Plan Committee ❑ John Richards, Area I ❑ Brian Bochner, Area II ❑ Laurie Corbelli, Area III O 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. O Chris Scotti, Councilman ❑ Marc Chaloupka dc'NONE ❑ Roger Reese ❑ Carolyn Ben -ow ❑ Anne Jackson ❑ Dale O'Riley ❑ David Hart, Alternate, Area I ❑ Dennis Corrington, Alternate, Arca 11 ❑ Tom Taylor, Alternate, Area III ❑ Adrian Williams, Alternate, Area N ❑ Douglas Rape', ETJ Resident ❑ Mike Guido, Alternate, Resident -At -Large ❑ Bill Davis, P&Z O Kathleen Ireland, Parks & Rec Alternate O Bo Miles, Building & Land Development O Larry Marriott, Home Builders Assoc. O Tedi Ellison, Intergovernmental Comm/Chamber of Commerce O James Massey, Intergovernmental Comm/TAMU Admin O Dr. Clark Ealy, Intergovernmental Comm/CSISD O Chuck Martinez, Intergovernmental Comm/ Research Valley Patnership O Linda LaSut, Intergovernmental Comm/MPO O Lindsey Guindi, Intergovernmental Comm/Chamber of Commerce O Rodney Weis, Intergovernmental Comm/TAMU Transit O Dr. Colleen Netterville, Intergovernmental Comm/BISD O Margie Lucas, Intergovernmental Comm/ Brazos Transit District O Chad Bohne, Intergovernmental Comm/TxDOT O Michael Parks, Intergovernmental Comm/BVCOG O Gary Arnold, Intergovernmental Comm/Brazos County Sheriff O Gary Teston, Intergovernmental Comm/ Easterwood Airport erI<IONE 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 McIlhaney 0 Ben White ' IONE Brazos Valley Council of / Governments O Ron Silvia, Mayor E NONE B/CS Metropolitan Planning Organization O Ron Silvia, Mayor l7 NONE BVCOG TMPA Regional Park Project Advisory Board O Lynn McIlhaney lid'NONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor 0 Chris Scotti 12tIONE City Center Committee ❑ Ron Silvia 0 Ben White 0 Dave Ruesink A7 NONE Intergovernmental Committee ❑ Ron Gay 0 Ben White 0 John Happ ONE O Dave Ruesink E610NE Joint City/School Intergovernmental Committee 0 Ben White 0 John Happ Sister Cities Association O Dave Ruesink grVONE Transportation Committee O Ron Gay 0 John Happ 0 Lynn McIlhaney O Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI O Michael Parker, BVCOG 0 Bryan Woods, TxDOT 4aNONE O Ron Gay Wolf Pen Creek Oversight Committee 0 Chris Scotti &IsiONE 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 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 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 busin ith 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 u der this section is a Class C misdemeanor. 1. Name Name of person doing business with local governmental entity. 2. FORM CIQ OFFICE USE ONLY Date Received 1. ---- 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. CI Glenn Brown, City Manager O Robert Alley, Fire Chief O Pete Caler, Landfill Mgr. 0 David Gwin, Economic Dev. O David Massey, Electric O Lance Simms, Planning & Dev O Cheryl Turney, Purchasing Mgr. 0 Terry Childers, Deputy City Mgr O Steve Beachy, Parks & Rec O Harvey Cargill, City Attorney O Connie Hooks, City Secretary El Becky Nugent, Public Relations O Mark Smith, Public Works O John Woody, W/WW El Kathy Merrill, Asst. City Mgr. O Olivia Burnside, Inf. Tech. O Michael Clancey, Police Chief O Jeff Kersten, Chief Fin.Officer O Julie O'Connell, Human Resources O Ed Spillane, Municipal Judge Eg-IcrONE 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 Ron Silvia, Mayor O Ron Gay, Place 3 O David Ruesink, Place 6 City of College Station Elected Officials College Station City Council O Ben White, Place 1 O Lynn Mcllhaney, Place 4 Er'NONE O John Happ, Place 2 O Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions O Larry Ringer, Chairman O Mary Fran Troy O Jennifer Bohac O Sarah Adams, Chair O James Batenhorst O David Chester O Donald Braune O Dan B. Sears, Chaiiman 0 Mike Lane O Steve Parker, alternate NONE B/CS Library Committee O Katherine Edwards O Jeanne Mitchell O James Bradford Cemetery Committee O Virginia Reese O Weldon Kruger 0 RC Slocum r1CIONE 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 /2KICIONE O Kevin Myers O Joe Wallace O James Matson O David Hart O Charles Thomas, alternate O Quinn Williams ❑ Hillary Jessup, Chairman E l Haskell Monroe El Ernie Wright ® NONE ❑ Rebecca Eplen El Rusleen Maurice ZONE El Jodi Warner, Chair ❑ Shawn Rhodes El John Crompton fAONE Historic Preservation Committee ❑ Bill Lancaster ❑ Jane Hughey ❑ Neal Nutall, Jr. Joint Relief Funding Review Committee ❑ J. Kevin Byrne El Charlotte Mikulee Parks and Recreation Board ❑ Kathleen Ireland ❑ Jody Ford ❑ Harry Green Planning and Zoning Commission ❑ John Nichols, Chair ❑ Glenn Schroeder El Marsha Sanford El Dennis Christiansen El Harold Strong RNONE Design Review Board ❑ Marguerite Anthony ❑ Meredith Waller ❑ Colleen Risinger ❑ Deborah Deitering El Peggy Samson ❑ Joan Perry ❑ Gary Thomas Cl Gary Erwin ❑ Derek Dictson ❑ Bill Davis ❑ l Rick Heany ❑ Hunter Goodwin El Nancy Sawtelle El Alan King El Ward Wells El John Nichols ❑ Susie Cox, alternate El Robert Rayburn, alternate 12'N--6-NE ❑ Jay Goss, Chair ❑ Denise Whisenant E NONE Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune El John Richards ❑ Thomas Mather ❑ Larry Hodges ❑ Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard ❑ Don Lewis ❑ Gregg Baird ❑ Chad Jones ❑ Stephen Syptak, Chair ❑ Tom Kirkland {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 ti -NONE Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ James Massey Outside Agency Funding Review ❑ Charles Taylor ❑ Sheryl Welford e ONE Northgate Tax Increment Finance Board ❑ David Scarmardo ❑ Glenn Thomas Comprehensive Plan Committee ❑ John Richards, Area I ❑ Brian Bochner, Area II ❑ Laurie Corbelli, Area III ❑ Jerry Cooper, Area IV ❑ 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 1C1ONE ❑ Roger Reese ❑ Carolyn Berrow ❑ Anne Jackson ❑ Dale O'Riley ❑ 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 O James Massey, Intergovernmental Comm/TAMU Admin O Dr. Clark Ealy, Intergovernmental Comm/CSISD ❑ Chuck Martinez, Intergovernmental Comm/ Research Valley Patnership O Linda LaSut, Intergovernmental Comm/MPO O Lindsey Guindi, Intergovernmental Comm/Chamber of Commerce ❑ Rodney Weis, Intergovernmental Comm/TAMU Transit ❑ Dr. Colleen Netterville, Intergovernmental Comm/BISD O 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 ONE 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 IKONE Brazos Valley Council of Governments O Ron Silvia, Mayor t2NONE B/CS Metropolitan Planning Organization O Ron Silvia, Mayor ®''NONE BVCOG TMPA Regional Park Project Advisory Board O Lynn Mcllhaney 21<ONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor 0 Chris Scotti EKSIONE City Center Committee ❑ Ron Silvia 0 Ben White 0 Dave Ruesink ZONE Intergovernmental Committee ❑ Ron Gay 0 Ben White 0 John Happ 'NOon/NE ❑ Dave Ruesink V! ONE Joint City/School Intergovernmental Committee ❑ Ben White ❑ John Happ Sister Cities Association ❑ Dave Ruesink ®'BONE Transportation Committee ❑ Ron Gay ❑ John Happ ❑ Lynn Mcllhaney ❑ Ken Fogle ❑ Linda LaSuit, MPO ❑ Dennis Christianson, TTI ❑ Michael Parker, BVCOG ❑ Bryan Woods, TxDOT ZONE ❑ Ron Gay Wolf Pen Creek Oversight Committee ❑ Chris Scotti LNONE Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 i 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 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 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 2 -G ---G7 Date Adopted 01/13/06 Form W'9 (Rev. November2005) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Name (as shown on your income tax return) OfficeMax Business name, if different from above Check appropriate Individual/Exempt Corporation ► • box: Sole 0 Partnership Other from backup proprietor withholding Address (number, street, and apt. or suite no.) 410 Harvey Road Requester's name and address (optional) City, state, and ZIP code College Station, TX 77840 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 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 Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Social security number II1-I+III or Employer identification number 314-1151713171315 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification 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 I 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 all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment 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.) Sign Signature of Here U.S. person ►` �la��G �!u Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. In 3 above, if applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. For federal tax purposes, you are considered a person if you are: Date ► 2 _ 6' 6 • An individual who is a citizen or resident of the United States, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or • Any estate (other than a foreign estate) or trust. See Regulations sections 301.7701-6(a) and 7(a) for additional information. Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: • The U.S. owner of a disregarded entity and not the entity, Cat. No. 10231X Form W-9 (Rev. 11-2005)