Form Ciq – Fill Out and Use This PDF

	CONFLICT OF INTEREST QUESTIONNAIRE	FORM CIQ
	For vendor doing business with local governmental entity
	This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.	OFFICE USE ONLY
	This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who
		Date Received
	has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the
	vendor meets requirements under Section 176.006(a).
	By law this questionnaire must be filed with the records administrator of the local governmental entity not later
	than the 7th business day after the date the vendor becomes aware of facts that require the statement to be
	filed. SEE Section 176.006(a-1), Local Government Code.

A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor.

1Name of vendor who has a business relationship with local governmental entity.

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 the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)

Name of Officer

A.Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor?

B.Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity?

5Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more.

6

Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).

7

	Signature of vendor doing business with the governmental entity			Date
Form provided by Texas Ethics Commission		www.ethics.state.tx.us			Revised 11/30/2015

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor doing business with local governmental entity

A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.

Local Government Code § 176.001(1-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on:

(A)a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity;

(B)a transaction conducted at a price and subject to terms available to the public; or

(C)a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency.

Local Government Code § 176.003(a)(2)(A) and (B):

(a)A local government officer shall file a conflicts disclosure statement with respect to a vendor if:

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(2)the vendor:

(A)has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that

(i)a contract between the local governmental entity and vendor has been executed;

or

(ii)the local governmental entity is considering entering into a contract with the vendor;

(B)has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that:

(i)a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor.

Local Government Code § 176.006(a) and (a-1)

(a)A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and:

(1)has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);

(2)has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or

(3)has a family relationship with a local government officer of that local governmental entity.

(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of:

(1)the date that the vendor:

(A)begins discussions or negotiations to enter into a contract with the local governmental entity; or

(B)submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or

(2)the date the vendor becomes aware:

(A)of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a);

(B)that the vendor has given one or more gifts described by Subsection (a); or

(C)of a family relationship with a local government officer.

Form provided by Texas Ethics Commission

www.ethics.state.tx.us

Revised 11/30/2015