CONFLICT OF INTEREST QUESTIONNAIRE

FORM E-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.

THIS FORM IS ONLY FOR PERSONS WHO ARE SEEKING CONTRACTS OR TO DO BUSINESS WITH THE CITY OF ABILENE, THE ECONOMIC DEVELOPMENT CORPORATION OF ABILENE, OR CIVIC ABILENE.

IT IS NOT AN AUTHORIZATION TO BE PLACED ON THE CITY’S VENDOR LIST, TO CONDUCT BUSINESS WITHIN THE CITY OF ABILENE, OR TO SOLICIT WITHIN THE CITY.

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 commits 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. 

    First Name:       

    MI:                        

    Last Name:  

2.  Are you filing an update to a previously filed questionnaire?

        Yes                  No

(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.

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.

This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business relationship.

 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.

NOTE:  If you have additional officers with whom the filer has affiliation or business relationship, please complete another form.  Do this for each officer named in Question 3 or 4.

6.  Describe any other affiliation or business relationship that might cause a conflict of interest.

7.  Electronic Certification

Please fill this online signature form out completely. Do not fax or mail it to us--just click the "Submit Form" button below.

I,    , hereby swear or affirm that I completed the online Form CIQ on   (mm/dd/yy). 

I understand that by clicking the “Submit Form” button below, I am submitting Form CIQ to the City of Abilene and hereby represent that the information provided by me is true and correct.  A false statement or misrepresentation by me may result in disqualification to transact business with the City of Abilene in the future and may subject me to penalties under Chapter 176 of the Texas Local Government Code.


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