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 commits 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

           entity.

       Gwendolyn w. Santiago, Executive Director

    Texas Association of School Business Officials 12

                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.)

                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

               expenditures of  money.

None

             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.

None

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor or other person doing business with local governmental entity

         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.)

       
        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. Attach additional pages to this Form CIQ as necessary.

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 serve
as an officer or director, or holds an ownership of 10 percent or more?

                                            Yes             X        No

          D. Describe each affiliation or business relationship.

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

                                                                                                                                                                                   Date