HomeMy WebLinkAbout2021 05 05 Steve Rockey CIS_CIQ Luxury Event Trailers - Texas Outhouse AgreementLOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg-, Regular Session.
OFFICEUSEONLY
This is the notice to the appropriate local governmental entity that the following local
Date ♦3er N
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government officer has become aware of facts that require the officer to file this statement
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in accordance with Chapter 176, Local Government Code.
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1 Name of Local overnmen 051er
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2 Office Held
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3 Name of ve or described by Sections 176.001(7) and 176.003(a), Local Government
Code
4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3. _ / d N
5 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
V1l N
Datccepted Description of Gift
Date Gift Accepted cription of
Date Gift Accepted escription of Gift
(attach additional forms as necessary
6 SIGNATURE I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the disclosure applies
to each family member (as defined by Section 176.001(2), Local Gtoiinlr ent Code) /this local government officer. I
also acknowledge that this statement covers the 12-month per bed by Se 'ion 176.003(a)(2)(B), Local
Government Code.
Signature of Local Gov rnment Officer
Please complete either option below:
;dETICIA C BRYSCH
M. EXPIRES 12-04-2022
NOTARY ID 12593027-0
Sworn to a d subscri efore me(&byle— this the ay of20
toce is ..tnseal of off
Signature of officer ini tering oath rimed name of officer administering oat ttle of officer a iniste ng oath
(2) Unswom Declaration
My name is , and my date of birth is
My address is 11 ,
(street) (City) (state) (zip code) (country)
Executed in County, State of , on the day of 20
(month) (year)
Signature of Local Government Officer (Declarant)
Form provided by Texas Ethics Commission www. ethics. state. tx. us Revised 8/17/2020
LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT
Section 176.003 of the Local Government Code requires certain local government officers to file this form. A "local
government officer" is defined as a member of the governing body of a local governmental entity; a director, superintendent,
administrator, president, or other person designated as the executive officer of a local governmental entity; or an agent of
a local governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of a vendor.
This form is required to be filed with the records administrator of the local governmental entity not later than 5 p.m. on the
seventh business day afterthe date on which the officer becomes aware of the facts that require the filing of this statement.
A local government officer commits an offense if the officer knowingly violates Section 176.003, Local Government Code.
An offense under this section is a misdemeanor.
Refer to chapter 176 of the Local Government Code for detailed information regarding the requirement to file this form.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of the local government officer filing this statement
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code. Enter the name of
the vendor described by Section 176.001(7), Local Government Code, if the vendor: a) has an employment or other
business relationship with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A), Local Government Code; b) has given to the local government officer or a family member of the officer
one or more gifts as described by Section 176.003(a)(2)(B), Local Government Code; or c) has a family relationship with
the local government officer as defined by Section 176.001(2-a), Local Government Code.
4. Description of the nature and extent of each employment or other business relationship and each family
relationship with vendor named in item 3. Describe the nature and extent of the employment or other business
relationship the vendor has with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A), Local Government Code, and each family relationship the vendor has with the local government officer
as defined by Section 176.001(2-a), Local Government Code.
5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3 exceeds $100.
List gifts accepted during the 12-month period (described by Section 176.003(a)(2)(B), Local Government Code) by the
local government officer or family member of the officer from the vendor named in item 3 that in the aggregate exceed $100
in value.
6. Signature. Signature of local government officer. Complete this section after you finish the rest of this report. You.
have the option to either: (1) take the completed form to a notary public where you will sign above the first line that
says "Signature of Local Government Officer" (an electronic signature is not acceptable) and your signature will be
notarized, or (2) sign above both lines that say "Signature of Local Government Officer (Declarant)" (an electronic
signature is not acceptable), and fill out the unswom declaration section.
Local Government Code § 176.001(2-a): "Family relationship" means a relationship between a person and another
person within the third degree by consanguinity or the second degree by affinity, as those terms are defined by Subchapter
B, Chapter 573, Government Code.
Local Government Code § 176.003(a)(2)(A):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(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.
Form provided by Texas Ethics Commission www.ethics. state. tx. u s Revised all712020
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).
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Bylaw this questionnaire must be filed with the records administrator of the local governmental entity not later
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than the 71h business day after the date the vendor becomes aware of facts that require the statement to be •
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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. Aa
,
offense under this section is a misdemeanor.
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1 Name of vendor who has a business relationship with o�ca--1 governmental entity.
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2
Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you fit n u aced
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.)
3 Name of local government officer about whor fe Wormation is beIrng disclosed.
Name of Officer
AJ Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIO as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investtmmenlllt income, from the vendor?
IkYYYl Yes 1-1 No
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?
t�71
ElYes IXI No
6 Describe 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.
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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 1 .003(a)(2) ), excluding gifts described in Section 176.003(a-1).
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Signature ji doing business with the governmental entity gDate
Form provided by Texas Ethics Commission www. ethics. state.tx. us Revised 1/l/2021
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
A complete copy of Chapter 176 of the Local Government Code maybe 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 § 176.0010-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:
v' (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 4176.003(a)(2)(A) and (B):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(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 S 176.006(a) and (a-1)
(a) Avendor 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 1/1/2021