03/29/2016
INSTRUCTIONS FOR
CONFLICTS OF INTEREST QUESTIONNAIRE
[Form CIQ]
Chapter 176 of the Texas Local Government Code requires vendors who wish to conduct business or
be considered for business with a city to file a “conflict of interest questionnaire.” The Texas Ethics
Commission (TEC) created the conflict of interest questionnaire (Form CIQ).
Who must complete and filed CIQ form?
Every vendor doing business with the City or seeking to do business with the City must complete Box
1 and sign and date in Box 7. Whether or not a conflict exists determines the other information to
include on the form.
Who is a vendor?
The term “vendor” includes a partnership, corporation or other legal entities, including those
performing professional services. Partnerships or corporations act through individuals, but it is the
partnership or corporation that is doing business with or seeking to do business with the City.
If the vendor seeking to do business with the City is a sole proprietorship, then just the name of the
person who is the vendor is needed.
What triggers the requirement to file the Form CIQ?
When a vendor (or an agent of the vendor) begins (1) contract discussions or negotiations with the city
or (2) submits an application, quote, response to request for proposals or bids, or anything else that
could result in an agreement (contract or purchase order) with the City, Form CIQ must be completed.
Whether the vendor initiates the discussion or the City initiates the discussions, Form CIQ must be
completed. The monetary amount or value of the contract/purchase does not matter. The contract or
purchase may involve the sale or purchase of property, goods, or services with the City of Waco
When does a conflict requiring disclosure exist? What has to be revealed?
A vendor shall file a completed conflict of interest questionnaire if the vendor has a business
relationship with the City of Waco and the vendor:
(1) has an employment or other business relationship with an officer of the City of Waco, or a
family member of an officer, that results in taxable income exceeding $2,500 during the 12
month period preceding the date a contract/purchase is executed or a contract/purchase is
being considered; or
(2) has given an officer of the City of Waco, or a family member of an officer, one or more
gifts with the aggregate value of more than $100 in the 12 month period preceding the date
a contract/purchase is executed or a contract/purchase is being considered
(3) has a family relationship with an officer of the City of Waco.
What family relationships create a conflict?
A “family member" is a person related to another person within the first degree by consanguinity
(blood) or affinity (marriage), as described by Subchapter B, Chapter 573, Texas Government Code.
The ending of a marriage by divorce or the death of a spouse ends relationships by affinity created by
that marriage unless a child of that marriage is living, in which case the marriage is considered to
continue as long as a child of that marriage lives.
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, Texas Government Code.
03/29/2016
Who are officers of the City of Waco?
Officers are the members of the Waco City Council, the City Manager, and any agent or employee
who exercises discretion in the planning, recommending, selecting, or contracting with a vendor. An
agent may include engineers and architects, as well as others, who assist the City is making a decision
on some contract or purchase.
When must a vendor file the conflict of interest questionnaire?
No later than seven days after the date the vendor: (a) begins contract discussions or negotiations with
the city, or (b) submits an application or response to a request for proposals or bids, correspondence, or
another writing related to a potential agreement with a city, or (c) becomes aware of an employment or
other business relationship with an officer or family member of the officer that the vendor (i) has made
one or more gifts of more than $100 or (ii) has a family relationship with.
How do I go about filling out the Conflict of Interest Questionnaire form?
Section 1: Fill in the full name of the person or company who is trying to do business with the City. If
the “person” is a corporation, partnership, etc., then it is the name of that corporation, partnership,
etc., that is required on Form CIQ. If a sole proprietorship, then just the name of the individual is
needed. If the “person” is an individual acting as an agent for some other person or a company,
then it is the agent’s name. Any time an agent is involved, two FORM CIQs must be
completed and submitted: one for the agent, and one for the person or company that the agent
acted for. The agent’s FORM CIQ must note the vendor that the agent acted for.
Section 2: Check box if the form is an update to a form previously completed. Updates are required
by the 7th business day after an event that makes a statement in a previously filed questionnaire
incomplete or inaccurate. Updates are also required by September 1 of each year in which the
person submits a proposal, bid or response to the City of Waco or begins contract discussions or
negotiations with the City.
Section 3: Insert the name of the City of Waco officer with whom there is an affiliation to or business
relationship. If there is more than one City officer with whom there is an affiliation or business
relationship, a separate form should be completed for each officer.
Section 4: Check the “Yes” or “No” box in Section 4 A or B.
4.A: State whether the officer named on the form receives or is likely to receive taxable income,
other than investment income, from the vendor filing the questionnaire.
4.B: State whether the vendor receives or is likely to receive taxable income, other than
investment income, from or at the direction of the officer named on the form AND the
taxable income is not received from the City.
Section 5: Describe each employment or business relationship with the local government officer
named on the form.
Section 6: Check box to acknowledge gifts made that require disclosure.
Section 7. Person completing form must date and sign the form. If the form is being completed for a
corporation, partnerships, etc., the person signing should be someone who is authorized to act on
behalf of the corporation, partnership, etc.
A signature is required in box #4 regardless of any other entry on the form.
A copy of Chapter 176 of the Texas Local Government Code can be found at:
http://www.statutes.legis.state.tx.us/SOTWDocs/LG/htm/LG.176.htm
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
FORM CIQ
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who
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.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
Date Received
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?
Yes 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?
Yes No
7
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).
Signature of vendor doing business with the governmental entity
Date
Name of vendor who has a business relationship with local governmental entity.
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 the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
2
3
Name of local government officer about whom the information is being disclosed.
Name of Officer
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
CIQ as necessary.
4
6
5
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.
Insert name of vendor seeking to do business with the City of Waco
This includes the
vendor name even
if a conflict does
not exist
Insert name of officer with whom there is business, employment or family relationship. If no conflict, insert N/A.
Identify and describe the relationship, if applicable
Signature required -- so sign and date, even if no conflict
Complete A-B if a conflict exist
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
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:
***
(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.
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
FORM CIQ
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who
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.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
Date Received
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?
Yes 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?
Yes No
7
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).
Signature of vendor doing business with the governmental entity
Date
Name of vendor who has a business relationship with local governmental entity.
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 the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
2
3
Name of local government officer about whom the information is being disclosed.
Name of Officer
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
CIQ as necessary.
4
6
5
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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