Disclosure Conflict of Interest Statement (Word)利益冲突声明披露（字）

Disclosure Conflict of Interest Statement (Word)利益冲突声明披露（字） 5.0.0 DISCLOSURE: CONFLICT OF INTEREST STATEMENT SPRING BRANCH INDEPENDENT SCHOOL DISTRICT – PURCHASING DEPARTMENT Notice to Vendors: Conflict of Interest Questionnaire Required by Chapter 176 of the Texas Local Government Code Effective January 1, 2006, any person or entity who contracts of seeks to contract with SBISD for the sale or purchase of property, goods, or services (as well as agents of such persons) (hereafter referred to as Vendors) are required to file a Conflict of Interest Questionnaire with the District. Each covered person or entity who seeks to or who contracts with SBISD is responsible for complying with any applicable disclosure requirements. SBISD will post the completed questionnaires on its website. The Conflict of Interest Questionnaire must be filed: No later than the seventh business day after the date that the Vendor begins contract discussions or negotiations with the government entity, or submits to the entity an application, response to a request for proposal or bid, correspondence, or other writing related to a potential agreement with the entity. The Vendor also shall file an updated questionnaire not later than September 1 of each year in which a covered transaction is pending, and the seventh business day after the date of an event that would make a statement in the questionnaire incomplete or inaccurate. The Conflict of Interest Questionnaire may be downloaded from the SBISD website at Completed form should be sent to: Spring Branch Independent School District Attn: Purchasing Department 1031 Witte Road, Building E Houston, Texas 77055-6016 Phone: 713.365.5223 C:\convert\temp\726886386.doc/adm 5.0.0 DISCLOSURE: CONFLICT OF INTEREST STATEMENT, continued CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity OFFICE USE ONLY This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. Date Received 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. Name of person doing business with local governmental entity. 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.) Name each employee or contractor of the local governmental entity who makes recommendations to a local government officer of the governmental entity with respect to expenditures of money AND describe the affiliation or business relationship. DUNCAN F. KLUSSMANN, Ed.D, SUPERINTENDENT OF SCHOOLS KAREN WILSON, ACTING ASSOCIATE SUPERINTENDENT, FINANCE BARBARA A. ROBILLARD, DIRECTOR OF PURCHASING JOHN W. KNOWLTON, MANAGER OF PURCHASING AND TEXTBOOKS GENE HORROCKS, SENIOR PURCHASING SPECIALIST Name each local government officer who appoints or employs local government officers of the governmental entity for which this questionnaire is filed AND describe the affiliation or business relationship. DUNCAN F. KLUSSMANN, Ed.D, SUPERINTENDENT OF SCHOOLS Adopted 11/02/2005 C:\convert\temp\726886386.doc/adm Page 3 of 21 5.0.0 DISCLOSURE: CONFLICT OF INTEREST STATEMENT, continued CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity Page 2 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 other 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 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. Signature of person doing business with the governmental entity Date Adopted 11/02/2 C:\convert\temp\726886386.doc/gh 2013-11-17 12:32 PM C:\convert\temp\726886386.doc/adm