CONFLICT OF INTEREST QUESTIONNAIRE FORMCIQ venetor or...CONFLICT OF INTEREST QUESTIONNAIRE FORMCIQ . For . venetor or . other person doing business with loe-al . govemm&ntal.nlJt~

CONFLICT OF INTEREST QUESTIONNAIRE FORMCIQ For venetor or other person doing business with loe-al govemm&ntal.nlJt~

OfFICe USE orfl.v

Local Government Coda by a porson doing business with the Thm questlonnalre is being flted In aooordanoo with chapter- 176 of lhe

(lrroRo....,?~(4

goYernmental entity. BV law 'hls qUQstlonnalr~ must be filed vAth .he rooords admin.i&tratot of 0'19 local government not lat4u 1.tIan tile 7th buslne9s day aftet the date I~ person becomes aworG of faels that require 'he ata'emont to be flied. See &o1lnH 1'76.000, Locol Government Code. A pGtson commits an Orr9nS9 Iflhe person \rmtates Secllon 176.006, Loctlll Governmen~ Code. An offense under this Sflctk>n Is. a Claso C miademeanor.

t Naml 011191'&0n dolno bUlilnG$S with lOcal goycwnl'Mt1tal enUty.

Char1es H. 'IIlJhite

:lI

D CbOi)k ihlt. boll If)lOu .re flilng 81\ updat& to II previously ftl8d quMUOnn41lr'h

(lhe llYN requll'ClB lhD1 you fI'o on updaClld ODmillewlt quoul*lnl)altlli Viilh lhl' ~&le<lPl1atJ)nIlAg8UU\Oflty 1'lOIIlal8r tn8n Sep;ember1of Ch. ye.nr F«whf(Jh 9n '101lvlly d'eWriboomSocUOn11e..ooe(liII). ()Cal Oovernment Codt.IQ psl'ld"tlg end DOt 11Ilot U)fJn tho 7th J:4l61ne.tlIJ cJliV ",f1~t 1M dll4BlhB nrfgl""lIv flied q4loslfannalro b8oom98Inoo~(J1o or ""nctJuUll>O',}

3 DRt"ribo Noh ."maUon or 1)~.IIlo<a. rGlaUollBhlp with an emploV-8 aroonC,..otor of thO l~u) ..1govemmlMtal ; oMny who mako rtcornmendatJGIlIa to e aocat gOYefnl11eJ'lt offl¢tr of ttlo lOe,1 g(WtllMMOntat enllty wllh l'ttllU'cl . to elq)lneJ'fu" 01 monel'. .

,

4 Deaeribe &uh alflllation or busI"".. ttlatlon.hlp Wfth l) pot,on who Ie ;II local government or"C41r and who appolnt8 Of emp4Q~' a'o(JLlIt gOYdrnmont o"loGr oJ ttl, 10(11' gtlllllrnrneniat et\tlIy that 18 thlt IvbJtet of t1tla q".~lonnalro.

I~

SNlkllOO-1HJ ",r.WIIl.SI.f 7a....... 11 Hul'll !ltK." (AdII.r.lultlll i_c.,nmD) ~19

CONFUCT OF INTEREST QUESTIONNAIRE For vondor or other person doing bUBlnltB8 wi1h 1000ai governmontal enUty

FORMCIQ Page2 .

fi. Name of local govemmenl 081011' wr.h """om mOt hat affl'll.t1Ot) 01' bLl"~'" WO'IMIol\'tN~. [COmpiott 'hit ••ction Clftt~~' the anawer to A. 81 or C fa .... es.)

lhls sec1100,. lIElm 5 Including Bubparla; A. 0, Ca. D, mil" b~ wm,pCl)ltld tar each otlioer vwilh wtlom t.J'rQ mar h$$ QlfilalJon or bu~eae. telallDf13ttlp, Attach Itddltfonaf pBga8 to thlJ ~oml CIQ88 nece9Bsry.

A. ~I$< O~ ro~l (JO'WImme~ olYJcm' named I" this oecl:ion rOO8Mng or IIke1y to ~ClI.IIV8 te~bl~ InClJmo fr(lm !he filer of thl) q~kHmlJ!(o?

o YQl/ '0 No

D, 1$ tiki f.fclr of 1ho qulJlSl.iunlto~lIrl1 roolJi'vinl,J Qr liicC)' lo.ceoh'u l.allulio rncorno rrolll or al ~ho dlroo1lun ut Iho!looul govlJ~tllnl»'1t ofllC(!Jr Ml'r'le<l fn (11i$ 6tlCU'QI'l AND tlte ti]l(elblO ~ll.come f3 ~ ffOfJl tlto loo~l iiIWOhlil'Gt'lI.ft1 ~~Y?

Dyos 0 No

C-. 1$11\0 fllOr <lIlhl8 ClUMlforwulltb MI1IIM~ 'M'(1_a corporaUon or olher ~$S(letls .,tl~W Ihlt1 UIG IOO~ll)(fflltnn~t o1JICGt 8(lr'\fe!!l tiS an OmO(lr or dlrec1or, or tlo'Xts on (lWI'lO'l'&l1lp ot to perotlnl ()t~?

6 D&9IIlrlbl!' any oUwr a1ti1~lon or buetnllsa relatlon.hlp that mfght C8UU 8 cOI1f1lct of In••ntst.

None

1

~%~t.,~.J MI. *._, .J'" .··J ... I ....

S~lllure {If p;t'~n 1:101110 bUW-9W WI1h 1119 9O'IWllm~1 ~,"Illy

Charles H.\Mlite, \lice President, Division Manager

t :tczla

212/10

S«,i1nOHJU (;Sf¥IO."'4 Vul .... 11 ~k;th ,,"icl..~ f,Alhldll,,""ll>ounl tIlTflll'jJ\l~.).(l

CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity

FORM CIQ

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

Dale Received

1 Name of person doing business with local governmental entity.

Gamma Construction

2

o Check this box if you are flIing an update to a previously flied questionnaire.

(The law requires that you file an updated completed questionnaire with the appropriate tiling 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.

Gamma Construction does not have any affiliation or business relationship with an employee or contractor of the local governmental entity.

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.

Gamma Construction does not have any 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.

Amended 01/1:Y2006 Amended 01/1312006

5

6

7


FORM CIQ 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 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 flier of the questionnaire?

DYes D 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?

DYes D 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?

DYes D No

D. Describe each affiliation or business relationship.

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

Gamma Construction does not have any other affiliation or business relationship that might cause a conflict of interest.

sittafure of person doing business with the governmental entity Date 2/0212010

2

3

4

I

CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmenta

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. Name of person doing business with local governmental entity.

Bart Cobb, ICI Construction, Inc.

D Check this box if you are filing an update to a previously filed questionnaire.

FORM CIQ mtityI I OFFICE USE ONLY

Dale Received

I

(The law requires that you file an updated completed questionnaire with the appropr"iClte filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Loca ~overnment Code, is pending and not later than the 7th business day after the date the originally filed questionnai'e becomes incomplete or inaccurate.)

Describe each affiliation or business relationship with an employee or contractor (f the local governmental entity who makes recommendations to a local government officer of the local gov rhmental entity with respect to expenditure of money.

None

Describe each affiliation or business relationship with a person who is a local gov~rnmentofficer and who appoints or employs a local government officer of the local governmental entity th~l is the subject of this questionnaire.

None

I'

Amended 01/1312000 Amended 01/1312000

5

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmenta entity Page 2

I Name of local government officer with whom filer has affiliation or business relau< r1ship. (Complete this section only if the answer to A, 8, or C is YES.) I

This section, item 5 including subparts A, B, C & D. must be completed for each officer'" ith whom the filer has affiliation or business relationship. Attach additional pages to this Form CIQ as necessary. I A. Is the local government officer named in this section receiving or likely to receive taxa Ie income from the filer of the questionnaire? i

DYes 5a No I

I

B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at hie direction of the local government officer named in this section AND the taxable income is not from the local 9 v:ernmental entity?

I II

DYes IX] No II

C. Is the filer of this questionnaire affiliated with a corporation or other business entity th t the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? I

DYes IX] No


None

6 Describe any other affiliation or business relationship that might cause a conflict <f1interest.

INone

7

Feb. 2, ?010 Signature of person doing business with the govemmental entity Da e


FORM CIQ


OFFICE USE ONLY

Date Received


Miner-Dederick Construction, LLP

2

o 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.)


Miner-Dederick does not have a conflict of interest with the Lone Star College System.

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.

Miner-Dederick does not have a conflict of interest with the Lone Star College System.

Amended 0111312006 Amended 01/1312006


FORM CIQ Page 2

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?

DYes 0 No


DYes o 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?

DYes o No


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

None

7

-----:;;/~~ Signature of person doing busin~s with the governmental entity

Thad S. Miner, CEOI

January 28, 2010 Date


FORM CIQ


OFFICE USE ONLY

Date Received

1 Name of person doing business with local govemmental entity.

Not applicable.

2

o Check this box if you are filing an update 10 a previously filed questionnaire.

(The law requires thaI you file an updaled 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 nollaler 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 govemmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money.

Not applicable.

4 Describe each affiliation or business relationship with a person who is a local govemment officer and who appoints or employs a local govemment officer of the local governmental entity that is the subject of this questionnaire.

Not applicable.

Amended 0111312006 Amended 01f1112008

Sec' ion 00 43 12 CSPIIIO-514 TombaU HC3llh Science (..... ddtndum HI issued 1/27/10) Page 19

7

6

5


FORM CIQ Page 2

Date

February 2, 2010

o No

o No

DYes

Dves

o Ves 0 No

Not applicable.


A. Is the local government officer named in this section receiving or lik.ely to receive taxable income from the filer of the questionnaire?

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?


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.

Signature of person doing business with the governmental enti~

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

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.)

Seelinn 00 43 12 CSP# 10·5)4 Tomboll He,hh Science (Add<ndum'\ isJuc:d In7n 0) Page 20

Martin - Harris - State Construction, aJoint Venture 14520 Wunderlich Dr., Suite 220

Houston, TX 77069-2836

Request for Competitive Sealed Proposal #10-514

LONE STAR COLLEGE SYSTEM 2008 BOND PROGRAM TOMBALL HEALTH SCIENCE BUILDING

TAB NO.3 Conflict of Interest Questionnaire

14520 Wunderlich Dr., Suite 220 • Houston, Texas 77069-2836.Telephone: (713) 849-1444. Fax: (713) 849-1410

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity

This queslionnaire is being filed in accordance with chapter 176 of the OFFICE USE ONLY

Local Government Code by a person doing busin ss with the Date ROCbivod

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.


Martin-Harris State Construction, A Joint Venture

2

o Check this box If you are filing an update to a previously filed questionnaire.

(The law requires thal you file an updated completed quesUonnalre with the appropriate filing aUl"orlty not laler than September 1 or 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 dale tho originally filed questionnaire becomes incomplete or inaccurate.)

3 Describe each affiliation or business relallonshlp wilh an employoo or contractor of the local govemmental entity who makes recommendations 10 a local governmont offIcer of the local govemmontal entity with respect to expenditure of money.

N/A

4 Describe each affiliation or business relationship-with a person who Is a local govemmont officer and who appoints or employs a local govern ment officer of the local governmental entity that is the subject of this questionnaire.

N/A

So.,ion ()(l ~3 12 C5P'10-314 Tomball H,~hh Science (Addel,dum MI ".ued 1/l7/10) PaBc 19

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity Page 2

5 Name of local govornment officer with whom filer has affiliation or businoss relationship. (Complete this section only if the answer to A. B, or C Is YES.) HIA

ThtS section, item 5 including sUbparts A, B, C & D. must be completed for eEd1 officer with whom the filer has affiliation or business relationship. Attach additional piJges 10 this Form CIQ as necessary,

A. Is the local government officer named In 1his section receiving or likely to receive taxable Income from the tiler of the questionnaire?

DYes 0 No

B. is the filor of 1he questionnaire receiving or likely to receive taxable Income from or at the direction of the local governmHnt officer named in this section AND the taxable income Is not from the !ocalgovemrnental entity?

DYes o No

C. Is the filer of this questionnaire affiliated with a corpora lion or other business entity that the local government officer serves as an officer or director. or holds an ownership of 10 percent or more?

DYes o No

D. Describe each affilialion or business relationship.

6 Doscribe any other affiliation or business relationship that might cause a conflict of Interest.

None

February 2, 2010 Dale

S\;CI~1Jn 00 ".'1, 12 C51'1110-l14 Tomb.1I He,lth So;.,,,,. (Addendum MI !os".d 1n7n 0) P.se 20

Tab 3: Conflict of Interest Questionnaire


FORMCIQ

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

Dale Received


Leslie B. Chipman eal Building and Construction, Ltd. dba TEAL CONSTRUCTION COMPANY

2


(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.)


None


None

Amended 01l13!2006 Amended 01/1lf2()(1)


FORM CIQ Page 2

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?

D Yes ~ No


DYes ~ No


DYes IKJ No


None

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

None

7

Signature of person doing business with the governmental entity

February 2, 2010 Date

1

2

3

4

CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity

OFFICE USE ONLY

Local Government Code by a person doing business with the This questionnaire is being filed in accordance with chapter 176 of the

Dale Received 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. Name of person doing business with local governmental entity.

The WhitIng-Turner Contracting CompanyI~ I?l-.o~


(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 expenditure of money.

N/A

Describe each affiliation or business relationship with a person who 18 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.

N/A

Amended 01r1311OOll Amended 01'1312OOl1

5

6

7

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 induding 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 govemment officer named in this section receiving or likely to receive taxable income from the filer of the . questionnaire?

D Yes X No


DYes X No

C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local govemment officer serves as an officer or director, or holds an ownership of 10 percent or more?

DYes X No


N/A

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

None

Signature of person doing business with the governmental entity

4

%S6=Cl T00: a6 E'd as SJSl:OI 29TL0bbT82 ;WOJ~ Wd2S:b0 0T02-20-83~

((., t' ,1wpmi,'ulaSS·

CONFLICT OF INTEREST

ICONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing b~5ine&s with local governmental entity

OFFICE USE ONLY

Local Government Code by a person doing business with the This questionnaire is being filed in accotdance with chapter 178 of the

Data Reooi~cd

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.

1 NamB of person doing business with local govemmental entity.

f'lI_A 1

o Cheek this box If you are filing an update to a previously filed quenonnaJre.

(The law requires that you file an updated colll)leted questionnaire with the appropriate filing authority not later th<ln September 1 of the year for which M activity described in Section 176.oo6(a), Local Government Code, is pending and not later than the 71h business day after the date the ongnally filed questionnaire bewmes incomplete or in accurate.)

3 Describe each affili.dion or business retationship with an employee or contractor of the local govermJe,dal entity who makes recommendations to a local governmentofficer of the lo~' governmental entity YJith respect to e.xpendituftl of money.E_=====_-_.-~

Describe each affiliation or businll" relaUonship with a person who 16 a local government officer and who appoints or employs a local government officer of the local govemmental entity that is the sUbject of this questionnaire.

E_A I

_01 'li11211l1l

Lone Sty College . Tmball HeNtn 5ciera Center

l 'd 6SS6 'C~

%S6=~ 200: d6 l?d as SJSl:OI 29lL01717m2 :wo,J~ Wd~S:170 0T02-20-83~ v'

q '-'1.•'-,na~,V( ~t'~~""~rJ ".; _1 .""u;<)

~

- - -

CONFLICT OF INTEREST QUESTIONNAIRE FORM cia For vendor or other person doing business with local govemmental entity Page 2

5 Name of local government officer with whom filer has affiliation or business relatiomthip. (Complete this section oJlly if the 3nswer to A, B, or C Is YES.)

This section, Item 5 induding subparts A. B, C & D, must be completed for each officer wilh whOm the filer has affiliation Of lxJsjness relationship. Attach additional pages to this Form CIQ as necessary.

A. Is the IOC'<l1 government officer named in this section receiving or likely to receive taxable income from the filer of the ques~onnaire?

D Yes j2g No

B. Is the filer of the questionnaire receiving or likely to receive taxable incolT\8 from or at the direction of the local government officer named in this section AND 1he taxable income is nat from the local governmental entity?

Dves ~ No

C_Is the filer of this questionnaire affitiated with a corporation or other business entity that the 1ol:81 government officer serves as an officer or director, or holds an ownership of 10 percent or more?

Dyes ~ No

D. Describe each aftilation or business rela1ion~hip.

N/A

6 Descrlbe any other affiliation or businest; relationship th:d might cause a conflict of interest.

NJA

7

February 2, 2010 Dote

Lone Star CoIlese - Tombal Hwtn Science Canter

l 'd


FORM CIQ

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 comrnits 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


N1A

2

o 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 tiling 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.)


N1A


N1A

Amended 0111312000 Amended 0111312000


FORM CIQ Page 2

5 Name of local govemment officer with whom flier has affiliation or business relationship. (Complete this section only If the answer to A, S, 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 aHiliation or business relationship. Attach additional pages to this Form CIQ as necessary.

A. Is the local government oHicer named in this section receiving or likely to receive taxable income from the filer of the questionnaire?

D Ves D No

B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government oHicer named In this section AND the taxable income is not from the local governmental entity?

Dves D No

C. Is the flier of this questionnaire aHiliated with a corporation or other business entity that the local government officer serves as an oHicer or director, or holds an ownership of 10 percent or more?

DVes D No


6

7

Describe any other affiliation or business relationship that might cause B conflict of Interest.

NlA

Paul E. Stlak I COO . g business with the governmental entity

February 2,2010

Date

Note: Jeffrey C. Stone Inc., dba Summit Builders has no personnel doing business with the local governmental entity.

Documents

CONFLICT OF INTEREST QUESTIONNAIRE FORMCIQ venetor or...CONFLICT OF INTEREST QUESTIONNAIRE FORMCIQ . For . venetor or . other person doing business with loe-al . govemm&ntal.nlJt~