OA

OFFICE21

G

AGRI-LIE BUILD10 E. LIVE

GUADCO

IFE EXTDING RE OAK ST

No.: 111 M

DALUOUNT

TENSIOENOVAT., SEGUI14-5313-A

March 201

UPETY

ON SERATION &IN, TEXAA1 14

E

RVICE & REMO

AS 78155

ODEL

TAB I LG

TAB II R

TAB III

C TAB IV

B TAB V

C TAB V

R

GOff

Legal NotGeneral C

Request fProjeSelecRequRFQ

I Criteria fo

V Bonding

Conflict o

I RFQ Evalu

GuadAgri

fice Bui210 E. Liv

ice – ReqContracto

for Generect and Scoction Scheuest for QuQuestionn

or Selecti

of Interest

uation Fo

dalu-Life Exilding Rve Oak S

No.: 111 M

TA

quest for or Service

ral Contraope of Wodule

ualificationnaire

on

t

orm

upe xtension

RenovatSt., Seguin14-5313-A

March 201

AB INDEX

Competies

actor rk

s

Coun Servicion & Rn, TexasA1 14

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itive Seal

untyce

Remode78155

led Propo

y l

osals for

TTAAB

B II

GuadaluContractprovide during a The projBuilding The conArchitec

A copy oCounty o

GuadaluProposa

R

upe Countytor serviceconstructio

and after the

ject to be c Renovatio

nstruction bct of Record

105 MSan AOffice

of the constoffice:

Kyle KGuad211 WSegu830.3

upe Countyals.

Request ffor G

AgOffice B210 E. L

B

y (“County”s until 09:0

on services e design of

completed: n & Remod

bidding docd:

Montclair StAntonio, Tee: 210-222-0

truction bid

Kutscher, Cdalupe CouWest Court in, Texas 7

303.8857x2

y reserves t

Legfor CompGeneral C

Guadagri-Life ExBuilding RLive Oak,Bid Numb

11 M

”) will acce00 a.m. onat a contrathe facility.

"The Guaddel” located

cuments ma

t.

exas 782090194

ding docum

County Comnty Justice Street

78155 2

he right to w

gal Noticeetitive Se

Contractoalupe Couxtension

Renovatio, Seguin, ber: 14-53

March 201

ept Compen 15 Aprilacted fee an.

alupe Cound at 210 E. L

ay be obta

9

ments are a

mmissionerCenter

waive any i

e ealed Proor Serviceunty Serviceon & Rem Texas 78313-A1 14

etitive Seale2014. Th

nd provide

nty Agri-LifeLive Oak S

ained electr

available for

, Pct. #2

informality a

oposals es

model 8155

ed Proposahe General consultatio

e ExtensionSt., Seguin,

ronically by

r review at

and to rejec

als for GeContracto

on to the Co

n Service OTexas.

y contacting

the followin

ct any or al

neral r will ounty

Office

g the

ng

ll

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CConCo

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210

ntracomp

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ffice Bu0 E. Live

cts fpetitsalsracto

daluri-Life Exuilding Re Oak St

No.: 111 M

for tive

s foror S

upe

xtensionRenovatit., Segu14-5313-A

March 201

Face Ser GeServ

Coun Servicion & Rein, TexaA1 14

cilitiealed

enervice

untyce emodel as 78155

es:d ral s

y 5

The folloFacilities 1. C

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T7Erec

The folconstruc

M E P C R C P P P

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re

owing projes: Competit

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pproximate

The propos8155. Ren

Extension Sequired Mompliance

llowing dection:

Manage the Establish BuPrepare SubConduct PreReceive BidConduct AwProvide andProvide CooProvide for Texas ArchitProvide for nMaintain an

ocumentatSummarize Provide ChaEstablish a QProvide for JProvide AccProvide JobProvide PosProvide Valu

f Each DesComplete alAttend Pre-epresentativ

PRO

ect narrativtive Sealed

n Project: Tnovation & ely: $_____

ed project ovation &

Service OfficMEP syste

and a new

escribes th

GMP Docuudget for Prb-contractoe-Bid Meetis

ward of Con coordinate

ordination aconformanctectural Banew systemd provide ion as outliMonthly Re

ange Order Quality ManJob Safety

counting Fusite Securit

st Constructue Engineesign Phase l work as sConstructioves

OJECT AN

ves are to Proposals

The GuadaRemodel.

__________

is located Remodel oces (Refer m upgradelevator fo

he anticipa

umentationroject Whiler Bid or Prongs

tracts/Purce all MEP reand Managece with therriers Act (A

m(s) integraLeadershipned by the eports and Contin

nagement PFunctionsnctions ty Functiontion Serviceering Optio(e.g., Scheoon as poson Meeting

ND SCOPE

assist youGeneral C

alupe CounThe Count

____

at 210 Eaof ~10,400to Floor Pl

des, sprinkor accessibi

ated servic

e Working ioposal Pack

hase Orderequirementement of Sue Texas AcArticle 9102

ation with exp in EnergyUS Green

ngency FunProgram

s es ns During

ematic Desissible after cg with Cou

OF WORK

u in responContractor S

ty Agri-Lifety estimate

ast Live Osquare fee

lan) to inclukler systelity as an a

ces expec

n Conjunctkages

rs ts ub-contractcessibility S2, Texas Cixisting systey and EnviBuilding Co

nds Control

and Concuign, Designcontract ininty Person

K

nding to thServices Qu

e Extensioned budget fo

Oak Street, et for the Cude new Mm installa

add alternat

cted durin

ion with Pro

tors Standards ivil Statutesem(s) ronmental ouncil for C

urrent with n Developmitiation nnel and th

e Contractuestionnaire

n Service Oor this proje

Seguin, TCounty AgrEP system

ation for te.

g design

oject Team

required bys)

Design (LECertification

the Complment, etc.)

heir design

ts for e.

Office ect is

Texas i-Life

m and code

and

m

y the

EED)

etion

nated

INSTRU

Tme

PcB

Tthin

Ta

Pthre

Astwec

LPud

Itad

UCTIONS T

The Bidder wmust be vali

stimated buProposals shontaining th

Bidder and tThe Contrachemselves ndicated anThe Owner r

lternate conProposals cahat would aejected as i

Attention is ctates that th

work throughvidence to ontract. ist of Sub-c

Proposal a lsed in comisqualify sut is mandatot the pre-biisqualified f

TO BIDDER

will submit d for 45 daudget propohould be cahe Proposathe name octor before with existin

nd specifiedreserves thnsidered adarrying ride

affect the Prirregular. called to thhey have thh its severathe Owner’

contractorsist of the su

mpilation of tuch a Geneory for a red site meetfrom biddin

RS

their Propoays (minimuosal for thearefully filleal should beof the projecsubmitting

ng conditiond. he right to redvantageouers or qualifroposal in c

e fact that the financialal stages to’s approval

: All Generaub-contracttheir Proporal Contracpresentativting. Any Gng.

osal on sepaum) after bide scope of wd out, signe

e identified ct, and deliva bid shall

ns on-site a

eject any anus. fications whcomparison

the Bidder ability, exp

o completionwill not be

al Contractoors whose sal. Failure

ctor. ve of a biddGeneral Con

arately boud opening awork to be ced and seaby the namvered in timinvestigate

and be prep

nd/or all bid

hich modify n with other

in signing tperience ann and unleseligible to

ors shall susub-bids the to submit

ing Generantactor not

und forms. and containcompleted. aled. The eme and addrme set by Oe and familiapared to com

ds or to acc

y the bid in acompetitiv

the Proposand facilities ss they canreceive the

ubmit with the General t such a list

al Contractoin attendan

Proposals n a full item

envelope ress of the wner. arize mplete wor

cept any bid

any mannee bids will b

al definitelyto carry the

n show suche award of

their Bid Contractorwould

or to be prence will be

ized

k as

d or

er be

y e h

r

esent

GENERSELECT ApprovaProposaCommis 1st Ad Plan 2nd APre-bid CompetNotify CSessionCompetCommisNotify CSessionGeneralFormal RGeneralOfficial N

RAL CONTRTION SCHE

al of the Coals for a Gessioners’ CodvertisemeRoom

AdvertisemeOnsite Conitive Sealedounty re: A (NLT Weditive Sealed

ssioners’ Coounty re: A (NLT Wed ContractorRecommen ContractorNotification

RACTOR EDULE

ntracts for neral Controurt nt – Seguin

ent – Seguinference @d Proposals

Agenda Itemd 12PM for Cd Proposalsourt: Prese

Agenda Itemd 12PM for Cr ndation to Cr Approval of Selectio

Facilities: Cractor by th

n Gazette

n Gazette@ 2:00 PM

s due m for next CCC followins nt Competi

m for next CCC followin

County in C

on

Competitivehe Guadalu

Commissionng Tue) – P

tive SealedCommissionng Tue) – S

ommission

e Sealed pe County

ners’ Court Present

d Proposalsners’ Court Selected

ers’ Court f

1

11221

s 1

for 2

2

11 Mar 201

16 Mar 20117 Mar 20123 Mar 20126 Mar 20115 Apr 2019 Apr 2014

15 Apr 20116 Apr 201

22 Apr 201

23 Apr 201

4

4 4 4 4 4

4

4 4

4

4

CONTRCOMPEGENER PursuanContractCompetGeneralBuilding All Comquestionthe reqmaterial Selected Six (6) cenvelop Kyle KutGuadalu211 WesSeguin, Bid NumAg Build No later Immedia Queries

105 MonSan AntOffice: 2Fax: 2

RACTS FORETITIVE SERAL CONTR

nt to the prots and Fitive Seale Contracto

g Renovatio

mpetitive Sennaire in thquested infs further de

d short liste

copies are pe to:

tscher, Couupe Countyst Court StrTexas 781

mber: 14-53ding

than: 09:0

ately therea

about the

ntclair tonio, Texas10-222-01910-222-019

R FACILITIEEALED PRORACTOR S

ovisions of Fund Manaed Proposaor for The on & Remod

ealed Prope sequenceformation, escribing th

ed proposer

to be subm

unty Commy Justice Cereet 155 313-A1

0 AM on 15

after, the Co

Project sho

s 78209 94 95

ES: OPOSALS FERVICES S

Title 10. Gagement,als, it is th

Guadalupdel.

posals are e and form

submittingheir capabili

rs may be r

mitted & ad

issioner, Pcenter

5 April 201

ounty will re

ould be add

FOR SELECTIO

eneral GovChapter 2

he intentionpe County

to includeat prescribe

g organizaities and ex

requested to

ddressed in

ct. #2

14.

eview the in

ressed to:

ON

vernment, S2269.153n of Guada

Agri-Life

e the infored. In add

ations mayxperience (u

o submit ad

n the lower

nformation.

Subtitle F. SContracts

alupe CounExtension

rmation reqdition to andy provide under sepa

dditional inf

r left hand

State and Lfor Facil

nty to seleService O

quested in d separate supplemen

arate cover)

formation.

d corner of

Local lities: ect a Office

this from ntary ).

f the

CONTRCOMPEGENER Please pquestionunder sethis form 1. Firm Nam Addr Phon

Fax: Form

Vent Year Prim

resum 2. Orga

2.1

2.2

2.3

2.4

2.5

2.6

3. Lice

3.1

3.2

RACTS FORETITIVE SERAL CONTR

provide thennaire. Supeparate cov

mat.

m Informatiome of firm: ress of princne:

m of Businture, other?r Founded: ary Individme)

anization How capacHow nameoperaIf youStateIf yoorganpartnIf youorganIf the and n

nsing List juqualifapplicList jufiled.

R FACILITIEEALED PRORACTOR Q

e following ipplemental ver attache

on:

cipal office:

ness Organ?):

ual to Con

many yeacity? many years

e? Underated? ur organizat of incorporur organiz

nization, tyer(s). ur organizanization, naform of yo

name the pr

urisdictionsfied to do cable. urisdictions

ES: OPOSALSQUESTIONN

informationmaterials pd, but the i

:

nization (C

ntact: Supe

rs has you

s has your r what oth

tion is a coration and l

zation is aype of par

ation is indme of owneur organizarincipals.

s and trade business a

s in which y

NAIRE

n in the seqproviding adnformation

Corporation,

erintendent

ur organiza

organizatioher or form

orporation, list all office

a partnershrtnership (i

ividually ower. ation is othe

categoriesand indicate

your organiz

quence anddditional infrequested

, Partnersh

/ Project

ation been

on been in bmer name

please provers of the cohip, answeif applicab

wned, answ

er than thos

s in which ye registrati

zation’s pa

d format preformation mbelow is to

hip, Individ

Manager (

in busines

business ues has you

vide date oorporation.

er the follole), names

wer the fol

se listed ab

your organion or licen

rtnership o

escribed bymay be incluo be provide

dual, and

(Please pro

ss in its cu

nder its preur organiz

of incorpora

owing: Dats of mana

lowing: Da

bove, descr

zation is lense numbe

or trade nam

y this uded ed in

Joint

ovide

urrent

esent ation

ation,

te of aging

te of

ribe it

egally ers, if

me is

4. Expe4.1

4.2

4.3

4.3.14.3.2

4.3.3

4.4

4.5

4.6

4.7

4.8

5. Fina

5.1

•

erience List tits owto bidList aand liClaimpleas

1 Has y2 Are t

outsta3 Has

regarWithinever compdetailCurre

Work

Public

Reno

ncial InforAttacorganfollow

Currenotesprepa

he categorwn forces. Wd all work toany subconist the categ

ms and suitse attach deyour organihere any juanding agayour organ

rds to constn the last fbeen an of

plete a conls.) ent work:

List the progress Risk, Bidproject, oscheduled

k over last 5List majofirm. Foproject/fudate, ownCM at ris

c/GovernmList majoleast $50years.

ovation/RefuList majorenovatiogovernmestructure)

rmation Suh a fina

nization’s lawing items: ent assets s receivablaid expense

ries of workWould you

o subcontrantractors in gories of wts (If the aetails). zation everudgments, inst your ornization filetruction confive years, hfficer or pri

nstruction c

major con(noting m

d, Proposaowner, archd completio

5 years: or projects r each pnction of thner, architek, bid, propental Proje

or projects 0,000 or m

urbishmentor projects n and/or reental agen).

ubmission ncial statatest balan

(e.g., cashe, accruedes).

k that your propose to

actors? which you

ork those sanswer to

r failed to coclaims, arbrganizationed any lawntracts withhas any offincipal of a

contract? (

nstruction method of s

l or other)hitect, conton date.

similar in sproject, prhe building,ect, and meposal or othect Experienin the pub

more constru

Experiencethat were

efurbishmenncy buildin

- OPTIONAement, pr

nce sheet

h, joint vend income,

organizatioo do any wo

ur organizasubcontractany of the

omplete anbitration pro or its office

wsuits or rin the last fficer or prin

another org(If the answ

projects yselection, ), giving thtract amou

size and srovide the , size (SF),ethod of seer.

nce: lic and/or gucted by yo

e: e solely ornt of an exng (60% o

AL: referably and incom

nture accoudeposits,

on normallyork with you

ation has sotors normale questions

ny work awaoceedings ers for the lrequested five years? ncipal of yoanization wwer is yes

your organi.e.: Desighe name ant, percent

cope const name, location, c

election, i.e

governmenour firm wit

r partly coxisting publior more

audited, me stateme

unts, accoumaterials

y performs ur own force

ome ownely perform.

s below is

arded to it?or suits filelast 5 yearsarbitration

our organizwhen it faile, please at

nization han-Build, CMand locatiot complete

tructed by nature of

cost, compl.: Design-B

ntal sector thin the last

onsidered aic sector anof an exi

including nt showing

unts receivinventory,

with es or

rship yes,

? ed or s?

with

ation ed to ttach

as in M at on of

and

your the

etion Build,

of at t five

as a nd/or sting

your g the

able, and

• •

• •

5.2

5.3

5.4

5.5 6. Insu 6.1

7. Exp

7.1

7.2

7.3

7.4

7.5

Non-cCurreexpenaccruNon-cCapitauthoearninNamethereIs theunderrespo(e.g., Will guaraProvi

urance.

ProviComp

erience wiDescwith tDescschedCost AttacPhasintentFeesConsDescphaseincludSavinDescrealizreturnContiDescdesigdispoa hist

current assent liabilitiesnses, provued payroll current liabtal accounorized and ongs). e and addreof. e attached r item 1 onsibility of

parent - suthe organ

antor of the de name, a

de Certificpensation s

th concepribe your othe Owner ribe your duling durinEstimates: h a sample of a projt is to see t:

struction Phribe your oe fee, i.e.,ded and/or ngs: ribe your

zed during ned to the Ongencies: ribe your

gn? During osition of cotory of proje

sets (e.g., ns (e.g., accoision for intaxes). ilities (e.g.,ts and reoutstanding

ess of firm

financial sabove? If the organubsidiary).ization whcontract fo

address, an

cates of showing the

ts for workorganization

and Archiorganizatio

ng the cons

le of a finject. (The ihe nature a

hase Serviceorganizatio, fixed feeexcluded fr

organizatioconstructio

Owner?

organizatioconstructio

ontingency ect cost bas

et fixed assounts paya

ncome taxe

notes payatained ear

g shares pa

preparing a

statement fIf not, expnization wh

hose financor constructnd phone fo

Insurance e County as

king as a pn’s conceptitect duringon’s metho

struction pha

al cost estdentity of t

and format o

es Fee n’s ideolog, percentarom the fee

on’s conceon. Is the

on’s conceon? What isfunds aftersed on bid

sets, other able, notes es, advanc

able). rnings (e.gar value, ea

attached fin

for the idenplain the rhose financ

cial statemtion?

or bank refe

for boths an additio

part of a cots for work

g the constods for coase.

timate prethe project of the cost

gy as it pege fee, an

e.

ept for thefull amoun

ept for cos your orgar the complcost versu

assets). payable (cu

ces, accrue

g., capital, arned surpl

nancial state

ntical orgarelationshipcial stateme

ment is at

erence.

h liability onal insured

onstructionking in a tetruction of ontrolling

pared duri may be cinformation

ertains to thnd particula

e dispositint or a perc

ost continganization’s etion of thes final cost

urrent), acced salaries

capital sus and reta

ement and

nization nap and finaent is prov

ttached ac

and Word party.

n team. am relationmajor projcosts, and

ng the Bidoncealed. n provided)

he construar items to

ion of savcentage the

gencies duconcept fo

e project? t noting rea

crued and

tock, ained

date

amed ancial vided

ct as

rker’s

nship ects.

d for

dding The .

ction o be

vings ereof

uring or the

Give sons

7.6

8. Safe

9. Sche

10. Paym

11. Refe

and ado yoCost Your constinformassur

ty Provimodifthe ladeath

edules Proviphasepast and m

ment

The Chave from Court conne

erences For thownenumborganmunic

amounts of ou carry withInformationfirm would

truction avmation woured that it is

de informatfier for ast five yearhs that have

de sampleses. Give a5 years. D

methods of

County will personally said CM amay withh

ected with t

he projects er and a rebers) whomnization’s scipal projec

change orh 100% conn: be required

vailable to ld be furnis

s complete

tion as pert

rs. List any e occurred

s of schedua history ofDescribe mcorrective a

authorize inspected

at Risk. Uhold a semihis project.

listed abovepresentatim we co

services. Icts of comp

rders. Whanstruction d

d to make aowner a

shed and hoand accura

tains to you

OSHA citaon your pro

ules that wf your abilitethods emaction to ov

progress pd and signepon compl-final paym

ve (re: itemve of the

ould contadeally, somarable scop

at percentadocuments?

all cost infond architeow the ownate.

ur firm’s acc

ations in theojects in the

will be usedty to deliveployed to kvercome sc

payments, ed the requetion of pr

ment if there

m 4.6), identarchitect (

act as refme of the pe.

age contrac?

ormation duect. Descner and arc

cident frequ

e last five yee last five y

d to control er projects keep projecchedule def

only after uest for paroject, the e are any u

tify a repre(provide naferences rreferences

ctor conting

ring designcribe how chitect wou

uency rate a

ears. List ayears.

various pron time fo

cts on scheficiencies.

County offiayment (invCommissio

unsettled cl

sentative oame, phonregarding s should be

ency

n and this

ld be

and

any

roject r the

edule

icials oice)

oners aims

of the e/fax your

e for

TABB

III

CRITER PursuanContractCompetGeneralBuildingdetermin

NOTIFIC a) A pe

advaentityof the

b) The

deterSubsCounacco

c) This

RIA FOR SE

nt to the prots and Fitive Seale Contracto

g Renovationing to who

a) the reb) the rec) the qud) past pe) the exf) the veg) vendoh) propoi) vendoj) the im

relatink) the to servicl) any o

selec

CATION OF

erson or buance notice y has beene conduct r

County marmines thatsection (a) nty must coomplished.

section doe

ELECTION

ovisions of Fund Manaed Proposaor for The on & Remom to award

eputation ofelevant expuality of theperformancxtent to whendor’s pasors safety rosed personors methodmpact on tng to historotal long-terces; and other relevacting a vend

F CRIMINA

usiness entto the Cou

convicted resulting in

ay terminatet the persoor misrep

ompensate

es not appl

Title 10. Gagement, als, it is th

Guadalupodel, Guadd the contra

f the vendoperience of te vendor’s sce of the veich the servst relationshrecord; nnel for the

dology for ththe ability rically underm cost to t

ant factor tdor.

AL HISTOR

tity that entunty if the pof a felonythe convict

e a contracon or businpresented t

the person

y to a publi

eneral GovChapter 2

he intentionpe County dalupe Coact for cons

or and of thethe vendor;services;

endor; vices meet hip with the

e project; he project;of the Cour-utilized buhe County

hat a priva

Y OF CON

ters into a person or a. The notiction of a felo

ct with a peness entity the conducn or busine

icly held co

vernment, S2269.153n of Guada

Agri-Life unty may

struction se

e vendor’s g;

the Countye County;

unty to comusinesses;to acquire

ate busines

NTRACTOR

contract wan owner oce must incony.

erson or bufailed to g

ct resultingess for wor

orporation.

Subtitle F. SContracts

alupe CounExtension consider trvices.

goods or se

y’s needs;

mply with

the vendor

ss entity wo

R

with the Coor operator clude a gen

siness entigive notice g in the cork or mater

State and Lfor Facil

nty to seleService O

he followin

ervices;

laws and

’s goods or

ould consid

ounty must of the busi

neral descri

ty if the Coas require

onviction. ials provide

Local lities: ect a Office ng in

rules

r

der in

give ness ption

ounty ed by

The ed or

TAABB

IVV

BONDINSec. 226or guaraawardedgovernmspecified(b) The after theconstructo the gorequiredestablishAdded b

NG 67.258. PEanteed maxd, the penamental entityd in the reqconstructio

e date the cction managovernmentad performanhed. by Acts 201

RFORMANximum pricel sums of thy must eac

quest for pron manager

constructionger-at-risk fal entity to ence and pay

1, 82nd Le

NCE OR PAe has not behe performah be in an aoposals or qr-at-risk shan manager-afurnishes aensure thatyment bond

eg., R.S., Ch

AYMENT Been determance and pamount eququalification

all deliver that-risk execbid bond o

t the constrds when a g

h. 1129, Se

OND. (a) Ifmined at thepayment boual to the cns. he bonds nocutes the coor other finaruction manguaranteed

ec. 2.08, eff

f a fixed cone time the conds deliver

construction

ot later thanontract unleancial securnager will fud maximum

f. Septemb

ntract amouontract is red to the n budget, as

n the 10th dess the rity accepta

urnish the price is

er 1, 2011.

unt

s

day

able

TAB V

Adopted 06/29/2007

FORM CIQ

OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Codeby a person who has a business relationship as defined by Section 176.001(1-a) with a localgovernmental entity and the person meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmentalentity not later than the 7th business day after the date the person becomes aware of factsthat require the statement to be filed. See Section 176.006, Local Government Code.

A person commits an offense if the person knowingly violates Section 176.006, LocalGovernment Code. An offense under this section is a Class C misdemeanor.

CONFLICT OF INTEREST QUESTIONNAIREFor vendor or other 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 the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

Name of person who has a business relationship with local governmental entity.1

2

3

Date Received

Name of local government officer with whom filer has employment or business relationship.

Name of Officer

This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has anemployment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additionalpages to this Form CIQ as necessary.

A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investmentincome, from the filer of the questionnaire?

Yes No

B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at thedirection of the local government officer named in this section AND the taxable income is not received from the localgovernmental entity?

Yes No

C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the localgovernment officer serves as an officer or director, or holds an ownership of 10 percent or more?

Yes No

D. Describe each employment or business relationship with the local government officer named in this section.

Signature of person doing business with the governmental entity Date

4

TAB VI

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