HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/6/2016 (2)LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS 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.
This is the notice to the appropriate local governmental entity that the following local
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176, Local Government Code.
OFFICE USE ONLY
Dar.tp Received
£ 1 E IV E
Name of Local Government Officer
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1-`)el C' lnoC - `Prr`,4 Ttc&n
DEC U 6 2016 I
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pvBL11I.otN�Pr!ARTMEN
J Office Held
JName of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
14E6 Pllunb\no<
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I Description of the nature and exte of each employment or other business relationship and each family relationship
with vendor named,in item 3.
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?\ t-LANnb1nE7
JList gifts accepted by-Hie local
from vendor named in item
Date Gift Accepted (ea` (o
government officer and any family member, if aggregate value of the gifts accepted
3 exceeds $100 during the
t�12-Lmonth period described
/`'bey,..Section 176.003(a)(2)(B).
1U
lie Description of Gift -11,31k-) tr � C)?' Cu-_R-r- c
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
J AFFIDAVIT
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
Government Code) of this local government officer. I also acknowledge that this statement
pia p
�e s ARACELI BOTELLO
;•
Ni.' • My Notary ID # 130905859
}„F.o„ ;,' Expires November 17, 2020
vers the 12-month period described by Section 176.003(a)(2)(13), Local Government Code.
,� bf .
AFFIX
Sworn
NOTARY STAMP / SEAL ABOVE
to and subscribed before me, by the said
�`�1_ l(�"�\�Signatuurree off'Local Government Officer
?
I l' 1p J
r II 11/K e.this the iP day
of IV/NW , 20 Ip to certify which, witness myyyyy hand and seal of office.
Pia C6 3 oketo -Plwit rceetARixotkk
Signa'. dof offi er adminisb"ri,'. oath Printed name of officer administering oath Title of officer administering oath
Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 11/30/2015