HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/6/2016LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
Thls questionnaire reilects changes made to the law by H.B. 23, 84ih Leg., Regular Sesslon. OFPICEUSEONLY
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 Date Received
in accordance with Chapter 176, Local Government Code.
7 Name of Local Government Officer A�j ��.n �./% �
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�v��� v.ee ri,ng `�Q�c..� �-,..e ..-�c-
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2 Office Held CITY SECRETARY'S OF�ICE
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
�-t 4 Q T cNvj, v�-2 C r��4 �
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q Description of the nature and extent af each employmenf or other business relationship and each family relationship
with vendor named in item 3.
5 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $100 during the 12-month period�described by Section 176.003(a)(2)(B).
Date Gift Accepted I Z�G I/(i Description of Gift C�c ,Pau.r.� � v� v�.-� C a
Date Gift Accepted Desc[iption of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary) �
6 AFFIDAVR
I swear under penalty of perjury that the above statement is true and correc�. I acknowledge
ihat Ihe disclosure applies to each famlly mem6er (as defined by Section 176.001(2), Local
Government Code) oi this local government officer. I also acknowledge that this statement
covers the 12-monih period described by Section 176.003(a)(2)(B), Local Government Code.
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;;�,�.'•;€ My Notary ID # 11092587 t�'
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Signature oi oc Government Oificer
AFFIX NOTAFY STAMP / SEAL ABOVE n 1
Sworn to and sub1scrihetl before me, by ihe said 1 i/ /�l �/ L�/�v , this the_,�� day
of L�Cemtl C , 20 , to certify which, witness my hantl and seal of oftice.
r� .� � 1 �.��5�-�n � ��� No�
Signature� of officer administering oath Printed name of officer administering oath Title of otiicer atlministaring oath
Form provided byTexas Ethics Commisslon www.ethics.state.�x.us Revised 77/30/2015