HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/14/2016 (3)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.rail
OFFICE USE ONLY
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CITY OF COLLEYV1LLE 1
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JName of Local Government Officer
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J Office Held J
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JName of vendor described by Sections 176.001(7) and 176.003(a), Local Government
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JDescription of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
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from
List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
Date Gift Accepted/ f 3 A (p Description of Gift of M -A.4-
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
,that the disclosure applies to each family member (as defined
GovernmentiCode) of this local government officer. I also
covers the 12-month period described by Section 176.003(a)(2)(B),
f
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is true and correct. I acknowledge
by Section 176.001(2), Local
acknowledge that this statement
Local Government Code.
i
"�v"n'" T WILSON
=-s . -t: Notary Public, State of Texas
Notary 108129045/1-8
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AFFIX NOTARY STAMP / SEAL ABOVE
. orn to and subscribed before me, by the said
of ho V . ' / , 20 . , to certify
tune of Local
Government
, this
the
Officer
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day
which, witness my hand and seal of office.
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ignatur: of of a ministering 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