HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/14/2016 (4)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.
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CITY OF C@LLEYVILL€_
BY BUILDING D PAI TME
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JName of Local Government Officer
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J Office Held
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11 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
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Description of the nature and extent of each employment or other business relationship and each family relationship
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with vendor named in item 3.
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JList
from
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 (a/ i� i • •-P Description of Gift l3 bZ b"T' prz, Czax'ZJ0
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
_ _ _ _ _ _ , — — — 4that the disclosure applies to each family member (as defined
is true and correct. I acknowledge
by Section 176.001(2), Local
acknowledge that this statement
Local Government Code.
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• r�.1 . T WILSON
,,`s. . Notary Public, State of Texas
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900714
i • • Notary ID. 12900714
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oGovernment Code) of this local government officer. I also
hovers the 12 -month period described by Section 176,003(a)(2)(B),
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AFFIX NOTARY STAMP / SEAL ABOVE
Sw n to and subscribed before me, by the said
of ee 0\Q , 20 to certify
Sig .ture of L.cal Government
this the
Officer
/4 day
which, witness my hand and seal of office.
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Sig ature .f office ministering oath Printed name of officer administering oath Title of officer administering oath
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Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 11/30/2015