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HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/14/2016 (7) 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. OFFICE USE ONLY 1 This is the notice to the appropriate local governmental entity that the following local 1 government officer has become aware of facts that require the officer to file this statement area 0 . in accordance with Chapter 176,Local Government Code. — • [FE 0 Name of Local Government Officer DEC 14 2016 Ev,T.N.e rte: .07,S: : o v1 CITY SECRETARY'S OFFICE © Office Held © Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government Code 1---r-e c y►N c vl, VV I 1 c...v, Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. © 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 12Jti.(it t: Description of Gift �: .,, 0 C)le e.•c).s Date Gift Accepted Description of Gift Date Gift Accepted Description of Gift (attach additional forms as necessary) 6 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 • t'overnment Code) of this local government officer. I also acknowledge that this statement U"' 4g,I CHRISTINE vers the 12-month period described by Section 176.003(a)(2)(B),Local Government Code. '•: -.' My Notary ID#11092587 ''t,oP .' Expires May 2,2018 1 gatur- of L.cal Government Officer AFFIX NOTARY STAMP / SEAL ABOVE /� Sworn to and subscribed� before me,by the said eg Cit- /Q/C_ , this the /WX I day 0'61_4_of / . �/20/1" 'certify which,witness my hand and seal of office. iev ; J e/4"es/n , /15/V A/0 Signature of officer adminis ering 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