HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/14/2016 (11) 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
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.
Name of Local Government Officer E1 n V E -
Jaime Gutierrez Facilities Maintenance Manager DEC 14 2016
E Office Held CITY SECRETARY'S OFFICE
Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government Code
Dealers Electrical Supply
] Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
Electrical Supply Vendor
6 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).
12-13-16 Desk Calendar,4 pens
Date Gift Accepted Description of Gift
Date Gift Accepted 12-13-16 Description of Gift 3 pocket note books
Date Gift Accepted 12-13-16 Description of Gift 2 note pads
(attach additional forms as necessary)
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
covers the 12-month period described by Section 176.003(a)(2)(B),Local Government Code.
V-sCHRISTINE LOVEN
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*t My Notary ID#11092587 r - -r + Expires May 2,2018 �'�' � x � zA.f,..jt.A `-i
Signature of Local Government 0ffjder
AFFIX NOTARY STAMP / SEAL ABOVE �QQ
Sworn to and subscribed before me,b y the said 14( ��-+`-�� , this the /J
'444.,„) day
of „/'C60 20 / ( ,to certify which,witness my hand and seal of office.
0-4114541111.C_, /./.)0 V'L.) Mo+
Signature of officer administering oath Printed name of officer administering oath Title of officer ad nistering oath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015