HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/16/2016LOCAL 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.S. 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.
OFFICE USE ONLY
Date Received
JName of Local Government Officer
STrkays WiLSO NJ
J Office H
\SN. 9-)Ca (NAi N 2 9--
11 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
—idUom carr Cks\creer.`ne .. T J c--
idDescription of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
er of «e Cvmp0.n1/4-\
1.1 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 Il--1 La —. (a Description of Gift -.—i IV D c C90 \C.-....9t
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 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 • •' or. I also acknowledge that this statement
overs the 12-month period des c' •r. •y Section 176.003,;/`2)(B), Local Government Code.
BELENDIA MOORE /
Notary Public, State of Texas
My Commission Expiresx
„ye��;� January 25, /% . /. / _ i[LL
T. Signature of Local Government Officer
/
AFFIX NOTARY STAMP / SEAL ABOVE '/�,y q /v//�
kyi /.So �/ this the [ / day
Sworn to and subscribed before me, by the said %'t''
LQ
of 1- 20 to certify which, witness my hand and seal of office.
AIo
S'/ J.1 lii,i be, Iend' &care-
Signature of officer administering oath Printed name of officer administering oath Title of officer administerin oath
Form provided by Texas Ethics Commission
www. ethics. state.tx.0 s
Revised 11/30/2015