HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016LOCAL 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.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.
OFFICE USE ONLY
Date Received
[CITY
a•
DEC
SECRETARY'S
[I v
22 2016
OFFIC
a
JName of Local Government Officer ,
Jo yee'Y n( WI ///4fflc, Oa
Office field
exe ()divebefi (/`-//
JName of vendor
described by Sections 176.001(7) and 176:603(a), Local Government Code
Irnle >>.1100,2
LI Description o the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
JList 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--�moo/nthhperiod described by Section 176.003(a)(2)(B).
/
Date Gift Accepted a Description of Gift MOS rl)& Gl'
,4
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
II 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
tosr\ Am ;. overs the 12-month period described by Section 176.003(a)(2)(B), Local Government Code.
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AFFIX NOTARY STAMP / SEAL ABOVE //,� ��". '-t f
Sworn to and subscribed before me, by the said (JU(JC.irt net'_ U, ,t 1 3
ignature of Local Government Officer
this the ad &A- day
o• Otte r 20 UQ to certify which, itness my hand and seal of office.
d.
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Sign t of office t. ministering oath Printed n e or agministering oath Titleofficer admini
ering oath
Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 11/30/2015