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HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016 (2)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. OFFICE USE ONLY Date Received CITY E I f DEC SECRETARY'S I E P �%� (�... 222016 OFF II Name of Local Government Officer JQl rP l(ln�IM til\ //�� nn l�'in5 �VUL0 J Office Held i 6kr(,�-�t vt $6 a e�v JName of vendor described by Sections 176.001(7) and rive Eno 176.003(a), Local Government (opertilc Code jjDescription of the nature and extent of each employment with vendor named in item 3. d or other business relationship and each family relationship 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-month period described by Section 176.003(a)(2)(B). Date Gift Accepted Oc �Description of Gift ( © n kyeS Date Gift Accepted Description of Gift Date Gift Accepted Description of Gift (attach additional forms as necessary) J AFFIDAVIT I that -------- Amy Shelley ru:. Notary Public _I_FState of Texas gh,a,h{PO My Comm. Exp.12/02/19 No ID# 12476110.5 swear under penalty of perjury the disclosure applies government Code) of this overs the 12-month period that the above statement is true and correct. I acknowledge to each family member (as defined by Section 176.001(2), Local local government officer. I also acknowledge that this statement described by Section 176.003(a)(2)(B), Local Government Code. Q1.41 yv f 1-t° • ([XY,'. t.ei 1/t/ AFFIX Sworn 1/.r Signature of Local Government Officer NOTARY STAMP / SEAL ABOVE r'/1 ''1 1111 ^^ to and subscribed before1tme, by the said �lnt1{. W'.11 1 �Ihl,S this the CPr1A day of L, P,tvb(l 20 L(e to certify which, witness my hand and seal of office. Stitt Signatu f officer ad istering oath Printed na of officer adphinistering oath Title of officer administ ng oath Form provided by Texas Ethics Commission www.eth ics.state.tx.us Revised 11/30/2015