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HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016 (3)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, 64th 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 DEC SECRE . 21 FARY'S - L16 OFFICE Officer J Name Jore(44t tam3 _CMQ L)(e (Aug )e(re1-afrt/ JName A of vendor described by Sections �nvp Line:6 176.001(7) and 176.03(a), Local Government Code c �O Can Val(4"Sam 1I�p JDescription with of t a nature and extent o vendor named In item 3. MeLint 6yoanu each employ or other business relation ip and JJJ R/air 4 S each family relationship List gilts acceted by the local govofficerSit t any family member, if aggregate v lue of the gifts accepted from vendor amed In Item 3 exceeds $100 during the 12-month(2- period described by Section 176.003(a)(2)(B). �Date Gift Accepted I 01 1 Description of Gift C©© CS 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) local I that of this government officer. also acknowledge this statement .0prvt% Amy Shelley covers the 12 -month period described by Section 176.003(a)(2)(B), Local Government Code. Notary Public ' OF " State of Texas y � 44.0F My My Comm. Exp. 12/02/19 Notary ID# 12476110-5 /����/ "/'YIIVI'l/l AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said ca I nature of Local Government Officer .l�I'/� '' I n/� l 4CCtnflc Wt U la S this the Ot pCRik day • j I. C�AVhe( 20 to certify which, witnesstmy hand and seal of office. mal II IA I Se[ t..7 h Signal g of officer al nistering oath Printe me of offi r dministering oath Title officer administ in oath Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015