HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016 (4)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.
0
E J, T
O
m
DEC 2 2 2016a,
JName of Local Government Officer
Hal 1,
J Office Held V
J Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government
J'Yl. a-- n v u e HtmeS
Cod
JDescription of the nature and extent of each employment or
with vendor named in item 3.
gencLitra1 c
other business relationship and each family relationship
/bu tcar
J List
from
Date
Date
Date
gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
Gift Accepted fa'O ) Up Description of Gift �C O 044C. n...4 e
Gift Accepted Description of Gift
Gift Accepted Description of Gift
(attach additional forms as necessary)
J
AFFIDAVIT
I swear under penalty of perjury
that the disclosure applies
Government Code) of this
that the above statement
to each family member (as defined
local government officer. I also
described by Section 176.003(a)(2)(B),
is true and correct. I acknowledge
by Section 176.001(2), Local
acknowledge that this statement
Local Government Code.
130905659
17, 2020
overs the 12-month period
g R "Y • ARACELI BOTELLO
My Notary ID #
m
�:e•eF ;• Expires November
�r Ili
Sworn
AFFIX NOTARY STAMP / SEAL ABOVE
to and subscribed before me, by the said
of r...P.tinipthr 20 1y to certify
nature of Local
Government
this
the
Officer
074' day
Ith Lt6 V
which, witness my hand and seal of office.
Ar'^deL ofe o ---pI ab„,,,...xt,
l W^i•v
Signal a • ad istering
oath Printed name of officer administering oath Title of offi er administering oath
Form provided by Texas Ethics Commission
www.ethics.state.tx.us
Revised 11/30/2015