HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/22/2016 (7)LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
7his questlonnalre reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICEUSEONLY
This is the notice to the appropriate Iocai governmental entity that the following local
government officer has become aware of facts that require the officerto file this statement Date Received
in accordance with Chapter 176, Local Government Code. �jt �� rr� ���
� Name of Local Government Officer I � �
�'1 V�-�-I�L � , ;-, .-, ",
� � � � � � � ._.
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2 Office Held �I � Y����i�f���'� ��C�'c�
3 Name of vendor described by Sectlons 176.001(7) and 176.003(a), Local Government Code
�2U. �u e, �,a- l I a,n-d pzrl� t�,�
q Descriptlon of the nature and extent of each employment or other business relatlonship and each famlly relationship
with vendor named In item 3.
5 List gifts accepted by the Iocal 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 descrlbed by Section 176.003(a)(2)(B).
Date Gift Accepted Description of Gift �� ����
Date GiftAccepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
ihat ihe 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
��, CHRISTINE LOVEN � covers ihe 12-month period described by Section 176.003(a)(2)(B), Local Government Code.
* ' My Notary ID # 11092587 �
;�tit ExpiresMay2,2078 �
Si ature of L cal overnment Officer
AFFIX NOTARV STAMP / SEAL ABOVE ///777
S m to and subscribed before me, by the saitl (i1C/1/ I �� l�7 �� this the� day
Gnw/ , t �— `T��
of K`� IO�iQ. , 20 { l O certify which, witness my hand and seal of office.
. �ST/ (/E�C.� � � �7
Signature of officer administering oath Printed name of officer administering oath Ti[le of officer administering oath
Form provided byTexas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015