HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-01/04/2017LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the neM p�qe.)
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg, Regular Session. pFPICEUSEONLY
This is the notice to the appropriate local governmentai entity that the following local
government officer has become aware of facts that require the officerto file this statement �° ���
in accordance with Chapter 176, Local Government Code.
1 Name of Local Government Officer
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2 Office Held
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3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
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q Description of ihe nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
5 List 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 72-month perlod described by Section 176.003(a)(2)(B).
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DateGiftAccepted � `'�� � 1 DescriptionofGift '>�� 1 `�
Date Gift Accepted �-i� `'1 �� � Description of Gift � � x � 1 ���`Y" �l C v1 b L 0 I��1 i
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
s AFFIDAVIT
I swear under penalty of perjury that the above statement Is true and correct. I acknowledge
that the disclosure applies to each family mem6er (as defined by Section 176.007 (2), Local
Govemment Code) of this local government officer. I also acknowledge that this statement
covers the 12-month period described by Section 176.003(a)(2)(B), Local Government Code.
;�,ti�'°�;;. CHRISTINELOVEN �
••�'.•*s My Notary ID # 11092587 � � , (
'";a;ar+fi� Ezpires May 2, 2018 � C' �; u.- 3�� ��,cil.t,��r
Signature of Local Government Officer
AFFIX NOTAFiV STAMP / SEAL ABOVE
Sworntoandsubscribedbeforeme,bythesaid 10(�(� ��u-4�5 ,this[he��day
of ua2- , 20 to certifywhich, witness my hand and seal of office.
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Signature of officer administering oath Printed name of officar administering oath Title of officer administering oath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Fevised 11/30/2015