HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-9/28/2009LOCAL 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. 1491, 80th Leg., Regular Session. OFFICE USEONLY
This is the notice to the a
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government officer has become aware of facts that require the officer to file this statement Date Received
in accordance with Chapter 176
Local Government Code
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3 Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code
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4 Description of the nature and extent of employment or other business relationship with person named in item 3
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5 List gifts accepted by the local government officer and any family member, excluding gifts described by Section
176.003(a-1 ), if aggregate value of the gifts accepted from person named in item 3 exceed $250 during the 12-month
period described by Section 176.003(a)(2)(B)
Date Gift Accepted Description of Gift _ jC~/~`
Date Gift Accepted Description of Gift iY/~-
Date GiftAccepted Description of Gift ~~
(attach additional forms as necessary)
G AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
that the disclosure applies to a family member (as defined by Section 176.001(2), Local
Government Code) of this local government officer. I also acknowledge that this statement
covers the 12-month period described by Section 176.003(a), Local Government Code.
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Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said ,this the day
of , 20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath "Title of officer administering oath
Adopted 06/29/2007