HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/30/2009LOCAL 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 USE ONLY
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. ~ ~C,r`, ~,~ L5
1 Name of Local Government Officer D
~.~:ss Icy-----
~ 1
CITY SECRETi~RY S
2 Office Held FFI
S Name of person described by Sections 176.002(a) and 1 6.003(a), L al Gove ment Code
4 Description of the nature and extent of employmen or other siness elations ~p with per named in item 3
5 List gifts accepted by the loc gove nment fficer d n y m ber, excluding gifts described by Section
176.003(a-1 ), if aggregate value f the ifts acc pted fr m erson n ed in item 3 exceed $250 during the 12-month
period described b Section 176. 03(a 2)(B)
Date Gift Accepted escr tion of ift
Date Gift Accepted Des riptio Gift
Date Gift Accepted Description o ift
(att additional forms as necessary)
6 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 o ' also acknowledge that this statement
covers the 12-month period described b ection 6.003(a), Local Government Code.
ture 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