HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-11/1/2010LOCAL GOVERNMENT OFFICER FORM CIS
CON~LICTS DISCLOSURE STATEMENT
(insWctions for completing and filing this form are provided on the next page.)
Thfs questlonnaira reflects changes made to the law by H.B. 1481, 80th Leg., Regular Session. OFFICE U3E ONLY
This is the notice to the appropriate local govemmental entity that the following local
govemment officer has become aware of facts that require the o~cer to file this statement Date Received
in accordance with Chapter 176, Local Government Code. ~~~ Q~~
~ Name of Local (iovernment Officer
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'
ITY SECRETARY
S OFFICE
2 Office Held
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3 Name of peraon 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 tocal government officer and any family member, excludi~g gifts described by Section
176.003(a-1), If aggregate value of the gifta accapted from person named in item 3 exceed 5250 during the 12-month
period described by Section 176.003(a)(2)(8)
Date GiftAccepted 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 corred. I acknowledge
that the disclosure applies to a family member (as defined by Sedion 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 176.0 a), Local Governme~t Code.
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NOI~Iy P~AIk.
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' IiAy Con~tion ~~s:
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AFFIX NOTARV STAMP I SEAL ABOVE
Swor and subscribed before ine, by [he said ^+~ , this the o29 ~ day
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and and S al office.
of/ , 20 _L~ , to certify which.. wi
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natu of oncer ad ering oat Printed name of off' r administering oath Title ot officer ad isterin
Adopted 06/29/2007
LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
Section 176.003 of the Local Government Code requires certain local government o~cers to file this form. A
"local government officer" is defined as a member of the governing body of a local governmental entiry; a
director, superintendent, administrator, president, or other person designated as the executive officer of the
local governmental entity; or an employee of a local governmental entiry with respect to whom the local
govemmental entity has, in accordance with Section 176.005, extended the requirements of Sections 176.003
and 176.004. This form is required to be filed with the records administrator of the local govemmental entity
not later than 5 p.m. on the seventh business day after the date on which the officer becomes aware of the
facts that require the filing of this statement.
A local government officer commits an offense if the o~cer knowingly violates Section 176.003, Local
Government Code. An offense under this section is a Class C misdemeanor.
Please referto chapter 176 of the Local Government Code for detailed information regarding the requirement
to file this form.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond fo the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of the local government officerfiling this statement.
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of person described by Sectio~s 176.002(a) and 176.003(a), Local Government Cade. Enter
the name of the person described by Section 176.002, Local Government Code with whom the officer has an
employment or other business relationship as described by Section 176.003(a), Local Government Code.
4. Description of the nature and extent of employment or business relatianship with person named
in ltem 3. Describe the nature and extent of the employment or other business relationship with the person
in item 3 as described by Section 176.003(a), Local Government Code.
5. List glfts accepted, excluding gifts described by Section 176.003(a-1), if aggregate value of the
gifts accepted from person named in item 3 exceed $250. List gifts accepted during the 12-month period
(described by Section 176.003(a), Local Government Code) by the local government officer or family member
of the officer, excluding gifts described by Section 176.003(a-1), from the person named in item 3 that in the
aggregate exceed $250 in value.
6. Affidavit. Signature of local government officer.
Adopted O6/29/2007