HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-7/11/2012Lf3CA~. GOVERNMENT C)FFICER FORNi G1S-
CaNFL{CTS DI~CLQSl1RE STATEMENT
(Instructians forcompleting and filing this farm are provided on the nexk page.)
This questionnaira reflects changes made ta the law By H.B. 1491, SOth l.eg., Regular Session. p~~~CEUSEONLY
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This is ti~e notice to the apprapriate lacal gavernEr~enta! entity that tne foilowing local ~
govemment officer has become aware of facts that raquire the officer to file this statement u~c~ r~ec~~ed
in accordance with Chapter 176, Local Governm~nt Code.
1 Name of Locaf Gavernment ~fficer
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2 Office Held
~(~t_L.~.:.y~l i L--~...~ ~-~-r~TC~I~-_ ~ (~~1 I `~"~`~ ~ ~M ~--i I i i ~.~..
3 Name of person described by Sec#tans 176.002(a) and 176.OQ3(a}, Loca( Government Cade
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4 DQSCription af the nature and extent of employment ar other buslness relatianship with person named in itsm 3
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5 list ~ifts accepted by the local gouernment officer and any famity membsr, exciuding gifts clescribed by Sectiort
176.003{a-1); tf ac~gregate value af the gifts accepted from person named In item 3 exceed 5250 during the 12-month
perFOd described by Spction 176.003{a)(2)(B)
Date GiftRccepted Description of Gift ~~_ ---
Date Gift Accepted Description oE Gift v_~___(.~+_~.~ -- --
Date Gift Accepted ~/~ Description of GifE „ ~~ 1~
(attach additional forms as nec;essa-y)
& AFFIDAVfT
I swear under penalty of peryury that the abnve statement is true ancl correct. 1 acknowledge
that the dlsclosure applies to o family membe~ {as dEfined by 5ection 17fi.001{2). Local
Government Code) of this local government officer. I also acknowledge fhat this staterneni
covers tl~c 12-month pe~iod de crit~d by S2ction 176.003(a}, Locat Govarnmt~nt Code.
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5ignature of Local Goverriment t)ffi~r
AFFIX NOTAkY STAMP ! SEAI_ kESOVf
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-.Yl ~ 5,..~_l~-~ i l' this the ______,~.L~..._ ~aY
Sworn to and sul~scribe ora ms, by tne said ,,.~____ ~~~a~• ---
.l ~ c.~ U- ~ , to ce~tify which, witness rny hand end seal of office.
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,~~~~~~Y° STATE OF T~XAS
'+or~ My Camm. ~xp. 04-07-12