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Home My WebLink AboutFinancial Disclosure Statements-Financial Disclosure Statements-01/14/2021City of Colleyville Financial Disclosure and Business Conflict of Interest Forms PERSONAL FINANCIAL STATEMENT AFFIDAVIT Financial Disclosure and Business Conflict of Interest Forms shall be provided by candidates for Mayor and City Council and by applicants seeking appointments to the Planning and Zoning Commission or the Zoning Board of Adjustment, and shall file such forms within two (2) business days following the end of the candidate filing period, or if for appointment, within (2) business day following the end of the application period stated in the official City advertisement for application for the position. The city manager and the city manager's senior staff members (including any staff member who is appointed with City Council approval) shall also file the same within thirty (30) days of hiring. All person(s), as outlined above, shall have a duty to file supplemental disclosures annually and within five (5) business days of an occurrence of any change in the information reflected in the forms previously filed by the individual. Before me, 4,e undersigned authority, personally appeared: /r✓//eP who, after being duly sworn upon their oath and deposed and stated as follows: "My name is 646 a Ltil and I hereby submit for filing the attached Financial Disclosure and Business Conflict of Interest forms. I have personal knowledge of all information contained in said forms and all information contained in the forms is true and correct." "Further, all information contained in the forms is plete. There is no information that has been withheld or not disclosed whi¢ is esp iv to or required to be disclosed b the forms." Affiant Sworn to and subscribed before me, this the Z�A day of �nnuag/ 20 &V CNRISTINE LOVEN My Notary ID # 11092587 EVIm May 2, 2022 , Notary Public, State of Texas INITIAL HERE: L�- DATE: Vy/,-w/ City of Colleyville Financial Disclosure and Business Conflict of Interest Forms INFORMATION STATEMENT TOTAL NUMBER OF FILED: OFFICE USE ONLY 1 NAME First, MI Date Received G. Last, Suffix 2 ADDRESS Address/City/State/Z p SOS �� %lS ItCQ� �y-., J e v �' �� 7 0 3 3 TELEPHONE Area Code, Ph ne Number, Extension NUMBER l n � S C8 O 4 REASON FOR FILING EMPLOYEE 1 (CITy Ml,,ANAGER OR *SENIOR STAFF) L�1 CAN Gc�6le,t,y+) )e DI DATE Gi4u �Jmc I i �Z K (INDICATE OFFICE) STATEMENT 0 ELECTED OFFICIAL (INDICATE OFFICE) ZONING BOARD OF ADJUSTMENT (APPLICANT OR APPOINTEE) 0 PLANNING & ZONING COMMISSION (APPUCANTORAPPOINTEE) ❑Two (2) business days following the end of the candidate filing period or if appointment, following the end of the application period stated in the official city advertisement for the position. Supplemental disclosure filed annually and within five (5) business days of an occurrence in previously filed form. *SENIOR STAFF is defined as those employees who are classified as directors and above in the City's classification system and the City Manager and City Secretary. SPOUSE NAME J ,�_i� �1L DEPENDENT 1. `- Q �� 3.1 e CHILD/CHILDREN 2. NAME(S) 3. 4. COPY AND ATTACH ADDITION PAGES AS NECESSARY INITIAL HERE � DATE: l City of Colleyville Financial Disclosure and Business Conflict of Interest Forms INTERESTS IN REAL PROPERTY Section 1 Describe the location, size, and current use of all property owned within the included map, or held in trust by the filer, spouse, and any dependent minor children, or any business entity in which the person has a financial interest. When reporting information about a dependent child's activity, indicate the child about whom you are reporting by providing the number under which the child is listed on the Information Statement. HELD OR ACQUIRED BY LX FILER OSPOUSE ODEPENDENT CHILD #_ Z DESCRIPTION / Lot I I� I� CitI(,l, -V I Block County 1 1- '� � n- Subdivision//W I le, V If / 1I//Q. Ad Valorum Tax Account Number 0J< Acre(s) and Tract• STREET ADDRESS I STREET ADDRESS, INCLUDING CITY, COUNTY, AND STATE IJr 4 NAME LIST THE NAMES AND ADDRESSES OF OTHER PERSONS OR BUSINESS ENTITIES WHICHOWNAN INTEREST IN THE REAL PROPERTY 1 `i--RVGQI� 1�O�K(��G I INDIVIDUAL aZvOS �V� �ct5� S�• Q BUSINESS 1l_J�y�e 3� r 1 7 roo yq oU 1 HELD OR ACQUIRED BY FILER OSPOUSE DEPENDENT CHILD # DESCRIPTION Lot City Block County Subdivision Ad Valorum Tax Account Number Acre(s) and Tract s STREET ADDRESS STREET ADDRESS, INCLUDING CITY, COUNTY, AND STATE 4 NAME LIST THE NAMES AND ADDRESSES OF OTHER PERSONS OR BUSINESS ENTITIES WHICH OWN AN INTEREST IN THE REAL PROPERTY 0 INDIVIDUAL 0 BUSINESS COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY ❑ NOT APPLICABLE INITIAL HERK� DATE:/�/ City of Colleyville Financial Disclosure and Business Conflict of Interest Forms FEE, SALARY, OR GIFT Section 2 The name and address of any person or corporation which currently has or during the preceding twelve (12) months has had a direct or indirect contractual relationship with the City and from which the person(s), their spouse, or dependent minor children have received a fee, salary, or gift of value exceeding one hundred dollars ($100.00). When reporting information about a dependent child's activity, indicate the child about whom you are reporting by providing the number under which the child is listed on the Information Statement. 'RECIPIENT = FILER =SPOUSE =DEPENDENT CHILD # 2FEE, SALARY, GIFT NAME AND ADDRESS 3 DESCRIPTION OF FEE, SALARY, GIFT 'RECIPIENT =FILER =SPOUSE =DEPENDENT CHILD # Z FEE, SALARY, GIFT NAME AND ADDRESS DESCRIPTION OF FEE, SALARY, GIFT 'RECIPIENT =FILER =SPOUSE =DEPENDENT CHILD # Z FEE, SALARY, GIFT NAME AND ADDRESS 3 DESCRIPTION OF FEE, SALARY, GIFT COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY U/ NOT APPLICABLE INITIAL HERE DATE:4` City of Colleyville Financial Disclosure and Business Conflict of Interest Forms BUSINESS INTERESTS Section 3 The name and address of any corporation or business, which currently has or in the preceding twelve (12) months has had a direct or indirect contractual relationship with the City, of which person(s), their spouse, or any dependent minor children own more than two percent (2%) of the outstanding equity interest or more than two percent (2%) of the assets. When reporting information about a dependent child's activity, indicate the child about whom you are reporting by providing the number under which the child is listed on the Information Statement. 1 HELD OR ACQUIRED BY =FILER =SPOUSE =DEPENDENT CHILD # ' DESCRIPTION NAME AND ADDRESS 3 NATURE OF BUSINESS 'HELD OR ACQUIRED BY =FILER =SPOUSE =DEPENDENT CHILD # 'DESCRIPTION NAME AND ADDRESS 3 NATURE OF BUSINESS 'HELD OR ACQUIRED BY =FILER =SPOUSE =DEPENDENT CHILD #_ ' DESCRIPTION NAME AND ADDRESS 3 NATURE OF BUSINESS COPY AND ATTACH ADDITIONAL PAGES AS NECESSARY KNOT APPLICABLE INITIAL HERB�'.� DATE:) 1