HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-10/17/2012Lt~CAL G{~VERNMENT OFFICER ~~~~ ~`S
C~N~'LICTS DISCLOSURE STATEMENT
(Instructians for compieting and filing this form are provided on the next page. j
7his questiannaire reflects changes made ta the iaw t~y Ff.B. 1499, 84th ~eg., Regutar 5ession. QFFICEU$EONLX
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This is the notice fo the apprapriate loca! governmental entity that the foilowing locai -'
government officer has become aware af facts #hat require the off~cer ta fife this s#atement
in accordance with Ghapter 176, Local Govemment Code. ~~ R n~
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'~ Name of Locat Government Ofificer Or~ 1~~oi~
~r 1 1
Brian J_ ~oftus
CITY SECRETARY'S OFFICE
2 Office Heid
Appointee to the Metroport Teen Court Advisory Board
a Name of persan described by Sectians 176.002{a} and 176.003{a}, Lacai Gavernrnent ~ode
Nane
a Des~ription of the nature and extent t~f emplQytnent crr other business relationship wtth persan named s`n itetn 3
None
~ Lis# gifts accepted by the 6aca1 gavernenent officer and any f~mity member, e~xctuding gifts described by SectiQra
176.003{a-1}, if aggregate value of the gifts accepted from person named in item 3 exceed $250 during the'{2-month
period descritred by Section 176.003(a}(2)(Bj
Date Gift Accepted NIA Description c~~ Gift ~flA
C?ate GiftAceepted N/A Description of Gift N/A
Date GiftAccepted N/A I7escriptiQn of Gift N/A
(attach additional fiorms as necessary}
6 AFFIDAWIT
I swear under penalt}r of pe~jury thai the abo~e stafement is true and correci. I ackr~ow{edge
thaf the dlsciosure appiies to a family member (as de#ined by Section 776 Ofl1{2}, Local
Govern~nent Code} af this Eocai govsrnment oificer. I a{so acicnowiedge that this statement
covers ihe 12-manth perior3 described by S~cfion 17 {a); Local tUovemment Code.
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Signature of Local Govemment Officer
AFFIX hlOTARY STRMP ~ SER!~ ABOVE
Sworn to and subscribed before me, by the said , this the day
of , 20 , ta certify which, witness my hand and seal of office.
Signature a;` otficer admin'sstering oath Printed name of offic~r administering oaYh Title af o#ficer administering oath
Adopted 06f29f2047