HomeMy WebLinkAboutAffidavit-City Council-Nakamura-07/06/21THE STATE OF TEXAS §
AFFIDAVIT ON ABSTENTION FROM VOTING
COUNTY OF TARRANT §
I, Tammy Nakamura, as a City Official of the City of Colleyville, Texas, make this affidavit and hereby on oath state the following:
I have a Conflicting Interest that would be specially affected by a vote or decision of Item 4b, listed under the Consent Resolution
R-21-4629 on the July 6, 2021 Colleyville City Council Agenda.
Item 4b, Resolution R-21-4629, Approval of the renewal for medical insurance and award of dental
insurance to BlueCross B1ueShield of Texas, and authorize the City Manager to execute the agreements
Each of the following categories constitutes a Conflicting Interest I have a Conflicting Interest for the following reason(s): (check
all which are applicable)
Ownership of 5% or more of the voting stock or shares of the business entity.
Ownership or receipt of $600.00 or more of the fair market value of the business entity.
Funds received from the business entity exceed $600.00 gross income for the previous year.
Ownership of an interest in real property with a fair market value of more than $600.00.
A relative of mine related in the third degree by either affinity or consanguinity has a Conflicting Interest in one or
more of the four categories listed above that would be affected by a decision of the public body of which I am a
member.
X The vendor has a business relationship with my spouse, Dr. Y Anthony Nakamura, MD, that may have resulted in
payments for healthcare services rendered to vendors members in excess of $2,500 during the preceeding 12 months.
Upon the Sling of this affidavit with the City Secretary, I affirm that I will abstain from voting or deliberating on any decision
involving this Conflicting Interest and from any further participation in this in
Signed this day of
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BEFORE ME, the undersigned authority, this day personally appeared T nimy /U*",qurag on oath stated that the facts
hereinabove stated are true to the best of her/his knowledge or belief.
SWORN TO AND SUBSCRIBED BEFORE ME, on this the ID+� dayof 7t,t_ k/ oiO PU ,
Notary Public, State of T A
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LOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS
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. 23, 84th Leg., Regular Session.
OFFICE USE ONLY
This is the notice to the appropriate local governmental entity that the following local
Date Received
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176, Local Government Code.
RECENED
1 Name of Local Government Officer
Tammy Nakamura
JUL - 6 2021
2 Office Held
City Councilmember, Place 1
CSo
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government
Code
Blue Cross and Blue Shield of Texas (BCBSTX)
4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in Item 3.
The vendor has business relationship with spouse (Dr. Y. Anthony Nakamura, M.D.) that may have resulted in payments for healthcare services rendered to vendor's
members in excess of $2,500 during the proceeding 12 months.
5 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
Date Gift Accepted N/A Description of Gift N/A
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 SIGNATURE I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the disclosure applies
to each family member (as defined by Section 176.001(A Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-mght i period descri f ction 176.003(a)(2)(B), Lee I
Government Code. /
Sig lure o Lo I Government Officer
Please complete either op n below:
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Tammy Nakamura
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Sworn to and subscribed before me by this the �1' _ day of
20 21 tocertifywhich, It ssmyhandandsealofoffice.
Christine Loven City Secretary
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Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
(2) Unsworn Declaration
My name is and my date of birth is
My address is ,
(street) (city) (state) (zip code) (country)
Executed in County, State of , on the day of , 20
(month) (year)
Signature of Local Government Officer (Declarant)
Form provided by Texas Ethics Commission www. ethics. state.tx. us Revised 8/1712020