Form Cis - Local Government Officer Conflicts Disclosure Statement
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1
2LOCAL
GOVERNMENT
OFFICER
FORM
CIS
CONFLICTS
DISCLOSURE
STATEMENT
(Instructions for completing and tHing 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
government officer has become aware of facts that require the officer to file this statement
Date Received
in accordance with Chapter 176, Local Government Code.
i
Name of Local Government
Officer
21 Office Held
Name of vendor described by Sections 176.007 (7) and 1 76.003(a), Local Government Code
4] Description of the nature and extent of employment or other business relationship with vendor named in item 3
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 72-month period described by Section 176.003(a)(2)(B).
Date Gift Accepted
Description of Gift
Date Gift Accepted
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 correct. I acknowledge
that the disclosure applies to each family member (as defined by Section 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 176.003(a)(2)(B), Local Government Code.
Signature of Local Government Officer
AFHX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said
this the
day
of
20
,
to certify which, witness my hand and seal of office.
Signature of officer administering oath
Printed name of officer administering oath
Title of officer administering oath
Adopted 8/7/2015
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