Form Cis - Local Government Officer Conflicts Disclosure Statement (Page 2 of 2) in pdf

LOCAL GOVERNMENT OFFICER

CONFLICTS DISCLOSURE STATEMENT

Section 176.003 of the Local Government Code requires certain local government officers to file this form. A

“local government officer” is defined as a member of the governing body of a local governmental entity; a

director, superintendent, administrator, president, or other person designated as the executive officer of a

local governmental entity; or an agent of a local governmental entity who exercises discretion in the planning,

recommending, selecting, or contracting of a vendor. This form is required to be filed with the records

administrator of the local governmental entity not later than 5 p.m. on the seventh business day after the date

on which the officer becomes aware of the facts that require the filing of this statement.

A local government officer commits an offense if the officer knowingly violates Section 176.003, Local

Government Code. An offense under this section is a misdemeanor.

Please refer to chapter 176 of the Local Government Code for detailed information regarding the requirement

to file this form.

INSTRUCTIONS FOR COMPLETING THIS FORM

The following numbers correspond to the numbered boxes on the other side.

1. Name of Local Government Officer. Enter the name of the local government officer filing this statement.

2. Office Held. Enter the name of the office held by the local government officer filing this statement.

3. Name of vendor described by Sections 176.007 (7) and 176.003(a), Local Government Code. Enter

the name of the vendor described by Section 176.001(7), Local Government Code, with whom the officer has

an employment or other business relationship as described by Section 1 76.003(a)(2)(A), Local Government

Code.

4. Description of the nature and extent of employment or business relationship with vendor named

in item 3. Describe the nature and extent of the employment or other business relationship with the vendor

in item 3 as described by Section 1 76.003(a)(2)(A), Local Government Code.

5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3

exceeds $100. List gifts accepted during the 12-month period (described by Section 176.003(a)(2)(B),

Local Government Code) by the local government officer or family member of the officer from the vendor

named in item 3 that in the aggregate exceed $100 in value.

6. Affidavit. Signature of local government officer.

Adopted 8/7/2015

Form Cis - Local Government Officer Conflicts Disclosure Statement Page 2