LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT (Instructionsi for completing and filing thisf form are provided ont the next page.) This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. 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 tot filet this statement Date Received  FORM CIS  OFFICEUSEONLY  ina accordance with Chapter 176, Local Government Code. Name of Local Government Officer  Office Held  Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code  Description of the nature and extent of each employment or other business relationship and eachi familyrelationship  with vendor named ini 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 12-month period described by Section 176.003(a/2)(B).  Date Gift Accepted Date Gift Accepted Date Gift Accepted AFFIDAVIT  Description of Gift Description of Gift Description of Gift  (attach additional forms as necessary)  Iswear under penalty of perjury that the above statement is true and correct. acknowledge that the disclosure applies to each family member (as defined by Section 176.001(2), Local Government Code) of this local government officer. lalso acknowledge that this statement covers the 12-month period described by Section 176.003a)2/B), Local Government Code.  Signature of Local Government Officer  AFFIX NOTARY STAMP I SEAL ABOVE Swornt toa and subscribed! before me, byt the said_  this the_  day  of  20  to certify which, witness my hand and seal ofc office.  Signature of officer administering oath Form provided by Texas Ethics Commission  Printed name of officer administering oath  Title ofc officer administering oath  www.ethessiale.kus  Revised 11/30/2015    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 ar member oft the governing bodyo ofald local governmental entity; a director, superintendent, administrator, president, or other person designated as the executive officer ofa al local governmental entity; or ani agent of al local governmental entity who exercises discretioni int the planning, recommending, selecting, or contracting of av vendor. Thist formi is required to bet filed withi ther records administrator of thel local governmental entity notl later than! 5p.m. ont the seventh business day after the date on whichi the officer becomes aware of thet facts that require thet filingo oft this statement. Alocal government officer commits an offense ift the officer knowingly violates Section 176.003, Local Government Code. Refer to chapter 176 oft thel Local Government Code for detailed information regarding the requirement tof file this form.  An offense under this sectioni is a misdemeanor.  INSTRUCTIONSI FORCOMPLETING THISI FORM  Thei followingn numbers correspond toi the numberedi boxes on the other side.  1. Name of Local Government Officer. Enter the name of thel 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 176.001(7)and 176.003(a), Local Government Code. Enter the name of the vendor described by Section 176.001(7), Local Government Code, if the vendor: a) has an employment or other business relationship with the local government officer or a family member of the officer as described by Section 176.003a)2)A,Loca Government Code; b) has given tot thel local government officer or afamily member of the officer one or more gifts as described by Section 176.030)2X8.Local Government Code;or c) has af family relationshipy with 4. Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. Describe the nature and extent of the employment or other business relationship the vendor has with the local government officer or at family member of the officer as described by Section 176.003(a)2)A), Local Government Code, and eachf family relationship the vendor has with thel local government officer 5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named ini item 3 exceeds $100. List gifts accepted during the 12-month period (describedl by Section 176.003(a)(2/B), Local Government Code)! by the local government officer ori family member oft the officer from the vendor named ini item 31 that int the aggregate exceed$ $100  the local government officer as defined by Section176.0012a), Local Government Code.  as defined by Section 176.001(2-a), Local Government Code.  invalue.  6. Affidavit. Signature ofl local government officer.  Local Government Code S 176.001(2-a): "Family relationship" means a relationship between a person and another persony withini thet third degree by consanguinity ort the second degree! by affinity, ast thoset terms are definedby Subchapter  B, Chapter 573, Government Code. Local Government Code $1 176.003a)2)A):  (a) Alocal government officer shall file a conflicts disciosure statement with respect toa av vendori if:  *** (2) the vendor:  (A) has an employment or other business relationship with the local government officer or a family member of the officer thatr resultsi int the officer or family member receiving taxablei income, other thani investment income, that exceeds $2,500 during the 12-month period preceding the () ac contract between the local governmental entity and vendor hasl been executed;or (i) thel local governmental entityi is considering enteringi into ac contract with thev vendor.  date that the officer becomes aware that:  Form provided by Texas Ethics Commission  www.etnics.state.kus  Revised 11/30/2015