LOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS DISCLOSURE STATEMENT (Instructions for completing andf filing thisi 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 Date Received government officer has become aware offacts thati require the officert toi filet this statement OFFICEUSEONLY inaccordance with Chapter1 176, Local Government Code. Name of Local Government Officer 2 Officel Duphney MayoR. Code Kirby Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government TOEE SERJICES Description of thet nature and extent ofe each employment or other business relationship ande eachi family relationship 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). with vendor named ini item 3. Husband- CLEARMY LAND Date Gift Accepted Date Gift Accepted Date Gift Accepted. Description of Gift Description of Gift Description of Gift. HR MA (attach additional forms as necessary) 6 SIGNATURE Iswear under penalty of perjury that the above statèment 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 goverment officer. I also acknowledge that this statement covers the bys Seclon/476003a12/8. Local Government Code. LIBBY ELAINE HILLIARD Notary Public, State of Texas Comm. Expires 02-03-2026 Notary ID 133568860 Officer H Please complete either option below: Tas NOTARY STAMP/SEAL Sworn to and subscribed before me by. r the Grk this day of_ puwy Title officer administering oath Nofary s Aol 20 df-officer oath Sigrfature administering T"-A--w-A Milliard lbly Printedi name ofo officer administering oath OR (2) Unsworn Declaration My name is My address is Executed in and my date of birth is (city) day of (month) (street) County, State of_ (state) (zip code) (country) on the. 20 (year) Signature of Local Govemment Officer (Declarant) Form provided by Texas Ethics Commission www.ethics.state.kuS Revised 8/17/2020