HomeMy WebLinkAboutTrusler Stmt 05 1205 LOCAL GOVERNMENT OFFICER FORM CJS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for comptefing and filing this form are provided on the back.)
This is the notice to the appropriate local governmental entity that the OFFICEUSEONLY
following local government officer has become aware of facts that require
the officer to file this statement in accordance with Chapter 176, Local Date Received
Government Code.
~ Name of LOcal Government Officer
1 OffiCe Held
~ Name of person described by Sections 176;002(a) and 176.003(a), Local Government Code
~ Description of the nature and extent of employment or business relationship with person named in item 3
5~ List gifts if aggregaf:e value of the gifts received from person named in item 3 exceed $250
Date Gift Received, Description of Gift r-~id NotAccept Gift
Date Gift ReCeived Description of Gift r'--'~id NotAccept Gift
Date Gift Received Description of Gift [-"~Did NotACcept Gift
(attach additional forms as necessary)
6_.J AFFIDAVIT
I swear under pe~3fly oiF pedu~' that the above statement is true and correct. I acknowledge that
the disclosure applies to a family member (as deflr~J by Section 176.001(2), Local Government
Code} of a 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
AFFIX NOTARY STAMP / SEAL ABOVE
' day
S~lla[ure of offiCer administ~ng oath Printed name of officer administering Ga