HomeMy WebLinkAboutPena Stmt 05 1213LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
(instructions for Completing and filing this form are provided on the back.)
FORM CIS
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 ststement in accordance with chapter 176, Local
Government Code.
l_.J Name;of Local Government Officer
~ Office Held
OFFICE USE ONLY
Bate Received
_J Name of person described by Sections 176.002(a) and 176~003(a), Local Government Code
De re and extent of employment or b~siness relationship with person
named in item 3
List gifts if aggregate value of the gifts'- 'received from Person named in item 3 exceed $250
Date Gift Received
Date Gift Received
Date Gift Received
Description of Gift
Description of Gift
Description of Gift
(attach additional forms as necessary)
r--1 Did NotAccept Gift
~ Did NotAccept Gift
~t Did NotAccept Gift
AFFIDAVIT
swear under penalty of perjuw that the above statement is true and correct. I acknowledge that
[he disclosure applies to a family member (as defined by Section 176.001(2), Local Government
Code) of a government officer. [ also acknowledge that this statement covers the 12-month pedod
described by Section 176.003(a)(2)(b), Local Govemment Code.
Signature of Local Government Officer
AFFIX NOTARY STAI~P / SEAL ABOVE
Sworn to and subscribed before me, by the said __
o' D~'~~1~ ~t ~' .20 ~ ,to certify which, witness my hand and seal of OffiCe.
Signature of o~cer administerin Printed name of officer administering oath