HomeMy WebLinkAboutTipton 05 1230LOCAL 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 statement in accordance with chapter 176, Local
Government Code.
OFFICE USE ONLY
Date Received
I.J N~,,~ Local G eve r nment Office r
Office Held
] Hame of person described by Sections 176.002(a) and 176.003(a), Local Government Code
__J Description of the nature and extent of employment Or business relationship with person named in item
5.~ List gifts if aggregate value of the gifts received from person named in item 3 exceed $250
Date Gift Received Description of Gift
Date Gift Received Descnption of Gift
Date Gift Received Description of Gift
(attach additional forms as necessary)
~'~ Did NotAccept Gift
[~ Did NotAccept Gift
~ Did NotAccept Gift
AFFIDAVIT
I swear under pena'ty of perjury that the above statement is [rue and correct. I acknowledge that
the disclosure applies to a family member (as defined by Section 1~.001(2), Locat Government
Code) of a government office~ I also ac~i~dge that/this statem'ent~vers the 12-month period
described by Section 176.0~(a)(~, Loca/Governme~/
/ ~-'~' Signature of,~ca~ Government Officer
Sworn to and subscribed before me, by the said ~ I/~ /~ ~ , this the ~/~ day
of ~D~'r~"J~ ,20 ~ ,tocerUfywhich. wffitessmyhandandsealofoffice.
S~g~abJre of officer administe~th
~r[nted name of officer adrninist~er[ng oath
R I*1 ~)~1 No~ P~lic