HomeMy WebLinkAboutNash 06 0408 LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
Cnstruct_Jons for completing and filing this form are provided on the back,)
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 Codg.
1~ Name of Local Government Officer
2_~ Office HeI¢
'
~j Name of person ~escrJbed~ 176.002(a) and 176.003(a), Local Governmen Cede
ten P yment or business relationship with person named in item 3
FORM
OFFICE USE ONLY
Date Received
g frs recewed from person nameo m item 3 exceed $250
Date Gift Received _
Date Gift Received.
Date Gift Received
AFFIDAVIT
Description of Gift
Description of Gift
Description of Gift
(attach additional forms as necessary)
Did NotAccept Gift
Did NotAccept Gift
Did NotAccept Gift
swear un(~er penalty oCperjury that the above statement is true and 2orrect. I acknowledge thai
i~ ~ ,disclosure applies t~ a family member [as defined by Section 176.001 (2) Local Government
b, re) of a government 8fficer. I also acknowledge tha this statement covers the t2-month pedod
Signature of Local Government Officer
AFFIX NOTARY STAMp SEAL ABOVE
of, ~ ,20 _(~(~ , to certify which, witness my hand and seal of o/~ce.
this the ~,t~
day
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 a member of a governing body of a local government entity or a
director, superinter~dent, administrator, president, or other person designated as the executive officer of the
local government entity. This form is required to be [~led with the records administrator of the local governmental
entity not later than 5 p.m. on the seventh business day after the date on which the officer 0ecomes aware of
the facts Ihat require the filing of this statement.
A local government officer commits an offense if the officer knowingly violates Section 176.003, Local
Government Code. An offense under this section is a Class C misdemeanor.
Please refer to chapter 176 of the Local Government Code for detailed information regarding the requirement
to file this form.
iNSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on fhe other side.
1. Name of Local Government Officer. Enter the name of 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 person described by Sections 176,002{a) and 176.003(a), Local Government Code. Enter
the name of the person described by Section 176.002, Local Government Cede with whom the officer has an
employment or other business relationship as described by Section 176.003(a), Local Government Code.
4. Description of the nature and extent of employment or business relationship with person named
in item 3. Describe the nature and extent of the relationship of the employment or other business relationship
with the person in item 3 as described by Section 176.003(a), Local Government Code.
5. List gifts if aggregate value of the gifts received from person named in number 3 exceed $250.
List gifts received during the 12-month period (described by Section 176.003(a)(2)(B), Local Government
Code) by the local government officer or family member of the officer ['rom the person named in number 3
that in the aggregate exceed $250 in value.
6. Affidavit. Signature of local government officer,