HomeMy WebLinkAboutAnderson 06 0814 LOCAL GOVERNMENT OFFICER FORM
CONFLICTS DISCLOSURE STATEMENT
(instructions for complet ng and filing this form are provided on the back.)
This is the notice to the appropriate local governmental entity that the OFFICE USE ONLY
following local government officer has become aware of facts that require
the officer to file this statement in accordance with chapter 176, Local Date Rec~v~
Government Code.
J Name of Local Government Officer
2_~ Office Held
-
Name of l~erson described by Sections 176.002(a) and 176.003(a), Local Government Code
~ [:iescriPtion of ihe naturre end extent of e~loyment or businees relationship with person named in item $
~_J L st gifts if aggregate value of the gifts received from person named in item 3 exceed $250
Date Gift Repeived /, , Description of Gift [~ Did NotAccept Gift
Date Gift ReCeived Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift r-~ Did NotAccept Gift
(attach additional forms as necessary)
_.J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct_ I acknowledge that
the disclosure applies ko a family member (as defined by Section 176.001(2), Local Government
Code) of a government officer. I also acknowledge that this statement covers the 12-month period
f ~BELiNDAHiNOJOSA~-,-,~,~-~-~'~'~t'~'''''~'''~'~'~'''''''~' described by Section--f ~./~3(a)(2)(b), Local Government
Code.
I~[.~'~'.c'~ Notary PublicU/ ~ S~~~
~,. ,~ ~ STATE OF TEXAS
i ~ My Comm. Exp. 04/23/2009~--
~ . __ _, ._ ._.. ', ignatufe of Local Govemment Officer
AFFIX NOTARY STAMP ! SEAL ASOVE
Swo, j~to and subscribed before me, bythesaid ('John C' Ar~-~"~O~
'gnature of officer ad ministering o~h) Printed name of offTcer administe~i~ oath TiE ,fflcer a~isterlng oath