HomeMy WebLinkAboutForm CIS King 06-06-2014LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and Sling this form are provided on the next page.)
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
OFFICEUSEONLY
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
Date Received
in accordance with Chapter 176, Local Government Code.
1 Name of Local Government Officer
2 office Held
3 Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code
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4 1 Description of the nature and extent of employment or other business relationship with person named in Item 3
5. List gifts accepted by the local government officer and any family member, excluding gifts described by Section
176.003(a•1), if aggregate value of the gifts accepted from person named in Item 3 exceed $260 during the 12-month
period described by Section 176.003(a)(2)(B)
Date Gift Accepted Description of Gift N 1
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 AFFIDAVIT
EI swear under penalty of perjury that the above statement is true and correct. I acknowledge
P PV that the disclosure applies to a family member (as defined by Section 6.001(2), Local
P�. Government Code) of this Ideal government officer. I also acknowledge t this statement
covers the 12 month period described by Section 176.003( , Local G mment Code.
11 k 1q� QF
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Signature of Local Gove ent Officer
AFFIX NOTAR'�'$iA�Yrp / SEAL ABOVE
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Swornjo and subscribed before I y the said —this the day
o!L9 20 to certify which, witness my hand and seal of office._ .
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Signature .1 administering oath Printed name of otfi r officer dmini.tering oath Title of ocer administers oath
Signature or 75
Adopted 06129/2007