HomeMy WebLinkAboutForm CIS King 06-06-2014 (2)LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing 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
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3 Name of described by Sections 176.002(a) and 176.003(a), Local Government Code
person
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4 Description of the nature and extent of employment or other business relationship with person named in item 3
S 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 $250 during the 12-month
period described by Section 176.003(a)(2)(B)
NNI Ot
Date Gift Accepted Description of Gift
Date GiftAccepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
that the disclosure applies to a family member (as defined by Section 1 001(2), !_ocat
Government Code) of this local govemment officer. I also acknowledge that is statement
covers the 12-month period described by Section 176.003(a), Gov nt Code.
Signature of Local Govemment Officer
AFFIX NOTARY STAMP ! SEAL ABOVE �` n,
sworn ✓1 and subscribed before m y she said �Q �� S ( t '— n 1 this the day
of 20 to certify which, witness my hand and seal of office.
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Signature of officer adI It
taring oath Printed name of of8 r dministering oath Title of officer administerin ath
Adopted 06/29/2007