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HomeMy WebLinkAboutNASH CISLOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT (Instructions for completing and filing this form are provided on the back.;i FORM CIS 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 Received Government Code. ~ Name of Local Government Officer L- © ~'~ 0 4.~~ o. S 2 Office Held s~ Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code S •'~~-~~ o~ ova ~ l~~ ~ ~s~ E~•t- `moo\o~ ~ Q ~ Description of the nature and extent of employment or bu Hess relationship with person named in item 3 List gifts if aggregate value of the gifts received from person named in item 3 exceed $250 Date Gift Received Date Gift Received Date Gift Received AFFIDAVIT ~o•`"PY p~ BELINDA HINOJOSA '~oF My Comm, XAS ~!~ Exp• 04/23/2009 Signature of Local Govemment Officer AFFIX NOTARY STAMP / SEAL ASOV2 _[~ /~ ~I c T•~ Sworn to and subscribed before me, by the said ~ ~ ~^'~' ~' "'- /~~`~~~ ,this the ~ day of , 2Q , to certify which, witness my hand and seal. of office. ~~-`r-da ~Irho osc~ Signature of officer administering oa Printed name of officer administe g oath Description of Gift Description of Gift Description of Gift (attach additional forms as nE:cessary) Did Not Accept Gift Did Not Accept Gift Did Not Accept Gift I swear under penalty of perjury thsit the above statement is true and t:orrect. I acknowledge that the disclosure applies to a family n-Member (as defined by Section 176.001(2), Local Govemment Code) of a government officer. I also acknowledge that this statement covers the 12-month period described by Section 176.003(a)(2;~(b), Local Government Code. ~~ Title of officer ng oath Adopted 11/02!2005