HomeMy WebLinkAboutAnderson CISLOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing 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 Received
Government Code.
~ Name of Local Government Officer
IQ /'~'1'~ C SID
2 Office Held
3 Name of erson described by Sections 176.002(a) and 176.003(a), Local Government Code
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4 Description of the nature and extent of employment or business relationship with person named in item 3
~I) ~f/ p,~JfT ~ '+~ ~ ~Y OAS
5 List gifts if aggregate value of the gifts received from person named in item 3 exceed $250
Date Gift Received Description of Gift ~ Did NotAcceptGift
Date Gift Received Description of Gift a Did Not Accept Gift
Date Gift Received Description of Gift 0 Did Not Accept 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 176.001(2), Local Government
Code) of a government officer. I also acknowledge that this statement covers the 12-month period
~~ct,~nnot~ described by Section 6. 3(a)(2)(b), Local Government Code.
~PPV P~~
BELINDA HINOJOSA
,
o
* ~ * Notary Public
STATE OF TEXAS
gig ~ ~ My Comm. Exp. 04f23/2009
Signatu of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
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Swor to and subscribed before me, by the said c.~~i~111 C ~ ~ ~" ' ~ ~ ,this the day
of , 20 ~ , to certify which, witness my hand and seal of office.
Signature of officer administering th Printed name of officer administe ' oath Title of officer a istering oath
Adopted 11!02!2005