HomeMy WebLinkAboutWaggoner 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 fife this statement in accordance with chapter 176, Local Dete Received
Gavemment Code.
1 Name of Local Government Officer
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z Office Hel
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3 Name of person described by Sections 1T6.002(a) and 1T6.003(a), Local Government Code
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a pescription of the nature and ent of employment or business relationship with person named in item 3
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5 List gifts if aggregate value of the gifts received from person named in item 3 exceed 1250
Date Gift Received Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift 0 Did NotAccept Gift
(attach additional forms as necessary)
6 AFFIDAVIT
1 swear under penalty of perjury that the above statement is true and correct. I acknowledge that
the dlsGosure applies to a famiy member (as defined by Section 176.001(2), Local Government
Code) of a government offices I also acknowledge that this statement covers the 12-month period
'~~ deskxit~ed by Section 176.003 )(2)(b), Local Government Code.
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ary Public
N~ STATE OF TEXAS -
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My Comm. Exp. 04/23/2009 Signature Of I Government Officer
AFFIX NOTARY STAMP ! SEAL ABOVE
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Sworn to and subskxibed before mo, by the said
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Signature of officer administer) oath Printed name of officer admini ring oath Title of adminiateNng oath
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LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
pnstructions 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.
1 Name of Local Government Officer
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2 Office Held
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3 Name of person 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
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8 List gifts if aggregate value of the gifts received from person named in item 3 exceed 5250
Date Gift Received Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift a Did NotAccept Gift
(attach additional forms as necessary)
B AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge that
the disclosure appNes to a family member (as defined by Section 176.001(2), Local Government
y\.,__~~ ~., f~~ Code) of a government oH'icer. t also acknowledge that this statement covers the 12-month period
cribed b
Section 176
003{a)(2)(b)
Local Government C
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p~PPY PCB, BELINDA HINOJOSA ~ w, ~ , ,~
~ Notary Public """"`~ aW~O'~
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OF TEXAS
9jFOF'(~~ My Camm. Exp. 04/23/2009 ~
ure of Lora nt Officer
AFFIX NOTARY STAMP / SEAL ABOVE
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Sworn o and subscribed before me, by the said
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Signature of officer administe oath Printed name of ofic:er ad staring oath Tide of office dminfatering oath
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LOCAL 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
2 Office Held
3 Name of person described by Sections 176.002(a) and 176.003(a). Local Government Code
4 Description of the nature and extent of employment or business relationship with person named in item 3
~~~~~~-~ i> -~ 1 ~~ o w~~~r-- ~ -~ ~~-~~.~s ~~~a:~s
S Ltst gifts if aggregate value of the gifts roceived from person named In item 3 exceed 5250
Date Gift Received Description of Gift 0 Did NotAccept Gift
Date Gift Received Description of Gift ~ Did NotAccept Gift
Date Gift Received Description of Gift ~ Did NotAccept Gift
(attach additional forms as necessary)
s AFFIDAVIT
1 swear under penally 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
ode) of a government otfioer. 1 also acknowledge that this statement covers the 12-month period
BELINDA HINOJOSA bed ~ ~~' 176.0o3(a)(2)(b), focal Government code.
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Notary Public
STATE OF TEXAS `~~
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~~ of + My Comm. Exp. 04/23/2009 ~ ~ u
ignatur+e of Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE ~ ~Iry, t I~-~y` rn,
Sworn o and subscribed before me, by the said w~ v - • ' ~ ,this the /~ day
of , 20 , to certify which witness m
y
nd and se 1 of office.
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S ature of officer administering Printed Hama of officer adminis ng oath Tito of officer ad taring oath
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