LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
(Click here for instructions for completing and filing this form.)
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 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

4. Description of the nature and extent of employment or business relationship with person named in item 3.
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 Not Accept Gift
Date Gift Received Description of Gift Did Not Accept Gift
Date Gift Received Description of Gift Did Not Accept Gift
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 described by Section 176.003(a)(2)(b), Local Government Code.
I AGREE to the affidavit statement above.