LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT

Section 176.003 of the Local Government Code requires certain local government officers to file this form. A
"local government officer" is defined as a member of a governing body of a local government entity or a
director, superintendent, administrator, president, or other person designated as the executive officer of the
local government entity. This form is required to be filed with the records administrator of the local governmental
entity not later than 5 p.m. on the seventh business day after the date on which the officer becomes aware of
the facts that require the filing of this statement.

A local government officer commits an offense if the officer knowingly violates Section 176.003, Local
Government Code. An offense under this section is a Class C misdemeanor.

Please refer to chapter 176 of the Local Government Code for detailed information regarding the requirement
to file this form.

INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of local government officer filing this statement.
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code. Enter
the name of the person described by Section 176.002, Local Government Code with whom the officer has an
employment or other business relationship as described by Section 176.003(a), Local Government Code.
4. Description of the nature and extent of employment or business relationship with person named
in item 3. Describe the nature and extent of the relationship of the employment or other business relationship
with the person in item 3 as described by Section 176.003(a), Local Government Code.
5. List gifts if aggregate value of the gifts received from person named in number 3 exceed $250.
List gifts received during the 12-month period (described by Section 176.003(a)(2)(B), Local Government
Code) by the local government officer or family member of the officer from the person named in number 3
that in the aggregate exceed $250 in value.
6. Affidavit. Signature of local government officer. The requirements for this section are satisfied by selecting the "I Agree" box.