Lee, Andy 01.30.2018LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
OFFICE USE ONLY
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
Date Received
in accordance with Chapter 176, Local Government Code.
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1 Name of Local Government Officer
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2 Office Held
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3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code 1 _ "n 7
4 Description of the nature and extent of each employment or other business relationship and each amily relationship
with vendor named in item 3.
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51 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
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Description Gift Co
Date Gift Accepted of
Date Gift Accepted Description of Gift
Date Gift Accepted Description of 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 each family member (as defined by Section 176.001(2), Local
vernment Code) of this local government officer. I also acknowledge that this statement
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��• �; vers the 12-month period described by Section 176.003(a)(2)(B), Local Government Code.
My Notary ID # 131047080
';E•oF ; ,+� Expires March 15, 2021
ignature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn` to and subscribed before me, by the said r�rl Gi ut- this the day
of )CkA ucv � , 20 , to certify which, witness my hand and seal of office.
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Signature of offi r administering oath Printed name of officer edrministering oath Title of officer administering oath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015