Dickinson, John 01.30.2019AFFIDAVIT
STATE OF TEXAS )(
COUNTY OF WICHITA )( t
�i
I, , s a member of the C'glloweli make this affidavit and hereby on oath
state the following: I and/or a person or persons related to me, have a substantial interes in a
business entity that would be peculiarly affected by a vote or decision of the �L� ice'
as those terms are defined in Chapter 171 of The Texas Local Government Code.
Date of Meeting: / '36/0— rS� Item No.
The business entity is z�
I (have/has) a substantial interest in this business entity for the following reasons: (Check all which
are applicable.)
Ownership of 10% or more of the voting or shares of the business entity.
Ownership of $5,000 or more of the fair market value of the business entity.
Funds received from the business entity exceed 10% of his/her income for the previous year.
Real property is involved and his/her has an equitable or legal ownership with a fair market
value of at least $2,500.
A relative of mine has a substantial interest in the business entity or property that would be
affected by a decision of the public body of which I am a member.
Upon the filing of this affidavit with the City Clerk„ I affirm that I will abstain from voting on any
decision involving this business entity and from any further participation on this matter whatsoever.
7� �
Signed this .36 day o v 20�
Signature of Official
Title
v
BEFORE ME, the undersigned authority, this day personally appeared j a h n Di c Ic rn Sri'l
and on oath stated that the facts hereinabove stated are true to the best of his/her -knowledge and
belief.
Sworn to and subscribed before me on this the �,v4 day of _)aw cu , 20 .
My Commission Expires:
(plank IS �vai
KIA BOONE
My Notary ID # 131047080
Expires March 15, 2021
RECEIVED N
CJTY CLERK'S OFFICE
By. �- TIME` _►a
I—tary Publi&
State of Texas
and for the