Lee, Andy 03.26.2018LOCAL 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 Date Received
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176, Local Government Code. 03
1 Name of Local Government Officer 0
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2 Office Held rri m
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3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
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4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
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5 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).
Date Gift Accepted �g Description of Gift
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
FF TI 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
Government Code) of this local government officer. I also acknowledge that this statement
covers the 12-month period described by Section 176.0)(2)(B), Local Government Code.
KIABOONE
My Notary ID # 131047080
Expi March15202res
Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE ,/�
( Alftdrf w this the o�L+� day
Sworntoand subscribed before me, by the said t, 4i-�
of +r 16V Ly 20 _ � _ , to certify which, witness my hand and seal of office.
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Signature of off ic administering oath Printed name of officer administering oath Title of of icer administering oath
Form provided by Texas Ethics Commission
www.ethics.state.tx.us Revised 11/30/2015