Lee, Andy 06.26.2018LOCAL 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,13. 23, 54th Leg,, Regular Session, OFFICE USE ONLY
This is the notice to the appropriate local governmental entity that the fdHowiing local
government officer has become aware of facts that require the officer to file thisstatement Cale Received
in accordance with Chapter 176, Local Government Code.
1 Name of Local Government Officer
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Le. . .... .
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M
ffice Held
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Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
M1
Description of the nature and extent of each employment or other, business relationship and each artily relationship
with vendor named in item 3.
2j 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 Ac ted Description of Gift
101��
Dat/et Accepted Description of Gift . ...... ...
-1110
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
AFFIDAVIT i swear under penalty of perjury that the above statement is twe 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
171 vers the 12-month period described by Section 17UO3(a)(2)(B), Locit Government Code.
KiA BOONE
My Notary ID # 131047080
2`1
'ww+^�4ig (nature of Local Government Officer
Expires'March 15, 2021
AFFIX NO-rARY STAMP � SEAt- ABOVE
Sworn to and subscribed before me, by the "said''- this the_ day
of - 3(4A& 20 to cortify which, witness my hand and seal of office.
Signature of off car administering oath Prrnled name of officer administering oath l'itnicer adrninusterjng oath
Form provided by Jexas Ethics Commission www.elhics.statc1Y_us Revised 11/30/2015