Santellana, Stephen - Anthony Inman Construction LOCAL GOVERNMENT OFFICER CONFLICTS FOTTI CIS
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. OIFICE US Q 14Y
This is the notice to the appropriate local governmental entity that the following local Date Re;elv
government officer has become aware of facts that require the officer to file this statement t
in accordance with Chapter 176,Local Government Code.
1 Name of Local Government Officer Z -i
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2 Office
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3 Name of vend+dr described by Sections 176.001(7)and 176.003(a), Local Government CC 0 0 co
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4 Description of the natal and extent of each employment or other business relationship and each family relationship
with vendor named in item// 3. // / L /�
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5 List gift accepted by the local government officer4nd 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 Description of Gift
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 SIGNATURE 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 Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-month p ' ribed by Sectio 176.003(a)(2)(B), Local
Government Code. 4,b i"---)
`� Signature of Lo I Government Officer
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`„oi,VP�B,� DEBORAH NORTON 1p
lease complete either option below:
f:/ ,,:Notary Public, State of Texas
, P' Comm. Expires 06-20-202"'
#,,,,,,,�� Notary ID 131612815
NOTARY STAMP/SEAL 1 / it/1-f—
Sworn Sworn to and subscribed before me by -A-t-4'- £4`L`- this the f 1 day of e`"41"--- ,
20 \ ,to certify which,witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
OR
(2)Unsworn Declaration
My name is , and my date of birth is .
My address is ,
(street) (city) (state) (zip code) (country)
Executed in County,State of ,on the day of ,20 .
(month) (year)
Signature of Local Government Officer (Declarant)
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020