Santellana, Stephen - M&F Littiken LOCAL GOVERNMENT OFFICER CONFLICTS FOR IS
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.) 1 CI
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFICE USE 4N +I
This is the notice to the appropriate local governmental entity that the following local Date Recei d ` •
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government officer has become aware of facts that require the officer to file this statement S2
in accordance with Chapter 176,Local Government Code.
Name of Local Government Officer II
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2 Office Head >
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3 Name of vendor described by Sections 176.001(7)and 176.003(a), Local Government
ea
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 nd any amily 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 pert cribed by Section 6.003(a)(2)(B),Local
��, i�sx�Government Code.
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X � . L` Signature of Cocal
'government
Officer
DEBORAH NORTON
i
i.2 A.Notary Public, State of feA�.:1,'lease complete either option below:
(1)Afl fdNV '+� Comm. Expires 06-20-202.
'1,02;�;.. Notary ID 1316{2b t`i
NOTARY STAMP/SEAL
JJ h�
Sworn to and subscribed before me by 5"4-1— �^-� z —� this the ri day of Oc
20 4-'k , 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 8117/2020