Santellana, Stephen - Earth Builders, Inc. LOCAL GOVERNMENT OFFICER CONFLICTS FOIT 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. FICE US OctiII4Y
This is the notice to the appropriate local governmental entity that the following local -
Date Ile i&vet
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176,Local Government Code.
1 Name of Local Government Officer
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2 OffIce Hem > --1
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3 Namfi of ven r described by Sections 176.001(7)and 176.003(a), Local GovernmentA"legCC C) C] CO
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.MIL 00' S c;- hi a viee SL r Vft e [v ova Gees l c�&,/1k -k r" !/P_n d4Y •
5 Lisk'gifts accept d y e local government officer a d an amity 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 ri scribedby S 76.003(a)(2)(B),Local
Government Code.
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-" Signdure of`Cocal Government Officer
"""'�� DEBORAH NORTON
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.`Pay Pt '.
..4: 1;:,:Notary Public,State of Texasts Please complete either option below:
'Pi Comm. Expires 06-20-2022
(1 V Notary ID 1316128I . 1
NOTARY STAMP/SEAL a
Sworn to and subscribed before me by 51-4,L-r 5-4.-le fi.--- this the i+ day of Q r4" ,
20 3-1. , 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