Santellana, Stephen - Corlett, Probst & Boyd Engineering LOCAL GOVERNMENT OFFICER CONFLICTS F01341 CIS
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
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This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. CIFFICE US 111.Y
This is the notice to the appropriate local governmental entity that the following local Date Re eivetil
government officer has become aware of facts that require the officer to file this statement U
in accordance with Chapter 176, Local Government Code.
1 Name of Local Government Officer 0
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2 Office Held > U
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3 Name of valor described by Sections 176.001(7)and 176.003(a), Local Government cC U 0 m
Code
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4 Description of the nature ar extent of ovti empioymeotor other busiints relationship and each family relationship
with vendor named in item 3. �1 1
j ynr iS Gar1.�tai' eV 1iAr,444 In.(ei a i/ {(?c'L,s( 4 V S;C�Y G_i e 5 .
5 Liat gifts accepted by the local goxiernme!ttofficer and aiiy familylriember, 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 period ribe by Section 176.003(a)(2)(B), Local
._ Government Code.
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`,���8�/1 'Signature of ocal G'YJvernment Officer
```��pvpGe�� DEBORAH NORTON 'lf
�,�?: :`toNotary Public, State of Tex sI' Please complete either option below:
I y'. +P:77 Comm. Expires 06-20.202- Li
ffiPAlicti►it Notary ID 131612815
NOTARY STAMP/SEAL Sworn to and subscribed before me by SL.I-- Sa- 11'»-- this the !�� day of 0e 44-' ,
20 2 . , 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