Santellana, Stephen - Biggs & Matthews Engineering LOCAL GOVERNMENT OFFICER CONFLICTS FOR 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. O+ICE USE pN11.1
This is the notice to the appropriate local governmental entity that the following local Date Race ved E
government officer has become aware of facts that require the officer to file this statement j-
in accordance with Chapter 176,Local Government Code.
1 Name of Local Government Officer JJ p q
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2 Office Held w W -
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3 Marne of vendor described by Sections 176.001(7)and 176.003(a), Local Government C.)LLI co m
Code ,�//�// �))����// 7^
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4 Deso ion of the nature and extent of eacb&mployment Qybther business relationship and each family relationship
with vendor named in item 3.
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5 Lisa gifts accepted by the local govertfinentjfficer and any fan{fty 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 Section 176.003(a)(2)(B),Local
n „„ nment Code.
,,"" ,, DEBORAH NORTON Signature' Local Governmen fficer
;_: _Notary Public,State of Texas
Comm. Expires 06-20-2022 Please complete either option below:
'',4,°,;�.` Notary ID 131612815
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NOTARY STAMP/SEAL Sworn to and subscribed before me by 5/ . 1- SN,'/1.-- this the t y1-1— day of °•17I--f,""
20 a‘ , 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