Santellana, Stephen - Bundy, Young, Sims & Potter LOCAL GOVERNMENT OFFICER CONFLICTS 1 rr jto IS
DISCLOSURE STATEMENT I
(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. OF=ICE USE ID4
This is the notice to the appropriate local governmental entity that the following local Date Rece ved W
government officer has become aware of facts that require the officer to file this statement w
in accordance with Chapter 176,Local Government Code. c�
1 Name of Local Government1
Officer /)
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0 cc2 Office Heed W W o
Atit-ti f)ri w
3 Name of venal'described by Sections 176.001(7)and 176.003(a), Local Government U Q m
Code CC J� j�
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4 Descriptio th nature a)fd extent of each e1x(pioyment or other business relationship and each family relationship
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with vendor named in item 3. ii� /
Aboi 0 -S 69 r [-ADx erg', 6. n ay 1✓e i ve4, ?1 S-✓/ljL e5 .
5 Lim gifts accepted by the local gover1men4/officer and any family member, it 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)(S).
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 per' escribed by Se ' 17 .003(a)(2)(B), Local
ovemment Code.
`"':"`'� DEBORAH NORTON
�•`;�a ?a% Signature of Local Government Officer
2i.: ;Notary Public,State of Texas
9•. :+P Comm. Expires 06 20-2022 'lease complete either option below:
�',,,„,,�`�� Notary ID 131612815
(1)A.nuava. '
NOTARY STAMP/SEAL
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Sworn to and subscribed before me by s+�'Y i-- s�•-1-t-)�°""`' this the I day of e rJ%`"' ,
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