Nelson, Larry - Will Kelty 01.04.2022 LOCAL GOVERNMENT OFFICER CONFLICTSFORM S
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.) I
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE 0i4iLYI I
This is the notice to the appropriate local governmental entity that the following local Date Receiv
government officer has become aware of facts that require the officer to file this statement w
in accordance with Chapter 176,Local Government Code. U
u- a
1 Name of Lcical Government Officer 0 "y
2 Office Held W W
� Co1) ,kic / 10 W �
3 Name of vendor described by Sectio s 176.001(7)and 176.003(a), Local Government 0 U m
Code �
4 Description of the nature and extent'of each employment or other business relationship and each family relationship
with vendor named in item 3. 7P,,,)7L ) WO,
5 List gifts accepted by the local government officer and any family 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), L I Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-mo h iod described y Sectio 176.003 a)(2)(B), Local
Government Code.
Signatur4 of Local Government Officer
Please complete either option below:
.,••Cwr nos, MARIE BALTHROP
(1)Affidavit i ;_9 Notary Public,State of Texas
i = My Commission Expires
October 26,2023
NOTARY STAMP/SEAL . .°„°°"` NOTARY ID 1173888-1_/
Sworn to and subscribed before me by Larof l V Y/ls� this the / day of i/dn )
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20 02 to certify which,witness my hand and seal of office.
`FYI a� 6cu ifl rIe Pc rola
Signature of officer administering Path Printed name of officer admingstering oath Titl - f 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