Nelson, Larry Petroleum Building, LLC. 01.18.2022 LOCAL GOVERNMENT OFFICER CONFLICTS I FORNNCIS
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. OFFICE USE ONL
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This is the notice to the appropriate local governmental entity that the following local
Date Receive
government officer has become aware of facts that require the officer to file this statement � c1
in accordance with Chapter 176,Local Government Code. ,
1 Name of Local Government Officer
at- sowtr. Y0 cc
2 Office Held
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3 Name of vendor described by Sections 176.001(7)and 176.003 a), Local Governme Lu
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Code 4 fiJl,l� i : nt�:�R f+�l�s
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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.
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) ocal Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-mo eriod descri d by Section 176.003(a)(2)(B), Local
Government Code. e- I
a,.4'py74 MARIE BALTHROP Signature of L al Government Officer
�11Notary PubG� State of Texas 1
*' My Commission Expires
;, 7..." October 11 386 Please complete either option below:
w,,,,,,,. NOTARY D 1173862-1 p p
(1)Affidavit
NOTARY STAMP/SEAL �r
Sworn to and subscribed before me by L .rfj Nei/Sall I this the t14- day of (,�"i1.�'
TG G " ,
20 a 1-- ,to cert' which,witness my hand and seal of office.
(WI" Mane Ref , C,� GcrrC
Signature officer administering oath Printed name of officer admini Bring 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