Lilley, Dave 08.02.2012 AFFIDAVIT FOR CONFLICT OF INTEREST
STATE OF TEXAS )(
COUNTY OF WICHITA
I, A,J E-Z LkL-Lz-t , as a member of the � ��K�T Cs�(r•R'R T�*1
make this
affidavit and hereby on oath state the following: I and/or a person or persons related to me, have a substantial
interest in a business entity that would be peculiarly affected by a vote or decision of the
4/! MJtD as those terms are defined in Chapter 171 of The Texas Local Government 26de.
�n A ,M►v ��cz.�. z-� wok. 1oa
Date of Meeting: 2 of AAusT ,2oa Item No.:
The business entity is: w tcN nA, Tk LS M g0%c.%'Phi f�►Qpo
Business Name
Address
I (have/has) a substantial interest in this business entity for the following reasons: (Check all which are
ap I* ble.
Ownership of 10% or more of the voting stock or shares of the business entity.
Ownership of$5,000 or more of the fair market value of the business entity.
Funds received from the business entity exceed 10% of (his/her) income for the previous year.
Real property is involved and (he/she) has an equitable or legal ownership with a fair market value of at
least $2,500.
A relative of mine has a substantial interest in the business entity or property that would be affected by
a decision of the public body of which I am a member.
Upon the filing of this affidavit with the City Clerk, I affirm that I will abstain from voting on any decision
involving this business entity and from any further ation on this matter whatsoever.
�+v
Signed this - day of 20 �2
Signature of Official
�r c��- W� "ice (� �s-� �C���-oVM�'� �e�p��'►�
Title /
BEFORE ME, the undersigned authority, this day personally appeared A �E L I L Ce
and on oath stated that the facts hereinabove stated are true to the best of (his/her) knowledge and Ifelief.
Sworn to and subscribed before me on this the 2-1--�day of 20 1
--------------------------------- P. hLa-�
rotMYP�evo Myma P Marks Nota Public in and for the
* Notary Public,State of Texas State of Texas
My Commission Expires:
�9jFOF I�Ph December 27,2015