Derr, Michelle 02.28.2017AFFIDAVIT FOR CONFLICT OF INTEREST
STATE OF TEXAS )(
COUNTY OF WICHITA )(
I, !�� 1( iC(� ("P (� as a member of the `',`�:•,'� i (��% 7i� 1'�, U 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 ( ?fy �r at �L
those terms are defined in Chapter 171 of The Texas Local Government Code
Date of Meeting: _ I - L �- -) I Agenda Item No.:
The business entity is: �� 1 �tw`vC { 0-i { 'E \ L 1, C
I (have/has) a substantial interest in this business entity for the following reasons: (Check all which
are applicable.)
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 participation on this matter whatsoever.
Signed this < Z �� T day of Y E �?N Lo20 -1-6/ r'
Signature of Official
I-C,�iy� h1G ` Cilllnll . ��� f7F
Title
BEFORE ME, the undersigned authority, this day personally appeared f'r , 6- kx F K
and on oath stated that the facts hereinabove stated are true to the best of (his/her)
knowledge and belief.
Sworn to and subscribed before me on this the I x4�) day of brvAY h 20 I_1
many I
TRACY B. NORR -- — —
My Notary lD#8363834 Notary Public in and for the
•i.�'•': `.'4
State of Texas
Expires September 9,2o�
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