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Lee, Andy 06.27.2017LOCAL GOVERNMENT OFFICER FORM CIS CONFLICTS 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. ®FFICEUSE©NLY This is the notice to the appropriate local governmental entity that the following local government officer has become aware of facts that require the officer to file this statement pate Received in accordance with Chapter 176, Local Government Code. 1 Name of Local overnmertt Officer (1)NIRS rf� 2 Office Fieldr- 1t-�r1Jim-41a< MtsS 3 Fume of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code �/Jyr'/ 4 GN' Co M /?L- L�� Z� SOep G bra 61'� G I_qz_P6-` kAl-+r GA -9- 1k 4 Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. a>llsrJ t-7vri rte. 5 Lis gifts ccepted by the local government officer and any family member, if aggregate value of the gifts accepted fro ndor named in item 3 exceeds $100 during the 12 -month period described by Section 176.003(a)(2)(B). Zca Date Gift Accepted Description of Gift Date Gift Accepted Description of Gift Date Gift Accepted Description of Gift (attach additional forms as necessary) 6 AFFIDAVIT 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 ers the 12 -month period described by SectiorA76.003(a)(2)(B), Local Government Code. ly5 KtA6(iONE l,+r` My Notary ID March 15,2021 res March 1 S, 2021 Signature of Local Government Officer AFFIX NOTARY STAMP / SEAL ABOVE A Sworn to and subscribed before me, by the said l-- k7dre.t�, this the R_-7 day of __]lLt1Le .20 —'-1---, to certify which, witness my hand and seal of office. - Aia &-XAe lie Ld ui"/ Clerk Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath Form provided by Texas Ethics Commission www. ethics. stat e.tx.us Revised 11130/2015