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Lee, Andy 10.24.2017LOCAL 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. OFFICE USE ONLY 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 Date Received in accordance with Chapter 176, Local Government Code. t Name of LocalGov-ernment Officer N "jol`"_ D M n m 2 Office Held a / � n Ci M m < C�1✓� — o 0n h21s S' v-n� M 3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code _ rI J 4PAt--�1 i c%i �.� L. 4 Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. k4sr aiV'Jj-;UT-4- -rl,V f? '% 1= t?tl/lw"k-, 51 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 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 vers the 12-month period described by Section 176.003(a)(2)(B), Local Government Code. ' KIA BOONE My Notary ID # 131047080 Expires March 15, 2021 Signature of Local Government Officer AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said this the y day of © C�06,, 20 to certify which, witness my hand and seal of office. 1a aIDA C- (. I U1 Signature of officer administering oath Printed name of officer administering oath Title of o cer ad inistering oath Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015