LOCAL GOVERNMENT OFFICER 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. FORM CIS ONLY OFFICE USE ONLY Date Received 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 in accordance with Chapter 176, Local Government Code. 1 Name of Local Government Officer 2 Office Held 3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code 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 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 covers the 12-month period described by Section 176.003(a)(2)(B), Local Government Code. Signature of Local Government Officer AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said _______________________________________________, this the ______________ day of ________________, 20 _______ , to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 American LegalNet, Inc. www.FormsWorkFlow.com LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT Section 176.003 of the Local Government Code requires certain local government officers to file this form. A "local government officer" is defined as a member of the governing body of a local governmental entity; a director, superintendent, administrator, president, or other person designated as the executive officer of a local governmental entity; or an agent of a local governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of a vendor. This form is required to be filed with the records administrator of the local governmental entity not later than 5 p.m. on the seventh business day after the date on which the officer becomes aware of the facts that require the filing of this statement. A local government officer commits an offense if the officer knowingly violates Section 176.003, Local Government Code. An offense under this section is a misdemeanor. Refer to chapter 176 of the Local Government Code for detailed information regarding the requirement to file this form. INSTRUCTIONS FOR COMPLETING THIS FORM The following numbers correspond to the numbered boxes on the other side. 1. Name of Local Government Officer. Enter the name of the local government officer filing this statement. 2. Office Held. Enter the name of the office held by the local government officer filing this statement. 3. Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code. Enter the name of the vendor described by Section 176.001(7), Local Government Code, if the vendor: a) has an employment or other business relationship with the local government officer or a family member of the officer as described by Section 176.003(a)(2)(A), Local Government Code; b) has given to the local government officer or a family member of the officer one or more gifts as described by Section 176.003(a)(2)(B), Local Government Code; or c) has a family relationship with the local government officer as defined by Section 176.001(2-a), Local Government Code. 4. Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. Describe the nature and extent of the employment or other business relationship the vendor has with the local government officer or a family member of the officer as described by Section 176.003(a)(2)(A), Local Government Code, and each family relationship the vendor has with the local government officer as defined by Section 176.001(2-a), Local Government Code. 5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3 exceeds $100. List gifts accepted during the 12-month period (described by Section 176.003(a)(2)(B), Local Government Code) by the local government officer or family member of the officer from the vendor named in item 3 that in the aggregate exceed $100 in value. 6. Affidavit. Signature of local government officer. Local Government Code § 176.001(2-a): "Family relationship" means a relationship between a person and another person within the third degree by consanguinity or the second degree by affinity, as those terms are defined by Subchapter B, Chapter 573, Government Code. Local Government Code § 176.003(a)(2)(A): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: *** (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 American LegalNet, Inc. www.FormsWorkFlow.com