Local Government Officer Conflicts Disclosure Statement - CIS

This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.

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.

Instructions for completing the CIS form

Local Government Officer Details

Name of Local Government Officer

Office Held

Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code

Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3.

List gifts accepted by the local government officer and any family member, if aggregate value of the gif t s 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:

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