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Home My WebLink About2021 11 01 Foreman, Mike - CIS for The Reporter NewsLOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS DISCLOSURE STATEMENT (Instructions for completing and filing this form are provided on the next page.) This Ruestlonnalre reflects changes made to the law by H.B. 0, Bath Leg., Regular Session. OFFICEUSEONLY This is the notice to the appropriate local governmental entity that the following local Date BeceNae government officer has become aware of fads that require the officer to file this statement in accordance with Chapter 176, Local Government Code. 1 Name of Local Government Officer /)7i 4 �mr2min 2 Office Held R4ays/ 3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code 7fie l�e rEei Iv Tm �re.�an d Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named In Item 3. yI ,�• {� // T•� /ie ^ Q� �. 6 List gifts accepted by the local government off lost 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 (a0ach additional forms as necessary) 6 SIGNATURE 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 Cade) of this local government officer. I also acknowledge that this statement covers th month pe iod described by Section 176.003(a)(2)(B), Local Govemment Code. i ature at Local Government Officer please complete el r optio below: LETICIA C BRYSCH (i)A OMM EMn", 120420PY NOTARY I0 12Ssazz7.0 NOTARY STAMP/SEAL �Y c+✓/x�El_ / day Sworn to and subscribed before me by /.r this the or 20 I ,to n6ywhich, witness my hand and seal ofafire. -a— Signature of officer admirritil oath Pdntee name of officer administers, oath ffftrofofflcaredmsnistarin oath (2) Unswom Declaration My name is and my sate of birth is My address is (street) (city) (state) (zip code) (country) Executed in County, Slate of , on the _ day of , 20_ (month) (year) Signature of Laval Government Ofiow (Declarant) Form provided by Texas Ethics Commission www.eth ics. state.tx. us Revised 8/17/2020 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 amity; 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 officerfrom the vendor named in item 3 t_hat in the aggregate gxceed $100 in value. i r 1, 6. Signature. Signature of local government officer. Complete this section after yoU finish the rest of this report. You have the option to either: (1) take the completed form to a notary public where you will sign. above the first line that says "Signature of Local Government Officer (an electronic signature is not acceptable) and your signature will be notarized, or (2) sign above both lines that say 'Signature of Local Government Officer (Declarant)" (an electronic signature is not acceptable), and fill out the unswom declaration section. Local Government Code § 176.001(2-a): "Family relationship" means a relationship between a person and another person within the third degree by consanguinity orthe 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 consideringenteringinto a contract with the vendor. Fnrm nmvirlM Fv T-- FMirq Commission — eIhins Oat. l a ux GaalenA YM]MMM