Berry, NancyLOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the back.)
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.
OFFICE USE ONLY
Date Received
JName of Local Government Officer
KC Ac-K1 C-/ BERRY
2 Office Held
CoUhictLMEMf3Ee PLACE--6,
3 Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code
— LEoNJA-g_6 L ;
PRoFES oR, T=)CA5 AtkA 0NlvosiT"Y - Sp0Qse
named in item 3
j) a li
4, Description of the nature and extent of employment or business relationship with person
D1RtcroR, LOW FS, IMC. -- ',PousG
I) I Re ero g) b A-Rb k E UTU // rS, I IQ C .
List gifts if aggregate value of the gifts received from person named in item 3 exceed
Date Gift Received Description of Gift
$250
Gift
Gift
Gift
Did Not Accept
Date Gift Received Description of Gift
Did Not Accept
Date Gift Received Description of Gift
Did Not Accept
(attach additional forms as necessary)
AFFIDAVIT
I swear under penalty of perjury that the above statement
the disclosure applies to a family member (as defined by
Code) of a government officer. I also acknowledge that this
described by Section 176.003(a)(2)(b), Local Government
is true and correct. 1 acknowledge
Section 176.001(2), Local
statement covers the 12-month
Code.
that
Government
period
iYVONNE S. CASARES
'
r*; � ! Notary Public, State of Texas 1 'YN-
f
( �gL :F1 My Commission Expires
( wqr�",F. t, AUGUST 5, 2006 Si nature of Local
Government Offi
t�
this the t day
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to subscribed before me, by the said`
and
of 20 b k.s to certify which, witness and seal of offic
. \-voh)t) L S . 0 5A2tS
S ature of officer administering oath Printed name of officer administering oath Title of officer a Inistering oath
Adopted 11/02/2005