Greenery, TheENT OFFICER 1 a-
CONFLICTSLOCAL
ODISCLOSURE STATEMENTJUS 2006 FORM CIS
(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
7204 6.4 1/41
J
Office Held
2 'u EGE 5r7=P7707ti Cr71, eeop.uG/L, Pc,4cE 3
JName of person described by Sections 176.002(a) and 176.003(a), Local Government Code
LEAJ 6,14-4-19-y am, cam, -h (6 giciezy
4I Description of the nature and extent of employment or business relationship with person named in item 3
.1— SELL 2oves. f i- l:- ;2-i /'Pt s 7 E/77 /!0 yE, rite-aze-ENerz y
-roec1(_mse0 4 ,Q»-T-N InA/07kJA-A%g-E Q24/ZAmo.,' /Z44 £T v" IcJN/r::
JList
gifts if aggregate value of the gifts received from person named in item 3 exceed $250
Date Gift Received Description of Gift Did NotAccept Gift
Date Gift Received Description of Gift Did NotAccept Gift
Date Gift Received Description of Gift Did NotAccept Gift
(attach additional forms as necessary)
J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge that
the disclosure applies to a family member (as defined by Section 176.001(2), Local Government
Code) of a govemment officer. I also acknowledge that this statement covers the 12-month period
described by Section 176.003(a)(2)(b), Local Govemment Code.
Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
before by the said this the day
Sworn to and subscribed me,
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
Adopted 11/02/2005