Gillespie, SharonLOCAL 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
�n s/21%/g
J Office Held
Ma yo/J
JName of person described by Sections 176.002(a) and 176.003(a), Local Government Code
S/Ia/'0/0 4 ''-'1i0 ill C,Sf ee
4J Description of the nature ajid extent/of employmenten11 or business relationship with person
i21y cliisv-T htPN „TApfiC?1 k Gi espi is. c 'psi hyrc/
named innitem 3
6
4,85 241
y.
1-4 1, / &XIS //"d AXioci lEr 1 -id 1-, '4-6 C 77?) .
9yrPrrn e.vtz ws Ctr(3 ray to do a tra,urtolo wz eLi ax sfue
JList gifts if aggregate value of the gifts received from person named in item 3 exceed
Date Gift Received Description of Gift
$250 Y10ne
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
the disclosure applies to a family member (as defined by Section
Code) of a government officer. I also acknowledge that this
described by Section 176.003(a)(2)(b), Local Government
true and correct. I acknowledge that
176.001(2), Local Government
statement covers the 12 -month period
Code.
•
`� ...dr._41/
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
Adopted 11102/2005