Koran, StevenLOCAL 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
Pvt1/4S GA •1
Office Held/� /}
C1'I" 1 COOn.)GIC.. 1 LiTL/ Qp CoLLE6..E Sri
Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code
r G'Tali l ' fZE hi rt i7-1 L C Z./AJ/ G
41 Description of the nature and extent of employment or business relationship with person named in item 3
I S 6 Lt A a (Z.OJ f' (j EUEF[T f7[.f}-N (Hz -P- W) 70 7 A26 itiA-7-4-L CG/,t)/c51 OL1rrE
JList gifts if aggregate value of the gifts received from person named in item 3 exceed $250
Date Gift Received Description of Gift Did NotAccept Gift
Date Gift Received Description of Gift Did NotAccept Gift
Date Gift Received Description of Gift
Did NotAccept Gift
(attach additional forms as necessary)
J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge that
the disclosure applies to a family member (as defined by Section 176.001(2), Local Government
12
— —0 — 0
Code) of a government officer. I also acknowledge that this statement covers the -month period
t , KATHRYN.$WiLa '
I 1 a/11 Nobly P'dc, Stale pf Taos
I I�I My Commission alpine
1 . FEBRUARY 13.2007
described by Section 176.0 (2)(b), Local G 41 ernment Code.
`/
Officer
Signature of Local Government
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the sai 0,i ("47 c this the / ?-i/ day
/7
of 4 ,. / 200 G to certify which, witness my hand and seal of office.
-
Al L it / I lei G.' Y T4.. - I Hifi iJ
—_ .
Signa re of officer administering oath Printed name o officer administering oath Title of offic- administering oath
Adopted 11/02/2005
Connie Hooks - Fwd: E-CIQ Submission (Steve Koran)
a
e
From: Cheryl Turney
To: Connie Hooks; Harvey Cargill
Date: Mon, Apr 3, 2006 9:08 AM
Subject: Fwd: E-CIQ Submission (Steve Koran)
Harvey or Connie,
Is this disclosure something that Ron Gay needs to disclose on his CIS form????
Cheryl
»> <webmaster@cstx.gov> 4/3/2006 9:00 AM »>
Filer's Name "J 7
Date Filed 4/3/2006
Affiliations
Question 5 Reference
Part A Is the local government officer named in this section receiving
or likely to receive taxable income from the filer of the questionnaire?
Part B Is the filer of the questionnaire receiving or likely to
receive taxable income from or at the direction of the local government
officer named in this section AND the taxable income is not from the
local governmental entity?
Part C Is the filer of this questionnaire affiliated with a
corporation or other business entity that the local government officer
serves as an officer or director, or holds an ownership of 10 percent or
more?
Affiliation Part A Part B Part C Description
Ron Gay, Council Place 3 No No No
Karen Kasper, Merchant No No Yes Clinic Board members
receive no renumeration for serving (they are volunteers)
Nancy Sawtelle No No Yes Clinic Board members receive no
renumeration for serving (they are volunteers)
Describe each affiliation or business relationship with an employee
checked in Question 3
Describe each affiliation or business relationship with an employee
checked in Question 4
Ron Gay: Our clinic uses Scott & White Health Plan for our employees'
health benefits package (I am Executive Director of The Prenatal Clinic)
Nancy Sawtelle: Current Board President of The Prenatal Clinic (I am
Executive Director of the clinic Karen Kasper: Curren Board Member of
The Prenatal Clinic (I am Executive Director of the Clinic)
Describe any other affiliation or business relationship that might cause
a conflict of interest