Robert McCallion LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and Ming this form are provided on the next page 1
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY
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 °'''" Pecc "`
in accordance with Chapter 176,Local Government Code.
11 Name of Local Government Officer
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!_.1 Office Held
Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government Code
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JDescription of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
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1.1 List gifts accepted by the local government officer 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 �4r/ Description of Gift ,��OO•40 ac,F.
Date Gift Accepted_ __.___ Description of Gill
Date Gift Accepted Description of 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 each familymember (as defined by Secl on 176 001(21,Local
���"Y'n'rrr.� LORNA BOUDREAUX pp
``oqs i. . Government Code)of this localgovernment officer. I also acknowledge that this statement
_ ,�,:Notary Public,State of Texas 9
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'�: 'i� Comm.Expires 01-20-2025 covers the t2-month period described by Section 176 003(ai(2)( i ocal Government Code.
V14°!„ ` Notary ID 130976764
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Signature of Local Government Officer
AFFIX NOTARY STAMP ; SEAL ABOVE
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Sworn toand subscribed before me.bythe said OA RI_ t.__._1,. Chi-LIO' ___ _, thisthe 5tk"fti. ,i.,y
of 4 J_AAL _ _ .20 01,
I ,to certify which,witness my hand and seal of office
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SKIT diW,�Of officer admmrsienng oath Printed name of ohicer administering oath Title of otticer administering oath
Form prov.dcd by Texas Ethics COMMISsron www.ethics stators us Revised 11%302015