Jennifer Crosby LOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
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 Date Received
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176,Local Government Code.
t Name of Local Government Officer
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2 Office Held
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3 Name of vendor described by Sections 176.001(7)and 176.003(a), Local Government
Code
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4 Description 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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5 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 Description of Gift
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
6 SIGNATURE I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the disclosure applies
to each family member (as defined by Section 176.001(2), Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-month period described by Section 176.003(a)(2)(B), Local
Government Code. l
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ignature of Local Government Officer
= _ = e either option below:
o`lque MICHELLE DEVOSS.
(1)Affidavit ,;(44.
_r *Notary Public,State of Texas
•
�q v Comm. Expires 09-26-2023
NOTARY STAMP/SEAS ��!�i��� Notary ID 128751055
Sworn
to and subscribed before me by 3 f n;C-e-c CAT>s this the l day of GeCe4146,
9
20 ,to certify which,witness my hand and seal of office. ,/) 1r�
-�ti Gi�G�c-c Q#Va (Vl im,veaC• �216s± `'�-pci tOc f 12111Iee(
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
OR
(2)Unsworn Declaration
My name is , and my date of birth is
My address is •
,
(street) (city) (state) (zip code) (country)
Executed in County,State of ,on the day of ,20
(month) (year)
Signature of Local Government Officer(Declarant)
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020