Shelley, Amy 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 1
This is the notice to the appropriate local governmental entity that the following local 111
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.
1 ame of Local Government Officer RECEIVED
2 Office He OCT - 4 2022
& t.4. Se cue_-Fa
3 Name of v ndor described by Sec ions 176.001(7)and 176.003(a), Local Government OFFICE OF CITY SECRETA
Code
61dd 006--(YW kV Evv.-er C
4 Description of the nature and extent of each eiIoyment o other busine s relationship and each family relationship
with vendor named in item 3.
‹. GOD r vs &lr ka 5 kd.irt S— 6A(4/-t--v .
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 th j'onth period described by Section 176.003(a)(2)(B), Local
Government Code. I►�,
•ture of Local Government Officer
. PV PUB�i MICHELLE DEVOSSPI se complete either option below:
Notary Public, State of Texas
(1)Affida/ 9.lV..., Comm. Expires 09-26-2023
//„„„o� Notary ID 128751055
NOTARY STAMP/SEAL
Sworn to and subscribed before me by 5 eile-yl this the 3 day of avit,
20 `Z—Z ,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
OR
(2)Unswom 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