Dennis Killough 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.
Name
of Local Government Officer
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2 Office Held \ /13/ dZ
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3 Name f vend r described by Sections 1f6.001(7)and 17 . 030), Local Government
Code
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4 Description of the nature and extent of each employment or other business rel ionship and each family relationship
with vendor nam�ed iwn item 3.
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5 List giftcepted by the local government offer many family member, if aggregate value of the gifts accepted
named in item exceeds$100 duringt elf 12-month period described bySection 176.003 a 2 B .
from vendora ed to 3 e ce ,A�// ( )( )( )
Date Gift Accepted 449 Description of Gift /v
Date Gift Accepted 41/7 Description of Gift A "//
Date Gift Accepted // Description of Gift /1
(attach additional forms as necessary)
6 SIGNATURE I swear under penalty of perjury that the above stateme ' true and correct. I . .. owledge that the disclosure applies
to each family member (as defined by Section 176 01(2), Lo al Govern -nt Code) •• this local government officer. I
also acknowledge that this statement covers the 2-month p nod descr'.ed ry Section 7's (a)(2)(B), Local
/
o PAY°ke, SELENA MARILU SERRANO .. r
_�--��`� Notary ID N13UU483G7 • /�
e.L4.- My Commission Expires ;I; ign.• / ocal Govern icer
�oFrce. December 17, 2022 R.
Please complete either option below:
(1)Affidavit
NOTARY STAMP/SEAL In
Sworn to and subscribed before me by 'ir 1'l/U C ki{ "� this the )4_ day of
20 , to certify which,witness my hand and seal of office.
-crr n n r re-lam
Signature of officer administering oath Printed name of officer administering oath Title of o '49administering 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
LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT
Section 176.003 of the Local Government Code requires certain local government officers to file this form. A"local
government officer"is defined as a member of the governing body of a local governmental entity;a director,superintendent,
administrator,president,or other person designated as the executive officer of a local governmental entity;or an agent of
a local governmental entity who exercises discretion in the planning,recommending,selecting,or contracting of a vendor.
This form is required to be filed with the records administrator of the local governmental entity not later than 5 p.m.on the
seventh business day after the date on which the officer becomes aware of the facts that require the filing of this statement.
A local government officer commits an offense if the officer knowingly violates Section 176.003,Local Government Code.
An offense under this section is a misdemeanor.
Refer to chapter 176 of the Local Government Code for detailed information regarding the requirement to file this form.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of the local government officer filing this statement.
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government Code. Enter the name of
the vendor described by Section 176.001(7), Local Government Code, if the vendor: a) has an employment or other
business relationship with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A), Local Government Code;b)has given to the local government officer or a family member of the officer
one or more gifts as described by Section 176.003(a)(2)(B), Local Government Code;or c)has a family relationship with
the local government officer as defined by Section 176.001(2-a),Local Government Code.
4. Description of the nature and extent of each employment or other business relationship and each family
relationship with vendor named in item 3. Describe the nature and extent of the employment or other business
relationship the vendor has with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A),Local Government Code,and each family relationship the vendor has with the local government officer
as defined by Section 176.001(2-a), Local Government Code.
5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3 exceeds$100.
List gifts accepted during the 12-month period(described by Section 176.003(a)(2)(B), Local Government Code)by the
local government officer or family member of the officer from the vendor named in item 3 that in the aggregate exceed$100
in value.
6. Signature. Signature of local government officer. Complete this section after you finish the rest of this report. You
have the option to either: (1)take the completed form to a notary public where you will sign above the first line that
says"Signature of Local Government Officer" (an electronic signature is not acceptable) and your signature will be
notarized, or(2)sign above both lines that say"Signature of Local Government Officer(Declarant)"(an electronic
signature is not acceptable), and fill out the unsworn declaration section.
Local Government Code§ 176.001(2-a): "Family relationship" means a relationship between a person and another
person within the third degree by consanguinity or the second degree by affinity,as those terms are defined by Subchapter
B,Chapter 573,Government Code.
Local Government Code§176.003(a)(2)(A):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable income,
other than investment income,that exceeds$2,500 during the 12-month period preceding the
date that the officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed;or
(ii) the local governmental entity is considering entering into a contract with the vendor.
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020