Amy Shelley LOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS
DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.) II
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.
1 i me of Local Government Officer
( ► V JI i CA, 1 2 fO►/Zoz,
2 ffice el.
9 ,
�c_C C
3 Name of yen or described by Sect ►i ns 176.001(7)and 176.003(a), Local Government
Code
��� ` )
4 Descriptiono a nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
5 List gifts accepted by the local governor t offic 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 N //A Description of Gift (V 1 14
Date Gift Accepted NA Description of Gift t'(M
Date Gift Accepted NIA-/ Description of Gift n`/�-
(attach additional forms as n///ecessary)
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 17. : 1(2), Local Government Code) of this local government officer. I
also acknowledge that this statement covers the j.� period described by Section 176.003(a)(2)(B), Local
Government Code. .�; r r
Sign-be of Local Government Officer
- ,: <.- - ._.•-+1 •_...- e either option below:
`"'�"�1� MICHELLE DEVOSS
(1)Affidavit ,o�"RY p`'e�%
_.3.1 4 ':��:Notary Public, State of Texas .
=5.' A.4: Comm. Expires 09-26-2023
NOTARY STAMP/SEAL 'ol„,,%0 Notary ID 128751055
i�
Sworn to and subscribed before me by '' ' Skt-el this the t 41— day of PeCwwtipe.r:
20 2 ( ,to certify which,witness my hand and seal of office.
stir a4:,2?-4- ' -1,A s iNA cA•e tip. (AS s pZc.64s rM c-
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
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
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.
1 Name f Local Government Officer
2 Office Held
cr r
3 Name of vendor defcribed by Sections 17 .001(7)and 176.003(a), Local Government
Code
_PC.rc o .
4 Description of the natured extent of `ach employment or other business relationship and each family relationship
with vendor named in item 3.
y— 't-S c - (O e-
5 List gifts accepted by the local government officer and any family member, if dggregatb value of the gifts accepted
from vendor named in item 3 exceeds$100 during the 12-month period described by Section 176.003(6)(2)(B).
Date Gift Accepted P f Pc Description of Gift N I I.
Date Gift Accepted t l,I�' Description of Gift i'
Date Gift Accepted I\} I (Pt Description of Gift 6 (�
(attach additional forms as necessary)
6 SIGNATURE l 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 176.00, , Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 12-m.jVh,p- iod described b Section 176.003(a)(2)(B), Local
Government Code. /1
,i9 natt•f Local Government Officer
. . . Please complete either option below:
(1)Affidavit MICHELLE DEVOSS
,��P�.•�e%
°'�� to:-..Notary Public,State of Texas
\ "'' Comm. Expires 09-26-2023
NOTARY STAMP/SEAL /.7,g,;0` Notary ID 128751055
.. .. -
Sworn to and subscribed before
me by me by S��lle� this the ( G'r day of n�-eCemIsue.-r
20 2, ,to certify which,witness my hand and seal of office.
l s 5 M r (3-e-V s (4,7.5,-�s ,e-a vesc—
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
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. ,
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.
1 Nam of Local Government Officer
iryli
2 Office Hel
3 Name of vendor described by Sections 176.001(7)and 176.003(a), Local Government
Code
- (h.LcAlk k1 (S
4 Description of the atu nd extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
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 v P Description of Gift N A
Date Gift Accepted Description of Gift ` R,
Date Gift Accepted hl J p Description of Gift N 14
(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 176:00 , Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 12_rn I \.eriod described by Section 176.003(a)(2)(B), Local
Government Code.
i,. ` _.
S ign ur of Local Government Officer
` `A:, _ ' plete either option below:
``ov p�,,�� MICHELL . v o
(1)Affidavit :z°'11�[n' Notary Public, State of Texas
Sox, A1;'Q Comm. Expires 09-26-2023
1 S,14.f.T ��`
....ili‘%0 Notary ID 128751055
NOTARY STAMP OFAI Aism
Sworn to and subscribed before me by )4 Y`C4 Srl.e_tl2.c-,t this the I ,day of ereyy. e. ,
20 1.I. ,to certify which,witness my hand and seal of office. l
ik"rG' t.bt-- a-19141,5 s rn,cArvti II c Oe.Yo s s 14_44.-fr-l-s iirtort4Q 8e-i
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
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