Amy Shelley 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
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176,Local Government Code. RECEIVED
1 N e��l Government Officer
1 JUN 2 4 2024
2 Office Heldl..
5 FFICE OF
3 Name of vend r described by Sections 1 6.001(7)and 176.003(a), Local Governme CITY SECRErA4
R
Code
12i ituan,Lot ki It 1)c MUNN
4 Description of the turd extent of each employment or other business relationship and each family relationship
with endor named in item 3.
S bay i _ Lkt t--f
5 List fts 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 Month period described by Section 176.003(a)(2)(B), Local
Government Code. .11
;
.ignature of Local Government Officer
Please complete either option below:
(1)Affidavit
NOTARY STAMP/SEAL
Swom to and subscribed before me by this the day of
20 , 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)Unsworn Declaration
My name isAlk.s...1'61r42-11-el , and my date of birth is' /'
My address is , •,�IJOFlct . , '1(1`''1, USk-
(street) (city) (state) (zip code) (country)
(country)
n�Executed i IA County,State of1`CQS ,on th- � of' day Lilt A— ,20 P'� .
� y� ....th) (year)
ign. ure Noce] Government Officer(Declarant)
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. RECEIVED
me of Local Government Officer
iti ' l-eAl
J U N 2 4 2024
2 Offic= Id
3 Name of vendor d scribed by Sections 176. 01(7)and 176.003(a), Local Government OFFICE OF CITY SECRET) RY
Code
4 Descri tion oft a naEafe and extent of each employment or other business relationshipand each familyrelationship
with vendor named in item 3.
5 List gifts accepted by the local govern nt officer a 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 17 01(2), Local Government Code) of this local government officer. I
also acknowledge that this statement covers th 12 onth period described by Section 176.003(a)(2)(B), Local
Government Code.
gnature of Local Government Officer
Please complete either option below:
(1)Affidavit
NOTARY STAMP/SEAL
Sworn to and subscribed before me by this the day of
20 ,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)Unsworn Declaration
My name is , and my date of birth is
My address is ,rl✓) fl _, I r , 9,0 CM, (LSbA .
f� (street) �— (city) , I/,(state) (zip code)/ (country)
Executed in��f(�L7� County,State of L`C-CC,S ,on the day of Vt1.k. _ ,20C '.
(month (year)
Si n e of Loca Government Officer (Declarant)
Form provided by Texas Ethics Commission www.efhics.;state.tx.us Revised 8/17/2020