Dennis KilloughLOCAL 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.
MMEM
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
Date Received
in accordance with Chapter 176, Local Government Code.
1 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 ) and 176.003(a), LoEal Government
Code q
L) A, I o'er -S
4 Description of the nat a 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 gov nmen officer and y family mem if aggregate value of the gifts accepted
from vendor named in item 3 exceeds $10 during the 1 -month period described by Section 176.003(a)(2)(B).
Date Gift Accepted Description of Gift
Date Gift 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 176.0 ocal Government e) of this local government officer. I
also acknowledge that this statement covers the 1 month riod desd b Sectio 176.003(a)(2)(B), Local
Government Code.
Signat oca enrt,y� t Officer
se complete either option below:
ORGAN BARCLAY
(1) Affida*: ;. My Notary ID # 134139449
Explres January 11, 2027
NOTA
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Sworn to and subscribed before me by K I t t� c� this the day of
my hand and seal of office.
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sig4. re 161. i c e r e oath = Printed na te of officer administeriny)alh Title of #er administering oath
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(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