Clif AltomLOCAL 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
Date Received
in accordance with Chapter 176, Local Government Code.
1 Name of Local Government Officer
Clif Altom
Q%IL7/2G2,�-
2 Office Held
Battalion Chief
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government
Code
Animal Emergency Hospital of North Texas
4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
My wife is a Veterinarian and works at this business
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 5/2024 Description of Gift My daughters cat had eye surgery and the cost was discount
Date Gift Accepted Description of Gift because of my wife's employment there.
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 overnment Code) of this local government officer. I
also acknowledge that this statement covers the 12 month per' described by Section 176.003(a)(2)(B), Local
— Qovgrrupeat Qodp.
MICHELLE M SUNDAYSignature of Local Government Officer
Notary ID #130768748My
Is
Commission Expires
August 13, 2024 Please complete either option below:
(1) Affidavit
NOTARY STAMP/SEAL
,� A
�u d etm
Sworn to and subscribed before me by this the +� day of
20 �k"[ , to certify which, witness my hand and seal of office.
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Signature of officer administe m oath Printed name of officer adm' i ering oath Title of offic a inistering oath
•
(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