Dakota MoudyLOCAL 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.
t Name of Local Government Officer
OA
OW-6 t12- C)
2 Office Held r
V t�
3 Name of vendor described by Sections 176.001(7) annd�176.003(a), Local
(Government
Code r.
4 Description of the nature and xtent of each ern oyment or her busin ss relationship d each family relationship
with vendor named in item 3. !
It( USA �t i
s List gifts accepted by the local government officer and any family member,' if aggregate vfilue of the gifts accepted
from vendor named in itemexceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
[3
Date Gift Accepted L \ Description of Gift
Date Gift Accepted Description of Gift
I
Date Gift Accepted I 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 178.001(2), Local Government Code) of this local government officer. I
S
also acknowledge that this statement covers the 12-month period described b ectio 76,003(a}(2)(B), Local
Government Code. t
Slgnatur -Local Governiiie 7116er
Please complete either option below:
(1)Affidavit r COLLEEN ANSON
�n Notary Public, State of Texas
'-"�'•`Q:
Comm. Ex .....• . ; Aires 04.09 2'0
NOTARY STAMP/SEAL �'��oFt`;` Notary ID 131521076
Run
Sworn to and subscribed before me by this the day of
seal of office.
20 _, to certify which, witness my hand and seal
Signature of officer administering oath Printed name of officer administering oath Title of oifJr administering 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 8/1712020