Lorrie FletcherLOCAL 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 of Local Government Officer
boy r'L'u
6,12- 0 2-
2 Office Held
T"D S 119e co ra S 51k-c
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government
Code -u-Ck
4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
S 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 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 12-month peri 0scribed by Section 176.003(a)(2)(B), Local
Government Code.
O'er
Signature of Local Government Officer
r...wrr mplete either option below:
(1) Affidavit MORGAN BARCLAY
My Notary ID# 13413"
EV►rgs Jarttrary 11, 2W
NOTARY STA PR�� ''
1
Sworn t and subscribed before me by r- awo this the day of
fitness hand
20 to ify s my a seal of officeRM(A41 Riwgtv� EL�21n
Signature of officer administering oath PrintedJame of officer administ g oath Title of officer d roistering 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