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Thomas RobersonLOCAL GOVERNMENT OFFICER CONFLICTS FORM CIS DISCLOSURE STATEMENT (instructions for completing and tiling 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. 0 1 Name of Local Government Officer Q - ©� 2 Office Held 3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code �} j r k1� d /�O-14,1 , 4 Description of the nature and extent of each employment or other business relationship and each family relationship with vendor nam d in i em 3. / G �. g 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 Giff 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 eriod described by Section 176.003(a)(2)(B), Local Government Code. Signature of Local Government Officer Please complete either option below: P (1)Affidavit .. NOTARY STAMOF EXP. ���`� I E < TJ ` J ('�u✓� this the 4d day of Sworn to and subscribed t1�uft , y i 20 L �_, to certify which, witness my hand and seal of office. �� f /j Signa i f officer adm— ikettering oath Printed name of officer administering oath Title of officer 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