2016-05-09 Parks Board PacketCITY OF
SOUTHLAKE
MEMORANDUM
May 2, 2016
TO: Parks and Recreation Board Members
FROM: Chris Tribble, Director of Community Services
SUBJECT: Agenda Item Comments for the Parks and Recreation Board
Meeting — Monday, May 9, 2016 at 6:00 p.m.
The meeting will begin promptly at 6:00 p.m. in the Town Hall Council
Chambers.
Please advise staff if you are not able to attend this meeting
(Icarpenter(c�ci.southlake.tx.us or 817.748.8184). Thank you.
N *ell] W_1 zW_1W 4 0117_1
1. Agenda Item No. 1. Call To Order
2. Agenda Item No. 2. Consent
A. Approve minutes from the regular Parks and Recreation Board
meeting held February 8, 2016. Please make any corrections to the
minutes part of the motion for consideration.
B. Absence of Parks and Recreation Board Members — The Board will
consider the absence of Lori Palmer from the February 8, 2016
meeting. A copy of the Attendance Report is in your packet.
3. Agenda Item No. 3 Public Forum
This is the public's opportunity to address the Board about non -agenda
items. During Public Forum, the Board will not discuss or take action on
any item brought up at this time
4. Agenda Item No. 4. Discussion
A. Construction Management Report - The Community Services
Department Construction Management Report will be available at
the meeting on Monday.
City of Southlake Values:
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
Parks and Recreation Board
Meeting Date — May 9, 2016
Page 2 of 3
Also included is the following update on the Southlake Program for
the Involvement of Neighborhoods (SPIN) presentation for The Marq
Southlake — Champions Club.
SPIN, the Southlake Program for the Involvement of
Neighborhoods, are Town Hall Forums hosted by the Community
Engagement Committee usually the second Tuesday of the month
and fourth Tuesday as needed to provide an opportunity for
community members to have an informal conversation regarding
topics of interest. The most frequently discussed items are
development cases. The SPIN Town Hall Forums provide a place to
discuss proposed developments and hear feedback from residents
before a case goes before the Planning and Zoning Commission or
City Council.
The City of Southlake has 11 designated SPIN neighborhoods.
These are used for various planning and communication purposes
and can help you identify projects or topics specific to your part of
town.
SPIN meeting agendas are posted on the City's website and on the
official bulletin boards located inside and outside of the Town Hall.
The SPIN Meeting Schedule and SPIN Meeting Reports are also
available online at www.cityofsouthlake.com/825/spin. For more
information about SPIN or questions, please contact Assistant to the
City Manager Daniel Cortez, the City's SPIN liaison, at
817.748.8029 or dcortez(a_ci.south lake.tx.us.
B. Parks & Recreation Update - This is a standing item on the agenda
to allow staff to update the Board about current and future Parks &
Recreation activities and events. A copy of the Parks & Recreation
Report will be available at the meeting.
C. Local Government Officer Conflicts Disclosure Statement — The City
Secretary's Office has requested all City -appointed board,
commission and committee members be informed of requirements
regarding disclosure of relationships with existing City vendors.
In accordance with Texas Local Government Code 176, a copy of
the Local Government Officer Conflicts Disclosure Statement is
included in your packet to review the requirements to determine if
you have any conflicts to disclose. Please consult the City's Vendor
List, available on the City's website at
http://www.cityofsouthlake.com/DocumentCenter/View/l1543. If you
City of Southlake Values:
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
Parks and Recreation Board
Meeting Date — May 9, 2016
Page 3 of 3
or a family member has employment or other business relationships
as described in the Statement with any existing City vendor, a Local
Government Officer Conflicts Disclosure Statement must be filed. By
law, this Statement must be filed no later than the seventh business
day after the person (board member) becomes aware of the facts
that require the Statement to be filed. Statements are filed with the
City Secretary's Office, 1400 Main Street, Suite 270, Southlake
Texas 76092. Please contact the City Secretary's Office at
817.748.8183 or Ipayne(a)-ci.south lake.tx.us for any questions
regarding this matter.
OTHER ITEMS OF INTEREST
5. City Council Action — There were no park and recreation -related action
items for considered by City Council at the April 5 or April 19, 2016
meetings.
If you would like to receive notifications for City Council meetings,
construction alerts, calendar and community events updates and more,
please sign up at the City's website by clicking on the "Notify Me" tab at
http://www.citvofsouthlake.com/list.aspx.
As always, we appreciate your commitment and service to the City.
Chris Tribble
STAFF CONTACT INFORMATION:
Telephone — (817) 748-8203
Facsimile — (817) 748-8027
1400 Main Street, Suite 210, Southlake, TX 76092
Chris Tribble, Director of Community Services, 817-748-8021,(ctribble(o).ci.southlake.tx.us)
Cassie Tucker, Assistant to the Director, 817-748-8036, (ctuckeraci.southlake.tx.us)
Candice Edmondson, Deputy Director of Community Services, 817-748-8311; cedmondson(@ci.southlake.tx.us
Kate Meacham, Deputy Director of Community Services, 817-748-8018; (kmeacham(a)ci.southlake.tx.us)
Linda Carpenter -Elgin, Administrative Secretary, 817-748-8184;(Caraenter(a-)ci.southlake.tx.us)
City of Southlake Values:
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
CITY OF
SOUTHLAKE
PARKS AND RECREATION BOARD MEETING
Monday, May 9, 2016
6:00 p.m.
LOCATION: Southlake Town Hall
Council Chambers
1400 Main Street
Southlake, Texas 76092
REGULAR SESSION: 6:00 P.M.
1. Call to Order
2. Consent
A. Approve minutes from the regular Parks and Recreation Board meeting held
February 8, 2016
B. Absence of Parks and Recreation Board members
3. Public Forum
4. Discussion
A. Construction Management Report
B. Parks & Recreation Update
C. Local Government Officer Conflicts Disclosure Statement
5. Adjournment
A quorum of the City Council may be present at this meeting.
CERTIFICATE
I hereby certify that the above agenda was posted on the official bulletin boards at Town Hall,
1400 Main Street, South10ei,44yas, on Friday, May 6, 2016 by 6:00 p.m. pursuant to
Chapter'551 of the Texa$��3 'r4Code.
s
Lori Payne, TvC e .e• �"
City Secretary .,
.... +i •. ,C
b .% 0,01s
If you plan to attend this public Nddfirig'and have a disability that requires special needs, please advise the City
Secretary 48 hours in advance at 817.748.8016 reasonable accommodations will be made to assist you.
City of Southlake Values:
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
CITY OF
SOUTHLAKE
PARKS AND RECREATION BOARD MEETING: FEBRUARY 8, 2016
LOCATION: Southlake Town Hall
Council Chambers
1400 Main Street
Southlake, Texas
TIME: 6:00 p.m.
PARKS AND RECREATION BOARD MEMBERS PRESENT: Chairman Tina Wasserman and
Secretary Frances Scharli; and Board Members Mitch Hill, Miguel Salinas and Paul Venesky
PARKS AND RECREATION BOARD MEMBERS ABSENT: Lori Palmer and Vice Chair Chad
Patton (vacated position on Park Board to file for place in May City Council elections)
STAFF PRESENT: Director of Community Services Chris Tribble; Deputy Director of
Community Services Kate Meacham; and Recreation Superintendent Steve Moore. Deputy
Director of Community Services Candice Edmondson and Recreation Supervisor Ryan
McGrail were present during Work Session.
WORK SESSION
1. CALL TO ORDER
The Work Session was called to order by Park Board Chair Tina Wasserman at 6:00
p.m.
2. TASK FORCE UPDATE
Director Chris Tribble presented the item and answered questions.
The Sports League Task Force has held meetings with representatives from the
Southlake Girls Softball Association and will meet with representatives from Dragon
Youth Football Association later this month.
Work Session was adjourned.
REGULAR AGENDA
1. CALL TO ORDER
Chairman Wasserman called the regular meeting of the Parks and Recreation Board to
order at 7:14 p.m.
City of Southlake Values. -
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
2A - 1
Minutes of the February 8, 2016 Parks Board Meeting
Page 2 of 4
2. CONSENT AGENDA
Consent Agenda items are considered to be routine and are enacted with one motion by
the Board.
2A. APPROVAL OF THE MINUTES FROM THE JANUARY 11, 2016 REGULAR PARKS AND
RECREATION BOARD MEETING.
There were no corrections to the January 11, 2016 Park Board meeting minutes.
2B. ABSENCE OF PARKS AND RECREATION BOARD MEMBERS
There were no board absences for consideration.
APPROVED
A motion was made to approve the Consent Agenda as presented.
Motion:
Salinas
Second:
Venesky
Ayes:
Hill, Salinas, Scharli, Venesky and Wasserman
Nays:
None
Abstain:
None
Vote:
5-0
Motion Carried.
3. PUBLIC FORUM
Chairman Wasserman opened public forum. There being no one to speak, Chairman
Wasserman closed public forum.
El Q6*'111111 1[a]ki
4A. ATHLETIC ASSOCIATIONS DASHBOARD REPORTS
Deputy Director Kate Meacham presented dashboard reports for Dragon Youth
Football, Grapevine Southlake Soccer Association, Miracle League Southlake, Dragon
Youth Baseball Association (formerly Southlake Baseball Association), Southlake
Carroll Lacrosse Association and Southlake Girls Softball Association and responded to
questions from the Board.
The following representatives of the athletic associations were present and available to
answer questions.
Clayton Reed and Clay Taylor, Dragon Youth Football Association
Dax Martin, Grapevine Southlake Soccer Association, 507 San Juan Drive, Southlake
John Slocum, Miracle League Southlake, 1425 Bentley Court, Southlake
Scott Smith, Dragon Youth Baseball Association
City of Southlake Values. -
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
2A-2
Minutes of the February 8, 2016 Parks Board Meeting
Page 3 of 4
Matt Deno, Southlake Carroll Lacrosse Association, 1403 McCrae Trail, Southlake
Greg Zenoble, Southlake Girls Softball Association
4B. SOUTHLAKE TENNIS CENTER IMPROVEMENTS
Director Chris Tribble presented an overview of the design plans for the new tennis
center and covered tennis courts to be constructed during Bicentennial Park Phase III
improvements and received feedback from the Board.
Tennis Center management contractors Mia and Stephen Poorman were present and
responded to questions.
The plan has incorporated feedback received from stakeholders meetings and the
tennis community. The following feedback points received from stakeholders were
discussed:
• Enclosed, climate -controlled courts
• Cover more courts (4-6) / Plan for addition of future covered courts
• Ensure protection from rain
• Consider side curtains, fans & lighting
• Good feedback on building & floor plans (some willing to give up nice building for more
covered courts)
• Appreciated addition of spectator area enhancements
The Board agreed the plan meets all expectations.
4C. PARKS & RECREATION UPDATE
Deputy Director Kate Meacham reviewed the Community Events Schedule included in
the meeting packet and was available to answer questions from the Board.
5. CONSIDER
5A. ELECTION OF VICE CHAIR POSITION
The Board considered the election of a vice chair to fill the remainder of the unexpired
term left by Chad Patton, who vacated the Vice Chair position in February to run for City
Council in the May election.
APPROVED
A motion was made to elect France Scharli, the Board's current Secretary, to serve the
remainder of the term of the Vice Chair position.
Motion: Hill
Second: Venesky
City of Southlake Values. -
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
2A-3
Minutes of the February 8, 2016 Parks Board Meeting
Page 4 of 4
Ayes:
Hill, Salinas, Scharli, Venesky and Wasserman
Nays:
None
Abstain:
None
Vote:
5-0
Motion Carried.
An election to fill the position of Park Secretary will be placed on the next meeting
agenda.
6. ADJOURNMENT
APPROVED
A motion was made to adjourn the meeting at 8:24 p.m.
Motion:
Venesky
Second:
Hill
Ayes:
Hill, Salinas, Scharli,
Nays:
None
Abstain:
None
Vote:
5-0
Motion Carried.
Tina Wasserman, Chairman
Parks & Recreation Board
Venesky and Wasserman
Chris Tribble, Director
Community Services Dept.
A recording of this meeting is available upon request from the Office of City Secretary.
City of Southlake Values. -
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
2A-4
CITY OF
SOUTHLAKE
MEMORANDUM
May 5, 2016
TO: Parks and Recreation Board
FROM: Chris Tribble, Director of Community Services
SUBJECT: Absence of Parks and Recreation Board Member(s) — Standing
Agenda Item
Action Requested: Park Board consideration to excuse the absence of Lori Palmer
from the February 8, 2016 Park Board meeting.
Background
Information: The "Absence Policy for Parks and Recreation Board" adopted July
12, 2004 provides a mechanism for consideration of absences of
Board members from regular or special Park Board meetings. This
item is listed as a standing item on meeting agendas.
Financial
Considerations: None
Strategic Link: N/A
Citizen Input/
Board Review: Park Board approved the Absence Policy at the July 12, 2004
meeting.
Legal Review: N/A
Alternatives: Any commentary as appropriate.
Supporting
Documents: Attendance Log
Staff
Recommendation: Park Board excuse the absence of Lori Palmer from the February
8, 2016 meeting.
City of Southlake Values. -
Integrity ♦ Innovation ♦ Accountability ♦ Commitment to Excellence ♦ Teamwork
2B-1
Park and Recreation Board Attendance Report
2016
Place
Name
1/11/16
2/8/16
3/14/16
4/11/16
5/9/16
6/13/16
7/11/16
8/8/16
9/12/16
10/10/16
11/14/16
12/12/16
Individual
Attendance
Rate
Hrs To
Date
Meeting Attendance
Rate (includes
1/11/16 Work Session held at 6pm, followed by regular meeting.
2015
1
Miguel Salinas
I
I
I
Individual
Rate
100%
Hrs To
6.75
2
Tina Wasserman
100%
15.5
3
Frances Scharli
X
X
X
70%
8
4
Lori Palmer
X
X
80%
10.75
5
Mitch Hill
X
X
80%
13.75
6
Chad Patton
X
X
X
70%
12.5
7
Paul Venesky
X
X
80%
13.25
1
Jeff Medici
X
411
80%
4
Meeting Attendance
Rate (includes
substitutions)
86%
86%
71%
71%
01/6
57%
0%
57%
86%
86%
100%
100%
0%
Total Hrs Per Month
0.75
0.75
1
1
0
1.5
0
3.75
2.25
0.5
2
2
0
8/6/15 Joint CC/SPDC/Park Mtg at 6:30pm; followed by Joint SPDC/Park Mtg at 9:00pm.
:m�
Average Monthly
Attendance Rate
2016 100%
11 In attendanc
x Not in attenc
M Substitute in
• Vacant posit
Meeting Car
Meeting Car
Change in R
Average Monthly
Attendance Rate
2015 80%
In attendanc
x Not in attenc
t Substitute in
• Vacant posit
Meeting Car
Meeting Car
Change in R
CITY OF
S0UTHLA1<..,E�
Agenda Item 4C is presented at the request of the City
Secretary's Office to inform the Parks & Recreation Board
about their obligation under Law to disclose if they or a
family member's relationship with any existing City vendors.
4C-1
I
Conflicts Disclosure Statements
Why? Chapter 176, Texas Local Gov't Code —AlI Local Gov't Officers must file
statements (Form CIS) no later than the 7th day after becoming aware of
facts that require filing. If you or family member has employment or
business relationship with a City Vendor, it requires disclosure and
must be filed on FORM CIS.
Who? Local Gov't Officers = Elected officials, city employees, appointed board and
commission members, directorslmanagers of 4A and 413 development corps.
Where? Go to www.cityofsouthlake.com >Transparency > Conflicts Disclosure
Statements (Website describes types of relationships subject to disclosure)
A�-_-. l
What? Consult City Vendor List to determine if you have any conflicts to disclos
How? Complete the Form CIS, obtain a notary, file form with City Secretary's
who is required by law to post all forms on the City's website
Attached is a complete copy of the Local Government
Officer Conflicts Disclosure Statement (CIS) with
detailed information on what types of relationships are
subject to disclosure and the requirements by Law.
Basically, if you or a family member has employment or
other business relationships with a City Vendor, that
relationship must be disclosed to the City Secretary's Office
within 7 days of you becoming aware of the conflict.
4C-2
2
LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
.. b.r•wa•.ww.�.
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emu. jjp City's Vendor List wwwCIS Form
.citvofsoulhlake.com >
http:llwww.cityofsoulhlake.com/DocumentCe_nterfView/l 1543 Transparency > Conflicts Disclosure Statements
IF you or a family member has employment or other
business relationships with a company on the City Vendor
List, THEN you must complete and submit the CIS Form
located online at www.cityofsouthlake.com > Transparency
> Conflicts Disclosure Statements. The Form must be
Notarized and submitted to the City Secretary's Office at
1400 Main Street, Ste 270.
Visit the City's Vendor List at
http:.11www.citvofsouthlake.com/DocumentCenter/View/
11543.
4C-3
3
Please contact the City Secretary's Office at 817.748.8015
for assistance or questions.
4C - 4
4
GUIDELINES FOR FILING CONFLICTS DISCLOSURE STATEMENTS
(revised March 2016)
WHO: If required by Chapter 176 of the Texas Local Government Code, the following
municipal officers must file conflicts disclosure statements:
1. Mayors and City Council Members;
2. City Manager;
3. Board and Commission members appointed by the Mayor or City Council members,
including the Building Board of Appeals, Community Engagement Committee,
Community Enhancement and Development Corporation (CEDC), Crime Control and
Prevention District, Library Board, Parks and Recreation Board, Planning and Zoning
Commission, Senior Advisory Committee, Southlake Arts Council, Southlake Parks
Development Corporations (SPDC), Metroport Teen Court Advisory Board, and Board of
Adjustment (ZBA);
4. Directors of 4A and 4B development corporations;
5. the executive directors or managers of 4A and 4B development corporations; and
6. City employees and agents who exercise discretion in the planning, recommending,
selecting or contracting of a vendor.
WHAT: A municipal officer must sign under oath and file a conflicts disclosure statement
(Form CIS). This form is available online at www.ethics.state.tx.us and a copy is attached to this
Guideline. The form is fairly self-explanatory.
Question No. 3 of the form requires the municipal officer to disclose the name of any vendor
with which the City is contracting or considering a contract i£
1. The officer has an employment or other business relationship with the vendor, or an
employee or agent of the vendor, that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2,500 during the 12-month period
preceding the date that the officer becomes aware of the contract or the consideration of a
contract;
2. The officer or a family member of the officer has received one or more gifts from the
vendor, or an agent or employee of the vendor, that have an aggregate value of more than $100
in the 12-month period preceding the date the officer becomes aware of the contract or the
consideration of a contract; or,
3. The officer has a family relationship with the vendor, or an agent or employee of the
vendor.
Question No. 4 of the form requires the officer to describe the relationship with the vendor, or an
agent or employee of the vendor, listed in Q0on5.
Page 1 of 3
Question No. 5 of the form requires the officer to list the gifts the officer or any family member
received from a vendor, or an agent or employee of the vendor, if the aggregate value of the gifts
accepted exceeds $100 during the 12-month period preceding the date the officer becomes aware
of a contract or the consideration of a contract. Note, political contributions defined by Title 15
of the Election Code or food accepted as a guest need not be disclosed.
An Agent means a third party who undertakes to transact some business or manage some affair
for another person by the authority or on account of the other person.
A "business relationship" means a connection between two or more parties based on commercial
activity of one of the parties. The term does not include a connection based on:
1. a transaction that is subject to rate or fee regulation by a federal, state, or local
governmental entity or an agency of a federal, state, or local government entity;
2. a transaction conducted at a price and subject to terms available to the public; or
3. a purchase or lease of goods or services from a person that is chartered by a state
or federal agency and that is subject to regular examination by, and reporting to,
that agency.
If a local government officer or the officer's family member has received income as a result of
one of these types of business relationships, the officer does not have to file a conflicts disclosure
statement.
A "family member" is a person related to the municipal officer within the first degree by
consanguinity (blood) or affinity (marriage) which includes a spouse, father, mother, son,
daughter, father-in-law, mother-in-law, and son-in-law, and stepson or step daughter. It does not
include a child of a stepparent when the stepparent is divorced from the parent of the child.
A 'family relationship" means a relationship between a person and another person within the
third degree by consanguinity or the second degree by affinity. See attached chart for the
relationships included within the third degree by consanguinity and the second degree by
affinity.
A "contract" includes a purchase order, or a written agreement for a sale or purchase of goods,
services, or an interest in real property.
If the income is investment income, the officer need not file a conflicts disclosure statement.
"Investment income" means dividends, capital gains, or interest income generated from:
1. a personal or business:
a. checking or savings account;
b. share draft or share account; or
C. other similar account;
4C-6
2. a personal or business investment; or
Page 2 of 3
3. a personal or business loan.
A "Gift" is any benefit offered by a person, including food, lodging, transportation, and
entertainment accepted as a guest. The term does not include a benefit offered on account of
kinship or a personal, professional or business relationship independent of the official status of
the recipient.
WHEN: The municipal officer must file the Form CIS not later than 5:00 p.m. on the seventh
business day after the date on which the officer becomes aware that a vendor has contracted with
the City or the City is considering doing business with the vendor.
WHERE: The local government officer must file the form with the City Secretary. The City
Secretary is required by law to post the form on the City's website.
ENFORCEMENT: The failure to file the required statement is a Class C misdemeanor if the
contract amount is less than $1 million or if there is no contract amount for the contract; a Class
B misdemeanor if the contract amount is at least $1 million but less than $5 million; or a Class A
misdemeanor if the contract amount is at least $5 million.
4C-7
Page 3 of 3
LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS 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
2 Office Held
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code
q Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
51 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 AFFIDAVIT
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 period described by Section 176.003(a)(2)(B), Local Government Code.
Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day
of , 20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed na-4Cf -WC8 administering oath Title of officer administering oath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015
LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT
Section 176.003 of the Local Government Code requires certain local government officers to file this form. A "local
government officer" is defined as a member of the governing body of a local governmental entity; a director, superintendent,
administrator, president, or other person designated as the executive officer of a local governmental entity; or an agent of
a local governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of a vendor.
This form is required to be filed with the records administrator of the local governmental entity not later than 5 p.m. on the
seventh business day after the date on which the officer becomes aware of the facts that require the filing of this statement.
A local government officer commits an offense if the officer knowingly violates Section 176.003, Local Government Code.
An offense under this section is a misdemeanor.
Refer to chapter 176 of the Local Government Code for detailed information regarding the requirement to file this form.
INSTRUCTIONS FOR COMPLETING THIS FORM
The following numbers correspond to the numbered boxes on the other side.
1. Name of Local Government Officer. Enter the name of the local government officer filing this statement.
2. Office Held. Enter the name of the office held by the local government officer filing this statement.
3. Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government Code. Enter the name of
the vendor described by Section 176.001(7), Local Government Code, if the vendor: a) has an employment or other
business relationship with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A), Local Government Code; b) has given to the local government officer or a family member of the officer
one or more gifts as described by Section 176.003(a)(2)(B), Local Government Code; or c) has a family relationship with
the local government officer as defined by Section 176.001(2-a), Local Government Code.
4. Description of the nature and extent of each employment or other business relationship and each family
relationship with vendor named in item 3. Describe the nature and extent of the employment or other business
relationship the vendor has with the local government officer or a family member of the officer as described by Section
176.003(a)(2)(A), Local Government Code, and each family relationship the vendor has with the local government officer
as defined by Section 176.001(2-a), Local Government Code.
5. List gifts accepted, if the aggregate value of the gifts accepted from vendor named in item 3 exceeds $100.
List gifts accepted during the 12-month period (described by Section 176.003(a)(2)(B), Local Government Code) by the
local government officer or family member of the officer from the vendor named in item 3 that in the aggregate exceed $100
in value.
6. Affidavit. Signature of local government officer.
Local Government Code § 176.001(2-a): "Family relationship" means a relationship between a person and another
person within the third degree by consanguinity or the second degree by affinity, as those terms are defined by Subchapter
B, Chapter 573, Government Code.
Local Government Code § 176.003(a)(2)(A):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable income,
other than investment income, that exceeds $2,500 during the 12-month period preceding the
date that the officer becomes aware that:
(i) a contract between t Ixloc overnmental entity and vendor has been executed; or
(ii) the local governor erltR# is considering entering into a contract with the vendor.
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015