Shelley, Amy LOCAL 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 11/
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176,Local Government Code. I l 1 1Is
1 Name of Local overnment Officer
l
2 Office Held
SCG/tt-t i
3 Name of vendor described b Sections 176.001(7d 176.003(a),Local Government
Code
( AA c,kL& :its
4 Description of the na ur and h►xtent of each employment or other business relationship and each family relationship
with vendor named in item 3.
TNtsr— 12�tcsst-!( 5h�ci zi 0 I,1CJ,1t2A µ,l(5
5 List gifts pted by the local government officer and a y family mbar, if aggr to val�e�f 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 r— 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 176.0 1(2), Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 1 th period described by Section 176.003(a)(2)(B), Local
Government Code.
Sin ure of Local Government Officer
Please complete either option below:
(1)Affidavit 40. TIFFANY COOPER
_;* My Notary ID#134137307
NOTARY fo ' 12}L Expires January 10,2027 ' ,• n
Sworn to and subscribed before me by P W\ S 1L1M this the 1 day of 3tA.' ,
20 15 , to certify which,witness my hand and seal of office. J J
'4-1 ' q-P�wy Co-e47 IV o-k-knv3
Signal a.f off(' administerin oath Printed name of officer administering oath Title of officer administering oath
i OR
(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
LOCAL 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 1
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. 119
1 Name Local Government Officer I
1#1vLl
2 Office eld
Cyr 5eCO
3 Name of vendor described by Sections 176. 01(7)and 176.003(a), Local Government
Code
GSA 0"1.-1 -x
4 Description of the n�ture td extent of each employment or other business relationship and each family relationship
with vendor named in ite 3.
t _ I a�vt 51,4 1 -- & �o t�'.t q Oc n FD
5 List gifts ccept d by the I cal government offic and any fa lily member, if aggregate l 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 176.0e Local Government Code) of this local government officer. I
also acknowledge that this statement covers the 1 j.nth period described by Section 176.003(a)(2)(B), Local
Government Code. �.
,.. .ture of Local Government Officer
11
- r"---- -- plete either option below:
(1)Affidavit
? :\ TIFFANY COOPER
(* **`• My Notary ID#134137307
''•'•ti o. ,�: Expires January 10,2027
NOTARY STAM ,/� n —�
Sworn to and subscribed before me by t'1�V1t� 8WiiilA) this the / day of . �1. l� ,
20 15 ,to certify which,witness my hand and
seal of office. J
Signature o office dministerin oath Printed name of o er administering oath Title of officer adATIfistering oath
nN
(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
LOCAL 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 1
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. I ! 15
1 Na of Local Government� �
Officer
(-el2 Office Held
3 Name of vendor d scribed by Sections 177601(7)and 176.003(a),Local Government
Code c 1 Gdd on5 /1
14,47^ &e m
4 Description of the nature and extent of each employment theisiness re tionship and each family relationship
with vendor named in' m 3.
Ot a" littA(q— L' �e e' 'G+�1YL,S.
5 List gifts accepted by th local government fficer and a y family membe , i aggregate value of the gifts accepted
from vendor named in item 3 exceeds$100 during the 12-month period d ribed 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 14114 period described by Section 176.003(a)(2)(B), Local
Government Code. *
lbw Sign 41 re of Local Government Officer
P4'^ ;.,, TIFFANY cdnplete either option below:
*= My Notary ID##1C��
(1)Affidavit t.• 1... Ifti
w
v. Expires January 10,2027
NOTARY STAMP/SEAL I
Sworn torand subscribed before me by /16
` Q/�� S `C.`I.€ this the n day of `UI ,
^
20 L7 ,to certify which,witness my hand and seal of office.
—"r4
Signature f offs administers Printed name of o icer administering oath Title of officer ad istering oath
OR
(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