Hernandez, Blas 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.
1 Name of Local Go ernment Officer
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2 Office Held
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3 Name of vendor descAbbd by Sections'176.001(7)and 176.003(a),Local Government
Code KITE (e_R
4 Description of the nature and extent of each employment or other business relationshipand each familyrelationship
with vend r named in item
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5 List gifts accepted by the local government officer add 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 perio• described by Sec'•• 176.003(a)(2)(B),Local
Government Code. IP-
egeeenniryo�
11",
_ o of�caf.•vern ent Officer
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.�a\4, ,"PuB cy Please complete -1 er optio - ow.
(1)Affidavits I
WOP4'IImn,�
NOTARY S 7-Sf.Llcr6r ti�.�
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Sworn to and subscrigeP before me by dN•mak tr" this the33t— day of 7 1/4_ ,
i
20 2 to certify whi ,witness my han and seal of office. r
Signature o officer administering oath Printed name of officer administering oath Title of officer administering 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
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 j
This is the notice to the appropriate local governmental entity that the following local Date Received 1111
government officer has become aware of facts that require the officer to file this statement
in accordance with Chapter 176,Local Government Code.
1 Na of Local Government Officer
,fx.s. A . -Q,'r,(va Yk C e 7i
2 Office Held
ca-,r
3 'Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government
Code rQ
�ou -�n\�l4Q 1 0 ` Sir CI..
v1/4..r-C
4 Description of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
U,m-r c- + TO l i Cp. SQ.cu4(`,a.. 1 mfS' Dry. et- — a�r�., -
5 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 erio described• Sectio. •.003(a)(2)(B),Local
Government Code.
`0,1•••tlp//os'
w��` Cep SMltiy���i
.2. st � putty" - Signature o ocal :�ernme t Officer
O i°
i p• i m
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o= Please complete either option below:
'-.°ram°F44 ��
-1110111110
NOTARY STAMPlSEAL
Sworn to an subscribed before me by B IL) titigiatells this the 30 day of SIP-t— ,
20 2 ,to certify which,witness my hand and seal of office. -
Signa re of officer administering oath Printed name of officer administering oath Title of officlai administering oath
OR
(2)Unswom 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