Womack, Clay 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 Government Officer
CJ Q/ Mac y- Q / 0
2 Office Held
o\tte_ C ,ce1
3 Name of vendor described by Sections 176.001(7)and 176.003(a), Local Government
Code
4 Description of the natu a and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
C4-P-cl ick! c ' \f 5 List gifts accepted by the local governme t officer and aril,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 t17�t -month period described by Section 176.003(a)(2)(B),Local
Government Code.
Signature of Local Government Officer
Please complete either option below:
(1)Affidavit
NOTARY STAMP/SEAL
Sworn to and subscribed before me by this the day of
20 ,to certify which,witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
OR
(2)Unsworn Declaration /
My address is
(street) (city) (state) (zip code) (country)
Executed in 1-0-AW�1"' County,State of ¶-e-)CO ,on the day of Rtt ,cJ— ,20 ZS .
(mWnth) (year)
Signature of ocal Government Officer (Declarant)
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 8/17/2020