Lomas, Veronica - CIS 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 U-SE 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 Pfaene of Local Government Officer RECEIVE®
L
0� o�n�ca 0,r,,I�S OCT 2 6 2026
2 Offlce Field OFFICE OF THE CITY SECRETARY
L) SccKQ�OlrL)
31 Marne of vendor described by Sections 176.001(7)and 176.003(a), Local Government Code
(��%Ie� `y'\ lAar',vi
4 Description of the nature and extent o each employment or other business relationship and each family relationship
with vendor named in item 3.
5 Last gifts accepted by the local government officer and any family member, if aggregate valve 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 o( '
Date Gift Accepted Description of Gift P A..
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
AMY SHELLEY covers the 12-month period described by Section 176.003(a)(2)(B), Local Government Code.
a=o.' , _Notary Public,State of Texas
s,..:4 Comm.Expires 12-02-2027
%�9 ....•h``
Notary ID 124761105 1 �
Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me,by the said V l� r IN' S this the l� day
20 4�- to certify which,witness my hand and seal of office.
"A n-
gn uqe of offiseaadministering oath Printed name of officer administ ring oath Title of officer administering oath