FORM CIS LOCAL GOVERNMENT OFFICER CONFLICTS

LOCAL GOVERNMENT OFFICER
CONFLICTS DISCLOSURE STATEMENT
FORM
CIS
(Instructions for completing and filing this form are provided on the next page.)
OFFICE USE ONL
Y
ONLY
This questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.
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
in accordance with Chapter 176, Local Government Code.
Date Received
1
Name of Local Government Officer
2
Office Held
3
Name of person described by Sections 176.002(a) and 176.003(a), Local Government Code
4
Description of the nature and extent of employment or other business relationship with person named in item 3
5
List gifts accepted by the local government officer and any family member, excluding gifts described by Section
176.003(a-1), if aggregate value of the gifts accepted from person named in item 3 exceed $250 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 a 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), 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 name of officer administering oath
Title of officer administering oath
Adopted 06/29/2007
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 the
local governmental entity; or an employee of a local governmental entity with respect to whom the local
governmental entity has, in accordance with Section 176.005, extended the requirements of Sections 176.003
and 176.004. 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 Class C misdemeanor.
Please 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 person described by Sections 176.002(a) and 176.003(a), Local Government Code. Enter
the name of the person described by Section 176.002, Local Government Code with whom the officer has an
employment or other business relationship as described by Section 176.003(a), Local Government Code.
4. Description of the nature and extent of employment or business relationship with person named
in item 3. Describe the nature and extent of the employment or other business relationship with the person
in item 3 as described by Section 176.003(a), Local Government Code.
5. List gifts accepted, excluding gifts described by Section 176.003(a-1), if aggregate value of the
gifts accepted from person named in item 3 exceed $250. List gifts accepted during the 12-month period
(described by Section 176.003(a), Local Government Code) by the local government officer or family member
of the officer, excluding gifts described by Section 176.003(a-1), from the person named in item 3 that in the
aggregate exceed $250 in value.
6. Affidavit. Signature of local government officer.
Adopted 06/29/2007