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Local Government Officer Conflicts Disclosure Statement CIS - Texas
| Local Government Officer Conflicts Disclosure Statement Form. This is a Texas form and can be used in Ethics Commission Statewide . |
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LOCAL GOVERNMENT OFFICER CONFLICTS DISCLOSURE STATEMENT (Instructions for completing and filing this form are provided on the back.) FORM CIS 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. 1 OFFICE USE ONLY Date Received 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 business relationship with person named in item 3 5 List gifts if aggregate value of the gifts received from person named in item 3 exceed $250 Date Gift Received __________ Description of Gift _______________________________ Date Gift Received __________ Description of Gift _______________________________ Date Gift Received __________ Description of Gift _______________________________ (attach additional forms as necessary) 6 Did Not Accept Gift Did Not Accept Gift Did Not Accept Gift 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 a government officer. I also acknowledge that this statement covers the 12-month period described by Section 176.003(a)(2)(b), Local Government Code. Signature of Local Government Officer AFFIX NOTARY STA M P / 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 11/02/2005 American LegalNet, Inc. www.USCourtForms.com 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 a governing body of a local government entity or a director, superintendent, administrator, president, or other person designated as the executive officer of the local government entity. 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 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 relationship 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 if aggregate value of the gifts received from person named in number 3 exceed $250. List gifts received during the 12-month period (described by Section 176.003(a)(2)(B), Local Government Code) by the local government officer or family member of the officer from the person named in number 3 that in the aggregate exceed $250 in value. 6. Affidavit. Signature of local government officer. Adopted 11/02/2005 American LegalNet, Inc. www.USCourtForms.com
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