2019-10-29 OWENS, WOODY CONFLICT DISCLOSURE STATEMENT 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 USE 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.
JName of Local Government Officer C _Zra k
Oe.624R0te) z f a./1.,s OCT 2
J Office Held ����
Ci-F,r �(f
J CITY SECRE TI H,o-eineiL
. ..
Name of v dor described by Sections 176.001(7)and 176.003(a),Local Government Code
jDescription of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
J 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 0-.23-/'1 Description of Gift c2/9 (0 I/ t:6° 7-
Date
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
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
overnment Code)of this local goy mment officer.' I also acknowledge that this statement
DAISY MATA .avers the 12-month period desc• d by Section 176. 3(a)(2)(B),Local Government Code.
NOTARY PUBLIC,STATE OF TEXAS
^,, MY COMMISSION EXPIRES , "fil)//e)
j
��� Expires:July 9.20I9
Err.iNotary tD N 123564254
Signal e of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE \ ��(( .. .. \\ (�
Sworn to and subscribed before me,by the said r c o U'CU W "i G��� Q, this the 2 1 day
of 9 9' ,20 t q ,to certify which,witness my hand and seal of office.
Si:nature of fricer ad •"roistering oath Printed name of off er administering oath Title of officer administer ath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015
other than investment income,that exceeds$2,500 during the 12-month period preceding the
• date that the officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed;or
tin tha Inca)nnvernmental entity is considering entering into a contract with the vendor.