2022-06-03 JOSEPH KOZA CONFLICT DISCLOSURE STATEMENTLOCAL GOVERNMENT OFFICER 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. 235 84th 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,
1 Name of Local Government Officer
2 Office Held p
3 Name of vendor described by Sections 176.001(7) and 176.003(a), Local Government
Code
OFFICE
USE ONLY
JUN 0 3 4ULL
CITI' OF
PFARLAND
61Y SECRETARY'S
OFFIC
4 Description of the nature and extent of each a�n ployme�j or other business rel tonshipp and ach Tamil relationship
with vendor named in item 3. rAwIJ Trt W&kW `ROV %Ju %C.ilik t7P MR."% VVE % .Cftf
. I a;, �,sc.�i�tt gnu► , Fricwg;� io tiJgs EXc
5 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepter
from vendor named in item 3 exceeds $100 during the 12-month period described by Section 176.003(a)(2)(B).
Date Gift Accepted
Date Gift Accepted
Description of Gift
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.
also acknowledge that this statement covers the 12-month period described by Section 176.003(a)(2)(B), Local
Government Code.
ianature of Local Government Officer
Please complete either option below:
(1) Affidavit ,otiP Y d 8.,, A LESLIE CRITTENDEN
Notary Public, State of Texas
My Commission Expires
NOTARY STAMP/ �{EoF;;„'` July D 13325
NOTARY ID 13322068-2
Sworn to and subscribed before me by �� U 9 i0k1V L14 this the 31
20 to certify which, witn s my hand and seal of office. g ,
Signature of officer administering oath Printed name of officer administering oath
(2) Unsworn Declaration
Title ofdfficer administeri
My name is ,and my date of birth is
My address is ,
Executed in
(street)
County, State of
Form provided by Texas Ethics Commission
(city) (state) (zip code) (country)
on the day of 120
(month) (year)
Signature of Local Government Officer (Declarant)
www.ethics.state.tx.us Revised 8/17/2020