GR CIS 2013-09-10 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. 1491, 80th 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
RECEffEB
Gam, ikoaer\ SEP 10 2013
Office Held I
City Secretary
City of Coppell
CoUnct
JName of person described by Sections 176.002(a)and 176.003(a), Local Government Code
c`UCC0 n L&
4J Description of the nature and extent of employment or other business relationship with person named in item 3
Su G ct)i.37)2 -^T 12 c T►o 1\J S CX, c 7S (- 7 I/f,2i t,u f
T. t'-3 )°!l V C Lo N I I `1 t yr�
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)
J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
w a a a a a _ — — s a a athot the disclosure applies to a family member (as defined by Section 176.001(2), Local
�P'"" °'�i Gyiernment Code) of thi o :I government officer. I also ackno -ige that this statement
CHRISTEL B PETTINOS co prs the 12-month perod d:scribed by Section 176.003 : , Li al Government Code.
!I My Commission Expires I
May 10,2015
Signature of Local Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE 71
Swo n to and subscribed before me,by the said 1'74f RD OIL.'L , this the /0 ~ day
of ,20 I '; ,to certify which,witnAs my hand and seal of office.
/ /,
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath l
Adopted 06/29/2007