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


1a. Email address


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