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CITY OF SAN MARC05 <br />DISCLOSURE AFFIDAVIT -BUSINESS ENTITY <br />STATE OF TEXAS <br />COUNTY OF HAYS <br />The undersigned member of the City of San Marcos CIA UAM 1, 11 (name of City Board, <br />Commission, etc.) states under oath as follows: <br />I have a substantial interest in a business entity that may be involved in a vote or decision of the governmental body <br />described above, and the vote or decision may have a special economic effect po the business entity that is <br />distinguishable from the effect on the public. The name of the business entity is <br />The nature and extent of my interest in the business entity is as follows: (check all that apply) <br />Ownership of 10 percent or more of the voting stock or shares of the business entity. <br />Ownership of 10 percent or more of the fair market value of the business entity. <br />Ownership of $15,000 or more of the fair market value of the business entity. <br />Funds received by me from the business entity exceed 10 percent of my gross income for the previous year. <br />The interest described above belongs to a person related to me in the first degree by consanguinity (natural <br />kinship) or affinity (marriage). Relative's name and relation: <br />I am abstaining only to avoid the appearance of impropriety. <br />The vote or decision involving th* interest is on the (date) agenda of the governmental body, <br />and is described as follows: 3.PiYvt .2��� - <br />EXECUTED on (date). <br />Signature <br />SWORN TO AND SUBSCRIBED before me on <br />Notary 5 <br />JAMIE LEE PETTIJOHN <br />Notary Public, State of Texas <br />My Commission Expires <br />March 04, 2018 <br />FILED on Cl / -Q- /I <br />Printed Name <br />&f <br />gl�l�y. <br />cry PA <br />to of T <br />City off 54n Marcos <br />COSM Form 11/10 <br />