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CITY OF SAN MARCOS <br />DISCLOSURE AFFIDAVIT <br />STATE OF TEXAS <br />COUNTY OF HAYS <br />1, l —O_KiV� a member of the City Council of the City of San Marcos, make this affidavit, and <br />�kln_koN <br />hereby on oath state the following: <br />I have a substantial interest in the below named 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 on the named entity that is distinguishable <br />from the effect on the public. <br />The name of the business entity is: <br />The real property 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 kinship) or <br />zn <br />affinity (marriage). Relative's name and relation: <br />I am abstaining only to avoid the appearance of impropriety. <br />The vote or decision involving this interest is on the XJ_54_2?L_1_kdate) agenda of the governmental body, and is <br />described as follows: <br />EXECUTED on <br />—(date). <br />- <br />Signatuie <br />Printed Name <br />SWORN -ANDUSIMS =A /,-J1,',J I A (date). <br />SIMS <br />Notary Stat y <br />M� <br />y Publi <br />State of TexaL <br />FILED on "(date): °' <br />City <br />(date): ­ <br />City Clerk of the City of San Marcos <br />COSM Form 11/10 <br />0 <br />