01122004 Regular Meeting - Laserfiche WebLink

Home Browse Search

CITY OF SAN MARCO5 DISCLOSURE AFFIDAVIT-BUSINESS ENTITY STATE OF TEXAS COUNTY OF HAYS The undersigned member of the City of Son Marcos GyU44.. , (name of City Board, Commission, etc.) states under oath as follows: I have a substantial interest in a business entity that may be involved in a vote or decision of the governmental body described above, and the vote or decision may have a special economic effect on the business entity that is distinguishable from the eff'ecct on the public. The name of the business entity is Telo 'V 5' 57-zrk -Fe-- 0 '1 i ? 2 rs i SAS ?V l,Q•y? o S The nature and extent of my interest in the business entity is as follows: (check all that apply) Ownership of 10 percent or more of the voting stock or shares of the business entity. Ownership of 10 percent or more of the fair market value of the business entity. Ownership of $15,000 or more of the fair market value of the business entity. Funds received by me from the business entity exceed 10 percent of my gross income for the previous year. The interest described above belongs to a person related to me in the first degree by consanguinity (natural kinship) or affinity (marriage). Relative's name and relation: The vote or decision involving this interest is on the ^KI'La 11Z00(date) agenda of the gover body, and is described as follows: T+44,yi 22 - 8•?dcc ..Qwt,K?' c2i Q,K ! e• s EXECUTED on a N K. R rj 12.., Zoo (date). Signature Printed SWORN TO AND SUBSCRIBED be ore me on \ ?ISIV 46 JANIS K. WOMACK Nota Notary Public, state of Texas zN My commission Expires 50August 13, 2005 Not y Public 4nM St e of Texas FILED on 1- (date). >7 w+ 4a 6;eAcrer4-,k r- 690) V' (date). CityMerk of the City of San Marcos COSM Form 4/02