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CITY OF SAN MARCOS <br />STATE OF TEXAS <br />COUNTY OFHAYS <br />The undersigned member of the City ofSon Marcos (name ofCity Board, <br />Commission, etc.) states under oath as follows: <br />I have osubstantial interest in business entity that may be involved inovote ordecision of the governmental body <br />described above, and the vote or decision may have o special economic effect h business <br />distinguishable from the affoct on the public. The name nf the business entity is, <br />The nature and extent of my interest in the business on+ifv is as follows: (check all that apply) <br />Ownership of 10perconf ormore of the voting stock orshares ofthe business entity. <br />Ownership of1Opercent ormore oƒthe fair market value oƒthe business entity. <br />Ownership oƒ$15'OOOormore ofthe fair market value ofthe business entity. <br />�1,1")Funds received by me from the business entity exceed 10 percent of my gross income for the previous year. <br />__ he interest described above belongs tooperson related to meinthe first degree byconsanguinity (natural <br />p)nraffinity (morrioge). Relative's name and relation: <br />I am abstaining only to avoid the of impropriety. <br />The vote or decision involving this interest is on the (date) age do of the governmental body, <br />and is described as follows; 777-774 -377 77 <br />EXECUTEDon (date). . . ...... <br />Signature <br />Printed Name <br />swc <br />FILE| <br />