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CITY OF SAN MARCOS <br />DISCLOSURE AFFIDAVIT -BUSINESS ENTITY <br />STATE OF TEXAS <br />COUNTY OF HAYS <br />The undersigned member of the City of San Marcos .. r C (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 on 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 this interest is on the I ? (date) agenda of the governmental body, <br />and is described as follows:wr <br />EXECUTED on I ! . I (date). <br />Signature, S. <br />Printed Name _"S\"..c <br />SWORN TO AND SUBSCRIBED before me or <br />'r <br />gal u�6s® <br />V ��h <br />S <br />Notary'P bli( <br />��„�,r�ku� <br />>� � p , <br />s <br />tate f <br />.,k'6i;dtP <br />&b.d 01 <br />°, f�"ex <br />xm�owimiomwe^ro;m^P!�rwu <br />FILED on <br />�� 7�. (date). <br />Clerk of"'` he City of 56q 4arcos <br />COSM Form 11/10 <br />