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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 � "1 C0 VllexGL (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 IVEMD <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 />nership 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 ;51 <br />and is described as follows: <br />agenda of the governmental body, <br />EXECUTED on l L _(date). <br />Signature <br />Printed Name <br />SWORN TO AND SUBSCRIBED before me on <br />JAMIE LEE WALSHAK <br />Notary Stamp: Z * ` Notary Public, State of Te <br />, My Commission Expir <br />March 04, 20W <br />Texas <br />FILED on ) `�) t) I 1 -�)- (date). <br />City Cler1�f the City <br />COSM Form 11/10 <br />L I ;I— (date). <br />Marcos <br />