In the Name and by the authority of



STATEMENT OF OFFICER

Statement

I, _________________________________ do solemnly swear (or affirm) that I have not directly or indirectly paid, offered, promised to pay, contributed, or promised to contribute any money or thing of value, or promised any public office or employment for the giving or withholding of a vote at the election at which I was elected or as a reward to secure my appointment or confirmation, whichever the case may be, so help me God.

Position to Which Appointed: ________________________________________________

City and/or County: CITY OF HOUSTON, TEXAS

Execution

Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated therein are true.

Date: ____________________ __________________________________

Signature of Officer

Please return form to Maria Del Pilar Montes, Director of Boards and Commissions, 901 Bagby, 3rd Floor, Houston, TX 77002 or

Fax to 832-393-1084

Based on Sec. of State Form 2201

Reviewed Feb. 2019

Z:\GENERAL\Resource Files\Boards & Commissions\Statement of Officer.docx

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