Revised 12/30/2014
DISCLOSURE OF RELATIONS WITH
CITY COUNCIL MEMBER, OFFICER, OR EMPLOYEE OF CITY OF WACO
Failure to fully and truthfully disclose the information required by this form may result in the termination of
any business the City is now doing with the entity listed below and/or could impact future dealings.
1. Name of Entity/Business/Person doing business with City: ________________________________________
Is the above entity: (Check one)
A corporation
A partnership
A sole proprietorship or an individual
Other (specify): ______________________________________________________________
Check all applicable boxes.
2. Is any person involved as an owner, principal, or manager of name listed in #1 related to or
financially dependent on Council member, officer, or employee of the City of Waco?
NO -- there is no such relationship between Entity/Business/Person and the City of Waco.
YES, a person who is a/an owner, principal, or manager of this entity/business/person
is: (Check all applicable boxes below)
related to by blood or marriage* and/or a member of the same household as
and / or financially dependent upon** and/or financially supporting**
to a City of Waco City Council member, officer or employee.
* As used here, “related to” means a spouse, child or child’s spouse, and parent or parent’s spouse. It also includes a former
spouse if a child of that marriage is living (the marriage is considered to continue as long as a child of that marriage lives).
** As used herein, “financially dependent upon” and “financially supporting” refers to situations in which monetary
assistanceincluding for lodging, food, education, and debt paymentsis provided by owner, principal or manger of #1 to
Council member, officer or employee of City of Waco, or that Council member, officer or employee of City of Waco provides
to owner, principal or manger of #1.
If YES, provide (a) the name of owner, principal, or manager, and (b) the name of the City Council member,
officer or employee (include the department the City officer or employee works for, if known), and (c) if a
relationship by marriage or by blood/kinship exists. (Use back of sheet if more space is needed)
(a) Name of owner, principal, or manager (b) Name of Council member, officer or
employee & department
(c) What is relationship or household
arrangement
3. Is a current City Council member or City employee involved with the name listed in #1 as an owner,
principal, manager, or employee, or employed as a contractor for name listed in #1?
NO (no person involved/working for Entity/Business/Person is Council member, officer or employee of the City).
YES, a person is (Check all applicable boxes)
(a) a current City of Waco City Council member, officer or employee ,
(b) and is an owner, a principal, or a manager of the entity/business/person listed in #1,
or an employee or an independent contractor of the entity/business/person listed in #1.
If YES, provide the name of owner, principal, manager, employee or independent contractor who is a City
Council member, officer or employee. Include the department the City officer or employee works for, if known.
________________________________________________________________________________________
________________________________________________________________________________________
Signature: ______________________________ Phone #:_____________________ Date: _______________
Print Name: _____________________________ Print Title: ________________________________________
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