City of San Marcos
City Council/Council Appointee/P&Z Commissioner
Annual Financial Disclosure Form
NOTES
1. This report covers the reporting period from:
2. Do not leave items blank. If item is not applicable, mark NA or NONE.
3. Attach information on additional pages, if necessary.
Name:
Residence address:
Title of position held with the City:
Name of spouse: NA or NONE
Names of all dependent children: NA or NONE
Names under which you, your spouse, or any of your dependent children do business: NA or NONE
1.
2.
3.
NOTE – You may use the following reporting categories to describe amounts and values:
1. Identify each source of income amounting to more than $100.00 received in the reporting period by
you, your spouse, or any of your dependent children: NA or NONE
Name & full address of income source
Nature of income
[e.g., salary, dividends,
rent, etc.]
Amount of income
[by reporting category]
Income of
[e.g., self, spouse,
or dependent child]
Category I At least $100.00 but less than $10,000.00
Category II At least $10,000.00 but less than $20,000.00
Category III At least $20,000.00 but less than $50,000.00
Category IV – At least $50,000.00 but less than $75,000.00
Category V At least $75,000.00 but less than $100,000.00
Category VI $100,000.00 or more report to nearest $100,000.00
2. Identify each option held, owned, acquired or sold by you, your spouse, or any of your dependent
children during the reporting period: NA or NONE
Nature of option
[real estate, stock, etc.]
Amount of transaction
[by reporting category]
Name & full address of other parties
to the transaction
3. Identify each business entity, nonprofit entity or union in which you, your spouse, or any of your
dependent children was a partner, manager, officer, member of the board of directors, proprietor or
beneficiary during the reporting period: NA or NONE
Name & full address of business or nonprofit entity or union
4. Identify each business entity, nonprofit entity or union in which you, your spouse, or any of your
dependent children had an ownership interest with a fair market value of more than $100.00 at any time
during the reporting period: NA or NONE
Name & full address of business
or nonprofit entity or union
Description of ownership
interest [e.g., owner,
partner, stockholder]
Value of
ownership
interest
[by reporting
category]
Number of
shares
held/shares
issued
[if applicable]
Net gain or
loss from
sale of stock
[by reporting
category]
5. Identify any real property in the City or ETJ in which you, your spouse, or any of your dependent children
had an interest as owner, beneficial owner (holder of a mortgage), business owner (partner in a partnership;
or board member, officer or owner of more than 5% of stock of a corporation), or a leaseholder:
NA or NONE
Full address or legal
description
Name & full address
of owner(s)
[if other than you, your
spouse or children]
Fair market value
[by reporting category]
and present use
For leased
property, annual
rental amount
[by reporting
category]
Homestead
exemption
on this
property?
6. Identify persons, business entities or guarantors to whom you, your spouse, or any of your dependent
children owed a debt of more than $100.00 during the reporting period (not including debts owed to persons
related within the second degree of consanguinity or affinity, or loans to a political campaign which were
reported as required by law): NA or NONE
Name & full address of person, business entity or
guarantor to which debt was owed
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
7. Provided this information is not privileged by law, identify persons, business entities or guarantors who
owed you, your spouse, or any of your dependent children a debt of more than $100.00 during the reporting
period (not including debts owed by persons related within the second degree of consanguinity or affinity:
NA or NONE
Name & full address of person, business entity or
guarantor that owed the debt
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
Name & full address of person, business entity or
guarantor that owed the debt
Amount of debt
[by reporting category]
Amount of repayment
during reporting period
[by reporting category]
8. Identify the source of each gift or accumulation of gifts from one source of more than $100.00 in value
received during the reporting period by you, your spouse, or any of your dependent children, or received
by another person for the use and benefit of you, your spouse, or any of your dependent children (not
including (1) a gift received from a relative if given because of kinship, or (2) a gift received by will, by
intestate succession or as distribution from an inter vivos or testamentary trust established by a spouse or
ancestor): NA or NONE
Name & full address of source of gift(s)
Description of gift(s)
Amount or value of gift(s)
[by reporting category]
9. Provided this information is not privileged by law, if you were the owner of 5% or more of any business
entity during the reporting period, list all customers from whom the entity received at least 10% of its gross
income during the reporting period: NA or NONE
Name & full address of customer
10. Identify any financial interest in any franchisee of the City held during the reporting period by you,
your spouse, or any of your dependent children [note: franchise holders are A)Time Warner Cable, B)
Pedernales Electric Cooperative, C) Bluebonnet Electric Cooperative, and D) CenterPoint Energy Entex]:
NA or NONE
Name of franchise holder
Description of financial interest held
[stock, mortgage, note etc.]
Value of financial interest
[by reporting category]
11. Identify any transaction during the reporting period by you, your spouse, or any of your dependent
children with any holder of any franchise issued by the City, other than as a customer or patron:
NA or NONE
Name of franchise holder
Description of transaction
Value of transaction
[by reporting category]
AF
FIDAVIT I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the
disclosure applies to a family member (as defined by Section 176.001(2), Local Government Code) of this local
government officer. I also acknowledge that this statement covers the 12-month period described by Section
176.003(a), Local Government Code.
S
ignature of Local Government Officer/Appointed Official
AF
FIX NOTARY STAMP / SEAL ABOVE
S
worn to and subscribed before me, by the said , this the day of
, 20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
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signature
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signature
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