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ityry <br /> Louisville r <br /> r•.vvnx <br /> �. u0'311V4tt 1816 S 7 y <br /> Ci.y Clerk's Office 7 0 J <br /> 749/Main 3u.reeL,rouisville,CO au11[! <br /> SUS-333-43/6/Fax 3u3-333-1330 Date Stamp <br /> Email: Itleretfytf1101 giouisvillece.go: <br /> DisCEOsORE BY PUBLIC OFFICEHOLDER <br /> REPORT OF GIFTS, RONORARIA AND 0i HER BENEFITS <br /> (Sec.24-6-zu3,C.R.a.J <br /> t;re,s should also review provisions of 3ecrion 3,Arricle AAM of r'ne l oror av E.,.,raer:p., <br /> MUNICIPAL FILING <br /> Filin5 required: 17''Quarter n 2"°uuartern P Quarter n 41h Quarter F� <br /> (due April 131 (nue duly iso (sae OctvUer is) (due January Z3) <br /> Name of Office Holder: D%rirli3 iviak 11 y Ward 3 <br /> Address: 314 v1 r ioi.d Ciicle, Louisville CO 80027 <br /> Check onz of the following: , ' I have nothing to report (Please sign and date below.) <br /> I received the following gifts, honoraria, or Benefit durin5 this period. <br /> .t) Mame or Terson rrom Who the Gift, Honoraria or Other Benefit Was Received: <br /> Amount/Value: 5 Date Received: <br /> Description: <br /> 2) Name of Person from Who the Gift_ Honoraria or Other Benefit was Reczived: <br /> Amount/value: $ Date Rzceived: <br /> Description: <br /> 3) Name of Person from vvflO Ole Gift, Honoraria or Other Benefit Was Received: <br /> Amount/Value: 5 Date Received: <br /> Description: <br /> 4) Name of Pei son from Who the Gift, Honoraria or Other Benefit vvas Receives: <br /> Amount/Value: $ Dare Receiveo: , <br /> Description; _ _ <br /> Signature 2 ?.14 L. �.- �`—�"�� Date: // / 6 0 <br />