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FL: .,. <br /> � ltyqf <br /> Louisville7q3 <br /> CULOKALAJ•,INCL 1s7l1 <br /> City CIE.R'.Office 717M <br /> /49 Main Street, Louisville,CO 80027 <br /> 303-335-4576/Fax 303-335-4550 Date stamp <br /> Email: MeredythM@Iouisvilleco.gov <br /> DISCLOSURE BY PUBLIC OFFICEROWER <br /> REPUR i OF GIF IS, HONORARIA AND OTHER BENEFITS <br /> ( ec.<<4-6-c0i,C.R. .) <br /> tilers snow!arso review prov;sions of Sect:—..s,Arr:dc AAM of me Loly.ora,,rm..,t:tor:o.. <br /> MUNICIPAL FILING <br /> 1 filing requires: ft Qmaric, n Z"d Qe.rte. In 3pd Quarter 4`h Quarter 0 <br /> (ace April 15) (ao.Jed,15) One October 1 (due January 15) <br /> Nam of Offize Holder: Dub ivtucklc Ward I avor <br /> Address: I Lth Lincoln ii,Criu% L01.11.3 yak. CU 80027 <br /> Checlt one of the rollowing: el I nave nothing to report(PIea3c Sign and date below) <br /> receive!the rollowing girls, honoraria, or benefit durins this pzriud. <br /> 11 <br /> 1) Name of Person from Who the Gift, honoraria or Dther Benefit vvas Receive!: <br /> Amount/Value: $ Date Received: <br /> Description: <br /> L) Mame or Person from Who the Gift, H;n7,raria ca.Other Benefit Wa3 Received: <br /> Amount/Value: $ Date Received: <br /> Description: <br /> r <br /> 3) Name of Person from Who the Gift, Honoraria or Other Benefit.Was Received: <br /> Amount/Value: 5 Date Received: <br /> Description: <br /> r) Mame or Person rrom veto the Girt, Ronoraria or Other Benefit Was Rzceived: <br /> Amount/value: $ Date Received: <br /> Description: <br /> , <br /> Zi,L <br /> f <br /> Sisnature 11 +, . Date: lU 3 I <br />