County Officer’s Name:
Last First Middle
Current Business/Government/Address/Phone Number:
Current Home Address:
Officer’s Title or Elected Office Sought:
Occupation of Officer:
Occupation of Officer’s Spouse:
I. BUSINESS INTERESTS
If you or any member of your family (see definition of family in § 32.01), have any interest in any organization doing business with county government or any agency or officer of County Government and
1. You or your family member have an interest in the organization that is greater than 5% of the total ownership OR has a fair market value of $10,000 or more;
2. You or your family member received more than $5,000 compensation from the organization in the preceding calendar year. (This does not include compensation from ownership of, OR income derived from publicly traded securities unless you OR your family member own more than 5% of the value of the publicly traded securities.)
Business Organization Name | Address | Phone Number | ||
II. REAL PROPERTY INTERESTS (Attach additional sheet(s), if necessary)
List below the location and zoning designation of all real property within Barren County, other than your primary residence, in which you or any member of your family had an interest of $10,000 or more during the preceding calendar year AND which was the subject of:
Check appropriate box:
( ) Any condemnation proceeding.
( ) Any planning and zoning proceeding.
( ) Any other administrative or court proceeding wherein Barren County OR any of its agencies is an interested party.
________________________________________________________________________________
Property Location
Zoning Designation Identify Proceeding
III. PRIVATE INTEREST IN PENDING PUBLIC ACTION
Identify any contract with or matter pending before any Barren County Government in which you or any member of your family has any private financial interest directly or indirectly:
NOTICE
This financial disclosure statement must be filed annually by February 1 AND/OR within twenty-one (21) days of initial appointment/employment of “Government Officers”. It must be amended and filed within ten (10) days of a change in circumstances that makes the previously filed statement inaccurate or incomplete.
1. Section 523.030 of the Kentucky Revised Statutes provides that “A person is guilty of perjury in the second degree when he makes a material false statement which he does not believe in a subscribed written instrument for which an oath is required or authorized by law with the intent to mislead a public servant in the performance of his official functions. Perjury in the second degree is a Class A Misdemeanor.”
2. Upon receipt by the Ethics Commission, all Financial Disclosure Statements shall be public records.
3. Nothing in this statement shall be construed to require any officer to disclose any specific dollar amounts.
4. After written notice of failure to timely file a Financial Disclosure Statement, any officer who fails to file within ten (10) business days of such notice may be fined by the Ethics Commission a sum not less than twenty-five dollars ($25) nor more than five hundred dollars ($500).
I, (Print Name), being duly sworn, do solemnly swear that all the information presented herein is true and correct to the best of my knowledge under the pains and penalties of perjury.
Signature Date
STATE OF KENTUCKY
COUNTY OF BARREN
Subscribed and sworn to before me this the day of 201 .
Notary Public
My Commission Expires:
(Ord. 556, passed passed 3-17-2015)