(Name of person for which this addendum is filed) |
(List each office or position of employment for which this addendum is filed) |
(Full post office address to which notification of an examination of this addendum should be sent) |
GENERAL DIRECTIONS |
The interest (if constructively controlled by the person making the statement) of a spouse or any other party; including dependent children or others of interest, shall be considered to be the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If additional space is needed, please attach a supplemental listing. |
1. Other than your principal residence, do you or any members of your immediate family own any interest in real property located within the county? |
If your answer is affirmative, state the following information for each such interest owned: |
a. The nature of your interest in the real property and your instrument of ownership as defined in 5 ILCS 420/1-115 (deeds, common or preferred stock certificates, rights, warrants, options, bills of sale, contracts, interests in proprietorships, partnerships and joint ventures, and beneficial interests in trusts or land trusts). |
b. The location of the real property (for improved property, provides the street address; for unimproved property, state its location in relation to existing streets). |
c. The property’s permanent real estate tax identification number. |
2. Do you or members of your immediate family own an interest in any business or professional entity doing business with the County or any other public/local government agency within Madison County? . Are you or any members of your immediate family an officer or director of any business or professional entity doing business with the county or any other local, public government agency within Madison County? . |
If your answer to either of the foregoing questions is in the affirmative, state the following: the name of the business or professional entity, the nature of your relationship to the business or professional entity; the type of product produced or service rendered by the business or professional entity and the extent or percentage of the interest . |
3. Other than a debt to secure a mortgage upon your principal residence or business loan are you or members of your immediate family indebted to any person or business or professional entity doing business with the county or any other local, public government within Madison County? |
Circle One: YES NO |
If yes, list each such person, business or professional entity to which you or members of your immediate family are indebted and the amount of each debt. EXCLUDE: Any liability of $1,200 or less; student loans; installment loans (cars, household effects and the like); medical and dental debts; credit card purchases; support or alimony obligations; debts owed to spouse or close relative; and debts incurred in the maintenance of your household . |
4. If you or members of your immediate family have been released from any indebtedness from any person, business or professional entity doing business with the county or any other local, public government within Madison County exceeding in its principal amount of $1,200 within the last year without repaying the total balance due on such indebtedness, list the name of the creditor providing the release, the nature and the amount of the indebtedness, and describe the circumstances surrounding the release. |
EXCLUDE: Any liability of $1,200 or less; student loans; installment loans (cars, household effects, etc.); medical and dental debts; credit card purchases; support or alimony obligations; debts owed to spouse or close relative; and debts incurred in the maintenance of your household . |
Verification: “I declare that this disclosure of economic interests (including any accompanying attachments) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Madison County economic interests resolution and conflicts of interest disclosure ordinance. I understand that the penalty for knowingly and intentionally filing a false or incomplete statement shall be an ordinance violation subject to fines and penalties not to exceed $1,000 (55 ILCS 5/5-1113).” |
(Date of filing) (Signature of person making the statement) |
(Ord. 2012-06, passed 6-20-2012) Penalty, see § 40.99