In accordance with Chapter 38 of the city’s code of ordinances, this statement of financial interests is required to be filed with the Board of Ethics, by filing with the City Clerk as the administrative official designated as the custodian of its records by the Board of Ethics, no later than January 1 of each year. A newly appointed officer or employee must file this statement no later than 30 days after the date of appointment. A candidate for city office must file this statement no later than 30 days after the date on which the person becomes a candidate for elected city office.
Note: Nothing in this financial interests statement should be construed to require any officer, employee or candidate to disclose any specific dollar amounts nor the names of individual clients or customers of businesses listed as sources of income.
1. Name:
2. Current Address(es)
a. Business | b. Home | |
Telephone: | Telephone: |
3. Occupation
a. Filer | b. Spouse | |
Name of Spouse, if any |
4. Please identify any source of income of the filer and the filer’s immediate family members that exceeds $5,000 during the preceding calendar year, and the nature of the income (e.g., salary, commissions, dividends, retirement fund distribution and the like), on Schedule A, attached hereto.
5. Please list the name and address of any business located within the state in which the filer or any member of the filer’s immediate family had at any time during the preceding calendar year an interest of $10,000 at fair market value or 5% ownership or more on Schedule B, attached herein. Do not list stock or bond ownership of stocks and bonds listed and customarily sold on national or regional stock exchanges where the company has not done business with the city for the past five years and is not reasonably expected to do business with the city in the next three years.
6. Please list the name and address of any business located outside of the state, if the business has engaged in any business transactions with the city during the past three years, or which is anticipated to engage in any business transactions with the city in which the filer or any member of the filer’s immediate family had at any time during the preceding calendar year an interest of $10,000 at fair market value or 5% ownership interest or more on Schedule C, attached hereto. Do not list stock or bond ownership of stocks and bonds listed and customarily sold on national or regional stock exchanges where the company has not done business with the city for the past five years and is not reasonably expected to do business with the city in the next three years.
7. Please designate as either commercial, residential or rural and the location of all real property within the county, other than the filer’s primary residence, in which the filer or any member of the filer’s immediate family had during the preceding calendar year an interest of $10,000 or more, on Schedule D, attached hereto.
8. Please list each source, by name and address, of gifts or honoraria having an aggregate fair market value of $200 or more from any single source, excluding gifts received from family members, received by the filer or any member of the filer’s immediate family during the preceding calendar year on Schedule E, attached hereto. Do not list gifts from sources which have not done any business with the city in the past five years and is not reasonably expected to do business with the city in the next three years.
9. Please list the name and address of any creditor owed more than $10,000, except debts arising from the purchase of a primary residence or the purchase of consumer goods which are bought or used primarily for personal, family or household purposes, on Schedule F, attached.
The undersigned hereby certifies that the foregoing and the attached schedules are true and accurate as he or she verily believes, and agrees that supplemental or amended schedules or disclosures will be filed in the event of any material change of circumstances.
Dated:
Signature of person filing
For administrative use only:
Dale Filed:
Received by: