In accordance with Ordinance No. 94-19, this statement of financial interest shall be filed with the Board of Ethics, or the administrative official designated as the custodian of its records by the Board of Ethics, no later than 4:00 p.m. December 31, 1994. A newly-appointed officer or employee must file this statement no later than thirty (30) days after the date of appointment. A candidate for city office must file this statement no later than thirty (30) days after the date on which the person becomes a candidate for elected city office.
1. Name:
2. Current Address
a. Business (including telephone number):
b. Home
3. Occupation
a. Filer:
b. Spouse:
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 (earned income only-list source but not amount):
a.
b.
c.
d.
e.
5. Please list the name and address of any business located within the state that is doing business with the city or has done business with the city within the past three (3) years, or which is reasonably 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 ten thousand dollars ($10,000) at fair market value of five percent (5%) ownership or more. (List name and address of business only. It is not necessary to estimate value of interest):
a.
b.
c.
6. Please list the name and address of any business located outside of the state, if the business is not or has engaged in any business transactions with the city during the past three (3) 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 ten thousand dollars ($10,000) at fair market value or five percent (5%) ownership interest or more. (List name and address only. It is not necessary to estimate value of interest):
a.
b.
c.
7. Please list the name and address of any creditor that is now or has within the past three (3) years engaged in any business transactions with the city, or which is reasonably anticipated to engage in any future business transactions with the city, owed more than ten thousand dollars ($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 person, family or household purposes:
a.
b.
c.
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.