(A) Verification of applicant for employment for compliance with municipal nepotism policy.
Verification of Applicant for Employment for Compliance with Municipal Nepotism Policy
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I, (printed name), have reviewed the direct line of supervision for the position I am seeking with the Town of Newburgh and I am not a relative of any employee who will be in my direct line of supervision in the position of . I understand that Relative means my spouse, parent or stepparent, child or stepchild, brother, sister, stepbrother, stepsister, niece, nephew, aunt, uncle, daughter-in-law or son-in-law (including half-bloods and adopted children). |
1 hereby verify under the penalty of perjury that the foregoing statements are true. Dated this day of , 20______. |
(signature) |
(printed name) |
(B) Town Council member and Clerk-Treasurer disclosure of relative’s contract with municipality.
Town Council Member and Clerk-Treasurer Disclosure of Relative’s Contract with Municipality (I.C. 36-1-21-5)
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Town Council Member and Clerk-Treasurer Disclosure of Relative’s Contract with Municipality (I.C. 36-1-21-5)
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A governing body of a municipality may enter into, or renew, a contract for goods, services or public works with an individual who is a relative of a member of the Town Council or Clerk-Treasurer of the municipality, or, a business entity in which an individual who is a relative of a member of the Town Council or Clerk-Treasurer has an ownership interest, if a Disclosure of Relative’s Contract is made by the elected official and the elected official does not violate I.C. 35-44.1-3.1. In addition the Town Council must make certain certified statements regarding price or selection of such relative or contractor. |
1. Name of Elected Official (Mayor/Councilmember) Submitting Disclosure: |
2. Name of Office: |
3. Name of Municipality: |
4. Description of Contract for purchase or public works (Describe the kind of contract, the project name, the governing body or person(s) proposing to execute the contract for the municipality, the length of the contract term and the contractor): |
5. Describe the ownership interest of the relative in the Contractor: |
6. Describe the relationship of the Elected Official with the Contractor from which the municipality is contracting for the purchase of goods, services or public works. |
(The relationship is the disclosure of which one of the following relatives - spouse, parent, stepparent, child, stepchild, adopted child, brother, half-brother, stepbrother, sister, half-sister, stepsister niece or nephew aunt of uncle, daughter-in-law or son-in-law is the Contractor or has an ownership interest in the Contractor): |
7. The appropriate agency of the municipality contracting for the goods, services or public works made its certified statements as required by law on the day of __________________, 20_____. |
8. This Disclosure of a Relative’s contract was submitted to the Legislative Body of the municipality prior to final action on the contract for goods, services or public works. |
Date Submitted to Council Anticipated Date of Action on Contract or Purchase |
Signed: |
(Signature of Elected Official) |
Date: |
9. Acceptance of Disclosure: The Town Council of Newburgh, this day of , 20_____ took action at its public meeting to accept the above Disclosure prior to the final action on the contract. |
Signed: |
(Signature of Presiding Officer of the Council) |
(Within 15 days after final action on the contract which is the subject of this Disclosure, copies of this statement must be filed with the State Board of Accounts, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204-2738 and the Clerk of the Warrick Circuit Court.) |
(C) Certification of elected official to the Executive of the town regarding compliance with the town’s contracting with the town policy.
Certification of Elected Official to the Executive of the Town of Newburgh Regarding Compliance with the Town’s Contracting with the Town Policy
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Certification of Elected Official to the Executive of the Town of Newburgh Regarding Compliance with the Town’s Contracting with the Town Policy
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I (printed name) (insert office) of the Town of Newburgh certify that have not violated the Town’s Contracting with a Unit Policy under I.C. 36-1-21, as amended or supplemented, relating to contracts involving my relatives or any business interest in which they have an ownership interest as described in Ordinance 2012-11. I understand that Relative means my spouse, parent or stepparent, child or stepchild, brother, sister, stepbrother, stepsister, niece, nephew, aunt, uncle, daughter-in-law or son-in-law (including half-bloods and adopted children). I intend for this to be submitted to the Town Council President prior to the end of this calendar year. |
I affirm under the penalty for perjury that the foregoing statements are true. Dated this day of , 20_____. |
(signature) |
(printed name) |
Accepted this day of , 20_____. |
Town Council President |
(D) Annual certification of elected official to the Executive of town regarding compliance with town’s nepotism policy.
Annual Certification of Elected Official to the Executive of Newburgh Regarding Compliance with Newburgh’s Nepotism Policy
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Annual Certification of Elected Official to the Executive of Newburgh Regarding Compliance with Newburgh’s Nepotism Policy
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I, (printed name), (insert office) of the Town of Newburgh certify that I have not violated the Town of Newburgh Nepotism Policy in hiring and supervision of defined in I.C. 36-1-20.2, as amended or supplemented, relating to my relatives’ employment with the town as further described in Ordinance 2012-11. I understand that Relative means my spouse, parent or stepparent, child or stepchild, brother, sister, stepbrother, stepsister, niece, nephew, aunt, uncle, daughter-in-law or son-in-law (including half-bloods and adopted children). I intend for this to be submitted to the Mayor or Town Council President prior to the end of this calendar year. |
I affirm under the penalty for perjury that the foregoing statements are true. |
Dated this day of , 20_____. |
(signature) |
(printed name) |
(Ord. 2012-11, passed 6-13-2012)