FINANCIAL INTERESTS STATEMENT
In accordance with Ordinance No. , this statement of financial interests 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 p.m. , 200 . 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 (e.g. salary, commission, dividends, retirement fund distribution, etc.):
a.
b.
c.
d.
e.
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 ten thousand dollars ($10,000) at fair market value or five percent (5%) ownership or more:
a.
b.
c.
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 (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:
a.
b.
c.
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 ten thousand dollars ($10,000) or more:
a.
b.
c.
8. Please list each source by name and address of gifts or honoraria having an aggregate fair market value of one hundred dollars ($100) 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:
a.
b.
c.
9. Please list the name and address of any creditor 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.