Loading...
HomeMy WebLinkAboutAdcockJeremy Affidavit Disclosure 2003 CITY OF LANSING AFFIDAVIT OF DISCLOSURE DATE: TO: -CITY CLERK, CITY ATTORNEY, or BOARD OF ETHICS J,� make the following disclosure under oath: (Name) PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF THE FOLLOWING ITEMS Yes No 1. e- ❑ 1 am an ❑ elected or ❑ appointed ❑ officer or ©:employee of the City of Lansing holding the position of in the department ❑ ❑ I am an immediate family member related to an elected or appointed officer or employee of the City of Lansing named holding the position of in the department. ❑ ❑ I am a Business Associate of an elected or appointed officer or employee of the City of Lansing named Holding the position of in the Department. 2. o ❑ I may derive income or benefit directly from a contract with the City or from any City action detailed below. (Charter 5-505.1) ❑ ❑ 1 may have a conflict between a personal interest and the public interest, the nature of which is disclosed below (Charter 5-505.2) [Chapter #290.04(I) of the Code of Ordinances] ❑ ❑ I may have a financial interest in a matter proposed to be acted upon by the City of Lansing as described below[Chapter 290.04(I) of the Code of Ordinances] o ❑ I make this disclosure because of a possible appearance that I may be in violation of or in conflict with the City of Lansing Ethics Ordinance as provided for in the Code or Ordinances and in the City Charter 3. This position is: ® Full time ❑ Part time (less than 25 hours/wk) ❑ Unpaid 4. My Address is: i_�_� �_ ��i-3" _ != ,� ,�„�. r ,—✓ CONTINUED ON PAGE 2 AFFIDAVIT OF DISCLOSURE-PAGE 2 5. My Business (daytime) Phone # is-. Si 7 - C ' PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE 6 AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST. i %�.22' 77 - 1441 ClC-- T� t j c-5c- �Ti.: -� - :i'�i� -�C�1 ✓c S. I hereby certify that this disclosure is complete and accurate to the best of my knowledge, information and belief. The foregoing Affidavit of Disclosure was executed on this if day of 20 > Signed State of Michigan, County of�� ' h�►`l Subscribed and sworn to before Me this l day of 0-0 C , 20 63 Notary Publicldi3D uty Clerk County, Michigan My Commission ^Exxpires: ��J ��� � � 2W7 m IV19C,1-iELi_.E K;A �.- hLl'\S.: Notary Public, Ingham Co.,IVi1 My Comm.Expires Mar.8,2007 DRAFT 5A;REVISED 10-09.01