HomeMy WebLinkAboutBeasingerPaul Affidavit Disclosure 2013 c
AFFIDAVIT OF DISCLOSURE
DATE:
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
I--&V Z- 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. ❑ I am an ❑ elected or ❑ appointed kofficer or❑ employee of the City of
Lansing holding the position of in the
d//G,r- 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.
❑ r 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. ❑ I may derive income or benefit directly from a contract with the City or from
any City action detailed below. (Charter 5-505.1)
❑ I 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]
❑ 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:
5. My Business (daytime) Phone# is:
CONTINUED ON PAGE 2 ,
AFFIDAVIT OF DISCLOSURE-PAGE 2
6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS .
DISCLOSURE AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST. .
6, J76i/ 7Z .SCGc 7 r ' [l
w l Hi
orJ Al
.1 hereby certify that-this disci is Com and accurate to the best of my knowledge,
information and belief.
h fom/ .
ng Affidavit of Disclosure executed on this day of
�.20
Signed
State of Michigan, County of -77-�4u
Subscribed and sworn to before me this c�� ` day of 2013
Notary Pu lic%r Deputy Clerk
e� County, Michigan
13 My Commission Expires:
PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION
DRAFT 5A;REVISED 11-05-04
r
ATTACHMENT A .
Please provide additional information about your outside business or
employment. Of special interest to the Board is how the activities of the business
or employment may directly or indirectly affect the City. This disclosure is about
information and is not an indication of any anticipated conflict of interest or
suspected wrongdoing. Therefore, please describe for the Board what it is you
actually do and be detailed and specific. You are riot required to limit your
disclosure only to the. following questions.. For each business, include in your .
answer such things as:
■ What is the form of your business entity and what percentage do you
own? . Z .
Are you self-employed?
Who is your employer, if applicable?
What are the things Lyou actually-do in the business?
fn M 9 /.y1 I'1/eFP4SG 1�1n,.1/
■ Who are your clients and who receives your goods or services?
An'SI-41 /.gt'1 ✓ti�C G7/J-2-6�S,
�/'�i//) ,/lei G���G�� �✓�h G� /�'I�.�'y//C/�/���
How and where are your services performed?
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// Page 1 of 3
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■ How often do you do outside work?
Hn
Does your business or employer contract with the City? -/ d
■ In performing your business or outside employment, do you use any City
facilities or equipment?L If so, describe:
Is any of your business or employment conducted in the City? If so,
describe: Y✓vh�i�/
Does your business advertisement or circulars, if any, contain any
reference to the City or your City employment?
If your business uses advertisements, circulars, applications, or order
forms that you have designed or have had designed for you, please attach
a copy of the applicable form(s).
Page 2of3
If you provide training or education as part of your business:
Do you identify yourself to your clients or students as being employed by
the City of Lansing?,_ � -4-) /.�����y /, oti-1'k
f'Jo�' � � yS�dl Jh 9ilyPl�/S/f9�/.
Do you include in any of the written materials or aids or reference in any
way in your presentations reference to policies, procedures, methods or.
materials as being those also.used by the.City,of Lansing?. If so,
attach a copy of the material.or aid and explain the reference in your
presentation.
Is there any additional information that you believe would assist the Ethics
Board in its review of your business or personal activities for potential
conflicts of interest? If so, please describe:
In providing this additional information, the Board of Ethics asks that you give
special attention to the Conflicts of Interest section of the Charter found at 5-
505.1- 5-505.3. A copy is enclosed for your convenience.
Page 3 of 3