HomeMy WebLinkAboutBooneDorthy Affidavit Disclosure 2004 cat -
CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
DATE: �'f/�
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
I i 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
El I am an El elected or Ei appointed,E] officer or 1t_e' mployee of the City of
Lansing folding the position of Abbu-, llbiif.,J4 A'J"t in the
"1 6 2 i 4, department
11 E 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. ❑ 1 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(l) of-the Code of Ordinances]
1:1 1 may have a financial interest in a matter proposed to be acted upon by
the City of Lansing as described below[Chapter 290.04(l) 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 El Part time (less than 25 hours/wk) El Unpaid
.:
4. My Address is:
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