HomeMy WebLinkAboutBuren-PriebeAmanda Affidavit Disclosure 2010 CITY OF LANSING -_
AFFIDAVIT OF DISCLOSURE
DATE:
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
I PrrhanL�q ��� �; 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. ❑ 1 am an ❑ elected or ❑ appointed ❑ officer or employee of the City of
Lansing holding the position of EC Tr in the
(y0mynUJI i c�.�`c���� 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. ❑ 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 XPart 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.
Z w�A
jl ik-yaiLiceC a ai,n i(n I
l 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 Q3 -4) day of
AU�LL_4; 20 i 0
r�
Signed
State of Michigan, County of
Subscribed and sworn to before me this 3 C)T day of A u&y 5: 2010
RO AILL. DAVIS Notary Public%r Deputy Clerk
NATARYPUM STATE OFMi 1
(X]1RM OF CUAITON County, Michigan
IIIY GOtAMISSiQN EXPIRES Apr 18,2012
ACTING IN COUNTY OF IN®HAM My Commission Expires:
PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION
DRAFT 5A;REVISED 11-05-04
ATTACHMENT A
Please provide additional information about your ou tside business or
employment. Of special interest to the Board is ho wthe activities ofthe business
oremployment may directly or indirectly affect the City. This disclosure is about
information and is not an indication ofany 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 not required to limit your
disclosure only to the following questions. For Each business, include in your
answer such things as:
F1 What is the form of your business entity and what
(what pe—r`centage do you
�'own? �E ICS IY\ ij IE.
F1 Are you self-employed? a)o `` l
FI Who is your employer, if applicable? L cky)51Yw, 3cYl0o� �;� ACT
r1 What are the things you actually do in the business? i
0}} ONYVi R4\ a-f kA(2 CEir�� yo��eJT�1
F-I Who are your clients and who receives your goods or services? I
n How and where are your services performed? 1
nN\AAIe
c�noc\ o-nA q !macc c,� n4�D r-
SC��bra\S -
Page 1 of 3
n How often do you do outside work? N�n� ;�11 4r a
Y` a C OU 12�(' rS- :
S can
1.1
Does your business oremployer contract with the City? NG?
Il In performing your business oroutside employment, do you use any City
facilities or equipment? N-) If so, describe:
ri Is any ofyour business orem\pl_oyment conducted in 7�
+q�the City? If so,
describe: �1 1'�1�h KWk
F1 Does your business advertisement orcirculars, ifany, contain \a'ny
reference to the Cityll or��your City employment?`` -� s �t�u �- 1cL
t�2 Gl l_o.V\S1ylCC� ��ad1
fl Ifyour business uses advertisements, circulars, applications, ororder
forms that you have designed or have had designed for you, please attach
a copy ofthe applicable form(s).
Page 2 of 3
P Ifyou provide training oreducation as part ofyourbusiness:
Do you identify yourself to your clients or student s as being employed by
the City of Lansing?
Do you include in any of the written materials or a ids or reference in any
way in your presentations reference to policies, procedures, methods or
materials as being those also used by the City ofLansing? If so,
attach a copy of the material oraid and explain the reference in your
presentation.
P 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 ofthe Charter found at5-
505.1- 5-505.3. A copy is enclosed for your conven ience.
Page 3 of 3