HomeMy WebLinkAboutChurchillJeromy Affidavit Disclosure 2016 S 1 �G
CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
C' N1G
TO: CITY CLERK DATE: /1 /tI.,
I �/�'�cr�y (-,Aur-J\f make the following disclosure under oath:
(Na'Me)
PLEASE CHECK THE BOX AND FILL IN THE APPROPRIATE BLANKS FOR EACH OF THE
FOLLOWING ITEMS
Yes No
1. ❑ I am an ❑elected or❑appointed ❑officer or 0 employee of the City of
Lansing holding the position of
in the (% La- a 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-ded-ve-i come- r_benefi.t- directlyor-indirectl_y-fro.-r-the-biddin.g f
negotiation of, solicitation of or entry into a contract with.the City or from
and 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]
f ❑ 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 of Ordinances and in the City Charter.
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 not 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? /06
■ Are you self-employed?
■ Who is your employer, if applicable?
Ij
■ What are the things you actually do in the business? Ad J
■ Who are your clients and who receives your goods or services? _
41,Nsi, r mr � c f S
■ How and where are your services performed? L4rns;l
llCi Q <k t,l CQL i
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