HomeMy WebLinkAboutDelineJamesAffidavit Disclosure 2013 i
CITY OF LANSING
STATEMENT OF FINANCIAL INTERESTS
Basic Filina Information
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By my signature, c ify that the information in this Statement of Financial Interest is true and
complete to the b of y knowledge, information and belief.
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Signature: Date:
Reserved for City Clerk's Office to Complete
Date Received by Clerk's Office
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Clerk's Office Acknowledgement:
STATEMENT OF FINANCIAL INTERESTS
1. Organization and Entities
For each organization that you list below, please complete and include Attachment A with
ithe disclosure form.
If all of the following apply:
• you are part of an organization or entity other than the City;
• you are an officer, director, associate, partner, proprietor or employee, or served in any
advisory capacity in the organization or entity; and
• you received more than$2,500 income last calendar year from the organization or entity,
please fill in the following:
Type of Your
Organization's Name Address Organization Function/Title
2. Capital Asset
If all of the following apply:
• you are owner or are part owner of real property, business equipment, fixtures, furniture,
inventory or other capital asset located in Lansing;
• the property was not your principal place of residence; and
• in the last calendar year the property increased in value more than $5,000 or produced
more than$5,000 in income or was sold and you received more than $5,000 from the sale,
please fill in the following:
Asset Description
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3. Governmental Employment Except for the City of Lansing
If you were employed by a governmental unit or agency in the last calendar year,please state the
unit/agency and briefly describe the nature of your employment duties.
Name of Governme tal Uni _ ency Duties
4. Gifts
If all of the'following apply:
• you received a gift or gifts that total more than $500 last calendar year fiom one-person or
entity or were paid more than a$500 honorarium in the last calendar year; and
• the gift or honorarium did not come from a relative, by blood or marriage, or was not a
campaign contribution under the Michigan Campaign Finance Act,
please fill in the following:
Name of Donor Address Your Relationship to Donor
5. Business Interest and Supplemental Employment
For each business that you list below, please complete and include Attachment A with the
disclosure form.
If all of the following apply:
• you, or a member of your immediate family, are owner or part owner of a business entity
(sole proprietorship, d/b/a,partnership, limited liability company, or corporations);
• the business entity conducts business in the City of Lansing; and
• the ownership is not based on holding stock in a public corporation,
please fill in the following and complete Attachment A:
Nature of Business Address of Business Nature of Ownership
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6. Real Estate
If all of the following apply:
• you own or have a financial interest in either: real property in the City; or real property
outside the City that has on it a drain or utility or anything else used or owned by the City
of Lansing or the BWL; and
• the property is not your principal place of residence,
please fill in the following:
Address or Description of Real Estate Type of Ownership
7. Permit, Zoning,License Franchise
If all of the following apply:
• you, a member of your immediate family, or a business of which you are a part, applied to
the City of Lansing for:rezoning or a zoning variance; a license;a permit; or a franchise,
please fill in the following and attach a copy of your application form or request:
Person's Name City Action Requested by Person
Penalties for Late Filing
Annual Statements — A person who fails to file a statement by May 1 of each year shall file his/her
statement on or before May 31, along with a late filing fee of $20.00. Failure to file by May 31 is a
violation of the Ethics Ordinance,unless the person has filed an extension.
New Reporting Individuals —A person who first becomes subject to the requirement to file a statement
within 30 days prior to May 1, shall file his/her statement on or before May 31 without penalty. If such
person fails to file a statement by May 31, the individual shall file his/her statement on or before June
15, along with a late filing fee of$20.00. Failure to file by June 15 is a violation of the Ethics Ordinance,
unless the person has filed an extension.
Extensions—A person who is required to file a statement of financial interests may have one thirty day
extension by filing a notice with the City Clerk by the date on which the statement is due. Failure to file
by the extended deadline is a violation of the Ethics Ordinance.
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