HomeMy WebLinkAboutEllisScott Affidavit Disclosure 2008 CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
DATE:
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
c Trt" EL.LLS make the following disclosure under oath:
(Name)
PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF TWE
FOLLOWING ITEMS
Yes No
1. (r!�' ❑ I am an ❑ elected or ❑ appointed ❑ officer or ❑ employee of the City of
Lansing holding the position of in the
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)
❑ aC 1 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(1) 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:
NA A:Sc ej 1-4 Z �°1J�j`3c/
5. My Business (daytime) Phone# is:
CLL%s 'I 5°7 --7( `S-4S 3L(
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.
1 A `nAk At7il M W*,aS
�,.�J�StUE: Po \.i lrL ��P�dLittil�rs
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I hereby certify that this disclosure is complete and accurate to the best of my knowledge,
information and belief.
sr
The foregoing Affidavit of Disclosure was executed on this day of
Ao'"t, 2009
Signe
State of Michigan, County of I S�
Subscriber and sworn to before me this I day of aU 200
Nota Publ"c/or Deputy Clerk
State off Michigan,,County of Eaton
Dawn Notary Public ry ( � County, Michigan
Michigan,
My Commission Expire 1/ 2011
Acting in the County of My Commission Expires:
11 -7- i I
PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION
DRAFT SA;REVISED 11-0"4