HomeMy WebLinkAboutEricksonHayden Affidavit Disclosure 2019 CITY OF LANSING AFFIDAVIT &ift9C1XMJRvE
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TO: CITY CLERK DATE: I a .- _ C�()`a
I A G,Q1 J- e, Cc, c�Son make the following disclosure under oath:
(Name-
PLEASE CHECK THE BOX AND FILL IN THE APPROPRIATE BLANKS FOR EACH OF THE
FOLLOWING ITEMS
❑ Yes ❑ No
1 x ❑ I am an ❑ elected or ❑ appointed;r officer or ❑ employee of the City of Lansing holding the
position of ?1 OW in the-Department
❑ K 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 ❑ pg, I may derive income or benefit directly or indirectly from the bidding of, 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]
❑ .Z 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 of Ordinances
and in the City Charter.
3 My City of Lansing position is:
Full-time ❑ Part-time (less than 25 hours/wk.) ❑ Unpaid
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4 PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE
AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST.
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I 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 1.3 day of
20�.
State of Michigan,County of I(1!�Jba,ry-1
Subscribed and sworn to before me this 13A—b gneL f VNQat- 0 2 0
Y
a
Lee Not Public/or puty Clerk
f MicniganCounty, Michigan
8/2021 My Commi ion Expires:
7/10
ATTACHMENT TO AFFIDAVIT OF DISCLOSURE
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
%
• Are you self-employed? y�5
• Who is your employer, if applicable?
• What are the things you actually do in the business? 1� ss",SV
arA
I
• Who are your clients and who receives your goods or services? 11 T�oC1�
COA bpz
• How and where are your services performed? p"�-\rnaC
C)�'
• How often do you do outside work? f C(
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,Does your business or employer contract with the City?
• In performing your business or outside employment, do you use any City facilities or
equipment?
N O If so, describe:
• Is any of your business or employment conducted in the City?cif so, describe:
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• Does your business advertisement or circulars, if any, contain any reference to the City or
your City employment? W o
• Is there any additional information that you believe would assist the Board of Ethics 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 of the Charter found at 5-505.1 — 5-505.3. A copy is enclosed for
your convenience.
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