HomeMy WebLinkAboutHallRaymond Affidavit Disclosure 2007 CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
DATE: CPS`- 117
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS t`.
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 am an ❑ elected or ❑ appointed ❑ officer ❑ employee of the City of
Lansing holding the position of in the ��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.
❑ 1 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. ❑ p/1 may derive income or benefit directly from a contract with the City or
from any City action detailed below. (Charter 5-505.1)
❑ e' 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]
P ❑ 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]
❑ WZ 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 f in the Code or Ordinances and in the City Charter
3. This position is: ull time El Part time (less than 5 hours/wk) ❑ Unpaid
4. My Address is:
CONTINUED ON PAGE 2
AFFID.,, OF DISCLOSURE-PAGE 2
5. My Business (daytime) Phone # is:���
PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS DISCLOSURE
6, AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST.
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 exec this /b day of QG
gn
State of Michigan, County of
Subscribed and sworn to before me this day of 20
Notary Public%r Deputy Clerk
County, Michigan
My Commission Expires:
DRAFT 5A; REVISED 10-09-01