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Home My WebLink AboutKacmarskyColin Affidavit Disclosure 2010 C17Y OF LANSING AFFIDAVIT OF DISCLOSURE From the 10-4-10 Council Meeting Packet C ' DATE: REFERRED TO THE CITY TO: CITY CLERK, ATTORNEY AND REFERRED TO THE o CITY ATTORNEY; or BOARD OF ETHICS - BOARD OF ETHICS '— r;7 c a 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 9 officer or❑ employee of the City of Lansing holding the position of /c5d�- in the 4&5ry tea zle-z" department ❑ I am an immediate family member related to an elected or a officer or employee of the City of Lansing named appointed 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. o I may derive income or benefit directly from a contract with the City or from any 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] o I make this disclosure because of a possible appearance that l 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. Thfs osftion is: m Fi,n times P )1d Part time (less than 25 hours/wk) ❑ Unpaid 4. My Address is: 5. My Business (daytime) Phone #is.- CONTINUED ON PAGE 2 AFFIDAVIT OF DISCLOSURE-PAGE 2 PLEASE DESCRIBE - IN DETAIL YOUR REASON(S) FOR SUBMIT77(VG THIS 6. DISCLOSURE_-AND EXPLAfA( WHY YOU THINK A CONF'lJCT MAY/MAY NOT EXIST OPJI�rC� �fJ -0f�f 7�1��{ �(� ' l�S�' ('1'r �o LrGr- 'wI I hereby certify that this disclasure is complete and accurate to the best ofmy knowledge, information and belies: The. foregoing Affidavit of Disclosure was execrated can this 2Q J71 day of Sign State of Michigan, County of Subscribed and sworn to before me this �� day of `�26 F—T'6M6P__ 201 a PP,"' d!L. E1AVty Notary P blic%r Deputy Clem NOTARY PU ,S"SMOC—M1 County, Michigan r�i9d'fYarf�.4PdT'aPQ \ hSYCQ.�,t,"tSSiRH�(FIf'FSRprifJ�12 1�f�-_�2 ACTING IN MUNTY GF INGHAM My Commission Expires: L 4 i PLEASE INCLUDE AND SUBMIT A COPS'OF YOUR CURRENT JOB (DESCRIPTION DRAFT5A;REVISED 11.0504 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: p What is the form of your business entity and what percentage do you own? Are you self-employed? .ti, Who is your employer, if applicable?. �5 1�u What are the things you actually do in the business? Who are your clients and who receives your goods or services? 1 a How and where are your services performed? Ski� z✓._�5'�f r_�� -�'��_��-�� 7 Page 1 of 3 a How often do you do outside work? g Does your business or employer contract with the City? tside employment, do . In performing your business or ou you Li' e any City facilities or equipment?V a If so, describe: Is any of your business or employment conducted in the City? MV If so, describe: ■ Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? � If your business uses advertisements, circulars, applications, or order forms that you have designed or have had designed for you, please attach a copy of the applicable form(s). Page 2of3 :! If you provide training or education as part of your business: Do you identify yourself to your clients or students as being employed by the City of Lansing? A)O Do you include in any of the written materials or aids or reference in any way in your presentations reference to policies, procedures, methods or materials as being those also used by the City of Lansing? d If so attach a copy of the material or aid and explain the reference in your presentation. Is there any additional information that you believe would assist the Ethics Board in its review of your business or personal activities for`potential conflicts of interest? A)0 If so, please describe: In providing this additional information, the Board of Ethics asks that you give special-attention-to-the-Conflicts-of inte-rest-section-of-the-Charter-found-at 5- 5D5.1- 5-505.3. A copy is enclosed for your convenience. Page 3 of 3 v TA S1c OFFICE OF THE CITY ATTORNEY IC 1-11 G�� MEMORANDUM FROM: DONALD J. KULHANEK,Assistan ity Atto ey DATE: September 9, 2010 �__... SUBJECT: AFFIDAVIT OF DISCLOSURE; LPD OFFICER'S SUPPLEMENTAL EMPLOYMENT I have been asked by LPD to forward to you the attached affidavit about an officer's supplemental employment. I understand this is for the Ethics Board. Thank you for your assistance. DJK/mjp = 4? Attachments i .. e SAAttorney_Statf\BOARDS&COMMITTEES\Ethics Bd\Swope aff disclosure re LPD officers.doc CITY OF LANSING AFFIDAVIT OF DISCLOSURE DAfiE: TO: CITY CLERK, /z- //0 CITY ATTORNEY, or BOARD OF ETHICS I_ 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 - - ❑ I am an ❑ elected or ❑ appointed psi officer or ❑ employee of the City of Lansing holding the position of in the 41(1 1-V1q z department ❑ A 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 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 orfrom any 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 Ordinancesj ❑ 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] ❑ 9d 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: Fi ill time )1d Part time (less than 25 hourslwk) ❑ Unpaid 4. My Address is _ 5. My Business (daytime) Phone #is: CONTINUED ON PAGE 2 t-d t7GS'RUS'/ LG /\NSJBWOB\,I uiio-) P-Q+,:7 i n i c7 5nti AFFIDAIgT OF DISCLOSURE-PAGE 2 6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS DISCLOSURE AND EXPLAIN WHY YOU THINK A CONFLICT MAWMAY NOT EXIST. 081A Pe-D 4 a-0fZ 7_1r C_ L)0!6 t`;' &U 1 s� WiGG tv0 Cel,uGyiCv" G+) 4?7' L:%i?�2l� Yd�7 z3fUSr ZV L 7-4 TZ, Lr c ivy Sy�r7.cJ 1�?L i/Ti�rsn _Ve.6 l,, C v ls-1110 C3 e"7,7 1 hereby certify that this disclosure is complete and accurate to the best ofmy knowledge, information and belief. The foregoing Afdavit of Disclosure was executed on this 2D J clay of 20 lL . Signee State of Michigan, County of Subscribed and sworn to before me this Z.B" day of 2010 F111tJWILL DAVIS Notary Publiclor Deputy Clerk NOTAIfiYF'1RX48TATEOFAV N G County, Michigan COWrYOFCUNM MYCOWSSfQ ISRFESW18,2012 ACTING IN COUNTY OF INGHANd My Commission Expires: PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION DRAFT SA;REVISED 11-05-04 G'd f7Q; ,QL 7.S,..j I.Q lJlln'1 P.4,4,-71 r11 r,7 fin\4 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? • Are you self-employed? ■ Who is your employer, if applicable? f r5�;- �uf ■ What are the things you actually do in the business? • Who are your clients and who receives your goods or services? G�',�z�✓c �ci.O 1 i c ■ How and where are your services performed? Page 1 of 3 9'd tgP.PP.7.S.J Lq ANSjewoeu Ulm-) P+,4i 71 ni n-7 R n w ■ How often do you do outside work? ■ Does your business or employer contract with the City? I '/V0 f ■ In performing your business or outside employment, do you use any City facilities or equipment? VO If so, describe: ■ Is any of your business or employment conducted in the City? NV If so, describe: ■ Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? A)8 ■ if your business uses advertisements, circulars, applications, or order forms that you have designed or have had designed for you, please attach a copy of the applicable form(s). Page 2 of 3 ■ If you provide training or education as part of your business: Do you identify yourself to your clients or students as being employed by the City of Lansing? ,VO Do you include in any of the written materials or aids or reference in any way in your presentations reference to policies, procedures, methods or materials as being those also used by the City of Lansing? -A/Q If so, attach a copy of the material or aid and explain the reference in your presentation. ■ Is there any additional information that you believe would assist the Ethics Board in its review of your business or personal activities for potential conflicts of interest? A,rP If so, please describe: In providing this additional information, the Board of Ethics asks that you give special-attention-to-the-Conflicts-of-Inter-est section-of-the-Charter-found-at 5- 505.1- 5-505.3. A copy is enclosed for your convenience. Page 3 of 3