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HomeMy WebLinkAboutPulverDamon Affidavit Disclosure 2019 yPN SINC CITY OF LANSING AFFIDAVIT OF DISCLOSURE C IGP TO: CITY CLERK DATE: 2/25/2019 I Damon Pulver 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. ❑✓ ❑ I am an❑ elected or❑ appointed ❑officer or ❑✓ employee of the City of Lansing holding the position of Cadet in the Police Department ❑ Z 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. ❑ 0 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(1) of the Code of Ordinances] ❑ Q 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(1)of the Code of Ordinances] ❑ a 1 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. M City of Lansing position is: Full-time Part-time (less than 25 hours/wk) ❑ Unpaid 4. PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE AND EXPLAIN WHY YOU THINKA CONFLICT MAY/MAY NOT EXIST. I am submitting this to get approval for secondary employment. I believe that a confict of interest does not exist due to the fact that the business that wants to hire me is in a different career field that has no benefit or gain from my employment with the City of Lansing. 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 ;� day of 4 ✓ -j. 201 r Signed State of Michigan, County of 7,1- � Subscribed and sworn to before mh this S day of /l,20 MICRELLE R REUUiS j NotarPPublic%or Deputy Creerk—� Notary Public - Michigan } % �. Ingham County —�% '-County, Michigan i My Commission Expires oct 3,2019 Acting in the County of My commis ion Expires:_ /G> / 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? The entity I am requesting employment for is Klavons 0 % • Are you self-employed? No ■ Who is your employer, if applicable? The employer would be Klavons • What are the things you actually do in the business? I would be starting off as a host. The duties would be checking in guests, sitting guests at tables, answering phones, and possibly cleaning. • Who are your clients and who receives your goods or services? The general public would be the customers. • How and where are your services performed? The resturant is located in Mason on Kipp rd, accross from Meijer. And I would be working at the front. ■ How often do you do outside work? I wouldn't work outside. Does your business or employer contract with the City? No In performing your business or outside employment, do you use any City facilities or equipment? No If so, describe: ■ Is any of your business or employment conducted in the City? No If so, describe: Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? No ■ 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? No 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. yt NSINC CITY OF LANSING AFFIDAVIT OF DISCLOSURE tcHtGP� TO: CITY CLERK DATE: 2/25/2019 I Damon Pulver 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. ❑✓ ❑ 1 am an❑ elected or❑ appointed ❑officer or ❑✓ employee of the City of Lansing holding the position of Cadet in the Police 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 ❑ 0 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. ❑ ❑✓ 1 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(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(1) of the Code of Ordinances] ❑ n I make this disclosure because of a possible appearance that 1 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. M City of Lansing position is: Full-time Part-time (less than 25 hours/wk) FlUnpaid 4. PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE AND EXPLAIN WHY YOU THINKA CONFLICT MAY/MAY NOT EXIST. I am submitting this to get approval for secondary employment. I believe that a confict of interest does not exist due to the fact that the business that wants to hire me is in a different career field that has no benefit or gain from my employment with the City of Lansing. 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,.)5 day of f° 'Ln; 20 l`r . ((% Signedyr State of Michigan, County of _ Subscribed and sworn to before m4 this —' f / n 5 day of it��'G �i`�''�', 20 Notary�Publiclor Deputy Cle'k MICHELLE R REDDISH Notary Public - Michigan i L, Ingham County i z / County, Michigan My Commission Expires Oct 3, 2019 Acting in the County al My Commis' ton Expires:_/G� - —/�j V - �-- 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? The entity I am requesting employment for is Klavons 0 % ■ Are you self-employed? No ■ Who is your employer, if applicable? The employer would be Klavons ■ What are the things you actually do in the business? I would be starting off as a host. The duties would be checking in guests, sitting guests at tables, answering phones, and possibly cleaning. • Who are your clients and who receives your goods or services? The general public would be the customers. • How and where are your services performed? The resturant is located in Mason on Kipp rd, accross from Meijer. And I would be working at the front. ■ How often do you do outside work? I wouldn't work outside. ■ Does your business or employer contract with the City? No • In performing your business or outside employment, do you use any City facilities or equipment? No If so, describe: Is any of your business or employment conducted in the City? No If so, describe: • Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? No 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? No 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.