HomeMy WebLinkAboutRemsonJackJR Affidavit Disclosure 2014 RECEIVED
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AFFIDAVIT OrnRI � O�FJRTLERv(
ICHIGP
TO: CITY CLERK, DATE: 7' /l/ /
CITY ATTORNEY or
ApBOARD OF ETHICS
I 1)2"1Scg 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
No
1. Cq ❑ I am an ❑elected or❑appointed [94fficer or❑ employee of the City of
Lansing holding the position of w/'cz t)��i�e�
/ in the /—��s s s po%ce Department
❑ 13' 1 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/ 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. ❑ d 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)
❑ G2" 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(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(1) of the
Code of Ordinances]
❑ d 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:
[a/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 THINK A CONFLICT MAY/MAY NOT EXIST.
6e
1 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 ofpf.
20 I q .
_ ign
State of Michigan, County offi�/!7
Subscribed and sworn to before me this day of t� , 20�
Notary Public/or Deputy Clerk
County, Michigan
My Commission Expires: Te CY L.scoTr
NOTARY PUBLIC•STATh OF
COUNTY OF INGHAM 20�
My Con j,,,10,ExpU April
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
0
own? ;DO /a
• Are you self-employed?
• Who is your employer, if applicable?
• What are the things you actually do in the business? L4xK -nd .5e.11
t�3
• Who are your clients and who receives your goods or services? Pubt,e_
• How and where are your services performed?
/1G'ck ,`.� •fir_ C&Y L ui�i
Page 1 of 3
• How often do you do outside work? �Iil^%zS
• 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? Yes_ If so,
describe: Jv((%z
• Does your business advertisement or circulars, if any, contain any
reference to the City or your City employment? A
• 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? N,
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'b 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? MU 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.
Page 3 of 3