HomeMy WebLinkAboutSimonBrian Affadavit Disclosure 2004 . OF LANSING Page 1 of 2
Print Form'',, I e �
CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
Date: C�-c�
To: City Clerk
City Attorney, or
Board of Ethics
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I �,y,+� � ✓YIC3n �7r1r'�� �5 `T�' �i�ti�" 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. ❑ 1 am an ❑ elected or❑ appointed ❑ officer or 51 employee of the
Gi#jr-ems-bolding the position of JL --iathc
Department. rro dpurm;loda.
❑ ❑ 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.
❑ ❑ 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. ❑ 1 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(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].
❑ ❑ 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
Ordinances as provided for in the Code or Ordinances and in the City
Charter.
3, This position is: Full time ❑ Part time (less than 25 hours/wk) ❑ Unpaid
4. My address is: iM' /�L` �L✓�'c� J/�r / �Y /N� `�r �?��
5. My Business (daytime) Phone# is: or �l7
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OF LANSING Page 2 of 2
6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS DISCLOUSRE AND
EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST.
�U��! Ca isf� 'f"�r'j� �✓,../� f rtn �cs7t��C�" t9d- i✓ll��/�5/,
I herby 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 30 k day of < < 200`
Signed
State of Michigan, County of
Subscribed and sworn to before me this 6 day of � 20�_
Nota Public eputy Clerk
County, Michigan
My Commission Expires: r1c.{A �
e4-7iA E.SOVA
Notary Public,Clinton Co.MI
Acting in Ingham Co.,Mich
M Comm.Ex Tres Seat 2$,
http://lbwl/lbwl/fs/msmrc/Affidavit%20of%2ODisclosure%20020418.htm 8/30/2004