HomeMy WebLinkAboutSouthworthDarin Affadavit Disclosure 2008 (2) ZDF �J ,,' r
CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
DATE:
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
r. 1 <>.h ,,, =1 : }rrr� r%c.'.r%�=`• �'r' make the following disclosure Linder oath:
(Igame)
PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF THE
FOLLOWING ITEMS
Yes No
❑ I am an ❑ elected or ❑ appointed 0 officer or ❑ employee of the City of
Lansing holding the position of in the
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.
❑ 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\ 1 may derive income or benefit directly from a contract with the City or from
II any City action detailed below, (Charter 5-505.1)
1p� ❑ 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(I) 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 Ordinance as
provided for in the Code or Ordinances and in the City Charter
3. This position is: ❑ Full time A' Parl 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 SUBMITTING THIS
G.
DISCLOSURE AND EXPLAIN WHY YOU THINK A CONFLICT MAYWAY NOT EXIST.
( L
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
_, 20
Signed
State of Michigan, County of
Subscribed and sworn to before me this day of 20
Notary Public/or Deputy Clerk
County, Michigan
My Commission Expires:
PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION
DRAFT 5A;REVISED 11-05-04