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HomeMy WebLinkAboutStAubinBrad Affadavit Disclosure 2012 1 CITY OF L_ANSING AFFIDAVIT OF DISCLOSURE DATE: TO: CITY CLERK, CITY ATTORNEY, or gBOETHICS I IuLn 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 p y y 1 ❑ 1 am an ❑ elected or❑ appointed ❑ o icer or -em to ee of the City o Lansinq/� (ding th position of /� e�� ,%' � in the ,��,� department ❑ l am an immediate family member related to an elected or appointed officer or employee of the City of Lansing named in the holding the position of department. ❑ I am a Business Associate of an elected or appointed officer or employee of the City of Lansing named in the Holding the position of 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) erest the ❑ Ian ture of which is disclosedetween a sbelowonal t d(Charter 5-505u2)c the [Chapter #290.04(I) of the Code of Ordinances] EY l 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 Ordinance as provided for in the Code or Ordinances and in the City-Charter "111 This position is: ❑ Full time Part time (less than 25 hourslwk) ❑ Unpaid 4. My Address is: 5. My Business (daytime) Phone#is: CONTINUED ON PAGE 2 AFFIDAVIT OF DISCLOSURE-PAGE 2 J PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS 6. DISCLOSUREAND EXPLAIN WHY YOU THINKA CONFLICT MAWMAYNOT EXIST. 61rG(/SGLlfScS G%LGUd)' .�'�•�.5' �`xDrC . -l- �� a Crin.�,2ccv •� � �.� �� � � �ram/ - G' C 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 1, , Signed g. 4WJ I=ate`-~ State of Michigan, County of Subscribed and sworn to before me this day of 2012 Notary Public%r Deputy Clerk County, Michigan JASON M.PIERCE NOTARY PUBLIO-STAfE OF MICHIGAN M Commission Expires: 2-(Z COUNTY OF CLINTON Y P� P My Commission Expires Dec.12,2013 Acting in the County of Ingham PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION DRAFT SA;REVISED 11-05-04 4 ti 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: A What is the form of your business entity and what percentage do you own? R Are you self-employed? %NO Who is your employer, if applicable? What are the things you actually do in the business? k �F/hCeAX / � Lam/ c•S a Who are your clients/and who receives your goods or services? v How and where-are your services performed? �r�e Page 1 of 3 v B .. Y How often do you do outside work? C5 S 1,2 r- R Does your business or employer contract with the City?._ �d In performing your business or outside employment, do you use any City facilities or equipment? � If so, describe: n Is any of your business or employment conducted in the City? If so, describe: J ffi 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 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? 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? fio 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 /�j conflicts of interest? y"o 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 oop•omatu 19ADO oinsoloslpgo �1010\pg so?El;H\SEj=. FIW00 W SGWOffW9I A0UIoAd\:S CJ t r � C:3 C= sluouigo'e dfuz� •aoue;srsse InM JOJ nod 7ILreLlL •pjuog sorq;g a)iR aoj si srE pue;saapun I quomSoldmo I-quoTuolddns s,00Soldzua poouaxajaz o-qj jo ;IA-ep V poTpap of noS o; pxemaoj 01 paalse clooq OAal I Nlgfl'V'LS GVUa `MMSOIDSIQ 90.LIA-V(1.I4JV aDargfiS fau.ro���pia �rt�isass�`�I���I't�I�7f1�I '1' Q'I�I�I()(I �IAI�2I�I *10fa TID amOAS.S Slum :®.L l 14,D r� a) Nd30 L L A� I ,� J, '40 a a I j A 0 �'�isrr� Z ElOVd NO ciEmNUNOO :sl# auogd (ewp Aep) sseulsn0 AN '9 :sl ssaappy AN ppedun ❑ ( Inn/sanoq 9E uegl ssel) awl}lied` awl}Ilnd ❑ :sl uol}isod slgl aa}.leg0 Aj10 aq} ul pue sa3ueulpj0 Jo apo0faq} ul ao} papinoid se aoueulp o solq}�] 6ulsue- }o Aj!O eq} q}lnn }oll}uoo ul Jo }o uolneloln ul eq Aew 11eq}aoueaeedde alglssod e}o asneoaq aansoloslp slLli e�ew I '1�, ❑ [saoueulp o }o apo0 aq;}o (I)t0'06Z aa}deg0] molaq pegljosep se 6ulsue�}o 40 aql Aq uodn pajoe aq o} pasodoid jai}ew e ul }saaa}ul Ieloueul} e aneq A13W I � ❑ [saoueulpa0}o apo0 aql}o (I)K-06Z# ja;deg0] (Z-909-9 aa;jeg0) nnolaq pasoloslp sl golgM }o ain}eu aqj '}saaap ollgnd eql pue}saaa}ul leuosaad e uaann}aq �oll}uoo e aneq 413W I -1j ❑ (G'909-9 ja4aeg0) 'Moleq pellejap uopoe Al10 Aue woa}jo A}10 aqj g11M}oea}uoo e wail Alloa.lip Il}auaq ao awooul anlaap Aew l —� ❑ Z •luaw}jedaa aqj ul }o uol}lsod aq} 6ulploH paweu 6uisue�}o 40 aqj}o &@Aoldwa ao aaogo pajulodde ao paaoala Lie}o aleloossy ssoulsn0 e we l —,A ❑ }uew:pedep aq} ul }o uol}lsod aq} 6ulploq paweu bulsue- }o Aj!O aql}o aaAoldwa ao noigo pa}ulodde ao paloala Lie o} pajelai aagwew Alpe} alelpawwl Lie we l ❑ ;uawpedep ' 2k 1��/ aq4 ul '?�' }o uolllsod ql 6ulpl l/6ulsue- }o Aj10 eqj}o eaAoldwa t'ao Jac)! o ❑ popodde ❑jo pajoala ❑ Lie we I ❑ G oN sa,� SW91I JNI11AO-110d 3Hl d0 HOt/FJ 210.d SMNVIS DHl NI -171d 'do X09 DiVMdO�IddV 3Hl MOEIHO 3S`d9ld (aweN) :gjeo aapun ainsoloslp 6uimollo}eq}@�ew v,ry 2l I SOIH10 d0 CRJ YOS -lo 'AS N2}011d,UO N JD-10 JkliO :Ol .Diva mnso-losla =10 ilnVal:IJa JNISNV-1 =10,U10 b0-90-LL CI3SIAEM!VS 1AV?N I NOIIdRIOS90 90f 1Nm:ni 1O NnoA d0 AdOO v lmms (INV San-IONI dSVEI ld wegoul}o Aiunoo ayl ul 6unoy 040Z-eG*oea sajldx3 uolsslwwoO AN �7 Z1- I :saaldxg uorsslwwo0 Allll NOiNM�o Al Nnoo Z NVOIHOIN dO Elivis-Tend AUVLON gSuEjid•N NOSdr ue,6lgollN `A;unoO Xaa10 Af ndaQ,io/oygndi MION Z 10a ��..�� �o�'ep srq; out a iojaq o; uaonns pue pagposgns w�•vi 5vT- jo Af unoq `uefilgoln jo a;e;S . f n j/ pauB/S -CI 0z jo Aep srq; uo pa;noaxa seM aansolos►© }o ;rnepl_4y 6uro,6ajoj eql -jallaq pue uogewmAi `afipajmou-yXw jo;seq aq;o;a;eanooe pue q;aldwoo sl oansolosfp sly;;eq;Aj1pao Aqa taq l s—r '1SIX3 ION AIMIAVMI10179NOD vmNIH1 nOAAHM NIV7dX3 GNvgHnS070S10 SIH1 JN111/W9nS 2103 (S)NOSV-9d &n0A wvi-g0 Ni 38/210sa7 3SV37d 9 r z 3,9vd-321nso7asra do 11nbaiddb 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: a What is the form of your business entity and what percentage do you own? ■ Are you self-employed? NO ■ Who is your employer, if applicable. ■ What are the things you actually do in the business? ■ Who are your clients and who receives your goods or services? v ■ How and where are your services performed? veld " Qr Page 1 of 3 ■ How often do you do outside work? Vd1ri C-5 S' z5 ■ Does your business or employer contract with the City? ■ In performing your busineNr-)_ s or outside employment, do you use any City facilities or equipment? If so, describe: ■ Is any of your business or employment conducted in the City?A If so, describe: ■ Does your business advertisement or circulars, if any, lcontain 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 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 A16 the City of Lansing? 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? fiU 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? r o 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 3of3