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Home My WebLink AboutThielenShannon Affadavit Disclosure 2008 CITY OF LANSING _ _ D_I V _ AFFIDAVIT OF DISCLO R DATE: TO: CITY CLERK, JAN 2010 CITY.ATTORNEY, or BOARD OF ETHICS . I Sn�nn on �h'i'E/E/1 make the followwl'n'g- rsc osure-un` er-�a (Name) PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF THE - FOLLOWING ITEMS Yes No �. ❑ I am an ❑ elected or ❑ appointed`T�?officer or ❑ employee of the City'of Lansing holding the position of in the La.n5i n IP6)1 CC ' 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.orernployee of the City.of Lansing named Holding the position of in the Department. 2. ❑ I may derive income or benefit directly from a contract with the City orfrom 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(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 Part 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 6. DISCLOSURE AND EXPLAIN WHY YOU THINK CONFLICT MAY/MAY NOT EXIST. rn i'v i S d r u ct 7-, does r o-t E 5--- e GaU T W '(A n J t 01'c ra 1'n i in G rl >� S� ��U�E J Jc d J /� 1�0,,/, A eCnS'n lO/iGL' L' a, yn�nZL I hereby certify that this disclosure is complete and accurate to the best of my knowledge, information and belief. 5{ The foregoing Affidavit of Disclosure was. executed on this C2 day of e� 20 D l Signed �-'^ ✓ ? State of Michigan, County of I Subscribed and sworn to before me this s� day of 200 17 Notary. Public%r Deputy Clerk County,.Michigan My Commission Expires; PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION DRAFT 5A;REVISED 11-05-04 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 own? ►Ue le� -5,,Z,7l;Ps a rG R r n m j ZLG {ALLY I C E v+-,P n Zt' i �t 1-h P_ ■ Are you self-employed? ■ Who is your employer, if applicable? 'fir i 1/e Tle � ■ What are the things you Ja/ctually do in the business? �ra;n k1w C'n'J- f-(_ernPn-1 Ge/S �///nt1J �o e_ SAP 5�T_�L.3p11P ■ Who are your clients and who receives your goods or services? ■ How and where are your services performed? �I�a/) c ,^ _ Gib ZII Lice r � C_ //n0LL.e I)7 Gr ,I17V Page 1 of 3 ■ How often do you.do outside w//ork? ■ Does your business or employer contract with the City? V03 ■ In performing your business or outside employment, do you use any City facilities or equipment? A y U If so, describe: ■ Is any of your business or employment conducted in the City? �V" If so, describe: ■ 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? %� ��/ c�s�� , /7c5 e U `L JAL Q Ce�_l _1 PC) D II L P � J l f LF/ l In -CAP 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? Uo 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? � 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 16—W r CWy V CITY OF LANSING AFFIDAVIT OF DISCLOSURE DATE: Li 'TO: CITY CLERK, CITY ATTORNEI', or BOARD OF ETHICS make the following disclosure under oath: (Name) PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF THE FOLLOWING OWING ITEMS Yes No 1, p' ❑ 1 am an ❑ elected or ❑ appointed 16ofificer or ❑ employee of the City of Lansing holding the position of �� c.!' '.�� r._r in the department i ❑ o 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. ❑ e' 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 may derive income or benefit directly from a contract with the City or from \\ any City action detailed below. (Charter 5-505.1) ❑ to 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(I) of the Code of Ordinances] ❑ ra 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 IKI Part time (less than 25 hours/wk) ❑ Unpaid Q. lily Address is: 5. Idly Business (daytime) Phone # is: CONTINUED ON PAGE 2 AFFIDAVIT OF DISCLOSURE-PAGE 2 PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS 6. DISCLOSURE AND EX'PLAIN 14W YOU THINK A CONFLICT MAY/MAY NOT EXIST. , rr _ l;'JV`T ✓`_`, 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 a I Signed State of Michigan, County of Subscribed and sworn to before me this �� day of 20 Notary Public%r Deputy Clerk County, Michigan My Commission Expires: PLEASE INCLUDE AND SUBMIT A COPY OF YOUR CURRENT JOB DESCRIPTION DRAFT 5A;REVISED 11-05-04