HomeMy WebLinkAboutThomasJulie Affadavit Disclosure 2018 N S 1 `�c
CITY OF LANSING cr• ,
AFFIDAVIT OF DISCLOSURE J
cHIGP
TO: CITY CLERK DATE:
I)y �� / r firm 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
1. ❑ I am an❑ elected or❑ appointed ❑officer or employee of
the City of Lansing holding the position of
in the T)C)l I L2 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 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)
❑ 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 of Ordinances and in the City Charter.
3. My City of Lansing position is:
Full-time Part-time (less than 25 hours/wk) FlUnpaid
4. PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE
AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST.
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 �n U-ern6-/_,
20 .
Signed
State of Michigan, County of
Subscribed and sworn to before me this_ , day of 20 q
ovary ublic/or Deputy Clerk
County, Michigan
My Commission Expires:
Lansing Police Department El Renewal
Supplemental Off-Duty ❑Reg, Off-Duty Employment
Employment Request Form Date:
Employee Requesting Approval: j1ALf I}mmgN Badge No: a
Current Duty Assignment: (P(�
Hours: Division: W°SUPPLEMENTAL EMPLOYEMENT INFORMATION
Name of Employer: Ljjt 1j&n,f)
Type of Business:
Business Address: :�\
Owner or Manager's Name: �Itr Z Telep one No:
Location of Employment: `3 3 V Tkll )e j911N__ I \Yd MS
Description of Work Duties:
Work Schedule:
Number of Hours PerWeek: I0— Z-0 Duration of Employment: 561' ;br-11 - �20d-M �7
Does this employment require any security or law enforcement responsibility including the enforcement of any state or local
law or the exercise of any police power on behalf of the employer? ❑ Yes ] No
I understand that in cases of supplemental employment, the only liability insurance coverage or workers compensation
coverage available would be that which may be supplied by the supplemental employer. Insurance procured by the City of
Lansing and other benefits are not applicable.
I understand that in cases of private security supplemental employment, the only liability insurance coverage or workers
compensation coverage available would be that which is supplied by the supplemental employer. While an indemnification
agreement and certificate of insurance is a prerequisite, these forms do not constitute a guarantee by the City or the Police
Department that insurance exists, is adequate, or has not been canceled without notice to the Police Department or employee.
Insurance procured by the City of Lansing and other benefits are not applica le.
� I
Employee Signature
Before any supplemental employment begins, this form must be filled out, signed, and approved by the Chief of Police or
the Chief's Designee. Approval may be revoked at any time by the Chief of Police.
Captains Recommendation Date: Oy \ <� Initials: [ Approved ❑ Disapproved
Captain's Comments: -�
Date Approved ❑ Disapproved
Michael4ankgvirski, Chief of Police
Copy of form sent to employee on
5/10