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HomeMy WebLinkAboutTravigliaJosh Affadavit Disclosure 2012 7 oC L CITY OF LANSING AFFIDAVIT OF DISCLOSURE DATE: TO: CITY CLERK, r� CITY ATTORNEY, or BOARD OF ETHICS v i"O Ni� make the following disclosure under.oath: (Name) PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FO.R.EACH OF.THE FOLLOWING ITEMS -Yes No 1. ❑ I am an ID elected or ❑ appointed plicer oryemployee of the City of Lansing olding the position of �cu D C4,r(--tom in the (��� C Q__ 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 t; 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 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(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 Apart time (less than 25'hours/wk) ❑ Unpaid a,fY`4. My Address is: 5. My Business (daytime) Phone#is: 1-3 CONTINUED ON PAGE 2 r-± AFFIDAVIT OF DISCLOSURE-PAGE 2 PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS 6. DISCLOSURE AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST. C"" 1 3 -s r 1 - 'C V\in$ n o-s CNa,ti i M Y1�A L-P , 1 hereby certify that this disclosure is complete and accurate to the best of my knowledge, information and belied : The foregoing Affidavit of Disclosure was executed on this day of JJ1 20 L . Signed State of Michigan, County of Subscribed and sworn to before me this day of �1/L� 20 1 J6.NOTARY Notary Public%r Deputy Clerk County, Michigan JESSICA MARIE KOLKA PUIiUC,SPATE OF MI I 2 — GOUWYOFINGHAM My Commission Expires; MY COMMISSION EXPIRES Nov 20,2016 ACTING IN COUNTY91F 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? r Are you self-employed? N-0 ■ Who is your employer, if applicable? C 'C'� ■ What are the things you actually do in the business? L .f Who are your clients and who receives your goods or services? 1��p ■ How and where are your services performed? Page 1 of 3 ■ How often do you do outside work? �`-� M.��4� -Do-es-your-business or.employer-contract with-the-City? pc p In performing your business or outside'employment, do you use any City facilities or equipment? ! " o If sc, describe: Is any of your business or employment conducted in the City? l ks. If so, describe: \ ■ Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? o ■ 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). 11 �1 Page 2of3 ■ 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? N ............ ...... 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? �V'C� If so, attach a.copy of the material or aid and explain the reference in your presentation. ■ ' Is'th'ere'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? kca 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. 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QN �peAoldwa-jlas nog( aay . v uMo nog( op abeluaoaad jaunn pup Alllua ssaulsnq anon( jo waol auj sl jaunt :se sbuigT yons aamsua anoA ul apnloul `ssaulsnq yoea and -suollsanb 5ulnnollOI aql 01 Aluo aansoloslp anon( j!wll of paalnbaa jou aae no,& -oljloads pua pallalap aq pup op Allunjoa nog( sl Il legm pa-eo8 auj aol a9posap aseald `aaojaj@q j •bulopbuoann pajoadsns ao isaialul jo }olllum paledlollua Aua }o uoljeolpul up IOU sl PUP uoljpuaaojui inoga sl aansoloslp slut 'AI1O ayj joalpe Alloaalpul ao Alloaalp Auw luawAoldwa ao ssaulsnq ayj jo salllnlIo-e aul nnou sl paeo8 ayj of isaaajul Iuloads jp -juawAoldwa ao ssaulsnq aplslno anon( jnoga uoll-ewaolul l-euollippa apinoad asaald `d 1N]WHOdlld • How often do you do outside work? kwr 'S , ;4-4 ■ Does your business or employer contract with-the City? r� ■ In performing your business or outside employment, do you use any City facilities or equipment? NO If so, describe: ■ Is any of your business or employment conducted in the City? If so, describe: \ �.,—�, �� S�o,I\ ■ Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? , V 0 ■ 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). NfA Page 2of3 ■ 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? 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? ko 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