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CITY OF LANSING
r' I'`,bAPPADAVIT OF DISCLOSURE
1"UrG Date: w6pg
To: City Clerk
City Attorney, or LA. 'S! €U" C CY CLENN
Board of Ethics
I �y 1aU�r/GLodE 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_
1. 93--" ❑ 1 am an ❑ elected or ❑ appointed ❑ officer or®'employee of the
City of Lansing holding the position of /0,v,v46e:,e in the
117ar�ZBL ,:S epartment.
❑ ❑ 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.
❑ ❑ 1 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)
❑ ❑ 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(1) 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(1) of the
/ Code of Ordinances].
f ' ❑ 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
Ordinances as provided for in the Code or Ordinances and in the City
Charter.
3, This position is: Gull time ❑ Part time (less than 25 hours/wk) ❑ Unpaid
4. My address
5. My Business (daytime) Phone# is: �S/��o�—G69f
http://lbwl/lbwl/ps/msmrc/Affidavit%2Oof%2ODiselosure%20020418.htm 8/27/2003
CITY OF LANSING Page 2 of 2
6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS DISCLOUSRE AND EXPLAIN WHY
YOU THINK A CONFLICT MAY/MAY NOT EXIST.
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I herby 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 ArS __day of � a_Sr 20a3
l +Signed
State of Michigan, County of�2
n�
Subscribed and sworn to before me this / ay of 20 D 3
Notary u eputy Clerk
County, Michigan
My Commission Expires:
G3S� Y SIDLLIVAN
�oiary PUb11C,Ingham Co.,Ml
;Uiy Comm.E�cpires Dec.2,2006
http://lbwl/lbwl/ps/msmrc/Affidavit%20o�/o2ODiselosure%20020418.litni 8/27/2003