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CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
Date:
To: City Clerk
City Attorney, or
Board of Ethics
4 make the following disclosure under oath:
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PLEASE CHECK THE APPROPRIATE BOX OR FILL IN THE BLANKS FOR EACH OF THE FOLLOWING ITEMS
YES NO
1. ❑ I am an ❑ elected or ❑ appointed ❑ officer or employee of the
C�evL)City of Lansing holding the position of /5, f sir, /�in the
Department.
❑ ,ie 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. ❑ ,R] 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(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].
❑ 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: XFull time ❑ Part time (less than 25 hours/wk) ❑ Unpaid
4. My address is: /D3S9 LAF 61T , ///
5. My Business (daytime) Phone# is:_�-s/�
http://lbwl/lbwl/fs/msmrc/Affidavit%20of%20Disclosure%20020418.htm 3/8/2004
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 _ day of 20e,1,Z
igned
State of Michigan, County of
Subscribed and sworn to before me this _ Gl� d of ( 200
Notary Pu lic eputy Clerk
i
County, Michigan
My Commission Expires: /52 a
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SE ARV TU_ VANy Public, Ingham Co.,MI
mm.Expires Dec.2,2006
http://Ibwl/lbwl/fs/msmrc/Affidavit%20of%2ODisclosure%20020418.htm 3/8/2004