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HomeMy WebLinkAboutZerfasRon Affadavit Disclosure 2014 CITY OF LANSING AFFIDAVIT OF DISCLOSURE Date: To: City Clerk City Attorney, or Board of Ethics 4' 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. 115 ❑ 1 am an ❑ elected or❑ appointed ❑ officer or 0 employee of the City of Lansing holding the position of B,Lj,t- : " f-7e-'_ in the F i e c' Department. ❑ 1 am an immediate family member related to an elected or appointed officer or employee of the City of Lansing named holding the position of at the Board of Water and Light. ❑ 91- 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. ❑ 121 1 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]. ❑ 1 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: 19 Full time ❑ Part time (less than 25 hours/wk) ❑ Unpaid 4. My address is: 7 Y S v fi -vim 1,-, e!. S i,z 7,r 5. My Business (daytime) Phone#is: �� �•�?O—� C�.. i 'QCT�r(� r1 ►'� C i r Pi�� �J .ice L✓1 + � ��� r�V f� � LJ -.1.' Continued on page 2 -1 - City of Lansing Affidavit of Disclosure 6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOUSRE AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST. 8 J tL 1 s t( �.- ce->.1 4 G"t•J' �t ki J per eY ILA G S T '�- lL. i oat e...--�. '—�+�-f NL +d i� E7 •¢•:/' C:.y� �- cr. �Y r G.2� G CX�1 E� � 1 mil. c o^ �+i �C.L�' �t �v(�c� c� �' �/.✓( �9-�•�-�:r� c w:..t 1ov✓ 1-:�., ., S y0 pie-{-�.z �1 J�c:�:*i c 2y�.,._1 � �? k � }v C .2 f fs c �- �i✓ t~:1 C r n�i ��'�, O� 9 h ��-Li C.t n i' ` uK �� e GY'� �� C� .. _L- Re, A) tir-f-t=.S -'n C r• /2 C Cie-k NE- 't' �-.S..0 �-, e.e Q`•� �cl tr>:!•�k �•� c. .�w� Su(� �F� cz •�d'd,���'�� a c� G��s , .z' �.�, «. .rz..l •z��-.�r �:4��� T�••;s ��-:-k �: t r b� C4 c.ciJ s-- s;kt vn.'S n.z,_('' '�� /+, �] L.c!•)� M iCI r*/ J cV� l:y it(�yI�.G� 'f'f q G � � r'ye �4�'� .� •T �f r•� K(' /yc C t�i-r ••f-�l L� 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 e 7 20A Yigned State of Michigan, County of Subscribed and sworn to before me this �� day of 13 4 20� otary Public Deputy Clerk 1 <� County, Michigan My Commission Expires: // lvf' MARY J.SCHEURER NOTARY PUBLIC-STATE OF MICHIGAN DRAFT 5A REVISED 10- 9-0lz,, COUNTY OF IONIA My commission Expires Novembers 6,2018, of �l -2- CITY OF LANSING AFFIDAVIT OF DISCLOSURE To: City Clerk Date: City Attorney, or ©© Board of Ethics r I Rba� 'v 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. 115 ❑ 1 am an ❑ elected or❑ appointed ❑ officer or JZ employee of the City of Lansin holding the position of B,W.L : c I cc;- in the �= I�� ✓ �� Department. ❑ l,� 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 at the Board of Water and Light. ❑ ® 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. ❑ 1 may derive income or benefit directly from a contract with the City or from any City action detailed below. (Charter 5-505.1) ❑ 4� 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]. ❑ 1 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: 12f Full time ❑ Part time (less than 25 hours/wk) ❑ Unpaid 4. My address is: 7 y 5,�, ti `v— y.,- ? [ :z.•Q M-, 4 ;Y cR-7-r 5. My Business (daytime) Phone# is: � 1-73 .3 ( -- Continued on page 2 -1 - City of Lansing Affidavit of Disclosure 6. PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOUSRE AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST. Q,t,J �� Zv�i� r C..G"' tL 0 C0 n rs d r�L{�- ��;r i •E--tri. Vt L� 1"z'�.� r^ 1 r:.•. �G � ��t�. ` CA ate - k,c-, C")' iA l � a c — I , G-. 1 :~ ecn C L" t , ef' Q as / ate, ( zC � c4-;'r, 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 e 7 20 r Igned State of Michigan, County of Subscribed and sworn to before me this / �h" day of I'lotary Public Deputy Clerk ern' ��-- County, Michigan My Commission Expires:_ �� ('� 2 MARY J.SCHEURER NOTARY PUBLIC-STATE OF MICHIGAN DRAFT SA REVISED I O- 9 0 COUNTY OF IONIA My Commission Expires November 20181 he animb,l,s 1 + G1 -z- 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? L L % • Are you self-employed? j �s ■ Who is your employer, if applicable? ■ What are the things you actually do in the business? • Who are your clients and who receives your goods or services? LL pp � K k ■ How and where are your services performed? /.a (e— cx'/ ;� • How often do you do outside work? &-[/fl' - � 3 c> • Does your business or employer contract with the City? _� (� � T'e-✓ SY�^c.r-J�o:2 � f c �. "f' li c,.T` LJ�_S �r ��`'1 ■ In performing your business or outside employment, do you use any City facilities or equipment? 7U e If so, describe: O i,:,J C"Lt ■ Is any of your business or employment conducted in the City? t -cj' If so, describe: • Does your business advertisement or circulars, if any, contain any reference to the City or your City employment? AJ b Is there any additional information that you believe would assist the Board of Ethics in its review of your business or personal activities for potential conflicts of interest? /Jr, 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.