HomeMy WebLinkAboutZuberNicholas Affadavit Disclosure 2020 CITY OF LA14V &IDAVIT OF DISCLOSURE
JUL -7 AM 11: 5-
TO: CITY CLERK DATE:
1 144,, � J 4-s Zv � er 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 E6❑ I am an ❑ elected or ❑ appointed ❑ officer or Amployee of the City of Lansing holding the
position of P-kt tf�iz in the-Department
❑ MI-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
in the Department
❑ Al 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 ❑ ff**" 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)
❑ rr 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]
❑ V"- 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]
❑ Y' I make this disclosure because of a possible appearance that I maybe 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.) ❑ Unpaid
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4 PLEASE DESCRIBE IN DETAIL YOUR REASON(S)FOR SUBMITTING THIS DISCLOSURE
AND EXPLAIN WHY YOU THINKA CONFLICT MAY/MAYNOT EXIST.
/o /;C.t 4CQ -(-47 �- e)
� V7 ,
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 - C ,
20 .
State of Michigan,County of5�`�v�
Subscribed and sworn to before me this gneLy of �� � ' , 20 `a-y
Notary Pub i r Deputy CI
Alan James ood ury Nr�,��.� County, Michigan_
"�� Mi
1ngham o County My Commission Expires:_�pJ
Expires 111i2/ 5
Acting in the County of=�--
7/10
ATTACHMENT TO AFFIDAVIT OF DISCLOSURE
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? ;
• Are you self-employed? No
/ vI �
Who is your employer, if applicable? L��Sr� � comlj('141�7
What are the things you actually do in the
e business?
AoJ4,,, 5��c�Llo( — EV o
• Who are your clients and who receives your goods or services?
LcC- S vdz/t'J-5
How and where are your services performed?
• How often do you do outside work?
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,Does your business or employer contract with the City?
1VO
• In performing your business or outside employment, do you use any City facilities or
equipment?
Alo If so, describe:
• Is any of your business or employment conducted in the City?YeA_lf so, describe:
ko-Je V4 t7 cj
• Does your business advertisement or circulars, if any, contain any reference to the City or
your City employment? ,/VO
• Is there any additional information that you believe would assist the Board of Ethics in its
review of your busAi,�.ess or personal activities for potential conflicts of interest? If so, please
describe: /V0
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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Lansing Police Department ❑Renewal
i Supplemental Off-Duty Leg. Off-Duty Employment
• • Employment Request Form Date: � f Zd
Employee Requesting Approval: �C,4 f_
[ o I cz_S ZulerBadge No:
Current Duty Assignment: mac' rcl 1 0;'v,
Hours: 1`/0o 0�70o Division: f�t' r,�
SUPPLEMENTAL EMPLOYEMENT INFORMATION
Name of Employer: LQ,1 i �v.'✓1�'/ -�i �a`��
Type of Business: CqJ-e_,?
Business Address: ` )I IV 64,,J , LaV7.5)y s 41,' 119Y33
Owner or Manager's Name: IZ Telephone No: 1i 7 V8 3 I U 2
Location of Employment: fir' /V G, 1i' , L4i51'.7 S A" V993 3
Description of Work Duties: Pofi,cz 14-c� 4,,
Work Schedule: Uo " /mot
Number of Hours Per Week: VeLa e S Duration of Employment: w
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 IKO
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 applicable.
E ee Signatu
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.
r /
Captains Recommendation Date: 6 �S o oxeg Initials: Ll Approved ❑ Disapproved
Captain's Comments:
Date ACC" pproved ❑ Disapproved
Dar reen, Chie ff Pool
Copy of form sent to employee on
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