HomeMy WebLinkAboutBaermanPaul Affidavit Disclosure 2003 CITY OF LANSING
• AFFIDAVIT OF DISCLOSURE
DATE:--
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
I t' I-- 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. 0 X I am an ❑ elected or O appointed O officer or O employee of the City of
Lansing holding the position of in the
department
❑ X 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)
❑ 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]
0 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 Ordinance as
provided for in the Code or Ordinances and in the City Charter
3. This position is: , Full time O Part time (less than 25 hours/wk) ❑ Unpaid
4. My Address is: 2Z/6 N CAt_
CONTINUED ON PAGE 2
AFFIDAVIT OF DISCLOSURE-PAGE 2
5. My Business (daytime) Phone # is: 1. �l 7) 8(' 7 - 23 C ' I. (M0S IQ
6 PLEASE DESCRIBE IN DETAIL YOUR REASON(S) FOR SUBMITTING THIS DISCLOSURE
AND EXPLAIN WHY YOU THINK A CONFLICT MAY/MAY NOT EXIST.
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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
. 200 _.
Signed
State of Michigan, County of_________
Subscribed and sworn to before me this cX—' day of AJOu E 2003
NI4ary Public/or
IA/G A/R A County, Michigan
My Commission Expires: 7 - 7 -
CRAFT 5k REVISED 10.09-07
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