HomeMy WebLinkAboutCochranThomas Affidavit Disclosure 2001 CITY OF LANSING
AFFIDAVIT OF DISCLOSURE
DATE:
TO: CITY CLERK,
CITY ATTORNEY, or
BOARD OF ETHICS
Ion�v.� U ac�i 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
❑ I am an ❑elected, or ®appointed officer or employee of the City of
Lansing
❑ ❑ 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. lk ❑ 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(I) 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 Ordinance as
provided for, in the Code or Ordinances and in the City Charter
3. This position is: Full time ❑ Part time (less than 25 hours/wk) O Unpaid
4. My Address is:
CONTINUED ON PAGE 2
AFFIDAVIT OFDISCLOSURE-PAGE 2
5. My Business (daytime) Phone # is:
PLEASE DESCRIBE IN DETAIL YOUR REASONS)FOR SUBMITTING THIS DISCLOSURE
6. 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 1 day of �U
20D
Signed
State of Michigan, County of L.%t
Subscribed and sworn to before tub this 5 day of J . T 20O/
Notary Public%or Deputy Clerk
County, Michigan
D - MEP,
My Commission Expires: _ ab11�, lnahaira County, Ma
My Comm, Expires Dec. 12, 2003
DRAFT 4A;REVISED 5-09-01