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HomeMy WebLinkAboutdisclosure statement- dennis juslius L p UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT':: C''013 "" �3 3� State Fo€rn 54256 (R f 6-12)1 Form 236 NOV 2 G � . STATE BOARD OF ACCOUNTS NO ,! 0 Indiana Code 35- 44.1 -1-4 .. A public servant who knowingly or intentionally has a pecuniary interest in or derives, ,prot,_frprr.:, w ; ;„ : ; — a contract or purchase connected with an action by the governmental entity served by the public servant commits conflict of interest, a Class D Felony,. A public servant has a pecuniary interest in a contract or purchase if the contract or purchase will result or is intended to result in an ascertainable increase in the income or net worth of the ptgalic servant or a dependent of the public servant "Dependent" means any of the following: the spouse of a public servant a child, stepchild, or adoptee (as defined in IC 31- 9 -2-2) of a public servant who is unemancipated and less than eighteen (18) years of age; and any individual more than one -half (1/2) of whose support is provided during a year by the public servant The foregoing consists only of excerpts from IC 35-44.1-1-4. Care should be taken to review IC 35- 44.1 -14 in its entirety. 1. Name and Address of Public Servant Submitting Statement: I C in 11■1 ) 2. Title or Position With Governmental Entity: G' Q 3. a. Governmental Entity: C d'S ` -'v` l_t`t b. County: 0 Cur /4 4. This statement is submitted (check one): a._ as a "single transaction" disclosure statement, as to my financial Merest in a specific contract or purchase connected with the governmental entity which I serve, proposed to be made by the governmental entity with or from a particular contractor or vendor; or b. as an `annual° disclosure statement, as to my financial interest connected with any contracts or purchases of the governmental entity which I serve, which are made on an ongoing basis with or from particular contractors or vendors. 5. Name(s) of Contractor(s) of vendols): J ( .7e-kvt5 6. Description(s) of Contract(s) or Purchase(s) (Describe the kind of contract Involved, and the effective date and term of the contract or purchase if reasonably determinable. Dates required if 4(a) is selected above. !f "dependent" is involved, provide dependent's name and relationship.): I!/ � fie.-+ 3 +' - � , _. � � fir/ �✓ QLr D f _ • A. "et 31 ei°_ ^�- 1 F c:t � ? / c J°'t -o'`r 2 i - 7. Description of My Financial Interest (Describe in what manner the public servant or "dependant" expects to derive a profit or financial benefit from, or otherwise has a pecuniary interest in, the above contract(s) or purchase(s); if reasonably determinable, state the approximate dollar value of such profit or benefit.): r dd'��?sif arm 1-4'0 ► � c �� _ c (Attach extra pages if additional space is needed) 8. Approval of Appointing Officer or Body (To be completed if the public servant was appointed by an elected public servant or the board of trustees of a state - supported college or university.): Corn I (We)being mo ,titncr 6P The. ar ^sr or,.. � ef5 a of (Title of Offeror Name of Governing Body) Crici o4 3 d er o n u r and having the power to appoint (Name of Governmental Entity) the above named public servant to the public position to which he or she holds, hereby approve the participation to the appointed disclosing public servant in the above described contract(s) or purchase(s) in which said public servant has a conflict of interest as defined in Indiana Code 35-44.1 -1-4; however, this approval does not waive any objection to any conflict prohibited by statute, rule, or regulation and is not to be construed as a consent to any illegal act. O R -4 ke ' . l iei • cial 8, Effective Dates (Conflict of interest statements mist be submitted to the governmental entity prior to final action on the Qr punch .): —( i 1 1— 13 Date Su fitted (month, stay, )ear) Date of Action on Contract or Purchase month, day, year) 10. Affirmation of Public Servant This disclosure was submitted to the governmental entity and accepted by the governmental entity in a public meeting of the governmental entity prior to final action on the contract or purchase. l affirm, under penalty of perjury, the truth and completeness of the statements made above, and that I am the above named public sere Signed $nature of 10 # Servant) Date: l "° ` / 3 (:month, day, year) Within fifteen (15) days after final action on the contract or purchase, copies of this statement must be filed with the State Board of Accounts, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapois, Indiana, 46204 and the Clerk of the Circuit Court of the county where the governmental entity took final action on the contract or purchase. A r•., j 1 NOV ' t'e •� "S NO ,$ } 0 a.., MAYOR /COUNCIL MEMBER DISCLOSURE OF RELATIVE'S CONTRACT WITH MUNICIPALITY Indiana Code 36- 1 -21 -5 A governing body of a municipality may enter into a contract or renew a contract for goods, services or public works with an individual who is or a business entity that has an ownership interest by an individual who is a relative of the Mayor or a council member of the municipality if a Disclosure of Relative's Contract is made by the above noted elected official and the elected official does not violate IC 35- 44- 1 -3.1, the criminal Conflict of Interest law. In addition the appropriate municipal governing body makes certain certified statements regarding price or selection of the contractor. The foregoing consists only of excerpts and clarifying language from I.C. 36- 1 -21 -5_ Care should be taken to review l.C. 36- 1 -21 -5 and 35- 44 -1 -3.1 in their entirety. 1. Name of Elected Official (Mayor /Councilmember) Submitting Disclosure: ) 2. Name of Office: 3. Name of Municipality: �- i y © e' r. k ∎�° 4. Description of Contract for purchase or public works (Describe the kind of contract, the project name, the governing body or person(s) proposing to execute the contract for the municipality, the length of the contract term and the contractor): 4 • G : ,. ' 12.-N c1 i S r ( -1 e---L) ) ` , B 7 . S - 1 Q r ✓° z- -� j �rJ c± t t . V et4 e 5T 3°b r r e o v- -) � �t -:�^ 5. Describe all of thownership interests of the Contractor: Cc> teir LLD c 1 i_ .. C9--v^ c e, 5 )7,1 rt Lif 7� 6. Describe the relationship of the Contractor from which the municipality is contracting for the purchase of goods, services or public works to the Elected Official submitting this Disclosure (Elected Official is Mayor or Councilmember)(the relationship is the disclosure of which one of the following relatives - -- spouse, parent, stepparent, child, stepchild, adopted child, brother, haft-brother, stepbrother, sister, half- sister, stepsister niece or nephew aunt of uncle, daughter -in -law or son -in -law is the Contractor or has an ownership interest in the Contractor): e--1; ) €7 pit 6 7 e—en-1-9 4 a (Attach extra pages as needed) 7. The appropriate agency of the municipality contracting for the goods, services or public works made its certified statements as required by law on the day of , 20 and believes that it has complied with state law. 8. Effective Dates: (Disclosure of a Relative's contract must be submitted to the Legislative Body of the municipality prior to final action on the contract for goods, services or public works.): Date Submitted to Council Anticipated Date of Action on Contract or Purchase 9. Affirmation of Elected Official: This disclosure was submitted to the municipality of (5' for acceptance by its Legislative Body in a public meeting prior to final action on the contract or purchase. I affirm, under penalty of perjury, the truth and completeness of the statements made above, th I am the above named public servant. Signed: Date: -- (Signature of Elected Official) 10. Acceptance of Disclosure: The Council of the fJ J pJ eJson 0t // .. municipality this / day of moo- , 20 f,took action at its p lic meeting to accept the above Disclosure for to the final action on the contract. Signed: (Signature of Presiding Officer of the Council) Within 15 days after final action on the contract which is the subject of this Disclosure, copies of this statement must be filed with the State Board of Accounts, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204 -2738 and the