HomeMy WebLinkAboutjOHN OBERMEIER 2017 ,
UY 4 0
UNIFORM CONFLICT OF INTEREST D<8CLOSURE2T�T�K8Ey�T OCT �0 >�AC LD
STATE BOARD opAccoJwrx� �-- - ^"'°
Indiana Code 35-44.1-1.4
Apublic servant who knowingly orintentionally has apecunia -'
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prou4R7S
aoonbactor haeeconnected with anaction bythe govemmenbs''yere«t�nordeh«eoa ��hn
commits c«nM/nt of interest, o Class O Felony. A public servant has aentity served by the public servant
pecuniary interest in a contract or
purchaseifdheconhan{nrpuruhaoewiU »esu/'orisintendedtmnou«|r inana*carte/nob/einoreaoainthem«omeor»etwmrthnfthepubUcaervantorodepondant of the public servant. ^Dependent^ means any
ofthe following: the spouse ufapublic servant; achild, stepchild, or adoptee (as defined in /C 31-
~�-2/»f o public servant who is unomonoipated and less than eighteen' U8 years ofage; and any individual
more than one-half(1/2)o/whose support isprovided during ayear Uythe public servant.
35-44.1-1-4
Thits entirety.
e noiobo only of excerpts from |C 35-44.1'1-4. Cane should be taken to review/C
1 Name and Address mfPublic Servant Submitting Statement:
2, Title or Position With GovernmenW Entity:
- - Governmental Entity: of e
_ County:
4. This statement is submitted (check one): ------
a� eoa "single transaction"disclosure statement, aahzmyfinancial interest/naspecific oontm/�
purchase connected with the governmental entity which / mema proposed to be made b contract
=-'......~..==.v,yvwwo,nnmapa�uu�rconbadbrcvvendo�'or yme
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b��/aoan ^annua/^ disdonunestmkoment aotomy�nan�a( /nUe
p«�haae»ofhhegomamme�e| entity
which ( same ���ho»eo«connected with any contracts or
/mmporbcu|mroon�m�omorvando" ' rcmade«nonongoing basis v�thor
5- Name(s)ofConbnctmr(s)orVeodor(s):
8. Description(s) mfConbact(o) or Purchase(s) (Describe the kind
»onu� / » * andben*»�edate and�rnofthe mznhecforpun�aoe�rea«o«a�yc��«ninvolved,
ie��� Dates if 4(a)
isselected above. ffldepeooent^i»involved,provide
m
dependent's name and relationship.):
7. Description of My Financial Interest (Describe in what manner the public servant or "dependent"
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 benerrt.):
(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.):
I (We) being the l)pa/�` Vi ?14Z1C �j I of
(Title of Officer or Name of Governing Body)
Z1& of TG7`TE'/'ro t4i I/e 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.
Ele ed Official — rce
9. Effective Dates (Conflict of i�terest statements must be submitted to the governmental entity prior to final
action on the contract or purchase.):
/� /1 G'/f /-,�
2 /f 1Qate ubmitted(month,day,year) Date orAction on Con etor Purchase(month,day,year)
10. Affirmation of Public Servant: This disclosure was submitted to the govemmental entity and accepted
by the governmental entity in a public meeting of the governmental entity prior to final action on the
contract or purchase. I affirm, under penalty of perjury, the truth and completeness of the statements
made above, and that i am the above named public servant.
Signed:
'-�S7qQature of Public Servant)
Date: /Q //I/f/-,�d I Ce
(month, d#, 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,
Indianapolis, Indiana, 46204 and the Clerk of the Circuit Court of the county where the governmental entity took
final action on the contract or purchase.