HomeMy WebLinkAboutConflict of Interest 2017 IF ff
JL 10]
ID
UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT MAR 2 2 2017
State Form 54266(R 16-12)/Form 236
STATE BOARD OF ACCOUNTS
r�
Indiana Code 35-44.1-1-4 CLERK CLARK CIRCUIT COURTS
A public servant who knowingly or intentionally has a pecuniary interest in or derives a profit from
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 public 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
35-44.1-1-4 in its entirety. // f
1. Name and Address of Public Servant Submitting Statement: /fi 1 C. LndAnJ
01107 15A;^7- .,t I bNu.l t.e, i TO tkZ l3ew�
2. Title or Position With Governmental Entity: kA1 ir3 LjRise�
3. a. Governmental Entity: CCt-t a f &Z FER ss ,,L LLej
b. County: OA 44 IC
4. This statement is submitted (check one):
a._ as a"single transaction"disclosure statement, as to my financial interest 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)or Vendor(s): Wa..KA�.I�LL C,
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. If"dependent'is involved, provide dependent's name and relationship.):
LArW►J SvV\c.e�
1
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 benefit.):
13A56- -oO G,nn&rc AVqrt
(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 servanPvt_r-d
r the board of trustee f a state-supported colleg`ee or university.):
I (We)being the l) !J Ur �✓ of
n T') C.
of Officer or Nam/a of Governing Body)
l _ �� r �` and having the power to appoint
ame 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 consent to any illegal act.
Elect$d Official Office
9. Effective Datles (Conflict of interest statements must be submitted to the governmental entity prior to final
action on the contract or purchase.):
- �3 PV I 111;1061 �
Date Submi ed(month,day,year) Date of Action on Contract or Purchase(month,day,yea4
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. I affirm, under penalty of perjury, the tru hand completeness of the statements
made above, and that I am the above named public servant.
Signed:
( ignature of Public Servant)
Date: 03 % 3 120'.7
(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,
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.