HomeMy WebLinkAboutDan Lawhorn UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEME 77
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State Form 54266(R/6-12)/Form 236 �e
� STATE BOARD OF ACCOUNTS
ger D
Indiana Code 35-44.1-1-4 APR
262017
A public servant who knowingly or intentionally has a pecuniary interest in or deriv profit from
a contract or purchase connected with an action by the governmental entity served by . 1.
ant
commits conflict of interest, a Class D Felony. A public servant has a pecuniary i�r ���� or
purchase if the contract or purchase will result or is intended to result in an ascertainableiffafrgf e
income or net worth of the public servant or a dependent of the public servant. "Dependent" meangTS
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.
1. Name and Address of Public Servant Submitting Statement: �o►v��t�
2. Title or Position With Governmental Entity:
3. a. Governmental Entity:
b. County:
4. This statement is submitted (check one):
ay/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): S<< ts.c�s
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.):
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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.):
(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 of
(Title of Officer or Name of Governing Body)
and having the power to appoint
(Name of Governmental Entity)
the above na ed public servant to the public position to which he or she holds, hereby approve the
particiYbest
he ap inted disclosing public servant in the above described contract(s) or purchase(s)
in whip blic s vant has a conflict of interest as defined in Indiana Code 35-44.1-1-4; however,
this ad es not aive any objection to any conflict prohibited by statute, rule, or regulation and is
not to ed as consent to any illegal act.
Elected Official Office
9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior to final
action on(he ontract or purchase.):
'(/,W, /I Z�h
Date S mitte ( onth,day,year) Date of Action orf qortracf-or/Pbrchase(month,day,yeao
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 governor ntaI entity prior to final action on the
contract or purchase. I affirm, under penalty of perjury, the tr t and completeness the statements
made above, and that I am the above named public servant.
Signed:
(SiZvll-7
re of Pub/ Se ant)
Date:
1(morAh, 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.