HomeMy WebLinkAboutJOHN OBERMEIER 2019 jUNIFO, State Foe„54266RM CONFLICT OF INTEREST DISCLOSUSTATE BOARD OF AC ACCOUNTS
238
RESTATEMENT
Indiana Code 35-44.1.1„4
A public servant who knowingly
a contract or purchase 9 y or intentionally has a
a contra conflict hinterest a cted with an action by the governmentalenti y set ine or deriveshepublic a profit from
commits fonfi t o of in et sr Class D Felon . P ty served b
ome
p rcha aonetcpurchase will result or is int nded tot result in an ascertains y lee crewin thine
of the following:worth of the public servant or a dependent of the has a pecuniary interest in a contract or
the spouse of a ascertainable increase my
public servant;a child, stepchild orra osep ee(as defined in
public servant who is unemancipated and less than
IC
of ae than one-half{1/2)of whose nc "Dependent"means any
support is provided duringeighteene (18)
he pub of age; and any individual
35-44.1_1-4 inpitsgenti a consists only of excerpts from IC by public servant.
35-44,1_T�. Care should be taken to review IC
1. Name and Address of Public Servant Submitting Statement:
,J
. /10. e - Z
, �
2. Title or Position With With Governmental Entity: ',3 `�P J-f�W� �"�
3. a. Governmental Entity: •
�, �J
b. County: e
4. This statement is submitted(check one):
a•_ as a "single transaction"disclosure statement as to m
purchase transaction"
with the governmental a
govemmental entity with or from awhich financial interest in a
Particular contraacrr vendor; proposed serve, rtobespecific contract or
b•�an "annual"disclosure statement, as to made by the
purchases of the sovemmental entitymy financial interest connected with an
from particular contractors or vendors.which I serve
which are made on an ongoing contracts or
5. Name(s)of Contractors going basis with or
( )or Vendor(s):
-,,tp i '
6. Description(s) of Contract(s)
effective date and tern» t r the contract or purchase if rscn'be b
( ) (Describe the kind of contract involved,
is selected above. if"dependent"is involved, and the
" p lY determinable. Dates required if 4(a)
_/ provide dependent's name and relationship.):
/7C y .,,(
P j Ce ,! < < /,Ce / o it
4-e Ivor
D
Page 1 of 3 MAR 13 2019
0 7)
CLERK CLARK 0-11ACU1T COURTS
7• Descripti°n of deny'expects to My Financial Interest
the above derive a profit or financial in what mannervalue the public
profit or benefit): (s)� if reasonably or otherwise has a servant or "depon-
ent
deferminab/e, state the ecunia pen-
�l��/ �.� r3 interest in,
�l�' approx/mate dollar
8. (Attach extra
Approval of q pages if additional s
an elected public Officer or B pace is needed)
servant or Of f is board o Body
be Completed if the
I(We) being the 4 `'trustees of a state-supportedic servant was erspointed by
(Title of 0(icer Y•)'
r or ofGoverning
a c' Body)
(Nam:of Governmenfal��V of
the na •
Entity)
and having the power to appoint
pat bn
the above,) n e apps d disclosing
position to which
he 44.1-t-4 ich said 4yeelic servant has clic servant in the or she holds,
rule, e er, this aid.. •bliconflict of above hereby approve the
pur
or r:=. a on and is does not waive interest as described contract(s)
X _ �no, o be construed as any objection i eg defined in Indiana ( ) or
a consent to any illegal Conflict prohibited Code 35-
gal act. by statute,
ci pr"
Elected Offic,,a,
9. Effective Dates (Conflict of interest statements must be submitted Office -----
Elected
to final action on the contract or purchase.):
� `1 //A 2a/ tted to/the governmental entity prior
Date Submitted(month,day,year)
C�i
Date of Action on Contractor Purchase(month,day,Y year)
Page 263
10.
Affirmation nnabon
accepted b of Pubic Se
the action on the cont act mmental Servant: This disclosure
was statements made above, that ffirm in a public
meeting tsubmitted to the Bove
am the abo p ne 1 tY°f perjugovernmental ental entity and
ve medo
.ub th and entity prior to final
Signed:
_, I Ilk f' COmPleteness of
11%
1 a of Public Servant)
Date: ��g ,J-4
(month, day, ZO/7
Y year)
Printed Name: T`i
(P/ease ° �✓ ��
print legibly.)
Within fifteen (15 e
Email Address:
filed with the State days after final action rei CA. Q
the preferred method
of Accounts b on the contract dbe eOr^2
South, 302 West of filing,or by mailing h Purchase
Circuit Court Washington Street, g it to the State Board tt s.// atewa° I °f this state
of the county Where the Room E418, Indianapolis, of Accounts,204-ine.or /sboament must be
�ovemmental entity pQl�s Indiana,46204-2765
o Indiana Gt or COlt which is
tY took final action 204-2765 and the Clerk Center e
on the contract or purchaseof.
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