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1 UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT FEB 13 2024
Si State FOOT,5'4€ (R2 t 6-1S)1 Form 23e
.1r STATE BOARD OF ACCOUNTS
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Indiana Code 35-44.1-1-4 CLERK LARK CI 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
1. Name and Address of Public Servant Submitting Statement: Michael Smith
2 Title or Position With Governmental Entity: Cpl. Police Officer. IT Manager
3 a Governmental Entity: Jeffersonville Police
b County: Clark
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
o � 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): JeriCko LLC. "Jencko Media"
6 Description(s) of Contract(s) or Purchase(s) (Descnbe 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.)
v eevte Management PhotograpttyIV,Qeograpny Services l I_/Q I / L 6 L y - I L/1 I/ (C L Y
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7 Description of My Financial Interest (Describe in what manner the public servant or "depen-
dent"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)
50"4 Omer
(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 \Lk(� 6( of
(Title of O icer or Name (Governing Body)
Ct , 0(�U
�—� � l!�� 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.
ji-i , I )
I i /)/' . I I \
J Elected Official Office
9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior
to final action on the contract or purchase):
— ''. - _.kf ,;2 -7-Q60,4-
Date Submitted(rncnth day year) Date of Action on Contract or Purchase(month day years
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10. Affirmation of Public Servant This disclosure was submitted to the governmental entity and
accepted,by the governmental entity En a public meeting of the governmental entity prior to final
action on the cord act or purchase. I affirm,under penalty of petjury,the truth and completeness of
the statements made above,and that I am the above named puservant.
Signed:x
Moat=of Public Servant)
Date:/` O l/U7/ LG I,
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Printed N M IAA el
(Please print )
Erna Address. e�•1{rci ;t r,'c k,LL.0• t o,
Mit—fift w O 4fEer ftrlal action on the centred or t rc ase,copies.of :, r must be
#ta t is ' upload•t�nt 1ttSo, yyhki .
' " l E4111, Ind nap s l$tlw.1. ! Y 1 :H '* % ofthe
; gtthe.c , , ;N •Ufle gavIerninental entity took final t t ton on 1he.contract er!psnthase:
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