HomeMy WebLinkAboutTim McCoy Filed 1/18/24 IF .. ,
JAN 18 2624
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' � , UNIFORM CONFLICT OF INTEREST DISCLOSURE STA.TTRI "' "'�
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4,y STAT5 IIUARI)OF ACCOUNTS
Indiana Code 35-44.1.1-4
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 0 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 not 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 adopted(as defined in IC 3142-2)
of a public servant who is unomancipated and less than eighteen (16) 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 3t3-44.1-1-4, Care should be taken to review IC
35-44,1.1.4 in its entirety.
1. Name and Address of Public Servant Submitting Statement: Tim McCoy
2. Title or Position With Governmental Entity: Green Space Manager
3. a, Governmental Entity:City of Jeffersonville _ _______
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 he 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.
6. Name(s)of Contractor(s)or Vondor(s): _McCoys Nursery LLC&McCoy's Lenscape Co. _ _
No Landscape Services Provided
G. Descriptlon(s) of Contract(s) or Purchase(s) (Describe 11w kind of contract involved, end the
effective dale and term of the contract or purchase if reasonably determinable. Dales requited If 4(a)
is selected above. if'dependent"is involved,provide dependent's name and mlotlonship.):
pt AN Am)r.Rino,mu.cl1,Mlsf,A ppiii31 r;„Vv111 tl,GAT19/Ap FS SIhAw r Tc
i:tape 1 of 3
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 purchoso(s); if reasonably determinable, state the approximate dollar
value of such profit or benefit.):
Mcceye r)RFO;({Y I'A4$Qr Pi IhD1.Ar1S iAPE MAKElakjraliPsCI CY.PF,h%1S 'Oft I41G,IT Y TAI;IIe AT PISCCM11 Gb M'.R. TT It?MA1l1 RRAfSNa
IS II IAl iT UAVI:5 MY NIP(MUMPS TO ASS15T MI!TO STAY WTI MY IIUITOF:T MCCUYS CAN OrFCII I.O'Mit PRICES OLIK TO II If PACT"THAT
]kC;OR_OW0IIN PI ANTS Ili(111R,1,)♦1All} cat I f 18{J,,Ewes 1,Qtls9/y4l rlf;l.t)FitecK Trim mW RII.1,tMrof,.,.'SA1.kTOAri'IA oot11.iiTe TIIAT
TI Ili CIrY TAKES AIN/AN'IAt)E01' MI.I. MNl,CIIISt7ROl101(rIwI3Y1Nl4TRM:TORTRhitEf2LOADANOOIIKIOUNTGDPNICE'STHATAss
PI\spt:pALUNo PR,i raiwf PARKS AUN 1I I NrtN c'ohIPARISON LAT f MLA.TxliatIP,S WE C.21,7MLN1,Y sal.(:(,4PAR[o To,[2VIRitJ17Nri..N
MCcOY't i Al,l 17AKCS IN RIII 2Kxr111ll 1.ty"1101R o c IU,rii<l o it III;III FACII II Y TO DOOM.OP WI 1E 1414::CfC :1$AT NO ci.vrH IS
(Attach extra pages If additional spaces needed.)
8. Approval of Appointing Officer or Body(To be completed if the public servant was appointed by
on elected ptrbllo servant or the board of trustees of a state-supported co/lope or university.):
I(We)being the_._._. _..._. _ --- of
(Title of Officer or Alamo of GavominjBody)
r___ __ ___ ____,^______,____ anc! 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
purchese(s) in which said public servant has a conflict of interest as defined in Indiana Code 3f-
44.1-1-4; however, this approval does not waive any objection to any onfllct prohibited by statute,
rule,or regulation and is not to bo construed as a consent to any Meg act.
_: ?�&� _-___ __ �._ Wiz•_.
Elected-official
Offiae.�_._..__._._�...____�.._�..
9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior
to final action on the contract or purchase): ��
L.--I
Dote SilblrTiRod(man!f 1,day,year) Dalte of Action on C(mtrllrl'or Purchase(mend.da,y,yaw)
Pngo2of1
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,th ruth end completeness of
the statements made above, and that I am the above named public, t.
r
Signed: ...e ...�'`_ '4
('S r1no(uro of l�ia,S (O
Date: z
i/defe"
(month, day,"-your) �f /f
Printed Name:.__.-.Z.
,.ree e5:
(Please print loglbly.) T /� -�-�
Email Address:..' .70Vre Y_.'4 i%i/0 .. ,•�ed 9'"
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 by uploading It hero jitlf;(/r}O.tee!g attexttg.QrQ/_slaeajnL which Is
the preferred method of filing, or by mailing it to the State Board of Accounts, Indiana Government Center
South, 302 West Washington Street, Room t„4103, Indianapolis, Indiana, 46204-2765 and the Clerk of the
Circuit Court of the county whore the governmental entity took final action on the contract or purchase,
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