HomeMy WebLinkAboutDAVID KASKIE 2021 C241"Aw
UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENTState Form 54266(R/6-12)/Form 236
STATE BOARD OF ACCOUNTS OCT 2 U 2016 U U
Indiana Code 35-44.1-1-4 -,
CtE.RKC
A public servant who knowingly or intentionally has a pecuniary interest in or 406f pat from
a contract or purchase connected with an action by the governmental entity served by the publics �%At
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: DGW-9 Ko'sk,% ee-
1�5 C(eQt'Vieu� �C i J� J2 e_cSov`����e �k X1-1130
2. Title or Position With Governmental Entity: e-yVeviav,,ar
3. a. Governmental Entity: _�' �-! .� o4 J ewer Sov��+�1e_
b. County: CiacK
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.Le"'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): KASkS2 Qe4tci c
6. Description(s) of Contract(s) or Purchase(s) (Describe the kind of contract involved, and the
effective date and term of the contractor purchase if reasonably determinable. Dates required if 4(a)
is selected above. If"dependent"is involved, provide dependent's name and relationship.):
EIej-t'Icn--\ ek,.& C,0r"mj�zLa+%b%_.5 Con�r'&C?Mr % Sub0A;f eshw,al r-s
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.):
p\Pt_t—r:c1\— 'Work. 7c-Tete Aok\c-- av, oOu�'r
C.6U1d. UCrj hU 2.4Lh
(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 artd� p f � "111, �tS of
�
[ (Title of Officer or Name of Governing Body)
Ci Q7 Te ` J C'1_fa,,1V111 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 construe s a consent to any illegal act.
El2aes
ed Official Offic
9. Effective (Conflict of interest statements must be submitted to the governmental entity prior to final
action on the contract or purchase.):
Date Submitted (month, day,year) Date of Action on Contract or Purchase(month,day,year)
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 truth and completeness of the statements
made above, and that I am the above named public servant.
Signed:
(Signature of Public Servant)
Date: /o ! '7 -ate t 4,
(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.