HomeMy WebLinkAboutCONFLICT OF INTEREST 2019 Tr
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MAR 18 2019
UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT
State Form 54266(R2/6-15)/Form 236
STATE BOARD OF ACCOUNTS
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CLERK CLARK CIRCUIT COURTS
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 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: Jere m 1/ fie-c-F
7 Cao i 5 4I/ 't - er-. * A L/7 Jo
2. Title or Position With Governmental Entity: L)►aPJaT ,C{' :7° r-r-,y�ott/t c-,/-+re,v07r971
3. a. Governmental Entity: L,' C I -j Aclef 0,1 1/27)t,p / 5 ro Q 1O-/-
b. County: C/ C< rK
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./ 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):
J ete kry My'
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.):
.f
Jo r '4e I L,/.�r�Ic,r/1_SPra;CPS ii-o , ce {i f)Ait-r'ri 6/7d I i/yP1 ern1 e rs
i n vo iveei ;r) .1,..:,./45:_i;4-i e5 or M,'n c%r in)(Jr,PS.
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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.):
PiRof/l -PRO r11 C1iGli.1/7 S4/Zyr'?es i,/o7/2/,o/caw/
(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 '..k.(.1...V:)( of
(� (Title of Office o(r Name of Governing Body)
CAi 0k 'Stg-cya ��\Q and having the power to appoint
(Nam6 of Governmental Entity)
the above named public servant to the public position to which he or she holds, hereby approve the
participation to th appointed disclosing public servant in the above described contract(s) or
purchase(s) in h said p blic servant has a conflict of interest as defined in Indiana Code 35-
44.1-1-4; how;ve , is approval does not waive any objection to any conflict prohibited by statute,
rule, or re. la,o d is of I. be construed as a consent to any illegal act.
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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.):
/;%a O fr4 2 O/`! Jam.✓ / Z /7
Date Submitted (month, day,year) Date of Action or1'Contract or Purchase(month,day,year)
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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:
(Sig t ru'e- Public Servant)
Date: 3- -ao/G
(month, day, year)
Printed Name: refill 7??71/'
(Please print legibly.)
Email Address: J/Je1f2C;ityac)ef.r,fie f.
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 here https://gateway.ifionline.orq/sboa coi/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 E418, Indianapolis, Indiana, 46204-2765 and the Clerk of the
Circuit Court of the county where the governmental entity took final action on the contract or purchase.
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