ANNUAL CONFLICT OF INTEREST DISCLOSURE FORM

 

The following disclosures are required to be made annually by all elected/appointed/employed persons of the City of East Carbon. If additional space is needed, please use a separate sheet of paper. The information provided will be kept on file with the City of East Carbon and may be subject to disclosure to the public.

 

I,________________________________(name) am the duly elected/appointed/employed, __________________________________________(position) of East Carbon City.

 

1. I am an officer, director, agent, employee or owner of a substantial interest in the following business entities which are subject to the regulation of East Carbon City, and within such business entities, I hold the following positions:

 

Business Entity Name:                                                 Position within Business Entity:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

2. I am an officer, director, agent, employee or owner of a substantial interest in the following business entities which do business with or anticipate doing business with East Carbon City:

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

3. The following personal interests or investments of mine create a potential or actual conflict between my personal interest and my public duties:

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

****OPTIONAL DISCLOSURES****

 

4. The following disclosures of other business interests, investments, and other matters are not required to be made by law, but are made with the intent to more fully disclose other interests that may be deemed relevant to the administration of public duties, or in furtherance of my intent to provide a more complete disclosure of my economic or personal activities, or for other reasons:

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

DATED THIS________DAY OF_______________________(month)______________(year)

 

By:______________________________________

 

Title/Office:________________________________

 

SWORN TO AND SUBSCRIBED BY ME

 

THIS_________DAY OF_________________________(month)_____________(year)

 

 

 

CITY RECORDER/NOTARY PUBLIC