Typeset from the PDF of the official document — headings, motions and recorded votes are detected automatically, so spacing may differ from the original. The official copy governs.
(a) Title of Position _________________________________________________ (b) Department, Agency or other Government Entity _______________________ ________________________________________________________________ (c) Office Telephone Number _________________________________________
I have received and read a copy of Local Law No. 2 of the Year 1990 of the Town of Clay establishing a Code of Ethics, creating a Board of Ethics, and requiring financial disclosure. As defined under that law, I know of no conflict that exists concerning my position with the Town of Clay except for ____________________________________ _____________________________________________________________________ _____________________________________________________________________ As my circumstances change, I will duly notify the governing body for the Town of Clay forthwith.
_____________________________________ Signature Sworn to before me this __________day of _____________________, 20_______.
______________________________________________ Notary Public
1. Name and Address.
___________________________________________________________________________ Last Name Middle Initial First Name ___________________________________________________________________________ Title ___________________________________________________________________________ Department or Agency ___________________________________________________________________________ Department or Agency Address Telephone No.
___________________________________________________________________________ Residence Address 2. Spouse and Children.
Please provide the name of your spouse (if married) and the names of any dependent children: ________________________________ _____________________________________ Spouse Child/Age ________________________________ ______________________________________ Child/Age Child/Age ________________________________ ______________________________________ Child/Age Child/Age Note: For questions 3 to 6, do not report exact dollar amounts. Instead, report categories of amounts, using the following:
Category A: Under $5,000 Category D: $25,001 to $50,000 Category B: $5,001 to $10,000 Category E: $50,001 to $100,000 Category C: $10,001 to $25,000 Category F: Over $100,000 3. Financial Interests.
A. Business Positions. List any office, trusteeship, directorship, partnership, or other position in any business, association, proprietary, or not-for-profit organization held by you and your spouse and dependent children, if any, and indicate whether these businesses are involved with the Town of Clay in any manner.
Name of Family Member Position Organization Town Dept. or Agency B. Outside Employment. Describe any outside occupation, employment, trade, business or profession providing more than $1,000/year for you and your spouse and dependent children, if any, and indicate whether such activities are regulated by any State or Local agency. Name of Family Name, Address and State or Loc. Category Member Position Description of Organization Agency of Amount C. Future Employment. Describe any contract, promise or other agreement between you and anyone else with respect to your employment after leaving your Town office position. D. Past Employment. Identify the source and nature of any income in excess of $1,000/per year from any prior employer, including deferred income, contributions to a pension or retirement fund, profit sharing plan, severance pay, or payments under a buy-out agreement. Category of Name & Address of Income Source Description of Income Amount E. Investments. Itemize and describe all investments in excess of five percent (5%) of the value in any business, corporation, partnership, or other assets, including stocks, bonds, loans, pledged collateral, and other investments, for you and your spouse and dependent children, if any. List the locations of all real estate within the Town of Clay or within five (5) miles thereof, in which you, your spouse, or dependent children, if any, have an interest, regardless of its value. Name and Address of Description of Category of Name of Family Member Business or Real Estate investment Amount F. Trusts. Identify each interest in a trust or estate or similar beneficial interest in any assets in excess of $2,000, except for IRS eligible retirement plans or interests in an estate or trust of a relative, for you and your spouse and dependent children.
Description of Category of Name of Family Member Trustee/Executor Trust/Estate Amount G. Other Income. Identify the source and nature of any other income in excess of S1,000/year from any source not described above, including teaching income, lecture fees, consultant fees, contractual income, or other income of any nature, for you and your spouse and your dependent children, if any.
Name and Address of Category of Name of Family Member Income Source Nature of Income Amount 4. Gifts and Honorariums. List the source of all gifts aggregating in excess of $250.00 received during the last year by you, your spouse or dependent child, excluding gifts from a relative. The term "gifts" includes gifts of cash, property, personal items, payments to third parties on your behalf, forgiveness of debt, honorariums, and any other payments that are not reportable as income.
Category of Name of Family Member Name and Address of Donor Amount 5. Third-Party Reimbursements. Identify and describe the source of any third-party reimbursement for travel related expenditures in excess of $250.00 for any matter that relates to your official duties. The term "reimbursement" includes any travel related expenses provided by anyone other than the Town of Clay for speaking engagements, conferences, or fact-finding events that relate to your official duties.
Category of Source Description Amount 6. Debts. Describe all debts of you, your spouse, and dependent children in excess of $5,000. Category of Name of Family Member Name and Address of Creditor Amount 7. Interest in Contracts. Describe any interest of you, your spouse, or your dependent children in any contract involving the Town of Clay or any municipality located within the Town. Name of Family Member Contract Description 8. Political Parties. List any position you held within the last five (5) years as an officer of any political party, political committee, or political organization. The term "political organization" includes any independent body or any organization that is affiliated with or a subsidiary of a political party.
9. Licensees. If a reporting officer, employee or appointed official practices law, is licensed by the Department of State as a real estate broker or agent or practices a profession licensed by the Department of Education, his or her annual disclosure statement shall include a general description of the principal subject areas of matter undertaken by such officer, employee or appointed official in his or her licensed practice. If such officer, employee or appointed official practices with a partnership, unincorporated association or corporation and is a partner or shareholder of the firm or corporation his or her annual disclosure statement shall include a general description of the principal subject areas or matters undertaken by such firm or corporation. The disclosure required by this section shall not include the names of individual clients, customers or patients.
10. Disclosure of unavailable information. If a reporting officer, employee or appointed official is not able, after reasonable efforts, to obtain some or all of the information required by this paragraphs "3" through "8" of this section which relates to his or her spouse or dependent children, he or she shall so state, as part of the annual disclosure statement. I hereby certify under penalty of perjury, that the information disclosed on this form is true and complete.
_____________________________ Signature Sworn to before me this ______ day of ____________, 20_____.
________________________________ Notary Public