Knowledgebase-Personal Interest Disclosure Form


Information Product

Title:Personal Interest Disclosure Form
Summary:Pursuant to the ethics policy adopted by the municipality, this model ethics code personal interest disclosure form is required to be filled out and submitted to the city recorder when a municipal employee or official must exercise discretion over a matter that he/she has a personal interest in that affects, or a reasonable person might believe affects, the employee or official’s exercise of discretion.
Original Author:Hodge, Elisha
Co-Author:
Product Create Date:01/18/2017
Last Reviewed on::01/19/2017
Subject:Ethics--Forms; Professional ethics; Conflict of interests--Forms
Type:Form
Original Document: Model Ethics Code Personal Interest Disclosure Form.pdfModel Ethics Code Personal Interest Disclosure Form.pdf

Reference Documents: Model Ethics Code Personal Interest Disclosure Form.docxModel Ethics Code Personal Interest Disclosure Form.docx

Text of Document: Personal Interest Disclosure Form

Pursuant to the Ethics Policy adopted by the municipality, this form is required to be filled out and submitted to the city recorder when a municipal employee or official must exercise discretion over a matter that he/she has a personal interest in that affects or a reasonable person might believe affects the employee or official’s exercise of discretion. Please print or type responses. Attach additional pages if necessary.
      1. Name: __________________________________________________________________

      2. Position with the city/town: _________________________________________________

      3. Phone number: ___________________________________________________________

      4. Are you an officer or employee who must exercise discretion over a matter that you have a personal interest in that affects or a reasonable person might believe affects your exercise of discretion? (See Chapter ___, Section ______ et seq. of the (insert city/town name) Municipal Code for applicable language.)

      5. If the answer to Question 4 is yes, please describe the personal interest(s).

      _____________________________________________________________________________________________________________
      _____________________________________________________________________________________________________________
      _____________________________________________________________________________________________________________
      _____________________________________________________________________________________________________________
      _____________________________________________________________________________________________________________
      _____________________________________________________________________________________________________________
      __________________________________________________________________

      6. Has the exercise of discretion referenced in Question 1 already occurred or will it be occurring in the future? ____________________________________________________


      ________________________________ __________________________

      Employee or Official’s Signature Date