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Personal Interest Disclosure Form

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Reviewed Date: January 19, 2017

Original Author: 
Hodge, Elisha
Date Created: 
Jan 18, 2017


Subjects:
Ethics--Forms
Professional ethics
Conflict of interests--Forms

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.

Knowledgebase-Personal Interest Disclosure Form

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


Attachment(s):

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