State Form 54266 - 2015 Uniform Conflict Of Interest Disclosure Statement Template
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UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT
State Form 54266 (R2 / 6-15) / Form 236
STATE BOARD OF ACCOUNTS
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:_____________________________
________________________________________________________________________________
2. Title or Position With Governmental Entity: ___________________________________________
3. a. Governmental Entity: __________________________________________________________
b. County: ______________________________________________________________________
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): ______________________________________________
________________________________________________________________________________
________________________________________________________________________________
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.):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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