State Form 54266 - 2015 Uniform Conflict Of Interest Disclosure Statement Template Page 3
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310.
Affirmation of Public Servant: This disclosure was submitted to the governmental entity and
accepted by the governmental entity in a public meeting of the governmental entity prior to final
action on the contract or purchase. I affirm, under penalty of perjury, the truth and completeness of
the statements made above, and that I am the above named public servant.
Signed: ________________________________
(Signature of Public Servant)
Date:
________________________________
(month, day, year)
Printed Name: __________________________
(Please print legibly.)
Email Address: __________________________
Within fifteen (15) days after final action on the contract or purchase, copies of this statement must be
filed with the State Board of Accounts by uploading it here
which is
the preferred method of filing, or by mailing it to the State Board of Accounts, Indiana Government Center
South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204-2765 and the Clerk of the
Circuit Court of the county where the governmental entity took final action on the contract or purchase.
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