Disclosure Of Financial Interest Worksheet - State Public Integrity Commission
Download a blank fillable Disclosure Of Financial Interest Worksheet - State Public Integrity Commission in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Disclosure Of Financial Interest Worksheet - State Public Integrity Commission with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3WORKSHEET FOR FILING DISCLOSURE OF FINANCIAL INTEREST
NOTICE: It is a condition of commencing and continuing employment or appointment
that persons subject to the Code of Conduct file a full disclosure of Financial Interests
in Any Private Enterprise Which Is Subject to the Regulatory Jurisdiction of, or Does
Business With, the Government Entity by which they are employed or appointed. EX:
State employees/officials file if they do business with or are regulated by the State; local
government employees/officials file if they do business with or are regulated by their
local government. 29 Del. C. § 5806(d). This Worksheet is an Aid in completing
disclosure, and does not guarantee the absence of a conflict. The disclosure is so the
Public Integrity Commission can decide if there is a conflict.
QUESTIONS ON THE LAW OR THE FORM? CALL THE COMMISSION - 302-739-2399.
YOUR NAME: _____________________________________________________________
ADDRESS: _______________________________________________________________
City _____________________________________________________________________
State: _____________________________________ Zip: ___________________________
Phone: ____________________________ E-Mail _________________________________
INSTRUCTIONS: Check Blocks Which Apply and Add Information Where Indicated. If a
block is not checked, give the reason in Block 11. EX: Block 7 is not checked; explain in
Block 11 why it is not completed. If the first block in items 5 through 7 or 9 through 10 is
checked, explain in Block 11 when you engaged in that conduct. In Block 11, add any
additional information you think will assist the Commission.
DEFINITIONS: "Private enterprise" means any activity by any "person", whether for
profit or not for profit. 29 Del. C. § 5804(8). "Person" means an individual, partnership,
corporation, trust, joint venture and any other association of individuals or entities. 29
Del. C. § 5804(7). "Financial interest" means (a) a legal or equitable ownership interest
of more than 10% (1% or more if the stock is regularly traded on an established
securities market); (b) an employee, officer, director, trustee or independent contractor
of the private enterprise who received or expects to receive income exceeding $5,000
annually; or (c) creditor of 10% or more of the enterprise's debt (1% or more if the
enterprise's securities are regularly traded on an established securities market).
1. My government position is with: _____________________________________________
2. I have a financial interest in a private enterprise which is subject to the regulatory
jurisdiction of ___ , or does business with ___ a government agency.
3. Name of the private enterprise _______________________________________________
4. Name of the government agency the private enterprise is regulated by or doing
business with: ____________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Statement Of Assets, Liabilities And Net Worth And Disclosure Of Business Interests, Financial Connections And Relative/s In The Government Service - Supreme Court
Legal
Pamd Form 28 - Disclosure Of Beneficial Interest To Seller Form - Department Of Employment, Economic Development And Innovation
Legal
Form Rec 1.44 - Notice Of Termination Of Developer Interest - North Carolina Real Estate Commission
Legal
Customer Authorization Of Disclosure Of Financial Records Form - California Department Of Corporations
Legal
Form Qr 500.261 Customer Authorization Of Disclosure Of Financial Records - California Department Of Corporations
Legal
Entry Of Appearance In An Administrative Hearing Form - Michigan Department Of Licensing And Regulatory Affairs Public Service Commission
Legal
Requirements For Cancellation Of Registration Of Foreign Limited Liabilty Company - Public Regulation Commission
Legal
Related Categories
Parent category: Financial