State Form 54266 - 2010 Uniform Conflict Of Interest Disclosure Statement Template printable pdf download

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UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT

State Form 54266 (4-10) / Form 236

STATE BOARD OF ACCOUNTS

Indiana Code 35-44-1-3

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 who is under the direct or

indirect administrative control of the public servant; or receives a contract or purchase order that is reviewed, approved, or directly or

indirectly administered by the public servant. "Dependent" means any of the following: the spouse of a public servant; a child,

stepchild, or adoptee (as defined in I.C. 31-3-4-1) 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 I.C. 35-44-1-3. Care should be taken to review I.C. 35-44-1-3 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):

_____

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):

_______________________________________________________________________________________

State Form 54266 - 2010 Uniform Conflict Of Interest Disclosure Statement Template