State Form 54266 - 2010 Uniform Conflict Of Interest Disclosure Statement Template (Page 2 of 2) in pdf

7. Description of My Financial Interest (Describe in what manner the public servant or "dependent" expects to derive a profit or

financial benefit from, or otherwise has a pecuniary interest in, the above contract(s) or purchase(s); if reasonably determinable,

state the approximate dollar value of such profit or benefit.):

_______________________________________________________________________________________

(Attach extra pages if additional space is needed)

8. Approval of Appointing Officer or Body (To be completed if the public servant was appointed by an elected public servant or

the board of trustees of a state-supported college or university):

I (We) being the ___________________________________________________________________ of

(Title of Officer or Name of Governing Body)

_____________________________________________________ and having the power to appoint

(Name of Governmental Entity)

the above named public servant to the public position to which he or she holds, hereby approve the participation to

the appointed disclosing public servant in the above described contract(s) or purchase(s) in which said public servant

has a conflict of interest as defined in Indiana Code 35-44-1-3; however, this approval does not waive any objection to

any conflict prohibited by statute, rule, or regulation and is not to be construed as a consent to any illegal act.

__________________________________________

Elected Official

Office

9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior to final action on the contract

or purchase.):

__________________________________________

Date Submitted (month, day, year)

Date of Action on Contract or Purchase (month, day, year)

10. Affirmation of Public Servant: This disclosure was submitted to the governmental entity and accepted by the governmental

entity in a public meeting to 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): _______________________________________

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, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204-2765 and the

Clerk of the Circuit Court of the county in which the governmental entity executed the contract or purchase. A copy of this disclosure

will be forwarded to the Indiana State Ethics Commission.

State Form 54266 - 2010 Uniform Conflict Of Interest Disclosure Statement Template Page 2