New York City Council Discretionary Funding Conflicts Of Interest Disclosure
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New York City Council Discretionary Funding
Conflicts of Interest Disclosure
Legal Name of Organization _____________________________________________________________________________
POSSIBLE CONFLICTS OF INTEREST WITH CITY ELECTED OFFICIALS AND THEIR ASSOCIATES
Report personal and financial relationships between all City Elected Officials, persons or firms associated with the City Elected
Official, and the organization and its staff that could give rise to an actual conflict of interest or the appearance of a possible
conflict of interest.
City Elected Official: Ch.68, S.2601(10)
•
New York City Mayor, Comptroller, Public Advocate, Borough President or Council Member
“Associated” Person or Firm: Ch68, S. 2601.5
•
Spouse, Domestic Partner, Child, Parent, Sibling of a City Elected Official:
•
Person with whom the public servant has a business or other financial relationship
•
Firms in which the City Elected Official has a present or potential interest
•
Employees of the Sponsoring Council Member and / or Spouse, Domestic Partner, Child, Parent, Sibling of Such
Employees
Connection to Organization Including:
•
Organization’s Employee, Board Member, Director, Trustee, Officer or Consultant of the organization
•
Persons with a direct or indirect financial interest in the organization
Persons who have received or will receive any direct or indirect financial benefit from the organization or from this funding
Attach additional sheets as needed.
This MUST be signed and sent in even if you have no conflicts to disclose.
Name, Title, Position of City Official or Associated
Name, Title, Position and Relationship of Person with Organization
Person
Sample Disclosure:
Sample Disclosure:
Council Member Chris Marks
Council Member Marks serves on our board of directors
Sample Disclosure:
Sample Disclosure:
Carol Smith, Council Member Marks’ Chief of Staff
Carol Smith, Chief of Staff to Council Member Marks, is one of our paid
consultants
Sample Disclosure:
Sample Disclosure:
Jake Jock, Council Member Marks’ Deputy Chief of Staff
Jake Jock’s son owns the business that supplied equipment to a baseball
team that we sponsored
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Authorized Official: ____________________________________________________________________________________
Signature
Date
____________________________________________________________________________________
Print Name
Title
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Parent category: Legal