TOWN OF BALLSTON
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CODE OF ETHICS REVIEW FORM
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NAME:
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ADDRESS:
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TITLE:
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DATE OF APPOINTMENT:
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I, the undersigned, hereby attest
that I have reviewed the Local Law providing for the filing of Financial
Disclosure Statements by certain Town officials and employees and
the Code of Ethics. I further attest that I understand the provisions
of such Code of Ethics and, to the best of my knowledge, I am not
in violation of any of its precepts or requirements.
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_______________________________________
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Subscribed and Sworn to
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before me this __________________
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day of _______ , 19_____
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______________________
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Notary Public
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State of New York
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TOWN OF BALLSTON
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FORM 200
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DISCLOSURE STATEMENT
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I hereby submit the following Disclosure Statement,
under oath, listing the assets and liabilities and sources of income
of me, my spouse and my unemancipated children with respect to entities
doing business of any kind with the Town of Ballston.
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Date of Statement:______________________
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For the Period Ended:___________________
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(1)
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General Information:
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Name: _________________________________
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Address: ______________________________
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Title: ________________________________
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Office Telephone: _____________________
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Date of Appointment: ___________________
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Marital Status: _______________________
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Name of Spouse: _______________________
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Occupation of Spouse: _________________
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(2)
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List any office, trusteeship, directorship or
position of any nature, whether compensated or uncompensated, held
by you or your spouse, with any proprietorship, partnership, corporation
or other organization, which at present or during the prior twelve
(12) months does business with the Town of Ballston:
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(3)
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List any occupations, trade, business or profession
presently engaged in by you or your spouse [presently or during the
prior twelve (12) months] which does business or has any matter pending
with or is licensed or regulated by a Town Agency or Department:
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_________________________________________________________________
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_________________________________________________________________
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(4)
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List all sources of income received by you,
your spouse or unemancipated children from entities doing business
with the Town of Ballston at present or during the prior twelve (12)
months' period or which you anticipate will engage in business with
the Town in the future:
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(a)
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All compensated continuing employment of whatever
nature with an entity doing business with the Town of Ballston:
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(b)
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All directorships or other fiduciary positions
for which compensation has or will be paid by an entity doing business
with the Town of Ballston:
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(c)
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All contractual arrangements producing or expected
to produce income from entities doing business with the Town of Ballston:
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(5)
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List the names and address of any proprietorship,
partnership or corporation doing business with the Town of Ballston,
or any instrumentality thereof, in which you, your spouse or your
unemancipated children presently have or have had in the prior twelve
(12) months, an interest of 5% or more:
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Company Name:
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Address:
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ATTESTATION CLAUSE
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I, the undersigned, being duly sworn,
hereby state that I have personally completed the above Disclosure
Statement, and that such Disclosure Statement is true and complete.
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Subscribed and Sworn to
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before me this
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day of _______, 19_________.
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Notary Public
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State of New York
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