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 Code of Ethics
provisions in the Town of Moreau Ethics and Disclosure Law.
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I also attest that I understand the provisions of the code and, to the
best of my knowledge, am not in violation of any of its precepts.
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________________________________________
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Sworn and subscribed to before me
this __________ day of __________ 19__.
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________________
Notary Public
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DISCLOSURE STATEMENT
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I hereby submit the following disclosure statement under oath, listing
the assets, liabilities and sources of income of myself, my spouse and unemancipated
children.
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Date of Statement
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(a)
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General Information:
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Name:
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Address:
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Occupation
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Title: __________ Date of Appointment:
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Name of Spouse:
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Occupation of Spouse:
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(b)
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Please 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, presently
or during the preceding 12 months, which does business with the Town of Moreau
or has any matter pending before the Town Board, Planning Board or Zoning
Board of Appeals:
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(c)
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Please list any occupation, trade, business or profession presently
engaged in by you or your spouse, presently or during the preceding 12 months,
which does business or has any matter pending with or is licensed or regulated
by a town agency or department (indicate what town agency or department):
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(d)
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Please list below all sources of income for you, your spouse or unemancipated
children from entities doing business with the Town of Moreau or having any
matter pending before the Town Board, Planning Board or Zoning Board of Appeals,
presently or during the preceding 12 months or anticipated within the next
12 months:
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All compensated continuing employment of whatever nature:
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All directorships and other fiduciary positions for which compensation
has or will be claimed:
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All contractual arrangements producing or expected to produce income:
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All honorariums, lecture fees and other miscellaneous sources of income:
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(e)
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Please list below the name and address of any proprietorship, partnership
or corporation doing business with the Town of Moreau or any instrumentality
thereof in which you, your spouse or unemancipated children presently have
or have had in the preceding 12 months an interest of 5% or more:
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Company Name
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Address
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(f)
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Please indicate below the location, general nature and acquisition date
of any real property in the Town of Moreau in which any direct, indirect,
vested or contingent interest is held by you, your spouse or unemancipated
children along with the names of all individuals or entities who share a direct
or indirect interest therein (exclude your primary residence):
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Location
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General Nature*
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Acquisition Date
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Individuals or Entities Sharing Interest
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* Please specify if commercial, industrial, residential, farm or vacant.
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(g)
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Please list any direct or indirect interest, whether vested or contingent,
of you, your spouse or unemancipated children in any contract made or executed
by the Town of Moreau or any instrumentality thereof:
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Instrumentality
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Description of Interes
and Nature of Contract
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(h)
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Please list below all notes and accounts receivable* in excess of $1,000
held by you or your spouse due from any entity doing business with or having
any matter considered before the Town of Moreau or any instrumentality thereof:
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Name of Debtor
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Type of Obligation, Date Due
and Nature of Security, If Any
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* Deposit or investment accounts at banks, savings and loan associations,
credit unions and investment firms do not constitute notes or accounts receivable.
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(i)
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Please list below all liabilities, including the name of the creditor,
of you and your spouse to any entity doing business with or having any matter
considered by the Town of Moreau or any instrumentality thereof (do not include
credit cards or ordinary and consumer debt such as automobile and mortgage
loans or ordinary and customary business loans from banks, savings and loan
associations and credit unions):
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Name of Creditor
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Type of Obligation, Date Due
and Nature of Security, If Any
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(j)
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ANY ADDITIONAL INFORMATION FOR WHICH SPACE IS INADEQUATE:
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ATTESTATION
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I hereby certify that I have read the foregoing disclosure statement
and the addendum thereto, if applicable, and that, to the best of my knowledge
and belief, they are true, correct and complete and that I have not and will
not transfer any asset, interest or property for the purpose of concealing
it from disclosure while retaining an equitable interest therein.
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(Signed)
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Sworn and subscribed to before me
this ____________ day of ______________
19____.
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_____________________
Notary Public
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