CITY OF ALBANY-ANNUAL STATEMENT OF
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FINANCIAL DISCLOSURE
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FOR CALENDAR YEAR
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NAME
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HOME ADDRESS
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TITLE OF POSITION
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DEPARTMENT/AGENCY
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BUDGET CODE
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MARITAL OR DOMESTIC PARTNER STATUS
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SPOUSE'S OR DOMESTIC PARTNER'S FULL NAME
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NAMES OF UNEMANCIPATED CHILDREN
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The following chart will be used for the completion of the disclosure
form:
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MONETARY CATEGORIES
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A. UNDER $10,000
B. $10,001 TO $50,000
C. Over $50,000
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1.
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PRIMARY SOURCE OF INCOME
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Name of employer
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Address of employer
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Salary range (letter only)
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1A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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Name of employer
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Address of employer
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Salary range (letter only)
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2.
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ADDITIONAL SOURCES OF EMPLOYMENT INCOME IN AMOUNTS OVER $10,001.
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Name of employer
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Address of employer
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Salary range (letter only)
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2A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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Name of employer
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Address of employer
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Salary range (letter only)
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3.
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ALL INTEREST AND DIVIDEND INCOME
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List all sources of income
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List annual amount after each source (letter only)
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Interest income: names and addresses of bank/financial institutions
where accounts are registered
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3A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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List all sources of income
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List annual amount after each source (letter only)
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Interest income: names and addresses of banks/financial institutions
where accounts are registered
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4.
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REAL ESTATE HOLDINGS
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Address of properties (street number, City, state-other specific information)
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Estimated value of ALL real estate holdings (letter only)
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4A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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Address of properties (street number, City, state-other specific information)
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Estimated value of ALL real estate holdings (letter only)
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5.
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DEBTS AND/OR LIABILITIES
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List all debts and/or liabilities in excess of $10,001. (DO NOT list
moneys for the following: matrimonial action, credit card charges, educational
loans, home mortgages/home improvement loans, home equity loans, auto loans,
recreational vehicle loans, furniture or appliance loans.)
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Name of creditor and type of liability
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5A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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List all debts and/or liabilities in excess of $10,001. (DO NOT list
moneys for the following: matrimonial action, credit card charges, educational
loans, home mortgages/home improvement loans, home equity loans, auto loans,
recreational vehicle loans, furniture or appliance loans.)
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Name of creditor and type of liability
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6.
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OFFICES OR POSITIONS HELD
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List any office, trusteeship, directorship or position of ANY nature,
whether compensated or uncompensated, held by you with ANY firm, corporation,
association, partnership or other organization who or which is known by you
to do or have any matter pending with, or be licensed or regulated by, any
City of Albany department, agency, authority or commission.
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Position held
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Name of firm, organization, corporation, etc.
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6A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER INFORMATION
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List any office, trusteeship, directorship or position of ANY nature,
whether compensated or uncompensated, held by you with ANY firm, corporation,
association, partnership or other organization who or which is known by you
to do or have any matter pending with, or be licensed or regulated by, any
City of Albany department, agency, authority or commission.
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Position held
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Name of firm, organization, corporation, etc.
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7.
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CONFLICT OF INTEREST DISCLAIMER
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To recognize that the citizens of the City of Albany are entitled to
a high standard of conduct from their public servants and to provide to the
citizens of the City of Albany a City government that is administered free
from any conflicts of interest by an employee which affect the integrity of
City government and to discourage conflicts of interest and the appearance
of impropriety and to instill in the public a sense of confidence, integrity
and impartiality in its public servants, I affix my signature as evidence
of this declaration.
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Signature
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Date
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7A.
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OPTIONAL SPOUSE OR DOMESTIC PARTNER DECLARATION
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Signature
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Date
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