Loading...
HomeMy WebLinkAboutFinancial Disclosure Form - fillable.pdf V. 10-2009 1 City of Bozeman Financial Disclosure Statement Required by Sect. 2.01.100 of Ordinance No. 1759 and the City Charter Introduction: The City of Bozeman and the Bozeman Board of Ethics would like to help individuals understand the need to complete the attached Financial Disclosure Statement. Those who serve the City of Bozeman represent the community by their actions each and every day. The public deserves to be represented by individuals that are free from conflicts of interest. With the completion of a Financial Disclosure Statement, individuals are further indicating to the community a responsibility to be above reproach in their financial affairs. With the annual completion of the financial statement, the signer will be reminded of the need to avoid financial conflicts of interest in fact or in appearance. Montana’s public records laws require that, once signed, these forms are on file in the City Clerk’s office, for review by the public. This is not meant to discourage individuals from participating in City government, but is meant to assure the public that relationships that may be of concern are properly disclosed. A list of individuals who are required to fill out this form will be prepared each year and will be on file with the City Clerk. Persons required to file will receive mailed notice each year. This form must be filled out annually by those who are “major financial decision makers:” All City Commission Members, the City Manager, and Department Directors; and Any employee or board member who is an “authorized signatory” for claims approval, according to the official signatory forms in the finance office; and Members of City boards that have expanded financial authority (not just advisory roles): o Library Board of Trustees o Parking Commission o Parks & Recreation Advisory Board (due to Park Improvement Grant program) o All Business Improvement District Boards o Board of Adjustment V. 10-2009 2 ANNUAL DISCLOSURE STATEMENT FOR THE YEAR BEGINNING JANUARY ________. Return to: Bozeman City Clerk, 121 N Rouse, PO Box 1230, Bozeman, MT 59771 Section 1. IDENTIFICATION Name: _______________________________________________________________________________ Address of Permanent Residence:_________________________________________________________ Current Position with City of Bozeman: _____________________________________________________ Section 2. BENEFITS CURRENTLY RECEIVED FROM EMPLOYERS (Present & Past) I currently receive salary and/or benefits (health insurance, retirement payments, retirement accounts that continue to accrue interest, dividends, or shares, etc.) from the following present or past employers: 1. Name of Employer: __________________________________________________________________ Employer’s Address:____________________________________________________________________ Type of Benefits_______________________________________________________________________ 2. Name of Employer: __________________________________________________________________ Employer’s Address:____________ ________________________________________________________ Type of Benefits_______________________________________________________________________ Section 3. BUSINESS INTERESTS I hold an ownership interest of 10% or more in the following businesses (including self-employed occupations), firms, corporations, partnerships or other businesses or professional entities or trusts. 1. Name of Business: ___________________________________________________________________ Address: __________________________________________ Type of Business:____________________ 2. Name of Business: ___________________________________________________________________ Address: __________________________________________ Type of Business:____________________ 3. Name of Business: ___________________________________________________________________ Address: __________________________________________ Type of Business:____________________ 4. Name of Business: ___________________________________________________________________ Address: __________________________________________ Type of Business:____________________ V. 10-2009 3 Section 4. POSITIONS HELD WITH OTHER GOVERNMENTS, NON-PROFITS, BOARDS OF DIRECTORS, ETC. In addition my current position with the City of Bozeman, I am also currently an officer, director, or registered agent for the following entities (including non-profits, government boards, private boards, etc.) 1. Name of Organization ___________________________________Office Held: ___________________ Address:______________________________________________________________________________ 2. Name of Organization ___________________________________Office Held: ___________________ Address:______________________________________________________________________________ 3. Name of Organization ___________________________________Office Held: ___________________ Address:______________________________________________________________________________ 4. Name of Organization ___________________________________Office Held: ___________________ Address:____________ __________________________________________________________________ Section 5. REAL PROPERTY Not including my home, I, as an individual, own or have an interest of 10% or more in the following real property. This includes property that I own outright, under a mortgage, leased, held in trust, is owned as a tenant in common or owned jointly with other individuals. (Indicate whether the nature of the interest is investment, vacation, business/commercial, timeshare, etc.) Attach list if necessary. 1. Address of the Property: _____________________________________ ________________________ Nature of Interest Held in the Property: ___________________________________________________ 2. Address of the Property: _____________________________________________________ ________ Nature of Interest Held in the Property: ___________________________________________________ 3. Address of the Property: _____________________________________________________________ Nature of Interest Held in the Property: ___________________________________________________ 4. Address of the Property: _____________________________________________________________ Nature of Interest Held in the Property: ___________________________________________________ V. 10-2009 4 Section 6. OTHER OPTIONAL : I would like to take this opportunity to disclose the following relationships that may be perceived as a conflict in the function of my duties. (ie. Spousal or familial relationships, past employers that I no longer work for, other items that are not required to be disclosed above, etc.) ______________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________ Section 7. CERTIFICATION I hereby certify that the foregoing statements are true and complete to the best of my knowledge. I also understand that filing of this statement DOES NOT release me from the requirements to disclose upon the record and/or abstain from voting in matters where I have a conflict of interest. _________________________________________________ ________________________ Signature Date ***Print and sign. Clerk must receive an original signed form.