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EXHIBIT "C" <br />(2/93) Form 236 <br />Uniform Conflict of Interest Disclosure Statement <br />Indiana Code 35-44-1-3 <br />A public servant who knowingly or intentionally has a pecuniary interest in or derives a profit from a <br />contract or purchase connected with an action by the governmental entity served by the public servant commits <br />conflict of interest, a Class D Felony. A public servant has a pecuniary interest in a contract or purchase if the <br />contract or purchase will result or is intended to result in an ascertainable increase in the income or net worth of the <br />public servant or a dependent of the public servant who is under the direct or indirect administrative control of the <br />public servant; or receives a contract or purchase order that is reviewed, approved, or directly or indirectly <br />administered by the public servant. "Dependent" means any of the following: the spouse of a public servant; a child, <br />stepchild, or adoptee (as defined in I.C. 31-3-4-1) of a public servant who is not emancipated and less than eighteen <br />(18) years of age; and any individual more than one-half (1/2) of whose support is provided during a year by the <br />public servant. <br />The foregoing consists only of excerpts from I.C. 35-44-1-3. Care should be taken to review I.C. 35-44-1-3 <br />in its entirety. <br />1. Name and Address of Public Servant Submitting Statement: <br />2. Title or Position With Governmental Entity: <br />3. a. Governmental Entity: <br />b. County: <br />4. This statement is submitted (check one): <br />a. as a "single transaction" disclosure statement, as to my financial interest in a specific <br />contract or purchase connected with the governmental entity which I serve, proposed to <br />be made by the governmental entity with or from a particular contractor or vendor; or <br />b. as an "annual" disclosure statement, as to my financial interest connected with any <br />contracts or purchases of the governmental entity which I serve, which are made on an <br />ongoing basis with or from particular contractors or vendors. <br />5. Name(s) of Contractor(s) or Vendor(s): <br />6. Description(s) of Contract(s) or Purchase(s) (Describe the kind of contract involved, and the effective date and <br />term of the contract or purchase if reasonably determinable. Dates required if 4(a) is selected above. If "dependent" <br />is involved, provide dependent's name and relationship): <br />M <br />