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7. Description of My Financial Interest (Describe in what manner the public servant or "dependent' expects to <br />derive a profit or financial benefit from, or otherwise has a pecuniary interest in, the above contract(s) or <br />purchase(s); if reasonably determinable, state the approximate dollar value of such profit or benefit.): <br />(Attach extra pages if additional space is needed) <br />8. Approval of Appointing Officer or Body (To be completed if the public servant was appointed by an elected <br />public servant or the board of trustees of a state -supported college or university): <br />I (We) being the of <br />(Title of Officer or Name of Governing Body) <br />and having the power to appoint <br />(Name of Governmental Entity) <br />the above named public servant to the public position to which he or she holds, hereby approve the participation to <br />the appointed disclosing public servant in the above described contract(s) or purchase(s) in which said public servant <br />has a conflict of interest as defined in Indiana Code 35-44-1-3; however, this approval does not waive any objection <br />to any conflict prohibited by statute, rule, or regulation and is not to be construed as a consent to any illegal act. <br />Elected Official Office <br />9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior to final action <br />on the contract or purchase.): <br />Date Submitted Date of Action on Contract or Purchase <br />10. Affirmation of Public Servant: This disclosure was submitted to the governmental entity and accepted by the <br />governmental entity in a public meeting to the governmental entity prior to final action on the contract or purchase. I <br />affirm, under penalty of perjury, the truth and completeness of the statements made above, and that I am the above <br />named public servant. <br />Signed: <br />(Signature of Public Servant) <br />Date: <br />Within 15 days after final action on the contract or purchase, copies of this statement must be filed with the State <br />Board of Accounts, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapolis, <br />Indiana, 46204-2765 and the Clerk of the Circuit Court of the county in which the governmental entity executed the <br />contract or purchase. A copy of this disclosure will be forwarded to the Indiana State Ethics Commission. <br />17 <br />