6.D.(3) Services Agreement Project IMPACT

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EXHIBIT “D” (2/93) Form 236 Uniform Conflict of Interest Disclosure Statement Indiana Code 35-44-1-3 A public servant who knowingly or intentionally has a pecuniary interest in or derives a profit from a contract or purchase connected with an action by the governmental entity served by the public servant commits conflict of interest, a Class D Felony. A public servant has a pecuniary interest in a contract or purchase if the contract or purchase will result or is intended to result in an ascertainable increase in the income or net worth of the public servant or a dependent of the public servant who is under the direct or indirect administrative control of the public servant; or receives a contract or purchase order that is reviewed, approved, or directly or indirectly administered by the public servant. "Dependent" means any of the following: the spouse of a public servant; a child, stepchild, or adoptee (as defined in I.C. 31-3-4-1) of a public servant who is unemancipated and less than eighteen (18) years of age; and any individual more than one-half (1/2) of whose support is provided during a year by the public servant. 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 in its entirety. Name and Address of Public Servant Submitting Statement: 1. ___________________________________________________________________________ ___ ___________________________________________________________________________ ___ ___________________________________________________________________________ ___ ___________________________________________________________________________ ___ Title or Position With Governmental Entity: __________________________________ 2. ___ Governmental Entity: _______________________________________________ 3. a. ___ County: ___________________________ b. ___________________________________ This statement is submitted (check one): 4. a. _____ as a "single transaction" disclosure statement, as to my financial interest in a specific contract or purchase connected with the governmental entity which I serve, proposed to be made by the governmental entity with or from a particular contractor or vendor; or b. _____ as an "annual" disclosure statement, as to my financial interest connected with any contracts or purchases of the governmental entity which I serve, which are made on an ongoing basis with or from particular contractors or vendors. Name(s) of Contractor(s) or Vendor(s): _________________________________________ 5.