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(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. 1. Name and Address of Public Servant Submitting Statement: 2. Title or Position With Governmental Entity: 3. a. Governmental Entity: b. County: 4. This statement is submitted (check one): 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. 5. Name(s) of Contractor(s) or Vendor(s): 6. Description(s) of Agreement(s) or Purchase(s) (Describe the kind of contract involved, and the effective date and term of the contract or purchase if reasonably determinable. Dates required if 4(a) is selected above. If "dependent" is involved, provide dependent's name and relationship): - 12 -