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9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity <br />prior to final action 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 <br />and accepted by the governmental entity in a public meeting to the governmental entity prior to <br />final action on the contract or purchase. I affirm, under penalty of perjury, the truth and <br />completeness of the statements made above, and that I am the above 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 <br />filed with the State Board of Accounts, Indiana Government Center South, 302 West <br />Washington Street, Room E418, Indianapolis, Indiana, 46204 -2765 and the Clerk of the Circuit <br />Court of the county in which the governmental entity executed the contract or purchase. A copy <br />of this disclosure will be forwarded to the Indiana State Ethics Commission. <br />14 <br />