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' <br />,�4�ypU7Ny V <br />) �' <br />rvacc . J;);--'I <br />v fit. <br />CITY OF SOUTH BEND <br />Filed In Via: ,le^W <br />zu1v <br />JONAf FOtJRDE <br />CITY CLERK, SOUTH SEND, IN <br />ECONOMIC INTEREST BACKGROUND QUESTIONNAIRE <br />Your Full Name <br />Your Emai A,rtdr7 <br />it vldi. <br />/ <br />/t�rdat al�Qn�Vr �. Co;n <br />Your Work Telephone, <br />71S r - JOC <br />our Mobile "relephone: <br />/7) bgo -/SEA/ <br />Your Employer's Name r/ / <br />rolCtS A MkY�f7 /S , LLr <br />Your Employer's Address 5- N y y 7 yh <br />Nature of Your Employer's Business le Q / <br />Your Social Security number <br />053.,yo_gz�3 <br />Have you ever been convicted of a felony or misdemeanor? <br />If Yes, please list the date, place, nature and disposition of each: <br />Yes El NoEl <br />State the name of any person(s) or business entity(ies) with which you intend to partner or work with on the intended project in which <br />you are currently in discussi n wi-th the City of Southall y7 � a P -- - <br />Have you or any business owned by you ever filed bankruptcy? if yes, please state date and venue. <br />Provide any additional information you would like to disclose below or on an attached sheet <br />or check None if there is no other additional information you would like to disclose. <br />NoneO <br />I AFFIRM U E HE PENALTIES FOR PERJURY THAT MY STATEMENTS ARE TRUE AND ACCURATE TO THE <br />BEST OF M KN LED E. <br />G/ 7 <br />Signaure Date <br />PLEASE SIGN, DATE, AND RETURN THIS COMPLETED FORM VIA E -MAIL TO: <br />Chris Fielding - Assistant Executive Director - Community Investment <br />cfieldin(a,southbendin.¢ov <br />(574) 235 -5822 <br />