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ayou rti rrF <br />IY(< <br />[oil 61 1 \ 1 <br />Filed Jn Clark's <br />0 '14] <br />JOHN YoOE'v I3E <br />CITY CLERK, S®UTN BEN { <br />D, IR! i <br />ECONOMIC INTEREST BACKGROUND QUESTIONNAIRE <br />Your Full Name <br />Your EmaiAdres p / <br />is a ar. f f al a1 %_'Q n h� emu. co rn <br />Your Work •rcicphonc: <br />%IS z r 6 cJ <br />our �tobile'felephone: <br />�/7 J 68i1 -ISd c/ <br />Your Employer's Name rr/� // <br />xo rvtCW %ik V ih is I /- L <br />Your Employer's Address 5 y y V7-111 1'06,w ,r /✓ ///0/ <br />VU / <br />Nature of Your Employer's Business <br />A LC Q Y / /Fi4„ <br />Your Social Security number <br />D53. �o_ 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 Q NgQ <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 with the City of South end,LIndian� <br />Have you or any business owned by you ever filed bankruptcy? If yes, please state date and venue. <br />f, <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 />NoneE] <br />I AFFIRM ffUE HE PE NALTIES FOR PERJURY THAT MY STATEMENTS ARE TRUE AND ACCURATE TO THE <br />BEST OF LED L <br />Signarrre — 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.Eov <br />(574) 235 -5822 <br />