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