Laserfiche WebLink
7. Description of My Financial Interest (Describe in what manner the public servant or <br />"dependent" expects to derive a profit or financial benefit from, or otherwise has a pecuniary <br />interest in, the above contract(s) or purchase(s); if reasonably determinable, state the <br />approximate dollar value of such profit or benefit.): <br />(Attach extra pages if additional space is needed) <br />8. Approval of Appointing Officer or Body (To be completed if the public servant was <br />appointed by an elected public servant or the board of trustees of aatate-supported college or <br />university): <br />I (We) being the of <br />(Title of Officer or Name of Governing Body) <br />and having the power to appoint <br />(Name of Governmental Entity) <br />the above named public servant to the public position to which he or she holds, hereby approve <br />the participation to the appointed disclosing public servant in the above described contract(s) or <br />purchase(s) in which said public servant has a conflict of interest as defined in Indiana Code 35- <br />44-1-3; however, this approval does not waive any objection to any conflict prohibited by statute, <br />rule, or regulation and is not to be construed as a consent to any illegal act. <br />Elected Official Office <br />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 Agreement 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 />- 12 - <br />