HomeMy WebLinkAboutContract - Re-Approval of Conflict Disclosure - Rides2UPage 2 of 3 IF PUBLIC SERVANT IS APPOINTED, COMPLETE SECTION 5
ALL OTHER PUBLIC SERVANTS, COMPLETE SECTION 6
5.Approval of elected public servant or board of trustees of a state supported college or university thatappointed the public servant:
f / WE hereby approve this Conflict of Interest Form concerning the public servant for the contract or purchase described herein on this day:
Date of Appointment: ______ _
Date of Approval of Conflict of Interest: _______ _
__________________________ Signature Printed Name, Job Title
___________________________ Signature Printed Name, Job Title
6.Approval by governmental entity at public meeting
a.Date this Conflict of Interest was submitted to the governmental entity: _______ _
b.Date of the public meeting this Conflict of Interest Form was accepted by the public entity (Note: this date MUST be prior to any final action on the contract or purchase): June 23, 2026
7.Affirmation of Public Servant:
This disclosure was submitted to and accepted by the governmental entity in a public meeting(identified above) prior to final action on the contract or purchase.
f affirm, under penal�y of perjury, the truth and completeness of the statements made above.
Signed: ______ ,,,,.__,_1.;s. ______ _
Printed Name: .....;C:;_;h.:..:;a;.;;;;d"'"M�a;.;;;;s.:..:;ta ... g'"'"h ______ _
Date: May 1st 2026
Email Address: chad@rides2u.com
8.Filing Requirement
Within fifteen (15) days after final action on the contract or purchase, copies of this statement must befifed with both:
1.The Indiana State Board of Accounts by uploading at https://gateway.ifionline.org/sboa coil; and
2.The Clerk of the Circuit Court of the county where the governmental entity took final action on thecontract or purchase.