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0 UNIFORM CONFLICT OF INTEREST DISCLOSURE STATEMENT <br />Slate Form 64288 (R218-16)1 Form 238 <br />STATE BOARD OF ACCOUNTS <br />Indiana Code 35-44.1-1-4 <br />A public servant who knowingly or intentionally has a pecuniary interest in or derives a profit from <br />a contract or purchase connected with an action by the governmental entity served by the public servant <br />commits conflict of interest, a Class D Felony. A public servant has a pecuniary interest in a contract or <br />purchase if the contract or purchase will result or is intended to result in an ascertainable increase in the <br />Income or net worth of the public servant or a dependent of the public servant. "Dependent" means any <br />of the following: the spouse of a public servant; a child, stepchild, or adoptee (as defined in IC 31-9-2-2) <br />of a public servant who is, unemancipated and less than eighteen (18) years of age; and any individual <br />more than one-half (112) of whose support is provided during a year by the public servant. <br />The foregoing consists only of excerpts from IC 3544.1-14, Care should be taken to review IC <br />35-44.1-1-4 in its entirety. <br />1. Name and Address of Public Servant Submitting Statement: <br />2. Title or Position With Governmental Entity: <br />3. 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 1n a specific contract or <br />purchase connected with the governmental entity which I serve, proposed to be made by the <br />governmental entity with or from a particular contractor or vendor; or <br />b._ as an "annual" disclosure statement, as to my financial interest connected with any contracts or <br />purchases of the governmental entity which I serve, which are made on an ongoing basis with or <br />from particular contractors or vendors. <br />5. Name(s) of Contractor(s) or Vendor(s): <br />6. Description(s) of Contract(s) or Purchase(s) (Describe the kind of contract involved, and the <br />effective date and term of the contractor purchase if reasonably determinable. Dates required if 4(a) <br />is selected above. If "dependent" is involved, provide dependent's name and relationship.): <br />Page 1 of 3 <br />