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10. Affirmation of Public Servant: This disclosure was submitted to the governmental entity and <br />accepted by the governmental entity In a public meeting of the governmental entity prior to final <br />action on the contract or purchase. I affirm, under penalty of penury, the truth and completeness of <br />the statements made above, and that I am the above named public servant, <br />Signed: <br />(Signature of Public Servant) <br />Date: <br />(month, day, year) <br />Printed Name: <br />(Please print legibly.) <br />Email Address: <br />Within fifteen (15) days after final action on the contract or purchase, copies of this statement must be <br />fled with the State Board of Accounts by uploading It here bttps://aateway.ifionline.org/sboa coil which is <br />the preferred method of filing, or by mailing it to the State Board of Accounts, Indiana Government Center <br />South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204-2765 and the Clerk of the <br />Circuit Court of the county where the governmental entity took final action on the contract or purchase. <br />Page 3 of 3 <br />