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(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 profit from a <br /> 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 who is under the direct or <br /> indirect administrative control of the public servant; or receives a contract or purchase order that is <br /> reviewed, approved, or directly or indirectly administered by the public servant. "Dependent" means any <br /> of the following: the spouse of a public servant; a child, stepchild, or adoptee(as defined in I.C. 31-3-4-1) <br /> of a public servant who is unemancipated and less than eighteen (18) years of age; and any individual <br /> more 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 review I.C. 35- <br /> 44-1-3 in its entirety. <br /> 1. Name and Address of Public Servant Submitting Statement: <br /> 2. Title or Position With Governmental EnNty: ' <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 in a specific <br /> contract or 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 '� <br /> or purchases of the governmental entity which I serve, which are made on an ongoing basis with or from <br /> � <br /> particular contractors or vendors. � <br /> 5. Name(s)of Contractor(s)or Vendor(s): � <br /> 6. Description(s) of Agreement(s) or Purchase(s) (Describe the kind of contract involved, and the <br /> effective date and term of the contract or purchase if reasonably determinable. Dates required if 4(a) is <br /> selected above. If"dependent" is involved,provide dependent's name and relationship): <br /> - 27 - � <br /> � <br />