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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 /> Date: <br /> Within 15 days after final action on the contract or purchase, copies of this statement must be <br /> filed with the State Board of Accounts, Indiana Government Center South, 302 West <br /> Washington Street, Room E418, Indianapolis, Indiana, 46204-2765 and the Clerk of the Circuit <br /> Court of the county in which the governmental entity executed the contract or purchase. A copy <br /> of this disclosure will be forwarded to the Indiana State Ethics Commission. <br /> 24 <br />