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So:nuw:a:ry (If Material Changes From Current Disclosure Form

1. Added "Your Obligation" instruction section. This instruction speaks to the need of the filer to disclose any possible conflicts of interest for which the form may not expressively ask and provides an appendix sheet for such disclosure.

2. Redefine which questions individuals need to complete. Individuals that have real authority over issues that can have affect over Village residents/business owners' property and/or livelihoods, namely elected officials, Village Attorney, Village Clerk/Treasurer, Village Manager. and members of the following boards:

Ethics, ZBA. BAR, HelMe, and Planning. still need to complete all questions. For the fire and police, we ask only for their own. households; information (not their family's) on the Real Estate Ownership question, and exempt them from answering the client and future employment questions. For all other filers, only the first five questions need to be completed.

3. Removed the "Earned Income" question. We found that the "Outside Employer or Business" question essentially obtains the disclosure that this question was seeking.

4. Renumbered the questions. We renumbered the questions, so that the questions that all filers need to answer are the first fi ve (approx. I % pages). The last four questions only need to be completed by a select group.

5. Added "to be kept confidential" to the phone number questions.

6. Made some formatting and verbiage changes to help clarify the form.

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VIL E OF MAMARONECK

ANNUAL DISCLOSURE ST TEMENT FOR THE CALENDAR YEAR 20 (year)

. Fils! Name ~

Department or oard

Initial

Last Name

Title

Phone Number ([0 be kepI roofide.oriil.l)

Work Address

E-Mail Address (Optional)

Phone Number (to be k.ept confidential)

Home Address

INSTRUCTION FOR COMPLETION OF FORM

A. Completion of this fonn is requir by Chapter 21 of the Village's Ethics Code and must be notarized and returned no later an February 15 of the current year. If the answer to any question is "none," please so' dicate. If the question is inapplicable. please so indicate (i.e. <in/a"). If the answe is left blank, it will be returned for an answer, unless its completion is not required.

. .

B. Use additional paper if necessary .

If additional space is needed, com lete the response on extra sheets of paper and clearly identify the number of the questio

C. Your obligation.

The intent of this fonn is to disci se any conflicts or potential contllets between the applicant and the Village of Ma roneck. To the extent this form does not expressly request the disclosure of certain fonnatioD; it remains your obligation to disclose any conflicts or potential conflicts. ease use Exhibit A to make these disclosures.

D. Privacy request.

If there are circumstances in wh ch a reporting individual believes that answers to any questions should not be made public, the reporting individual may request, upon submission of this completed ~'nD, that certain infonnation be kept conncemia]. A privacy request cannot be considfred until a completed form has been submitted.

E. Advice in answering questions.

A reporting individual may reques advice from the Board of Ethics as to the completion of this form or as to any question in is tcrrn. Questions should be addressed to the Board of Ethics, in care of the Village Cler -Treasurer,

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Please return notarized disclosure 11 rm in the enclosed envelope which will be opened ONLY by the Board of Ethics, You must sign before a Notary Public (do Dot sign and then bring to the notary.) Please n e that the Village Clerk is a Notary.

1. Gifts. (Completed by All) List all gifts that you or your spouse received last year from any entity or person, or agent or repre;entative of such entity or person, who (i) within the past twenty-four (24) months has ree ived or sought a financial benefit from the Village of Mamaroneck, has made an applic tion to the Village of Mamaroneck. or has bad business dealings with the Village of Ma.Jjll3l"oneck or (ii) has a financial interest in any matter proposed or pending before the Vi age of Mamaroneck.

Gifts include, but are not li 'ted to. tangible items of value, cash in any form, entertainment, any interest, secu ity or item tor which the donee paid less than fair consideration or did not pay fo i expenses for trip or accommodations, or travel or accommodations provided at a co t of less than full value or at no cost. loans for which interest payments are deferred, no interest is paid, or interest is paid at less than prevailing rates, or other economic benefits, excluding earned income from wages derived from the Village of Mamaroneck.

Indicate whether the gift was r ceived by you or your spouse,

Name of Donor

Self Or Spouse

Gift (Describe)

APprOXjte Value

2. Loans. (Completed by All) List all loans in excess of $500.00. except those from commercial lending institutions, which you or your spouse has received from any person or entity. or agent or representative ( f person or entity who is (i) employed by the Village of Mamaroneck, (ii) who within the past twenty-four (24) months has received or sought a financial benefit from the Village of Mamaroneck, has made an application to the Village of Mamaroneck, or has business d eallngs with the Village of Mamaroneck; or (iii) who has a financial interest in any matter p oposed or pending before the Village of Mamaroneck,

N arne of Creditor

Descripti on of Obligat on

Amount

Self or Spouse

3. Relatives Employed by the Villa~ e of Mamaroneck or by Businesses or Persons

Doing Business with the Village ( f Mamaroneck. (Completed by All) List any relatives, including any spouse, child, grand hild, parent, grandparent. sibling, in-law. aunt. uncle, first cousin, niece, nephew, steppa ent, stepchild, half brother or half sister, whether or not

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they are living with you. employe1 by the Village of Mamaroneck or by persons or entities known by you to be doing = with the Village of Mamaroneck.

Name of Employer Name of Relative Relationship Position Held

4, Interest in Village of lItamaron+ Coo_.(Completed by All) List any financial interest that you or your spouse ha in any contract made or executed by the Village of

Mamaroneck; excluding bonds notes purchased on the open market.

Description of Interest

Self or Spouse

5. Volunteer Positions. (Completed y All) List each volunteer office or position that you currently hold with any not-for-pr fit organization in a policy making, administrative capacity. Do not list entities of w¥~~ you were a member only or for which you volunteered only in a non-policy ~g, non-administrative capacity, such as a Little League coach. Provide the same' ormation for your spouse.

Self or Spouse

Name of Entity

Position

Nature of Business

6. Real Estate Ownership.

(Completed by elected officials; V Uage Attorney, Village Clerk/Treasurer, Village Manager, and members of the foll wing boards: Ethics, ZBA, BAR, HCZMC, and Planning.) List the address of ea~Piece of property located in the Village of Mamaroneck that you and/or your spo. use, child grandchild, parent, grandparent, slbllng, in-law, aunt, uncle, first cousin, niece, nephew, stepparent, stepchild, half brother and half sister (collectively "family members") 0 us or leases, whole or in part, or otherwise have a

financial interest, including your p . residence.

(Completed by Fire Chiefs and Po ice.) List the address of each piece of property located in the Village of Mamaroneck that you and/or your spouse or other family member that resides ill your household owns or leases, whole Dr in part, or otherwise have a financial interest.

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As to investment property, provide the type and percentage of ownership by you or your spouse or other relative.

Owner's Name

Self or Spouse

Address

Invesrmenr or Primary Residence

7. Outside Employer or Business. (Completed by elected officials, Village Attorney. Village Clerk/Treasurer, Village Manager, Fire Chiefs, Police Chief & Lieutenants, and members of the following boards: Ethics, ZBA, BAR, HCZMC, and Planning.) List the name of your and your spouse's outside employer or business from which you receive compensation. Also, list any entity in which you or your spouse had an Ownership interest, except a corporation of which you owned less than five percent (5%) of the outstanding stock or debt of the entity or $10,000 whichever is less. Identify the name and type of business, and list the relationship to the business (i.e .• owner, partner, officer, director, member, employee, or shareholder.

Name of Business

Type of Business

Relationship

Self or Spouse

8. Client Disclosure. (Completed by elected officials, Village Attorney, Village Clerk!

Treasurer. Village Manager, and members of the following boards: Ethics; ZBA. BAR, HCZMC, and Planning.) List the names of your or your firm's clients or customers known to you who had matters before the Village of Mamaroneck, active clients within the last two (2) years.

Name

Oescription of Matters

9. Agreements for Future Employment. (Completed by elected officials, Village Attorney, Village Clerk/ Treasurer, Village Manager, and members of the following boards: Ethics, ZBA, BAR, HCZMC, and Planniug.) List any assurances or promises of future employment and/or contracts you received during the reporting year 'from any person or enterprise engaged in business with the Village of Mamaroneck.

Future Prospective Employer

When Applicable

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Sworn to me this day of

-~~-

___ , (year)

Notary Public

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I attest under oath that all information given here is true and accurate to the best of my knowledge.

(Signature) Please Print:

Name

Address

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APPENDIX A

Miscellaneous InfonD.9tion I Would Like to Disclose:

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