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Ethics Disclosure Form - Financial Interest in Town Transaction

  1. Ethics Disclosure Form - Financial Interest in a Town Transaction

    Town Officers, including all elected or appointed officials, Town employees or agents or consultants to the Town, are required to report financial interests in Town Transactions. They must report if they or a related party receive payments or other compensation having a value of $200 or more during any Town Fiscal Year as a result of  transactions with the Town. The following form has been approved by the Board of Ethics for on-line filing. Please follow the instructions below to complete and file the form on-line. Items marked by an asterisk are required to be completed. If exact dates or amounts are not known, please use best estimates and provide an explanation. Click here to access additional line-by-line instructions.  You are also permitted to file a report using a paper form directly with the Town Clerk. Click here to access a copy of the paper form. By filing this form on-line, you are agreeing to accept the Terms and Conditions and the Town’s Privacy Policy.

  2. Give your full name as it appears in the Town’s official records.
  3. List all positions currently held with the Town, including: 1) any elected or appointed offices, 2) employment by the Town or any entity owned or controlled by the Town, 3) membership on any Town Board, Commission, Committee or other agency or 4) services as an agent for or consultant to the Town.

  4. Describe the nature of the Town transaction, indicating the department or agency involved and the materials, supplies or services furnished or to be furnished or the real or personal property otherwise involved. A separate form is required foreach transaction. Where the Town enters into an arrangement for a series of sales or engagements for services under a single contract, it should be considered a single transaction.

  5. Enter the date the contract for the transaction was entered into or the date a bid was submitted or offer proposed. (If transaction was initiated prior to June 30, 2020, a default date of 06/30/2020 may be entered.)

  6. Provide the total estimated amount of payments to be made by the Town or other value to be given by or received from the Town. If actual amount varies significantly in the future, you should file an amended disclosure.

  7. If you are providing goods or services to the Town directly as an individual, enter "Self." If you are not the direct contractor with the Town, please provide the legal name used by the person or legal entity entering into the above transaction with the Town and also indicate the names of any persons or entities through which you have an indirect interest in the transaction.

  8. Describe the nature of your interest in the transaction, such as contracting party or an owner, general or limited partner, shareholder or employee of the contracting party (or family member thereof).Family members include parents, spouses, siblings, children, nieces and nephews, grandchildren, in-laws and any other person legally entitled or reasonably expected to receive substantial financial support. If your interest in the transaction is as a family member of the contracting party indicate the nature of the relationship (e.g. spouse, child, parent, sibling, aunt, uncle, cousin, in-law, legal guardian, civil partner). Nominal interests having an aggregate value of less than $200 in any Town fiscal year are not considered substantial financial interests and do not need to be reported.

  9. To the best of your ability, estimate the total value expected to be received during the current fiscal year by you or the family member or other contracting party through which you have an interest in the transaction. The value should include increases in the value of tangible or intangible property owned, as well as other amounts received. If your interest is indirect, you are entitled to reasonable reliance on the amount reported or estimated by the contracting party. If the value of the transaction is not currently fixed, provide your best estimate of the value and file an amended report later if the value significantly varies from the estimate.

  10. If you do not expect to benefit from all or any of the value received by contractor, you may enter the portion of value you expect to receive above. You may indicate a percentage, a fraction or a dollar amount, or simply state "none" or "to be determined." If you are a direct contractor or subcontractor, you may estimate the net profit that you expect to receive. 

  11. If desired, you may provide any additional information that you consider relevant
  12. Check below if this is required to be aggregated with another transaction
  13. Please provide date other transaction(s) was/were reported
  14. Check below if this is an amended filing
  15. Provide the date of the original filing above.
  16. 6. Electronic Signature and Online Filing System Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. By checking the "I agree" box below, you also agree to the Terms and Conditions for the Board of Ethics on-line filing system.

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  18. This field is not part of the form submission.