ANNUAL STATEMENT OF FINANCIAL DISCLOSURE
FOR THE TOWN OF CLAY FOR THE CALENDAR YEAR _______ FOR LEVEL I OFFICERS,
EMPLOYEES AND APPOINTED OFFICIALS
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1.
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Name and Address.
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Last Name
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Middle Initial
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First Name
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Title
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Department or Agency
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Department or Agency Address
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Telephone No.
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Residence Address
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2.
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Spouse and Children
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Please provide the name of your spouse (if married)
and the names of any dependent children:
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Spouse
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Child/Age
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Child/Age
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Child/Age
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Child/Age
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Child/Age
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Note: For questions 3 to 6, do not report exact
dollar amounts. Instead, report categories of amounts, using the following:
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Category A: Under $5,000
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Category D: $25,001 to $50,000
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Category B: $5,001 to $10,000
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Category E: $50,001 to $100,000
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Category C: $10,001 to $25,000
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Category F: Over $100,000
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3.
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Financial Interests.
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A.
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Business Positions. List any office, trusteeship,
directorship, partnership, or other position in any business, association,
proprietary, or not-for-profit organization held by you and your spouse
and dependent children, if any, and indicate whether these businesses
are involved with the Town of Clay in any manner.
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Name of Family Member
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Position
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Organization
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Town Department or Agency
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B.
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Outside Employment. Describe any outside occupation,
employment, trade, business or profession providing more than $1,000/year
for you and your spouse and dependent children, if any, and indicate
whether such activities are regulated by any state or local agency.
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Name of Family Member
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Position
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Name, Address & Description of Organization
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State or Loc. Agency
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Category of Amount
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C.
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Future Employment. Describe any contract, promise
or other agreement between you and anyone else with respect to your
employment after leaving your Town office or position.
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D.
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Past Employment. Identify the source and nature
of any income in excess of $1,000/per year from any prior employer,
including deferred income, contributions to a pension or retirement
fund, profit sharing plan, severance pay, or payments under a buy-out
agreement.
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Name and Address of Income Source
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Description of Income
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Category of Amount
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E.
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Investments. Itemize and describe all investments
in excess of 5% of the value in any business, corporation, partnership,
or other assets, including stocks, bonds, loans, pledged collateral,
and other investments, for you and your spouse and dependent children,
if any. List the locations of all real estate within the Town of Clay
or within five miles thereof, in which you, your spouse, or dependent
children, if any, have an interest, regardless of its value.
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Name of Family Member
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Name and Address of Business or Real Estate
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Description of Investment
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Category of Amount
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F.
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Trusts. Identify each interest in a trust or
estate or similar beneficial interest in any assets in excess of $2,000,
except for IRS eligible retirement plans or interests in an estate
or trust of a relative, for you and your spouse and dependent children.
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Name of Family Member
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Trustee/Executor
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Description of Trust/Estate
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Category of Amount
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G.
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Other Income. Identify the source and nature
of any other income in excess of $1,000/year from any source not described
above, including teaching income, lecture fees, consultant fees, contractual
income, or other income of any nature, for you and your spouse and
your dependent children, if any.
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Name of Family Member
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Name and Address of Income Source
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Nature of Income
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Category of Amount
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4.
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Gifts and Honorariums.
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List the source of all gifts aggregating in
excess of $250 received during the last year by you, your spouse or
dependent child, excluding gifts from a relative. The term "gifts"
includes gifts of cash, property, personal items, payments to third
parties on your behalf, forgiveness of debt, honorariums, and any
other payments that are not reportable as income.
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Name of Family Member
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Name and Address of Donor
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Category of Amount
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5.
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Third-Party Reimbursements.
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Identify and describe the source of any third-party
reimbursement for travel related expenditures in excess of $250 for
any matter that relates to your official duties. The term "reimbursement"
includes any travel related expenses provided by anyone other than
the Town of Clay for speaking engagements, conferences, or fact finding
events that relate to your official duties.
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Source
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Description
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Category of Amount
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6.
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Debts
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Describe all debts of you, your spouse, and
dependent children in excess of $5,000.
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Name of Family Member
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Name and Address of Creditor
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Category of Amount
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7.
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Interest in Contracts.
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Describe any interest of you, your spouse, or
your dependent children in any contract involving the Town of Clay
or any municipality located within the Town.
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Name of Family Member
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Contract Description
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8.
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Political Parties.
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List any position you held within the last five
years as an officer of any political party, political committee, or
political organization. The term "political organization" includes
any independent body or any organization that is affiliated with or
a subsidiary of a political party.
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9.
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Licensees.
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If a reporting officer, employee or appointed
official practices law, is licensed by the Department of State as
a real estate broker or agent or practices a profession licensed by
the Department of Education, his or her annual disclosure statement
shall include a general description of the principal subject areas
or matter undertaken by such officer, employee or appointed official
in his or her licensed practice. If such officer, employee or appointed
official practices with a partnership, unincorporated association
or corporation and is a partner or shareholder of the firm or corporation
his or her annual disclosure statement shall include a general description
of the principal subject areas or matters undertaken by such firm
or corporation. The disclosure required by this section shall not
include the names of individual clients, customers or patients.
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10.
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Disclosure of unavailable information.
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If a reporting officer, employee or appointed
official is not able, after reasonable efforts, to obtain some or
all of the information required by paragraphs 3 through 8 of this
section which relates to his or her spouse or dependent children,
he or she shall so state, as part of the annual disclosure statement.
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I hereby certify under penalty of perjury, that
the information disclosed on this form is true and complete.
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Signature
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Sworn to before me this ________ day of _____________,
_____________.
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Notary Public
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ANNUAL STATEMENT OF FINANCIAL DISCLOSURE
FOR THE TOWN OF CLAY FOR THE CALENDAR YEAR ________ FOR LEVEL II OFFICERS,
EMPLOYEES AND APPOINTED OFFICIALS
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1.
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Name
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(a)
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Title of Position
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(b)
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Department, Agency or other Government Entity
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(c)
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Office Telephone Number
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2.
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Please verify the following statement:
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I have received and read a copy of Local Law
No. 2 of the Year 1993 of the Town of Clay establishing a Code of
Ethics, creating a Board of Ethics, and requiring financial disclosure.
As defined under that law, I know of no conflict which exists concerning
my position with the Town of Clay except for
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As my circumstances change, I will duly notify
the governing body for the Town of Clay forthwith.
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Signature
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Sworn to before me this _______ day of _____________,
______________.
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Notary Public
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