HomeMy WebLinkAboutTiffany Kumar 2025 Financial Disclosure
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ANNUAL STATEMENT OF FINANCIAL DISCLOSURE
CITY OF ITHACA, NEW YORK
For Year: __________
Directions: This form must be completed in its entirety and submitted to the City Clerk by
February 1st of each year, regardless of whether there have been any changes in your
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section is not applicable to you. If you require more space to provide information, please
attach additional sheets as necessary. Please consult with the City Attorney if you have any
questions regarding the completion of this form.
1.Please provide your name, address and position with the City of Ithaca.
2. Please provide the name of your spouse, domestic partner, adult dependents, or adult
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reside with you and who intend to reside with you for the foreseeable future, and to whom
you are committed to mutual care and support. When used in this statement, Domestic
Partner shall mean a person defined as a domestic partner pursuant to Chapter 215,
Article IV, of the City of Ithaca Municipal Code.
Last Name First Name Middle Initial
Residential
Address Number
Street City State Zip Code
Telephone E-Mail Address
City Title Department
Spouse/Partner Last Name First Name Middle Initial
Household
Member
Household
Member
Household
Member
Household
Member
3. Financial Interests:
A.Outside Employment:
Please state any other employment, occupation, trade, business, office or business title or
profession held by you, your spouse, domestic partner, adult dependents, or H/M. Please
indicate whether such activity is licensed or regulated by any local agency.
B.Leave of Absence:
Are you on leave, paid or unpaid, from any business or organization?
Yes: ________ No: _______
If yes, please identify the business or organization:
C.Associations and Organizations:
Please list any position that you hold in any proprietary or not-for-profit association,
organization, or political party as an officer, decision or policy maker, whether you received
monetary compensation or not. This includes honorary positions, self-appointed positions,
and positions held by virtue of your municipal position. This excludes general membership
and liaison roles where you have no decision or policy-making authority.
Occupation Name of
Business/Activity
Regulated By If yes, nature of
Organization Position Held Date(s) Held
D.Real Estate:
List the location of all real estate in or within five (5) miles of Tompkins County that is owned
in whole or in part by you, your spouse, domestic partner, adult dependents, or H/M.
E.Business Connections:
Please indicate if you, your spouse, domestic partner, adult dependents, or H/M, are involved
in any profit-making or non-profit enterprise not previously disclosed, which has a business
connection, including contracts, with the City of Ithaca:
(Please describe the principal activities and nature of the connection or contract with the city.)
F.DBA (Doing Business As):
Do you or anyone in your household have a current DBA, or ownership in a corporation that
has a DBA in Tompkins County?
Yes: _______ No: ________
G.Investments and other assets:
You may exclude Mutual Funds and Blind Trusts from this section. Please itemize and
describe all investments (e.g. capital stock, bonds, IRA, trusts, etc.), which you, your spouse,
domestic partner, adult dependents, or H/M hold in any business, corporation, or partnership
as a majority owner or a significant interest (5% or more).
Property Address Owned By
Principle Activities Nature of Connection with the City
DBA Name(s) Owner
Investment (Please specify as noted above) Owned By Whom
H.Loans:
List any outstanding loans payable or receivable over $1,000 involving people who live, work
or own property in Tompkins county, excluding established financial institutions and family
members.
I.Gifts:
List any personal gifts and who gave them received by you, your spouse, domestic partner,
adult dependents, or H/M during the last 3 years from people who live, work or own property
in Tompkins County, of a value greater than $1,000, other than from a relative:
4.Other Information:
A. To the best of your knowledge are you or anyone in your household involved in any
organization or activity or holding any asset, excluding those listed above, that could be a
conflict of interest in performing the duties of your city position?
Yes: ________ No: _______
If yes, please explain:
B. Do you have any holdings, assets, or property held under any other name?
Yes: ________ No: _______
Please explain:
5.Certification:
I certify that the responses herein are true and I understand that any willful misstatement
constitutes a violation of the City of Ithaca Municipal Code and subjects me to penalties
provided in Section 55.12 of the City Code.
Signature Date
05/04
01/19
Amount of Loan Purpose of Loan Lender or Recipient
Gift Given To Received from