HomeMy WebLinkAboutEthics Disclosure and Distribution List OF rx TOWN OF ITHACA ETHICS DISCLOSURE STATEMENT
o , Form must be completed and filed with the Town Clerk by April 30"
yob For the Calendar Year
YOUR NAME HOME ADDRESS(#, Street,Town)
PLACE of USUAL EMPLOYMENT w/TITLE TOWN DEPARTMENT or BOARD POSITION
Please do not leave any area blank.
If there is nothing to list,please write "NONE"in the space provided.
If an error is made,please draw a single line through it and initial it.
Answers must cover the 12-month period Prior to the date you file this form.
Updated forms must be submitted within 30 days of any significant change in information.
A. Real Estate Ownership: List the address of each piece of property that you or any member of your household own or have a
significant financial interest in that is located in Tompkins County.
Name Relationship Property Address Nature of Property
Example.,John Smith Self 8 Main Si,Newfield Primary Residence
Jack Smith Father 122 East Shore Dr,Lansing,, Vacation House
B. Outside Interests:
1. List the name of any partnership or unincorporated business(located or doing business in the State of New York)or
unincorporated association(which does business with the Town of Ithaca) of which you or any member of your Household is a
member,partner,officer,or employee,or has a significant proprietary interest in
Name Business/Organization Nature&type of Nature of Affiliation
Business or Organization (Position,Duties)
Example;John Smith Goldman Apt Complex Real Estate Corporation' 10%Ownership
2. List the name of any corporation organized for profit or organized not-for-profit(located or doing business in the State of
New York)of which you or any member of your Household is an officer,director, employee,or who owns or controls,
individually or in combination with you or other members of your Household, more than 10%of the outstanding stock.
Name Business/Organization Nature&type of Affiliation
Business/Organization (Position,Duties)
Example;John Smith' Coalition for Healthy Children Non Profit Board Member
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3. List the name of any municipality or organized not-for-profit located or doing business in the State of New York for whom
you have provided contracted or paid services. (Other than for licensed professions and associated services covered under C.)
Example; Town ofAanadne Municipality Legal con ultationlservices
4. List the nature of any self-employment from which you or a member of your Household has derived a gross income of
$5,000.00 or more during the previous twelve months. (Omit reference to any not-for-profit entity that has no business dealings
with the Town oflthaca)
Name Business/Organization Nature&Type of Affiliation
Business/Organization (Position,Duties)
Example;Self Goldman's Produce Partnership—Produce Farm Owner
C. Licensed Professions: If you practice law,are a NYS licensed real estate broker or agent,practice a profession licensed by the
NYS Department of Education,or are involved in a corporation or business described in Subsection B above,please include a general
description of the principal subject matters undertaken in the stated practice,including the nature of your clients' businesses. This
disclosure shall not include the names of individual clients. Attorneys for the Town must obtain from the Town Clerk a list of
corporations or businesses described in Subsection B. above with which the Town contracts for services and disclose to the Town
Clerk those for which they also provide services.
Your Profession Specialty Nature of Business
Name of Employer or Business Description of Business Activities including Nature of Clients
Example; Broker—Perfect Plc mung' , Real Estate Solicit listings of homes for sale and sale of home
D. Interest in Contracts: Describe any interest you,your spouse,household partner,or your children under 18 years of age have in
any contract involving the Town of Ithaca(excluding your current employment with the Town of Ithaca)*:
Contractor Contract w/Town Nature of business with the Town
Example; Self ABC Gravel—Gravel Supplier Supplies gravel materials to'the Town
E.Relatives Employed: Please list the name,relationship,department and position of any relative employed by the Town of Ithaca
Name Relationship Position Held
Example; John Doe Uncle Secretary;
F. Certification
I hereby certify, under penalty of perjury, that the information disclosed on this form is true and complete and that I have read section
32-4, titled "Gifts,"of the Town of Ithaca CODE OF ETHICS.
Signature Date
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Definitions
a. For purposes of this form, "household" shall include an official's or employee's spouse or equivalent member of a
household sharing living expenses,and any of the following, if residing with the official or employee: child, stepchild,
brother,sister,parent,dependent.
b. For the purposes of this form,"relative"shall include a parent, step-parent,spouse, spouse equivalent,domestic partner,
sibling,step-sibling, sibling's parent, siblings spouse,child,step-child,grandparent,parent of spouse or spouse
equivalent or domestic partner;including in-laws and members of the household of a Town officer or employee,and
individuals having any of these relationships to the spouse or spouse equivalent of the officer or employee.
c. 1. Officials,employees,their spouse/equivalents,or any person or entity acting on their behalf may not solicit or accept
monetary gifts or loans of any amount or promise thereof,or any gift,including services,entertainment,thing,or
promise thereof,having a value of$75 or more,from any person or agent of a person,corporation,partnership,
unincorporated association or other entity who the official or employee knows is considering or has had,within the
previous 12 months,any business dealing with the Town of Ithaca that involves any discretionary act by the official or
employee.
2. Refreshments or meals that are provided as part of an informational presentation in a group setting or as part of a
reception shall not be considered gifts under this section.
Ethics Disclosure Form Distribution List
Town Board Members
Planning Board Members
Ethics Board Members
Zoning Board of Appeals Members
Highway Superintendent
Town Clerk
Town Engineer
Town Justice(s)
Receiver of Taxes
Finance Officer
Human Resources Manager
Network/Records Specialist
Director of Code Enforcement
Director of Planning
Attorneys for the Town
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