82-160 Ordinance - Laserfiche WebLink

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. f'UIiLIC U1SC1.1)SUltl: S7'A" 1?N7. .• . 1'A(;1; 'l. 11. LIST THE SOURCE OF EACH GIFT OR ITEM OF VALUE WORTH $500 OR MORE RECEIVED BY YOU, IN YOUR OWN NAME, OR BY ANY OTHER PERSON FOR YOUR USE AND BIsNEFIT DURING THE PRECEEDING YEAR. YOU DO NOT HAVE TO DISCLOSE G'iFTS RECEIVED UNDER A WILL OR BY INHERITANCE, OR GIFTS RECEIVED BY WAY OF DISTRIBUTION FROM ANY INTER VIVOS OR TESTAMENTARY TRUST ESTABLISHED BY AN ANCESTOR OR SPOUSE. A. C. B. D. 12. LIST THE NAME OF EACH CORPORATION INCORPORATED OR AUTHORIZED TO DO BUSINESS IN OHIO, AND EACH TRUST, BUSINESS TRUST, PARTNERSHIP OR ASSOCIATION TRANSACTING BUSINESS IN OHIO, IN WHICH YOU OR ANY OTHER PERSON FOR YOUR USE OR BENEFIT HAD AN INVESTMENT OF MORE THAN $1,000 DURING TEiE PRECEEDING YEAR (AT FAIR MARKET VALUE AS OF DECEMBER 31st, OR THE DATE OF DISPOSITION, WHICHEVER IS EARLIER) OR IN WHICH YOU HOLD AN OFFICE OR HAVE A FIDUCIARY RELATIONSHIP (REGARDLESS OF ANY MONETARY INVESTMENT). YOU DO NOT HAVE TO DISCLOSE ACCOUNTS WITH BANKS, BUILDING AND LOAN ASSOCIATIONS, SAVINGS AND LOAN ASSOCIATIONS, AND CREDIT UNIONS IF THE AMOUNT IS A DEPOSIT OR WITHDRAWABLE SHARE ACCOUNT. FOR EACH LISTING, GIVE A BRIEF DESCRIPTION OF THE INVESTMENT, OFFICE OR RELATIONSHIP. A. Investment• Nature of Investment: B. Investment: Nature of Investment: C. Investment: Nature of Investment: D. Investment: Nature of Investment: E. Investment• Nature of Investment: F. Investment: Nature of Investment: 13. LIST ALL INTERESTS IN REAL ESTATE LOCATED IN CUYAHOGA COUNTY TO WHICH YOU HOLD LEGAL TITLE OR IN 'WHICH YOU HAVE ANY BENEFICIAL INTEREST. YOU DO NOT HAVE TO LIST YOUR PERSONAL RESIDEPICE. LIST BY ADDRESS OR OTHER DESCRIPTION. A B C Street) (City) (Zip Code) (Street) (City) (Zip Code) (Street) (City) (Zip Code) D (Street) (City) (Zip Code) HAVE YOU COMPLETED ALL SECTIONS? IF NOT APPLICABLE, STATE "NONE." USE ADDITIONAL PAGES IF REQiIIR ATTESTATION: By affixing my signature immediately below I acknowledge awareness of the provisions of Section 107.15 of the Codified Ordinances which provide that knowingly filing 4 false statement may be punishable by a f ine of up to $1,000 and/or suspension, re-- moval from office or employment, or other disciplinary action according to the pro- visions of Section 107.13 of the Codified Ordinances of the City of North Olmsted. I swear or affirm that this statement, any any attachments thereto, have been pre- pared or carefully reviewed by me and constitute a complete, truthful and correct disclosure of all information required therein. Date: Signature: Date Received by Ethics Commission: Date riled by Clerk of Council: