You can always press Enter⏎ to continue
FINANCIAL DISCLOSURE FORM - Advisory
20
Questions
START
1
Please Confirm the Year you are filing for
*
This field is required.
2023
Previous
Next
Submit
Press
Enter
2
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
County Agency Phone Number
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
4
Email
*
This field is required.
example@example.com
Confirm Email
Previous
Next
Submit
Press
Enter
5
Department or Agency
*
This field is required.
Please Select a Department or Agency.
Community Services Board – Donald B. Smith (Building 2) 110 Old Route 6 Carmel, NY
Emergency Services Safety Advisory Board – Training & Operations Bldg. 112 Old Route 6 Carmel, NY
Enhanced 911 Advisory Board 112 Old Route 6 Carmel, NY 10512
Region 3 Fish & Wildlife Management Board – David Bruen County Bldg 40 Gleneida Ave Carmel, NY
Traffic Safety Board – Sheriff’s Dept. 3 County Center Carmel, NY
Transportation Advisory Council – Planning Dept. 841 Fair St. Patterson, NY
Veterans Memorial Park Advisory Board – County Park Office 223 Alms House Lane Kent, NY
Youth Board – Donald B. Smith (Building 3) 110 Old Route 6 Carmel, NY
Previous
Next
Submit
Press
Enter
6
SPOUSE & CHILDREN
The item above DOES apply to me.
This item DOES NOT apply to me.
Previous
Next
Submit
Press
Enter
7
DO YOU HAVE A SPOUSE AND / OR DEPENDENT CHILDREN?
*
This field is required.
Provide the name of your spouse (if married) and the names of any dependent children
a Spouse
Dependent Children
Previous
Next
Submit
Press
Enter
8
What is the name of your Spouse?
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
9
What is the name(s) of your dependent Child(ren)?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
10
a. Employment
*
This field is required.
Describe any occupation, employment, trade, business or profession (other than employment with Putnam County) held by you, your spouse and your dependent children, if any. Please indicate whether such activities were regulated by any State or local agency, as well as any contract, promise or agreement for future employment or volunteer service with respect to your employment with Putnam County in the year 2023.
The item above DOES apply to me.
This item DOES NOT apply to me.
Previous
Next
Submit
Press
Enter
11
a. List Employment
*
This field is required.
In the Category Column, List the amount “if any” of compensation you have received for the calendar year of 2023.
Category Key -- A = Up To $5000 B = $5001 to $20000 C = $20001 to $60000 D = $60001 to $100000 E = $100001 to $250000 F = $250001 or over, V = Volunteer or unpaid position
Family Member
Position
Organization
Government Agency
Category
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 4
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 4
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 4
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 4
1
2
3
4
Family Member
Row 0, Column 0
Position
Row 0, Column 1
Organization
Row 0, Column 2
Government Agency
Row 0, Column 3
Category
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 4
Family Member
Row 1, Column 0
Position
Row 1, Column 1
Organization
Row 1, Column 2
Government Agency
Row 1, Column 3
Category
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 4
Family Member
Row 2, Column 0
Position
Row 2, Column 1
Organization
Row 2, Column 2
Government Agency
Row 2, Column 3
Category
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 4
Family Member
Row 3, Column 0
Position
Row 3, Column 1
Organization
Row 3, Column 2
Government Agency
Row 3, Column 3
Category
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 4
1
of 4
Previous
Next
Submit
Press
Enter
12
b. Outside Leadership
*
This field is required.
List any office, trusteeship, directorship, partnership, board membership, or other leadership position in any association or not-for-profit organization (other than those listed in 3a. above) for you, your spouse and your dependent children, if any, and indicate whether these organizations were involved with the County of Putnam in any manner.
The item above DOES apply to me.
This item DOES NOT apply to me.
Previous
Next
Submit
Press
Enter
13
b. List Leadership Positions
*
This field is required.
Family Member
Position
Organization
Gov't Agency
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
1
2
3
4
Family Member
Row 0, Column 0
Position
Row 0, Column 1
Organization
Row 0, Column 2
Gov't Agency
Row 0, Column 3
Family Member
Row 1, Column 0
Position
Row 1, Column 1
Organization
Row 1, Column 2
Gov't Agency
Row 1, Column 3
Family Member
Row 2, Column 0
Position
Row 2, Column 1
Organization
Row 2, Column 2
Gov't Agency
Row 2, Column 3
Family Member
Row 3, Column 0
Position
Row 3, Column 1
Organization
Row 3, Column 2
Gov't Agency
Row 3, Column 3
1
of 4
Previous
Next
Submit
Press
Enter
14
c. Real Estate (Home Address)
*
This field is required.
List the location of your home address if it is within the County, or within five (5) miles of the County, and if you, your spouse or your dependent children personally own such home.
The item above DOES apply to me.
This item DOES NOT apply to me.
Previous
Next
Submit
Press
Enter
15
c. List Real Estate (Home Address)
For the Category Column Select the total value for the listed Real Estate (Home Address) from the reporting category box - ¹This is your Reporting Category for Value. Only enter the letter that corresponds to this area.
Category Key -- A = Up To $5000 B = $5001 to $20000 C = $20001 to $60000 D = $60001 to $100000 E = $100001 to $250000 F = $250001 or over, V = Volunteer or unpaid position
Family Member Owning the Home
Home Address
Category+
1
Row 0, Column 0
Row 0, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 2
1
2
3
4
Family Member Owning the Home
Row 0, Column 0
Home Address
Row 0, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 2
Family Member Owning the Home
Row 1, Column 0
Home Address
Row 1, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 2
Family Member Owning the Home
Row 2, Column 0
Home Address
Row 2, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 2
Family Member Owning the Home
Row 3, Column 0
Home Address
Row 3, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 2
1
of 4
Previous
Next
Submit
Press
Enter
16
Does Interest in Contracts apply to you?
*
This field is required.
For the Category Column Select the total value for the listed Interest in Contacts from the reporting category box
Yes
No. This does not apply to me.
Previous
Next
Submit
Press
Enter
17
List any Interest in Contracts
*
This field is required.
¹This is your Reporting Category for Value. Only enter the letter that corresponds to this area.
Category Key -- A = Up To $5000 B = $5001 to $20000 C = $20001 to $60000 D = $60001 to $100000 E = $100001 to $250000 F = $250001 or over, V = Volunteer or unpaid position
Family Member
Contract Description
Category+
1
Row 0, Column 0
Row 0, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 2
1
2
3
4
Family Member
Row 0, Column 0
Contract Description
Row 0, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 2
Family Member
Row 1, Column 0
Contract Description
Row 1, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 2
Family Member
Row 2, Column 0
Contract Description
Row 2, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 2
Family Member
Row 3, Column 0
Contract Description
Row 3, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 3, Column 2
1
of 4
Previous
Next
Submit
Press
Enter
18
Political Parties
*
This field is required.
The item above DOES apply to me.
This item DOES NOT apply to me.
Previous
Next
Submit
Press
Enter
19
List the Political Parties that you are affiliated with.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
20
Disclaimer
*
This field is required.
I hereby certify, under penalty of perjury, that the information disclosed on this form is true and complete. I also acknowledge that I have a continuing duty to disclose conflicts of interest and am subject to the other requirements of the Putnam County Code of Ethics.
YES
NO
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
20
See All
Go Back
Submit
