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FINANCIAL DISCLOSURE FORM - Advisory
20
Questions
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1
Please Confirm the Year you are filing for
*
This field is required.
2024
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2
Name
*
This field is required.
First Name
Last Name
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3
County Agency Phone Number
Please enter a valid phone number.
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4
Email
*
This field is required.
example@example.com
Confirm Email
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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
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6
SPOUSE & CHILDREN
The item above DOES apply to me.
This item DOES NOT apply to me.
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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
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8
What is the name of your Spouse?
*
This field is required.
First Name
Last Name
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9
What is the name(s) of your dependent Child(ren)?
*
This field is required.
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Small
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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 2024.
The item above DOES apply to me.
This item DOES NOT apply to me.
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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 2024.
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
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B
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D
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Row 3, Column 4
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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
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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.
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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
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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.
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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
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V
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
A
B
C
D
E
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V
A
B
C
D
E
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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
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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.
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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
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18
Political Parties
*
This field is required.
The item above DOES apply to me.
This item DOES NOT apply to me.
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19
List the Political Parties that you are affiliated with.
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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
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