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FINANCIAL DISCLOSURE FORM - Policy

FINANCIAL DISCLOSURE FORM - Policy

31Questions
  • 1
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  • 3
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  • 4
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  • 5
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  • 6
    Please Select a Department or Board.
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  • 7
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  • 8
    Provide the name of your spouse (if married) and the names of any dependent children
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  • 10
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  • 11
    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.
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  • 12
    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
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  • 13
    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.
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  • 14
    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
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  • 15
    Other Income. Identify the source and nature of any other income from any source not described above, including teaching income, lecture fees, consultant fees, contractual income or income which you continued to receive from past employment or other income of any nature, for you, your spouse and your dependent children, if any.
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  • 16
    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
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  • 17
    Itemize and describe all investments or capital stock above a 5% share of ownership in any business, corporation or partnership, for you, your spouse and your dependent children, if any.
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  • 18
    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
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  • 19
    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.
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  • 20
    For the Category Column Select the total value for the listed Real Estate (Home Address) from the reporting category box 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
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  • 21
    List the location of all real estate (other than your home address) owned by you, your spouse or your dependent children, or in which you, your spouse or your dependent children had an interest, if such real estate is within the County, or within five (5) miles of the County.
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  • 22
    For the Category Column Select the total value for the listed Real Estate (Other than Home Address)from the reporting category box 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
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  • 23
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  • 24
    For the Category Column Select the total value for the listed 4. Third-Party Reimbursements, Gifts and Honoraria from the reporting category box 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
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  • 25
    For the Category Column Select the total value for the listed Interest in Contacts from the reporting category box
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  • 26
    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
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  • 27
    Describe all debts that you, your spouse or your dependent children had in 2024 in excess of $20,000.
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  • 28
    For the Category Column Select the total value for the listed Debt from the reporting category box 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
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  • 30
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  • 31
    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.
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