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FINANCIAL DISCLOSURE FORM - Policy
31
Questions
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1
Please Confirm the Year you are filing for
*
This field is required.
2023
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2
Enter your Full Name
*
This field is required.
First Name
Last Name
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3
County Agency Title
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4
County Agency Work Number
Please enter a valid phone number.
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5
Email
*
This field is required.
example@example.com
Confirm Email
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6
Department or Board
*
This field is required.
Please Select a Department or Board.
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
Agriculture & Farmland Protection Board 841 Fair St. Patterson, NY
Auditing -David Bruen County Bldg. 40 Gleneida Ave. Carmel, NY
Board of Elections -Board of Elections 25 Old Rt 6 Carmel, NY
Board of Electrical Examiners – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Board of Ethics – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Board of Health - Health Dept. 1 Geneva Rd. Brewster, NY
Bureau of Emergency Services - Training & Operations Bldg. 112 Old Rt. 6, Carmel, NY
Consumer Affairs– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
County Clerk -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
County Coroner - Training & Operations Bldg. 112 Old Rt. 6, Carmel, NY
County Executive -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
County Historian – 68 Marvin Ave Brewster, NY
County Legislature -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
District Attorney -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
East of Hudson Watershed Corporation, 2 Route 164, Patterson, NY
Finance -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
Health Department – Health Dept. 1 Geneva Rd. Brewster, NY
Highways & Facilities – Highway Dept., 842 Fair St. Patterson, NY
Home Improvement Board – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Information Technology/GIS– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Law Dept. – Law Dept. 48 Gleneida Ave. Carmel, NY
Office for Senior Resources – Donald B. Smith Gov’t Campus (Building 1) 110 Old Route 6 Carmel, NY
Office for People with Disabilities– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Off-Track Betting Board – Planning Dept 841 Fair St. Patterson, NY
Personnel– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Planning, Dev. & Public Transp. – Planning Dept. 841 Fair St. Patterson, NY
Plumbing Board – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Probation -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
Purchasing -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
Putnam County Industrial Development Agency – 2 Route 164, suite 2B, Patterson, NY 12563.
Real Property -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
Sheriff’s Dept. – Sheriff’s Dept. 3 County Center Carmel, NY
Social Services & Mental Health – Donald B. Smith Gov’t Campus (Building 2) 110 Old Route 6 Carmel, NY
Soil & Water–Planning Dept. 841 Fair St. Patterson, NY
Tourism -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
Putnam County Veterans Service Agency– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
Youth Bureau – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
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7
SPOUSE & CHILDREN
*
This field is required.
The item above DOES apply to me.
This item DOES NOT apply to me.
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8
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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9
What is the name of your Spouse?
*
This field is required.
First Name
Last Name
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10
What is the name(s) of your dependent Child(ren)?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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11
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.
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12
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
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Government / Agency
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13
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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14
b. List Leadership Positions
*
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,
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Organization
Government / Agency
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15
c. Other Income
*
This field is required.
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.
The item above DOES apply to me.
This item DOES NOT apply to me.
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16
c. List Other Income
*
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
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17
d. Investments
*
This field is required.
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.
The item above DOES apply to me.
This item DOES NOT apply to me.
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18
d. List Investments
*
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
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19
e. 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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20
e. List Real Estate (Home Address)
*
This field is required.
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
Family Member Owning the Home
Home Address
Category+
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Home Address
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21
f. Real Estate (Other than Home Address)
*
This field is required.
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.
The item above DOES apply to me.
This item DOES NOT apply to me.
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22
f. List Real Estate (Other than Home Address)
*
This field is required.
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
Family Member
Name of Real Estate
Address of Real Estate
Description of Real Estate
Category+
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Address of Real Estate
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Address of Real Estate
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23
Does the Third-Party Reimbursements, Gifts and Honoraria Apply to you?
*
This field is required.
The item above DOES apply to me.
This item DOES NOT apply to me.
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24
List any Third-Party Reimbursements, Gifts and Honoraria
*
This field is required.
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
Source
Description
Category+
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25
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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26
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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27
Debts
*
This field is required.
Describe all debts that you, your spouse or your dependent children had in 2023 in excess of $20,000.
Yes
No. This does not apply to me.
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28
List all Debts that you have
*
This field is required.
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
Name of Debtor
Name of Creditor
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
Name of Debtor
Row 0, Column 0
Name of Creditor
Row 0, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 0, Column 2
Name of Debtor
Row 1, Column 0
Name of Creditor
Row 1, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 1, Column 2
Name of Debtor
Row 2, Column 0
Name of Creditor
Row 2, Column 1
Category+
A
B
C
D
E
F
V
A
B
C
D
E
F
V
Row 2, Column 2
Name of Debtor
Row 3, Column 0
Name of Creditor
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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29
Political Parties
*
This field is required.
The item above DOES apply to me.
This item DOES NOT apply to me.
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30
List the Political Parties that you are affiliated with.
*
This field is required.
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Small
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31
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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