Revised Cache County Disclosure Form

Disclosure Form - Conflicts of Interest
Name

First NameLast Name
Please Indicate the Purpose of this Conflict of Interest Disclosure:

I am a Candidate (State, County, School Board, Special District) and intend to file a Declaration of Candidacy with the Cache County Clerk's Office.I currently hold an elected or appointed position for Cache County, and I am required to file an annual Conflict of Interest disclosure.
I currently hold the following position with Cache County:*
I am filing as a candidate for the following position*
Office/Position and District (if applicable)
OVERVIEW

Appointed employees and elected officials of the County are required to comply with Utah law, Cache County Code, and policies of the County when it comes to disclosures of potential and real conflicts of interest and ethics. The purpose of this form is to inform you about prohibited acts related to employee ethics and for appointed employees and officers to disclose potential and real conflicts of interest. This form is to be completed at the beginning of each calendar year and anytime a new potential or real conflict of interest arises as specified in this form. It is each employee's responsibility to ensure they disclose such conflicts.

PROHIBITED ACTS

Appointed employees and officers of the County shall not:
1. Disclose confidential information acquired by reason of their official position or use that information to secure special privileges or exemptions for themselves or others;
2. Use or attempt to use their official position to secure special privileges for themselves or for others; or
3. Knowingly receive, accept, take, seek, or solicit, directly or indirectly, any gift or loan for themselves or for another, if the gift or loan tends to influence them in the discharge of their official duties.

DISCLOSURE REQUIRED

Please complete the following by checking the box to indicate whether you do or do not hold any of the following positions. Per Utah Code, the information provided shall be kept on file and may be subject to disclosure to the public. If you are an elected official and answer "yes" to questions 1-3 then your sworn statement will be posted by the County Clerk on the County's website until you leave office in accordance with Utah Code.
1) I hold a position where I receive or agree to receive compensation¹ for assisting² a person or business entity³ in a transaction involving Cache County (Utah Code Section 17-16a-5), Local School Board, or Special District (if I am a candidate or electee for such School Board or Special District).
No, I do not hold such a position.Yes, I do hold such a position.
¹ Compensation is defined in Utah Code Section 17-16a-3(4) as anything of economic value, however designated, which is paid, loaned, granted, given, donated, or transferred to any person or business entity for or in consideration of personal services, materials, property, or any other thing whatsoever.

² Assist is defined in Utah Code Section 17-16a-3(2) as to act, or offer or agree to act, in such a way as to help, represent, aid, advise, furnish information to, or otherwise provide assistance to a person or business entity, believing that such action is of help, aid, advice, or assistance to such person or business entity and with the intent to SO assist such person or business entity

³ Business entity is defined in Utah Code Section 17-16a-3(3) as a sole proprietorship, partnership, association, joint venture, corporation, firm, trust, foundation, or other organization or entity used in carrying on a business.
1A) Please provide a brief description of the transaction or the service that is rendered or is to be rendered, the nature and value of the service performed, the nature and value of your interest in the business entity, and/or the investment creating a conflict of interest as it pertains to the position described in Item 1. *
2. I hold a position where I am an officer, director, agent, employee, or the owner of a substantial interest⁴ in a business entity which is subject to the regulations of Cache County (Utah Code Section 17-16a-6), Local School Board, or Special District (if I am a candidate or electee for such School Board or Special District).
No, I do not hold such a position.Yes, I do hold such a position.
⁴ Ownership of a substantial interest is defined in Utah Code Section 17-16a-3(8) as 10% of the outstanding shares of a corporation or 10% interest in any other business entity, legally or equitably held or owned by the officer or employee, their spouse, or their children.
2A) Please provide a brief description of the transaction or the service that is rendered or is to be rendered, the nature and value of the service performed, the nature and value of your interest in the business entity, and/or the investment creating a conflict of interest as it pertains to the position described in Item 2. *
3. I hold a position where I am an officer, director, agent, employee, or owner of a substantial interest in a business entity which does or anticipates doing business with Cache County (Utah Code Section 17-16a-7), Local School Board, or Special District (if I am a candidate or electee for such School Board or Special District).
No, I do not hold such a position.Yes, I do hold such a position.
3A) Please provide a brief description of the transaction or the service that is rendered or is to be rendered, the nature and value of the service performed, the nature and value of your interest in the business entity, and/or the investment creating a conflict of interest as it pertains to the position described in Item 2. *
4. I hold a position where I have a personal interest or investment which creates a potential or actual conflict between that interest and my public duties (Utah Code Section 17-16a-8)
No, I do not hold such a position.Yes, I do hold such a position.
4A) Please provide a brief description of the transaction or the service that is rendered or is to be rendered, the nature and value of the service performed, the nature and value of your interest in the business entity, and/or the investment creating a conflict of interest as it pertains to the position described in Item 4. *
I, First Name* Last Name* acknowledge I have read and understand the disclosure requirements in the sections above. I also acknowledge I completed the relevant portions of the "Disclosure Required" section, that all of the information I provided is true and accurate to the best of my knowledge. I also understand that any elected official or appointed employee who knowingly and intentionally violates the County Officers and Employees Disclosure Act shall be dismissed from employment or removed from office as required by Utah Code Section 17-16a-10. If I am a candidate for office, I have provided all required disclosures in accordance with local and state statute. Please contact the County Attorney's Office for any legal questions you have.
Candidate or Officer/Appointed Employee Signature*

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Disclosure Form - Conflicts of Interest