_______________________________________
Last Name First Name M.I.
APPENDIX A
AFFIDAVIT
Please check the appropriate boxes below and sign this form in front of a valid Notary Public for the
State of Wisconsin.
STATE OF WISCONSIN )
) ss.
MILWAUKEE COUNTY )
The undersigned, being duly sworn on oath, deposes and says they are a/an employee/ appointed
official/ elected official/ candidate for public office of/for Milwaukee County and that they
have read, understand and, to the best of their knowledge and belief, have complied with the provisions
of Chapter 9 of the General Code of Ordinances of Milwaukee County relating to a Code of Ethics.
___________________________________
Signature of Affiant
____________________________________
Title of Affiant
Subscribed and sworn to before me
this ______ day of _______________, 20___
_____________________________________
(Signature of Notary)
My commission expires on __________________
(Affidavit is pursuant to S. 9.03(5) of Chapter 9 – Code of Ethics, C.G.O.)
THIS SPACE FOR ETHICS BOARD OFFICE USE ONLY
2021
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