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DISTRICT SUPERVISOR DISCLOSURE FORM (Information Technology Services)

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NCDA&CS NC-CSPs-SD
DSWC (09/2011)
District: _________________ Supervisor: ____________________________
DISTRICT SUPERVISOR DISCLOSURE FORM
The purpose of this form is to aid district supervisors in completing the required disclosure
pursuant to Commission Policy Addressing District Supervisors’ Involvement as Cost Share
Contractors (policy attached). This form should be completed before an appointed or elected
district supervisor begins responsibilities with the district. It should be updated annually by all
district supervisors.
I acknowledge that I have read the policy and that (please initial one statement):
___ I do not own, operate, or receive a benefit from a business that performs or may perform
paid services related to the implementation of Cost Share Agreements. Proceed to
Section 2.
___ I own, operate, or receive a direct benefit from a business that performs or may perform
paid services related to the implementation of Cost Share Agreements. Please complete the
remainder of this form under Sections 1 and 2.
Section 1
This section should be completed by those district supervisors that own, operate, or
receive a benefit from a business that performs or may perform paid services related to the
implementation of Cost Share Agreements. Please complete each question below to the best of
your knowledge, consulting the district and/or Division for the required information if necessary.
Additional pages may be attached to this form.
Please provide below the name(s) of any business you own, operate, or receive a direct benefit
from that performs, may perform, or provides paid services for Cost Share Agreements approved
within the district for which you are a supervisor. Also include the types of services offered and
your affiliation with the business(es).
Business Name Type of Service Affiliation
Example: Tom Smith
Excavators
Example: Grading service Example: Wife owns business
If the business with which you are associated currently provides or has been retained to provide
paid services related to the implementation of a Cost Share Agreement, please complete and
submit a
District Supervisor Disclosure Addendum. This addendum is not required for a
District Supervisor who operates a business that sells supplies or materials where he/she
cannot be reasonably expected to know whether they are used to implement specific cost share
contracts. This addendum is not required if the District Supervisor is performing work on a
contract for which he/she is the applicant or landowner.
Section 2
By signing below I further acknowledge that:
(a) I am under a continuing duty to update this information to ensure the accuracy and
completeness of the information.
(b) I shall not vote on the approval or denial of any Cost Share Agreement application with
the intent to unduly influence the outcome of any action on any application for which I may
be a potential contractor, supplier, or receive personal gain.
(c) I shall provide notice at the next scheduled board of supervisors’ meeting and shall
provide an amendment to this form when a business that I own, operate and/or receive
benefit from is contracted to perform paid services for a Cost Share Contract that I voted
to approve.
This original signed document must be submitted and kept on file in the district office for which
you are a supervisor. You must also provide a copy to the Commission to be kept on file in the
Division office. Forms should be submitted to the Division as soon as possible after election or
appointment or before February 28 of each year.
I hereby certify, that I have completed this disclosure including any attachments thereto
and that the information provided on the disclosure and any attachments is true, correct,
and complete to the best of my knowledge and belief.
_______________________________________________
SIGNATURE OF DISTRICT SUPERVISOR
_______________________________________________
DATE SIGNED
____________________________________________
PRINTED NAME OF DISTRICT SUPERVISOR
DistrictSupervisorDisclosureAddendum
Cooperator Name and Contract Number: Example: John Smith Contract # 09-2008-01for
BMP “ABC”
Type of service provided: Example: grading services
Did you vote on this Cost Share Agreement? Yes No
If you voted to approve the Cost Share Agreement, please note whether your business
was retained pre- or post- approval. Example: I participated in the approval of this
contract for Cost Share funding in September 2009. I was contacted by the cooperator in
October 2009 to perform the grading work because the cooperator could not find another
grading contractor.
Cooperator Name and Contract Number:
Type of service provided:
Did you vote on this Cost Share Contract? Yes No
If you voted to approve the Cost Share Contract, please note whether your business was
retained pre- or post-contract approval.
Supervisor Name:_______________________ Signature:_________________________
Cooperator Name and Contract Number:
Type of service provided:
Did you vote on this Cost Share Contract? Yes No
If you voted to approve the Cost Share Contract, please note whether your business was
retained pre- or post-contract approval.
Supervisor Name:_______________________ Signature:_________________________
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DISTRICT SUPERVISOR DISCLOSURE FORM (Information Technology Services)

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Completed 14 August 2020

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