Fillable Financial Interests Disclosure Form (Motlow State Community College)

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Financial Interests Disclosure Form (Motlow State Community College)

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The Financial Interests Disclosure Form (Motlow State Community College) form is 5 pages long and contains:

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  • 17 other fields

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File type: PDF

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Motlow State Community College
Financial Interests Disclosure Form
INSTRUCTIONS: This form must be used to report all interests required to be disclosed under the Conflict of Interest
Disclosure Act (T.C.A. § 8-50-501 et seq.) and under TBR Policy 1:02:03:10. Disclosure statements must be filed
annually by January 31 by those persons holding offices for which such statements are required by State law or TBR
Policy. This statement must also be filed by persons newly appointed to such offices. Reports shall be filed with the
Office of the General Counsel of the Tennessee Board of Regents, 1415 Murfreesboro Road, Suite 336, Nashville, TN
37217, phone number 615-366-4438, fax number 615-366-3910. Current officeholders (not new appointees) may
complete items 1 through 4 and skip to item 14 if there has been no change in condition since the last report. The
statement must be signed by a witness, but need not be notarized. Attach additional sheets as necessary. Please type or
print all information in black or dark blue ink.
1. Date of Disclosure
2. Name of Official
3. Address and Phone
4. Title of Office Held
5. Sources of Income. List major sources of your private income of more than $1,000 and that of your spouse or of
dep
endent children. “Major sources of private income” includes, but is not limited to, offices, directorships, and
salaried employments. No dollar amounts need be stated.
6. Investments.
List any investment by you, your spouse, or dependent children in any corporation or other business
organization in excess of five thousand dollars ($10,000) or five percent (5%) of the total capital. It shall be sufficient
to identify the industry. No firm or organization need be named nor dollar amounts or percentages stated.
7. Lobbying. List any person, firm, or organization for whom or which compensated lobbying is done by you, your
spouse, or dependent children. Also, list any firm in which you, your spouse, or dependent children hold any interest
for whom or which compensated lobbying is done. Explain the terms of any such employment and the measures to be
supported or opposed.
8. Professional Services. List in general terms (by areas of the client’s interests) the entities to which professional
services, such as those of an attorney, accountant, or architect, are furnished by you or your spouse.
9. Retainer Fees. List any retainer fee you receive from any person, firm, or organization who is in the practice of
promoting or opposing, influencing, or attempting to influence directly or indirectly, the passage or defeat of any
legislation before the Tennessee General Assembly, the legislative committees, or the members thereof.
10. Bankruptcy. List any adjudication of bankruptcy or discharge received in any United States district court within
five (5) years of the date of this report.
11. Loans. List any loan or combination of loans for more than one thousand dollars ($1,000) from the same source
made in the previous calendar year to you, your spouse, or dependent children. Loans need not be disclosed on this
report if they are:
1) From spouse, parent, sibling, or child.
2) From a federally insured financial institution or made in accordance with existing law in the
ordinary course of doing business of making loans. The loan must bear the usual and customary
rate of interest, be made on a basis
which assures repayment, evidenced by a written instrument and
subject to a due date and amortization schedule.
3) Secured by a recorded security interest in collateral, bearing the usual and customary interest rate
of the lender and made on a basis which assures repayment, evidenced by a written instrument and
subject to a due date and amortization schedule.
4) From a partnership in which you have at least ten percent (10%) partnership interest.
5) From a corporation in which more than
fifty percent (50%) of the outstanding voting shares are
owned by you or by your spouse, parent, sibling, or child.
12. Additional Information. List any additional information you wish to disclose.
13. No Changes Option (only for officeholders who have previously filed a disclosure report).
There has been no change in conditions since my previous report.
14. To be signed by the reporting Official (must be attested to by a witness):
I certify that the information contained in this disclosure statement is true and that it is a complete and accurate report
of all matters that I am required to disclose under the Conflict of Interest Act and / or Tennessee Board of Regents
Policy.
___________________________________________ _________________________
Signature of Official Date
I, the undersigned, do hereby witness the above signature which was signed in my presence.
___________________________________________ _________________________
Signature of Witness Date
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Financial Interests Disclosure Form (Motlow State Community College)

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Completed 27 July 2020

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