GIFT DISCLOSURE - EMPLOYEE
Year: _______
If disclosure of a gift is required, an employee must file this Gift Disclosure form within 5
business days after the date the gift was received, pursuant to A.R. 2.93. Refer to Phoenix City
Code §2-52(D) for disclosure requirements and §2-52(A)(7) for the definition of a “Gift”.
Full Name of Recipient: ______________________________________________________________
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By checking this box and typing my name below, the undersigned, does hereby state under penalty of
perjury that all the information contained in this Gift Disclosure form is filed timely and is true and correct
to the best of my knowledge; and by typing my name below I acknowledge that such action constitutes
the legal equivalent of signing my name and I hereby waive any requirement that this form be notarized
in order to be legally enforceable.
Typed Name: ____________________________________________________ Date: _________________
How to file: Email the completed form to mailbox.city.clerk.department@phoenix.gov or mail to the City of
Phoenix, City Clerk Department, Records & Elections Division, 200 West Washington Street, 15th Floor,
Phoenix, AZ 85003-1611
Date Gift
Received
Estimated
Fair Market
Value
Brief Description
of Gift
Full Name of
Gift Giver
Gift Giver Organization
Affiliation
