GIFT DISCLOSURE - ELECTED OFFICIAL
Year: ________
Quarter: __ First (Gifts received in January – March; file by April 30)
__ Second (Gifts received in April – June, file by July 30)
__ Third (Gifts received in July – September, file by October 30)
__ Fourth
(Gifts received in October – December, file by January 30 of following year)
If disclosure of a gift is required, this Gift Disclosure form must be filed with the City Clerk
within 30 calendar days following the end of the calendar quarter in which the gift was
received. 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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Continued on back side of form
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By checking this box and typing my name below, the undersigned does hereby state under penalty of
perjury that all of the information provided 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
