Fill - Free fillable M STATEMENT OF ECONOMIC INTERESTS (City of Milwaukee) PDF form

DUE WITHIN  DAYS OF NOMINATION, EMPLOYMENT OR APPOINTMENT

STATEMENT OF ECONOMIC INTERESTS

For: Nominee to City Board, Committee or Commission

or Newly Employed or Appointed Persons

(Rev. 12/15)

ilwaukee strives to maintain a reputation for good

government and high ethical standards. Each employee,

oicial, and board/commission member can support this

reputation through conduct that shows integrity and concern for

public interest. Ethical behavior involves using good judgment

and common sense in performing duties and responsibilities.

All employees, oicials and board/commission members are

covered by the City Code of Ethics, found in the Milwaukee

Code Ordinance (MCO), Chapter 303, which describes

standards of conduct and conflicts of interest. The Milwaukee

Common Council determines which individuals are required to

file the Statement of Economic Interests pursuant to Chapter

303.

These persons include:

• All elected city oicials

• City employees identified by department heads as having

discretionary powers

• Members and nominees of designated boards and

commissions

• Candidates for elective oice

The Ethics Board takes the information you provide in the

Statement of Economic Interest seriously. Each form is checked

when it arrives for completion. Each year the Board conducts a

random review of the entire filing. Some forms may be returned

for clarification or completion.

The Statement of Economic Interests form is a public record

as defined by the Wisconsin Public Records law, Sec. 19.31-39,

Wis. Stats. Any member of the public may request a copy or

inspection of your Statement of Economic Interests form.

Any nominee to a city board, commission or committee who is

required to file as so designated by the city positions ordinance

shall file a Statement of Economic Interests within 21 days of

being nominated unless the nominee has previously filed a

statement with the board for that year. The information on the

statement shall be current as of the date he or she is nominated.

Any newly appointed or employed individual required to file

as so designated by the city positions ordinance shall file a

Statement of Economic Interests within 21 days following the

date he or she assumes oice if the individual has not previously

filed a statement with the Board during that year.

The fees and penalties for filing the Statement of Economic

Interests form after the date required for filing are as

follows: $25 if 11 days or more late; $5 per day for forms filed

more than 30 days late; up to a maximum of $100 in daily late

fees. See s. 303-11-2-a, MCO

Any statement of economic interests that is filed late shall

not be considered a completed statement without payment

of the appropriate fee for late filing. See s. 303-11-2-a, MCO

Employees, city oicials and board/commission members

who have not filed Statement of Economic Interests Forms

within 45 days of the deadline may be referred to the City

Attorney for charges in Municipal Court, with a conviction

subject to a forfeiture of $250 to $1,000 and imprisonment

for failure to pay the forfeiture of 10 to 40 days. See s. 303-11-

2-d, MCO

To view the City of Milwaukee Ethics Code and the Board

of Ethics Rules and Procedures, visit our web site at

www.milwaukee.gov/ethics. If you have any questions, please

contact the City of Milwaukee Ethics Board Oice

at ethics@milwaukee.gov or (414) 286-8641.

Thank you,

Your Milwaukee Ethics Board

Annie Wacker – CHAIR

Robert Shelledy – VICE CHAIR

Joanne Barndt

Carrie Davis

Patricia Hintz

Martha De La Rosa

Bradley Kalscheur

SEE REVERSE FOR LOCAL AND STATE ETHICS GUIDELINES

As you go about your oicial duties, please keep

these general guidelines in mind:

• A city employee or oicial should not accept

anything of value that could appear to influence his/

her public duties.

• A city employee or oicial should not accept

anything of value that could appear to be a reward

for action taken in his/her public duties.

• A city employee or oicial must report any gift or

entertainment totaling more than $50 received

during the year.

• A city employee or oicial should not use his/her

public position for personal gain or for the gain of

immediate family members or for organizations in

which he/she has an interest.

• A city employee or oicial should not use work

place information that is unavailable to the public,

for personal gain.

• Contracts of more than $3,000 between a city

employee or oicial and the city are prohibited

without written disclosure to the Ethics Board and

to the contracting department.

Many city oicials are also covered by the requirements

for Local Oicials put forth in the Wisconsin State

Statutes. The State Code of Ethics for Local Oicials

does not apply to all city employees and oicials.

Section 19.59 of the Wisconsin Statutes cover:

• Elected oicials

• Individuals appointed to a position for a

specified term

• Individuals who serve in a position at the pleasure

of the Mayor or Common Council

• A city employee or oicial should not represent

persons, for compensation, before city departments,

commissions, or boards unless as part of his/her

oicial duties or at a recorded open hearing.

• For 12 months after leaving city employment,

an employee or oicial may not represent, for

compensation, persons before city departments,

commissions or boards related to his/her

former position.

These comments are only a general description of

parts of the Ethics code itself. The actual statutes, rules,

and opinion summaries, as well as the Ethics Board

itself, should be consulted when questions arise. The

complete text of the ethics code can be found in

Chapter 303 of the Milwaukee Code of

Ordinances. City departments also have copies

of the code for posting.

Positions within City government that fit this definition

are not only covered by local ethics code but also have

responsibilities to conform to the requirements of the

State of Wisconsin Ethics Code for Local Oicials as

well.

We are attaching State Ethics Form 219, which oers

guidelines on gifts and entertainment. Please take

a few moments to review it. Our Board recommends

that you keep it on file for future reference. If you

have any questions regarding the State Guidelines for

Local Oicials please contact the State of Wisconsin

Government Accountability Board at (608) 266-8123.

LOCAL GUIDELINES

STATE GUIDELINES

Definitions:

• “Immediate family member” means your spouse, and any child,

step-child, parent, or parent-in-law who receives more than

one-half his or her support from you or from whom you receive

more than one-half of your support.

• “Income” means gross income before deductions and

depreciation, from whatever source derived, as defined by the

Internal Revenue Code, but excludes dividends and interest.

DUE WITHIN 21 DAYS OF BEING NOMINATED, APPOINTED OR EMPLOYED.

General filing information:

• The information sought in this form is required by Chapter 303,

Milwaukee Code of Ordinances.

• Attach additional pages if necessary.

• Go to the Ethics Board website at www.milwaukee.gov/ethics

for extra forms and instructions.

• Questions?

Email ethics@milwaukee.gov or call (414) 286-8641.

INSTRUCTIONS

STATEMENT OF ECONOMIC INTERESTS

For: Nominee to City Board, Committee or Commission or Newly Employed or Appointed Persons

LIST:

• partnership (general, limited or limited liability)

• corporation (regardless of tax status and including

service corporations)

• limited liability company (LLC)

For any BUSINESS that is a partnership, limited liability company, Subchapter S, or Subchapter

C corporation in which you or your immediate family, directly or indirectly, separately or together,

owned or controlled at least 10% interest and from which you or your immediate family has

received $1,000 or more during the current year up to the date of appointment, list the name of

the business and identity of each payer of $1,000 or more to the business.

DO NOT LIST:

• an individual (unless the individual was a lobbyist,

your employer, or acting on behalf of a business or

organization)

• a decedent’s estate

A. EMPLOYERS. List each EMPLOYER from which you and your immediate family received $1,000

or more for the current year up to the date of appointment.

LIST:

• each employer from which you and your

immediate family member received $1,000 or more

during the year

• City of Milwaukee if applicable

B. OTHER SOURCES OF INCOME. List other sources from which you or your immediate family

received income of $1,000 or more for the current year up to the date of appointment.

DO NOT LIST:

• an individual (unless the individual was a lobbyist,

your employer, or acting on behalf of a business

or organization)

LIST:

• any entity from which you or your immediate

family has received income of $1,000

• Social Security payments

• an entity from which you or your family received

retirement benefits

• an entity from which you or your family received

directors fees

DO NOT LIST:

• the source of dividends or interest

• the source of insurance benefits, inheritances,

scholarships (if no teaching or services were required

in return)

• a decedent’s estate

• a political contribution that has been reported to the

Election Commission

• an individual (unless the individual was a lobbyist,

your employer, or acting on behalf of a business or

organization)

Ethics Board

Part 1 – Sources of Income

Part 2 – Business

LIST THE NAME OF EACH:

• stocks and stock options

• bond

• note or other evidence of indebtedness

• sponsor of mutual fund and money market fund

(i.e. Fidelity or Janus Fund)

• security issued by the State of Wisconsin or by

local governmental entities within Wisconsin

• any of the above held directly or:

◆ in a deferred compensation plan, profit sharing

plan, or pension plan whose investments you or

your immediate family direct

◆ in an individual retirement account (IRA)

◆ in a trust in which you or your immediate family

member has beneficial use

◆ held for you by a corporation, partnership, or

other entity which you or your immediate family

member controls

List stocks, bonds, limited partnerships, Wisconsin governmental securities you and your

immediate family held with a minimum of $5,000 for the current year up to the date of appointment.

DO NOT LIST:

• savings accounts

• checking accounts

• certificates of deposit

• annuities

• insurance contracts

• securities issued by the federal government or a

government outside Wisconsin

• securities in a company in which you and your

immediate family’s total interest is valued at less

than $5,000

Investments held in a trust: List the name of each security

valued at $5,000 or more, held in a trust created by you or in

which you have a vested beneficial interest.

Investments held in a Tax Qualified Account: If an investment is

owned in a tax qualified account (a deferred compensation plan,

profit-sharing plan, or pension plan), you must list the name of

the security only if you or a member of your immediate family

controls the selection of that security in your account. (If the

individual investments in your plan are selected by someone

other than you, such as an investment advisor or plan trustee,

then you do not have to list the individual securities in that plan.)

Because you control investments in your Individual Retirement

Account (IRA), you must list individual securities held by your IRA.

City of Milwaukee Deferred Compensation Plan: This plan

is not directed by the employee unless you have the PCRA

(Personal Choice Retirement Account). If you are involved in the

PCRA you must list the name of each security valued at $5,000 or

more.

Wisconsin Governmental Securities: any security issued by

the State of Wisconsin or by local governmental entities within

Wisconsin.

List the security by name. For example, list “Harley Davidson”

or “IBM.” Do NOT list “deferred compensation plan” or “IRA”

or “Charles Schwabb,” since these terms do not identify the

securities within the deferred compensation plan, IRA, or

brokerage account.

Name of sponsor of mutual fund or money market fund:

List the sponsor name only, NOT each separate fund within each

mutual fund or money market. Combine the value of all within

each sponsor name.

To determine whether an investment meets the $5,000

minimum for reporting add the total value of all types of

securities you and your immediate family held in an individual

business or other entity.

Investments held by a corporation, partnership or other entity

which you and your immediate family control: Investments

must be listed (if aggregating $5,000 or more) if they are owned

by another entity which you and your immediate family control

(i.e. have more than 50% of outstanding voting interests or have

a majority of the directors or managers of the entity).

LIST:

• real estate you or your immediate family owned

directly or through: (a) partnership; (b) a

corporation; (c) a trust; or (d) other enterprise

List specific location of REAL ESTATE in Milwaukee, Ozaukee, Racine, Washington and Waukesha

counties (except your principal residence) in which you or your immediate family hold at least 10%

interest which is valued at $5,000 or more for the current year up to the date of appointment.

DO NOT LIST:

• your principal residence unless it was used for the

conduct of a business or for rental purposes

Part 3 – Investments

EXPLANATIONS

Part 4 – Real Estate

LIST:

• each creditor (for personal and business debts,

including mortgages) if you or a family member

was personally liable for the debt

• your portion of any partnership debts

List each creditor to whom you and your immediate family owed $5,000 or more for the current

year up to the date of appointment.

LIST THE NAME OF EACH:

• each business, labor union, association,

cooperative, or other organization with which

you were associated and the nature of your

association (e.g., oicer, member, director,

authorized representative or agent)

• non-profit social or community service

organizations

• bar association

List every organization with which you are associated and the nature of your association with

that organization for the current year up to the date of appointment.

DO NOT LIST:

• charitable organizations (entities to which a

contribution is tax deductible, e.g., American Red

Cross)

• political organizations (entities whose primary

purpose is to influence voting)

• trusts

• federal, state, or local governmental agencies

List individuals and organizations that, directly or indirectly, provided you with

ENTERTAINMENT or GIFTS totaling more than $50 for the current year up to the date

of appointment.

DO NOT LIST:

• gifts from your spouse, child, parent, brother, sister, grandchild, grandparent, aunt, uncle, niece, nephew,

fiancé(e), parent-in-law, grandparent-in-law, brother-in-law, or sister-in-law

A “gift” includes any money, property, favor, service,

entertainment, travel, or payment furnished without

valuable consideration. Includes tickets to sporting

or theatrical events, golfing fees, prizes, samples and

promotional items, items from sales representatives,

or a part of business promotions, and similar items.

A “gift” does not include political contributions reported

to the Election Commission, or meals, beverages, items,

or lodging that an individual oers as hospitality at his

or her own expense, and not as a business expense, for

reasons unrelated to your holding a city oice or position.

Part 5 – Creditors

Part 6 – Associations

Part 7 – Gifts

LIST :

• each individual or organization from which you

received lodging, transportation, meals, expenses,

or honoraria having a total value of more than $50,

for attendance at a conference, presentation of a

talk, participation in a meeting, or for a published

work about issues initiated by or aecting city

government or city agencies

List sources of HONORARIA and payment of EXPENSES more than $50 related to your city duties

as provided for in Chapter 303-9-2a, MCO, for the current year up to the date of appointment.

DO NOT LIST:

• information about lodging, transportation, meals,

money or any other thing of pecuniary value if:

◆ you returned it within 30 days

◆ you received it from the agency of which your

city public oice is a part

◆ you received it from a source already listed in

Part 1 or Part 2

◆ you already reported the payment to the Ethics

Board as a matter of public record

◆ the expense is unrelated to holding public oice

and did not arise from holding public oice

Mail, email or fax completed form to:

City of Milwaukee Ethics Board ethics@milwaukee.gov

200 East Wells Street, Room 205 Fax: (414) 286-3456

Milwaukee, WI 53202

Due within 21 days of nomination, employment or appointment.

PLEASE NOTE: Forms filed after the due date may be subject to late filing fees.

If you email the form, you will receive confirmation of receipt. If you do not receive a confirmation,

contact the Ethics Board Oice at (414) 286-8641.

If you fax the form, keep the original and do not mail it to the Ethics Board.

Keep a copy of your completed form for your records.

For questions regarding the City of Milwaukee Ethics Code contact the City of Milwaukee Ethics Board

Oice at ethics@milwaukee.gov, (414) 286-8641 or visit our web site at www.milwaukee.gov/ethics.

Part 8 – Honoraria and Payment of Expenses

Ethics Board

A. List each EMPLOYER from which you and your immediate family received $1,000 or more for the current year up

to the date of appointment (e.g., City of Milwaukee).

Name of Payer City and State Nature of Business Self (S) or Family (F)

B. List other sources of income from which you or your immediate family received income of $1,000 or more for the

current year up to the date of appointment.

Name of Payer City and State Nature of Business

Print legibly in black ink or type.

Name:

City Position sought:

Do you live in the City of Milwaukee? ☐ Yes ☐ No

(Rev. 12/15)

For: Nominee to City Board, Committee or Commission or

Newly Employed or Appointed Persons

DUE WITHIN 21 DAYS OF BEING NOMINATED, APPOINTED OR EMPLOYED.

For any payer listed above that is a partnership, limited liability company, Subchapter S or Subchapter C corporation in

which you or your immediate family has a 10% or greater interest, list the IDENTITY OF EACH PAYER of $1,000 to such

partnership, LLC, Sub-S or Sub-C corporation (see instructions for certain payers which do not have to be listed).

Name of Payer Name of Business Receiving Payment Nature of Business City and State

List stocks, bonds, limited partnerships, Wisconsin governmental securities you and your immediate family held

($5,000 or more) for the current year up to the date of appointment.

SEE THE INSTRUCTION SHEET FOR EXPLANATIONS, EXAMPLES AND EXCEPTIONS.

Name of each Security or Mutual Fund Sponsor

TYPE OF SECURITY  ☑ ONE

Bond,

Note

WI Gov’t.

Sect.

Mutual Funds or

Money Market

$5,000-

$50,000

more than

$50,000

Stock, Options,

Futures

AMOUNT  ☑ ONE

Statement of Economic Interests

For Oice Use Only

Ethics Board

Part 1 – Sources of Income Current year

Part 2 – Business Current year

Part 3 – Investments Current year

List sources of HONORARIA and payment of EXPENSES of more than $50 related to your city duties for the current year up

to the date of appointment.

Payer Approximate Value of Expenses Amount of Honorarium Circumstances of Receipt

List every organization with which you are associated and the nature of your association for the current year up to the date

of appointment.

Name of Organization City and State Nature of Association (i.e. member, oicer, director)

List specific location of REAL ESTATE in Milwaukee, Ozaukee, Racine, Washington and Waukesha counties (except your

principal residence) in which you or your immediate family hold at least 10% interest which is valued at $5,000 or more.

Street Address County Type of Property Nature of Interest

List each creditor to whom you and your immediate family owed $5,000 or more for the current year up to the date

of appointment.

Creditor ($5,000 or more) City and State $5,000 - $50,000 (check ✓) more than $50,000 (check ✓)

List individuals and organizations that provided you with ENTERTAINMENT or GIFTS more than $50 for the current year up

to the date of appointment.

Name of Provider City and State Description of Gift Approx. Value

I have read the accompanying instructions and certify that the information contained in this Statement of Economic Interests is true, complete

and correct to the best of my knowledge, information and belief. If any part has been left blank, I have done so intentionally because there is

nothing to report. Typing your name on the line below constitutes your signature of this document. Please sign and date your form and list your

daytime telephone number and e-mail address. Clearly indicate if your daytime telephone number or e-mail address is your home telephone

number or home e-mail address. In the event of a public records request, all information required by law will be released.

Signature Date

Daytime telephone number Is this your home telephone number? ☐ Ye s ☐ No

E-mail address

Is this your home e-mail address? ☐ Yes ☐ No

Part 4 – Real Estate Current year

Part 5 – Creditors Current year

Part 6 – Associations Current year

Part 7 – Gifts Current year

Part 8 – Honoraria and Payment of Expenses Current year

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