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STATE OF NEW JERSEY Department of Education P.O. (The State of New Jersey)

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Page 1 of 11
STATE OF NEW JERSEY
Department of Education
P.O. Box 500
Trenton, New Jersey 08625-0500
SCHOOL ETHICS COMMISSION
2022 PERSONAL/RELATIVE DISCLOSURE STATEMENT
This Personal/Relative Disclosure Statement is required annually of all school officials in
accordance with N.J.S.A. 18A:12-21 et seq., the School Ethics Act (the Act). The
Personal/Relative Disclosure Statement must be filed by April 30th of each year, or within thirty
(30) days of assuming office or position if newly elected or appointed. This statement is a public
record.
SECTION I. Personal Information
Role of School Official:
First Name: Middle Initial:
Last Name:
Name and Business Address of the Local School District or Charter School (Street, City, State, Zip):
County of Local School District or Charter School:
Spouse
Information (if applicable):
Last Name:
First Name:
I do not have a spouse.
Middle Initial:
- SELECT ROLE -
- SELECT COUNTY -
Page 2 of 11
SECTION II. Relative Information
1. Do you have a relative, or a person related to you by marriage, who is employed by the
local school district or charter school with which you hold office or are employed? For officers
or employees of the NJSBA, do you have a relative, or a person related to you by marriage, who
is employed by any local school district or charter school?
YES NO
If YES, please provide the following information:
FULL NAME OF THE
INDIVIDUAL
RELATIONSHIP
TO THE
SCHOOL
OFFICIAL
NAME OF THE LOCAL
SCHOOL DISTRICT OR
CHARTER SCHOOL AT
WHICH THE INDIVIDUAL
IS EMPLOYED
POSITION HELD BY
THE INDIVIDUAL
Page 3 of 11
2. Are you or a relative a party to a contract with the local school district or charter school
with which you hold office or are employed? For officers or employees of the NJSBA, are you,
or a relative, a party to a contract with any local school district or charter school?
YES NO
If YES, please provide the following information:
FULL NAME OF THE
INDIVIDUAL
RELATIONSHIP
TO THE
SCHOOL
OFFICIAL
NAME OF THE LOCAL
SCHOOL DISTRICT OR
CHARTER SCHOOL
THE NATURE OF
THE CONTRACT
Page 4 of 11
3. Are you or a relative employed by, or do you or a relative receive compensation from or
have an interest in, any business which is a party to a contract with the local school district or
charter school with which you hold office or are employed? For officers and employees of the
NJSBA, are you, or a relative, employed by, receive compensation from, or have an interest in
any business which is a party to a contract with any local school district or charter school?
YES NO
If YES, please provide the following information:
NAME OF THE LOCAL
SCHOOL DISTRICT OR
CHARTER SCHOOL
THE NATURE OF THE
CONTRACT
Page 5 of 11
2022 FINANCIAL DISCLOSURE STATEMENT
This Financial Disclosure Statement is required annually of all school officials in accordance
with the Act. The Act requires that the financial information provided by a school official relates
to the preceding calendar year. The Financial Disclosure Statement must be filed by April 30th
of each year, or within thirty (30) days of assuming office or position if newly elected or
appointed. This statement is a public record.
SECTION III. Financial Information
If the information has changed from the preceding calendar year, it is recommended that the
official also provide financial information which is current as of five days prior to the date of this
filing.
1. In the preceding calendar year, did you or a member of your immediate family receive
income, earned or unearned, in excess of $2,000.00?
YES NO
Before providing responsive information below, please note that:
• Individual client fees, customer receipts, or commissions on transactions received
through a business organization do not need to be separately reported as sources of
income; and
• If a publicly traded security or interest derived from a financial institution is the source of
income, the security or interest derived from a financial institution does not need to be
reported unless the school official or a member of their immediate family has an interest
in the business organization or financial institution.
If YES, please provide the following information:
NAME OF SOURCE
OF INCOME
ADDRESS FOR
SOURCE OF INCOME
(STREET, CITY, STATE, AND ZIP)
RECIPIENT OF
SOURCE OF
INCOME
RELATIONSHIP
TO
SCHOOL
OFFICIAL
Page 6 of 11
NAME OF SOURCE
OF INCOME
ADDRESS FOR
SOURCE OF INCOME
(STREET, CITY, STATE, AND ZIP)
RECIPIENT OF
SOURCE OF
INCOME
RELATIONSHIP
TO
SCHOOL
OFFICIAL
Page 7 of 11
2. In the preceding calendar year, did you or a member of your immediate family receive a
fee or honorarium having an aggregate amount exceeding $250.00 from any single source for
personal appearances, speeches, or writings?
YES NO
If YES, please provide the following information:
NAME OF SOURCE
ADDRESS FOR
SOURCE OF INCOME
(STREET, CITY, STATE, AND ZIP)
RECIPIENT OF
SOURCE OF
INCOME
RELATIONSHIP
OF RECIPIENT
TO
SCHOOL
OFFICIAL
Page 8 of 11
3. In the preceding calendar year, did you or a member of your immediate family receive a
gift, reimbursement, or prepaid expense having an aggregate value exceeding $250.00 from any
single source, excluding relatives?
YES NO
If YES, please provide the following information:
NAME OF SOURCE
ADDRESS FOR
SOURCE OF INCOME
(STREET, CITY, STATE, AND ZIP)
RECIPIENT OF
SOURCE OF
INCOME
RELATIONSHIP
OF RECIPIENT
TO
SCHOOL
OFFICIAL
Page 9 of 11
4. In the preceding calendar year, did you or a member of your immediate family have an
interest in a business organization?
YES NO
If YES, please provide the following information:
NAME OF BUSINESS
ORGANIZATION
ADDRESS FOR
BUSINESS ORGANIZATION
(STREET, CITY, STATE, AND ZIP)
Page 10 of 11
CERTIFICATION
I understand that this Certification constitutes my representation of the accuracy of my
Personal/Relative and Financial Disclosure Statements. I hereby certify that the within
Personal/Relative and Financial Disclosure Statements contain no willful misstatement or
omission of material fact, and constitute a full disclosure with respect to all matters required by
N.J.S.A. 18A:12-21 et seq. I am aware that if I fail to file my Personal/Relative and Financial
Disclosure Statements, or I file Personal/Relative and Financial Disclosure Statements
containing information that I know to be false, I shall be subject to disciplinary action up to and
including removal pursuant to N.J.S.A. 18A:12-29.
Certified by:
Date of Certification:
Page 11 of 11
DEFINITIONS
N.J.S.A. 18A:12-23. Definitions
For the purposes of the School Ethics Act, unless the context clearly requires a different meaning:
“Administrator” means any officer, other than a board member, or employee of a local school
district who (i) holds a position which requires a certificate that authorizes the holder to serve as
school administrator, principal, or school business administrator; or (ii) holds a position which does
not require that the person hold any type of certificate but is responsible for making
recommendations regarding hiring or the purchase or acquisition of any property or services by the
local school district; or (iii) holds a position which requires a certificate that authorizes the holder to
serve as supervisor and who is responsible for making recommendations regarding hiring or the
purchase or acquisition of any property or services by the local school district;
“Board member” means any person holding membership, whether by election or appointment, on
any board of education other than the State Board of Education;
“Business” means any corporation, partnership, firm, enterprise, franchise, association, trust, sole
proprietorship, union, political organization, or other legal entity but shall not include a local school
district or any other public entity;
“Interest” means the ownership or control of more than 10% of the profits, assets, or stock of a
business but shall not include the control of assets in a labor union;
“Local school district” means any local or regional school district established pursuant to chapter 8
or chapter 13 of Title 18A of the New Jersey Statutes and any jointure commission, county
vocational school, county special services district, educational services commission, educational
research and demonstration center, environmental education center, and educational information and
resource center;
“Member of immediate family” means the spouse or dependent child of a school official residing in
the same household;
“Relative” means the spouse, natural or adopted child, parent, or sibling of a school official;
“School official” means a board member, an employee or officer of the New Jersey School Boards
Association, but not including any member of the secretarial, clerical or maintenance staff of the
association, or an administrator; and
“Spouse” means the person to whom a school official is legally married under New Jersey law.
Return to Personal/Relative Disclosure Statement, Section I, Personal Information
Return to Personal/Relative Disclosure Statement, Section II, Relative Information
Return to Financial Disclosure Statement, Section III, Financial Information
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STATE OF NEW JERSEY Department of Education P.O. (The State of New Jersey)

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Completed 11 February 2022

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