Fillable STATEMENT OF ECONOMIC INTEREST (City of Milwaukee)

Fill Online, Printable, Fillable, Blank STATEMENT OF ECONOMIC INTEREST (City of Milwaukee) Form

Use Fill to complete blank online CITY OF MILWAUKEE (WI) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STATEMENT OF ECONOMIC INTEREST (City of Milwaukee)

On average this form takes 65 minutes to complete

The STATEMENT OF ECONOMIC INTEREST (City of Milwaukee) form is 6 pages long and contains:

  • 1 signature
  • 7 check-boxes
  • 253 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Milwaukee

BROWSE CITY OF MILWAUKEE (WI) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATEMENT OF ECONOMIC INTEREST
Milwaukee County Ethics Board
Courthouse Room 212
901 North 9
th
Street
Milwaukee, WI 53233
Telephone – 278-5332 * Fax – 223-1897
CURRENT INFORMATION: All information given below must be current; that is, not prior to the 15
th
of the month
preceding the month this statement is prepared.
TYPE OR PRINT: Additional directions, definitions and other pertinent information are contained in the Instruction
Sheet (yellow insert). Please read it carefully BEFORE completing the Statement. If more space is needed, please use
additional sheets.
DATE PREPARED: ___________________________________
(Month) (Day) (Year)
NAME: __________________________________________________________________________________
(Last) (First) (Middle Initial)
POSITION SOUGHT/HELD w/COUNTY GOVERNMENT: _________________________________________
SPOUSE’S NAME: _________________________________________________________________________
(Last) (First) (Middle Initial)
1. OFFICES, DIRECTORSHIPS & POSITIONS
* In this section, “Organization” means any corporation, partnership, proprietorship, firm, enterprise, franchise, association,
trust, Board, Commission or other legal entity other than an individual or body politic.
1A: As of the dated cited above, were you or your spouse an officer, partner, sole proprietor, director or trustee of any
business or other organization?
Yes No
1B
: As of the date cited above, were you or your spouse an officer of or did you or your spouse hold a position with any
organization doing business with Milwaukee County or receiving funds from Milwaukee County? (9.04(1)(a) and
(f)).
Yes No
If you have answered no to both above items, please check here:
Proceed to Item #2
I
f you have answered yes to either 1A or 1B above, identify each business or organization and position held:
Name of Business or Corporation
City & State
Position Held
THIS SPACE FOR ETHICS BOARD OFFICE USE ONLY
J
anuary 2015
2020
2. SIGNIFICANT FIDUCIARY RELATIONSHIPS
As of the date cited on the first page, did you or your spouse own or control any of the following directly or indirectly:
A) At least ten (10) percent of the outstanding stock of any business corporation; or
B) Stock having a value of at least $5,000 ;or
C) An interest of at least ten (10) percent or $5,000 of any business? (9.04(1)(a) and (18))
If no to all of the above items, please check here:
Proceed to Item #3
If yes to any of the above items, please identify the business and the type of ownership:
**Note: You need not report the actual dollar values or number of shares, etc.
Business Entity
City & State of its
principal office
Type of Ownership
(e.g. Common Stock, Limited Partnership)
3. BOND, DEBENTURES & DEBT OBLIGATIONS
As of the date cited on the first page, did you or your spouse hold any bonds, debentures or debt obligations of a municipal
corporation or other corporation in excess of $5,000? (9.04(1)(b))
If no, please check here:
Proceed to Item #4
If yes, please identify each Issue and place a checkmark in the proper column below to indicate the value.
Issuer Name
City & State
Value Over
$50,000
January 2015
4. CREDITORS
As of the date cited on the first page, did you or your spouse owe, separately or together with another person, to any creditor
$5,000 or more? (9.04(1)(c))
If no, please check here:
Proceed to Item #5
If yes, please identify each creditor. Place a checkmark in the appropriate column for the amount owed.
Creditor’s Name
City & State
Value Over
$50,000
5. REAL PROPERTY
As of the date cited on the first page, did you or your spouse hold an interest valued at $5000 or more in real property other
than your principal residence or other than property in which the pro rata share held is less than 10% of the outstanding
shares? (9.04(1)(c))
* Report only on properties located in the counties of Milwaukee, Ozaukee, Washington, Waukesha and Racine.
If no, please check here:
Proceed to Item #6
If yes, please identify the property and nature of interest held.
Location of Real Property (street/rural route address; fire number &
municipality)
Type of property (farm,
commercial property or
recreational home)
Nature of Interest (own,
lease, option land
contract, partnership)
6. TRANSFERS
As of two calendar years preceding the filing of this statement, have you or your spouse transferred to any member of your
immediate family any significant fiduciary relationship (as defined in the instruction sheet) or any real property or any bonds,
debentures or debt obligations of municipal corporation or other corporation which is in excess of $5,000? (9.04(1)(d))
If no, please check here:
Proceed to Item #7
If yes, please identify each significant fiduciary relationship bond, debenture, or debt obligation of a municipal
corporation or other corporation, which is in excess of $5,000.
Business, Issuer, Real Property, Creditor
Address
Description of Interest
January 2015
• INCUMBENTS now in elective public office and current County employees are to SKIP Item #8.
• CANDI
DATES for elective public office are to SKIP Item #7.
7. GIFTS, HONORARIA, FEES & EXPENSES
List each individual and organization from which you or your spouse received a GIFT, HONORARIUM, FEE and
EXPENSES during the preceding taxable year. (9.14) For a full understanding of this reporting requirement, it is importan
t
th
at you read Section 9.14, Code of Ethics, in its entirety.
7
A: GIFTS including ENTERTAINMENT. A “gift” is the receipt of anything of value (9.02(1)), which is furnished
without valuable consideration. Do not include anything received, which was made for a purpose unrelated to duties
or responsibilities of the position of the official or employee. List all individuals and organizations from which you
received in the past year entertainment or gifts having a total value of $50 or more, not including the value of food
or beverage offered coincidentally with a talk or meeting related to the business of the County. Include tickets to
sporting or theatrical events, golfing fees, prizes, samples of promotional items from sales representatives or as part
of business promotions and similar items.
7B:
HONORARIA, FEES AND EXPENSES FOR TALKS AND PUBLICATIONS RELATED TO PUBLIC OFFICE.
List each individual or organization from which you or your spouse receiv
ed, in the past year, lodging,
transportation, money or other things having a total value of $50 or more, not including the value of food or
beverage offered coincidentally with a talk or meeting where the subject matter of which was related to your duties
or responsibilities of your position with the County. You do not have to list information about a payment: (1) if you
returned it within 30 days; (2) If you received it from the County; or (3) If you have previously reported the payment
to the Ethics Board as a matter of public record (9.14(2)(a) and (b) and 9.14(3))
If you or your spouse has no reporting(s), please check here:
If you or your spouse has reporting(s) for Item #7, please use the enclosed form titled for this purpose and submit with
you Statement.
P
roceed to signature section at the bottom of this page.
8. CANDIDATES ONLY for elective public office are to furnish the following information:
Name of present employer and position you hold:
____
________________________________________________________________________________________________
(Employer) (Position)
9. ALL FILERS SIGNATURE:
B
y signing this form, I certify that the information contained in this Statement of Economic Interests is true,
correct and complete to the best of my knowledge, information and belief.
X____________________________________________ _____________________________
Signature of person filing Statement Date of Signature
____
_________________________________________
Telephone number during normal business hours
N
OTES:
Chapter 9, County General Ordinances, authorizes this form and prescribes penalties for the failure of a County
Officer or employee and candidate for County Public Office to file this form in a timely manner. (S. 9.03 & 9.04, Code
of Ethics, C.G.O.)
In all cases when the Statement is submitted, it is to be accompanied by the completed form titled “Appendix A
Affidavit”, (form enclosed) pursuant to S. 0.03(5) and Appendix A of Chapter 9, Code of Ethics, C.G.O.
January 2015
click to sign
signature
click to edit
STATEMENT OF ECONOMIC INTERESTS – REPORT FORM FOR ITEM #7
Your Name: _________________________________________________ Date Prepared: ___________________________
(Last name) (First name & middle initial)
7A: GIFTS including ENTERTAINMENT Please type or Print
A. Name of Giver & Organization
B. Date of Gift
C. Approx Value
D. Circumstances
You may duplicate this form if you need additional space.
January 2015
STATEMENT OF ECONOMIC INTERESTS – REPORT FORM FOR ITEM #7
Your Name: _________________________________________________ Date Prepared: ___________________________
(Last name) (First name & middle initial)
7B: HONROARIA, FEES & EXPENSES for TALKS & MEETINGS related to public office: Please type or Print
A. Name of Payer & Organization
B. Approx
Cost/Expense
C. Amount of
Honorarium or
Payment
D. Date & Circumstances
Y
ou may duplicate this form if you need additional space.
January 2015
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STATEMENT OF ECONOMIC INTEREST (City of Milwaukee)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document