2. List below the name(s) and address(es) of all family members of public officials/public employees with whom you, members of your
immediate family, or any of your employees have a family relationship and who may directly personally benefit financially from the
proposed transaction. Identify the public officials/public employees and State Department/Agency for which the public officials/public
employees work. (Attach additional sheets if necessary.)
NAME OF NAME OF PUBLIC OFFICIAL/ STATE DEPARTMENT/
FAMILY MEMBER ADDRESS PUBLIC EMPLOYEE AGENCY WHERE EMPLOYED
If you identified individuals in items one and/or two above, describe in detail below the direct financial benefit to be gained by the public
officials, public employees, and/or their family members as the result of the contract, proposal, request for proposal, invitation to bid, or
grant proposal. (Attach additional sheets if necessary.)
Describe in detail below any indirect financial benefits to be gained by any public official, public employee, and/or family members of the
public official or public employee as the result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach
additional sheets if necessary.)
List below the name(s) and address(es) of all paid consultants and/or lobbyists utilized to obtain the contract, proposal, request for pro-
posal, invitation to bid, or grant proposal:
NAME OF PAID CONSULTANT/LOBBYIST ADDRESS
By signing below, I certify under oath and penalty of perjury that all statements on or attached to this form are true and correct
to the best of my knowledge. I further understand that a civil penalty of ten percent (10%) of the amount of the transaction, not
to exceed $10,000.00, is applied for knowingly providing incorrect or misleading information.
Signature Date
Notary’s Signature Date Date Notary Expires
equires the disclosure statement to be completed and filed with all proposals, bids,
