SPECIAL OCCASION GIFT WAIVER REQUEST
ELECTED OFFICIALS AND BOARD AND COMMISSION MEMBERS
Phoenix City Code § 2-52(c)(4)
This form is for use by City of Phoenix elected officials and board and commission members to request a
waiver of the gift rules in City Code Section 2-52(D) for gifts received in connection with a special or unusual
occasion. Upon approval by the Ethics Commission, please file this form with the City Clerk.
REQUEST FOR WAIVER OF:
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Receipt of Gifts
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Disclosure of Gifts
Name of Requestor: __________________________________________________________________________
Requestor Status:
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Elected Official
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Board/Commission Member
Address: ____________________________________________________________________________________
Phone: ___________________________ Email: __________________________________________________
Occasion:
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Wedding/Engagement
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Birth/adoption of child
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Death in family
Date of Occasion (or anticipated date): __________________
CONDITIONS FOR APPROVAL
Notwithstanding the grant of this waiver, you should exercise caution in accepting any gift that
likely would not have been offered but for your status as an elected official, board or commission
member, employee or volunteer. With regard to any such gift, you should consider its source,
nature, and value, as well as any possible conflict of interest with official duties. Any gift that
creates the appearance of undue influence or a conflict of interest is prohibited.
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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 the Special Occasion Gift Waiver Request form 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.
Acknowledged and Submitted By:
Typed Name: ______________________________________________________ Date: ________________
ETHICS COMMISSION APPROVAL
Request Approved by
_______________________________________________________ _______________________________
Authorized Signature of Ethics Commission Date
Note: This approval only applies to the City of Phoenix Gift requirements. It does not provide a waiver of any
federal or state requirements.
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
