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HomeMy WebLinkAboutExhibitFORM 4A DISCLOSURE OF BUSINESS TRANSACTION, RELATIONSHIP OR INTEREST LAST NAME - FIRST NAME - MIDDLE INITIAL OFFICE / POSITION HELD MAILING ADDRESS AGENCY OR ADVISORY BOARD CITY ZIP COUNTY ADDRESS OF AGENCY HOW TO COMPLETE AND FILE THIS FORM: arts A and B of this form serve two different purposes. Part A is for advisory board members who wish to use an exemption in thi thics laws that is applicable only to advisory board members. Part B is for public officers and employees who wish to use a sepa- ate exemption that is applicable when the business entity involved is the sole source of supply within the political subdivision. In rder to complete and file this form: • Fill out Part A or Part B, as applicable. • Sign and date the form on the reverse side. • File Part A with the appointing body or person that will be waiving the restrictions of 112.313(3) or (7), Fla. Stat., prior to the waiver. • File Part B with the governing body of the political subdivision in which the reporting person is serving, prior to the transaction. PART A - DISCLOSURE OF TRANSACTION OR RELATIONSHIP CONCERNING ADVISORY BOARD MEMBER Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain business relationships on the part of public officers and employees, including persons serving on advisory boards. See Part III, Chapter 112, Florida Statutes, and/or the brochure entitled "A Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees" for more details on these prohibitions. However, Section 112.313(12), Florida Statutes, permits the appointing official or body to waive these requirements in a particular instance provided: (a) waiver by the appointing body must be upon a two-thirds affirmative vote of that body; or (b) waiver by the appointing person must be effected after a public hearing; and (c) in either case the advisory board member must fully disclose the transaction or relationship which would otherwise be prohibited by Subsections (3) of (7) of Section 112.313, Florida Statutes. This Part of Form 4A has been prescribed by the Commission on Ethics for such disclosure, if and when applicable to an advisory board member. LEASE COMPLETE THE FOLLOWING: 1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, or contractual relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is held by [please check applicable space(s)]: ( ) The reporting person; ( ) The spouse of the reporting person, whose name is ; or ( ) A child of the reporting person, whose name is 2. The particular transaction or relationship for which this waiver is sought involves [check applicable space]: ( ) Supplying the following realty, goods, and/or services: ( ) Regulation of the business entity by the governmental agency served by the advisory board member. 3. The following business entity is doing business with or regulated by the governmental agency: 4. The relationship of the undersigned advisory board member, or spouse or child of the advisory board member, to the busi- ness entity transacting this business is [check applicable spaces]: ( ) Officer; ( ) Partner; ( ) Associate; ( ) Sole proprietor; ( ) Stockholder; ( ) Director; ( ) Owner of in excess of 5% of the assets of capital stock in such business entity; ( ) Employee; ( ) Contractual relationship with the business entity; ( ) Other, please describe: CE FORM 4A -- REV. 1-98 [CONTINUED ON REVERSE SIDE] PART B - DISCLOSURE OF INTEREST IN SOLE SOURCE OF SUPPLY MUST COMPLETE THIS PART: Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain employment and business relationships on the part of pub- lic officers and employees. See Part III, Chapter 112, Florida Statutes, and/or the brochure entitled "A Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees" for more details on these prohibitions. However, Section 112.313(12)(e), Florida Statutes, provides an exemption from the above -mentioned restrictions in the event that the business entity involved is the only source of supply within the political subdivision of the officer or employee. In such cases the officer's or employee's interest in the business entity must be fully disclosed to the governing body of the political subdivision. This Part of Form 4A has been prescribed by the Commission on Ethics for such disclosure, if and when applicable. LEASE COMPLETE THE FOLLOWING: 1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, or contractual relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is held by [please check applicable space(s)]: ( ) The reporting person; ( ) The spouse of the reporting person, whose name is ; or ( ) A child of the reporting person, whose name is 2. The following are the goods, realty, or services being supplied by a business entity with which the public officer or employee, or spouse or child of such officer or employee, is involved is: 3. The business entity which is the only source of supply of the goods, realty, or services within the political subdivision is: (NAME OF ENTITY) (ADDRESS OF ENTITY) 4. The relationship of the undersigned public officer or employee, or spouse or child of such officer or employee, to the busi- ness entity named in Item 3 above is [check applicable spaces]: ( ) Officer; ( ) Partner; ( ) Associate; ( ) Sole proprietor; ( ) Stockholder; ( ) Director; ( ) Owner of in excess of 5% of the assets or capital stock in such business entity; ( ) Employee; ( ) Contractual relationship with the business entity; ( ) Other, please describe: SIGNATURE SIGNATURE DATE SIGNED DATE FILED NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES s. 112.317, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES GROUNDS FOR AND MAYBE PUNISHED BY ONE OR MORE OF THE FOLLOWING: IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $10.000. CE FORM 4A -- REV. 1-98 [CONTINUED FROM FIRST SIDE]