HomeMy WebLinkAboutItem #10 - Discussion ItemFORM 4 MEMORANDUM Ot VOTING CONFLICT
PART A
Ratite t
Address
PART B
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Agency is a unit of [check one]: ( ) State of Florida; (V County, City or other 1' litical Subdivision;
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PART Ci
MEMORANDUM OF CONFLICT OF INTEREST IN A VOTING SITUATION [Required by § 112.3143, F'.5., 19751
If you have voted in your official capacity upon any measure in which you had a personal, private, or professional interest
which inures to your special private gain or the special private gain of any principal by whom you are retained, please
disclose the nature of your interest below.
1. } Description of the matter upon which you voted in your official capacity: l /
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PART E
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3. Person or principal to whom the special gain described above will inure:
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(NAME) Q
a. ( ) Yourself b. (v) Principal by whom you are retained :
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SIGNATURE of PERS•N t71SG6• ". PATE SIGNED
2. Description of the personal, private, or professional interest you have in the above matter which inures to you special
private gain or the special private gain of any principal by whom you are retained •
PART D
FILING INSTRUCTIONS
This memorandum must be filed within fifteen (15) days following the meeting during which the voting conflict occurred
with the person responsible for recording the minutes of the meeting, who shall incorporate the memorandum in the meet-
ing minutes. This form need not be filed merely to indicate the absence of a voting conflict, Florida law permit's but does
not require you to abstain from voting when a conflict of interest arises; whether you abstain or not, however, the con-
flict must be disclosed pursuant to the requirements described above.
•
NOTICE: UNDER PROVISIONS OF SECTION 112.317, FLORIDA STATUTES, 1975, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE
CONSTITUTES GROUNDS FOR AND MAY RE PUNISHED EY ONE OR MORE OF THE FOLLOWING; IMPEACHMENT, REMOVAL OR SUS,
PENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY, REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED
s5'000.