HomeMy WebLinkAbout1978 09 19 Regular
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,TE ON WHICH VOTE OCCURRED:
FOR... 4
MEMORANDUM OF VOTING CONFLICT
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"-"'ART A
Name: {!~ A IJt;nl
( LAST;
Address: 7.
PART B
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(MIDDLE)
Telephone: 3tJS -1.11-3 f?:{
(A/C) (NU SER)
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(ZIP CODE) (COUNTY)
Agency is a unit of [check one] :
State of Florida; M County, City or other Political Subdivision
Name of Agency:
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Position held in Agency:
PART C
MEMORANDUM OF CONFLICT OF INTEREST IN A VOTING SITUATION [Required by Florida Statutes ~ 112,3143 (1975)]
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.
Desc iption of the matter upon which you voted in your official capacity:
2.
Description of the personal, private, or professional interest you have in the above matter which inures to your special private gain or
the special private gain of any principal by whom you are retained:
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3.
Person or principal to whom the special gain described above will inure:
a, ( 1 Yourself b. ( ) Principal by whom you are retained: #1/ T I' I?iM ~/;;;;z) (f:l 4 ~ y () vi;
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 meeting minutes. This form need not be
filed merely to indicate the absence of a voting conflict. Florida law permits but does not require you to abstain from voting when a conflict
of interest arises; if you vote, however, the conflict must be disclosed pursuant to the requirements described above,
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SIGNATURE OF PERSON DISCLOSING
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NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES ~112,317 (1975), A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES
GROUNDS FOR AND MAY BE 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 $5.000.
CE FORM 4- EFF. 1/1/77