HomeMy WebLinkAbout1980 12 15 Special
FORM 4 MEMORANDUM OF VOTING CONFLICT
-MIDDLE NAME
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MAILING ADDRESS ~. (7 ,
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. ZIP COUNTY
AGENCY is unit of:
DOTHER
DSTATE
DCOUNTY
~MUNICIP ALITY
MEMORANDUM OF CONFLICT OF INTEREST IN A VOTING SITUATION [Required by Florida Statutes ~112.3143 (1979) ]
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.
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2.
Description of the personal, private, or professional interest you have in the above matter which inures to your special private gain or
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3.
P",on 0< p'""'pu to whom ~, 'p,ciu goio """,ribed .bove will '0"''' n . _7/---(' ....
a.D Yourself b.~ Principal by whom you are retained: - ~
~ (NAME)
DA TE ON WHICH FORM 4 WAS FILED WITH THE PERSON
RESPONSIBLE FOR RECORDING MINUTES OF THE MEETING AT
WHICH THE VOTE OCCURRED:
FILING INSTRUCTIONS
NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES ~1l2.317 (1979), 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 - REV. 12-79