Download Disclosure of Interests and Conflicts PDF Form or fill out the form below

Pursuant to the purposes and intent of the policy adopted by the Agency, requiring the disclosure of certain interests and conflicts. I hereby state that I have received a copy of the policy and understand that my responsibilities to the agency require that I disclose any duality of interest or possible conflict of interest, for myself and any member of my immediate family. that I will not vote or use influence on any matter in which I have a conflict or duality of interest: and will not accept gifts. favors. or hospitality with a monetary value in excess of $25.00, and will make every effort to Comply with the Agency Policy.

    I hereby disclose the following interests and activities of possible conflicts: