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<br />\ <br /> <br /> <br />City of Centerville <br />Disclosure of Financial Interests <br /> <br />Each public official, as defined in the City of CenterviIle Code of Ethics Policy, shall file <br />a "Disclosure of Financial Interests Statement" not less than thirty (30) days after the date <br />ofhislher entrance on duty. <br /> <br />Each public official who made an initial filing shall file a new statement by January 30 of <br />each year thereafter giving the information called for above as of the time of the new <br />statement. If a change in financial interest or property ownership occurs between filings, <br />a new filing shall be made within thirty (30) days of the change. <br /> <br />......................................................................... <br /> <br />DISCLOSURE OF FINANCIAL INTERESTS STATEMENT <br /> <br />I, , a duly elected or appointed public official of the City of <br />(Name) <br />CenterviIle, hereby affirm that I serve the City of Centerville in the capacity of <br /> <br />, and make the following representations concerning any <br /> <br />(Position) <br />financial interests I may have with the City of Centerville. <br /> <br />1. A list naming an business enterprises known by me to be licensed by or to be <br />doing business with the city, which I or any member of my immediate family is <br />connected as a (an) employee, officer, owner, investor, creditor of, director, <br />trustee, partner, advisor, or consultant: <br /> <br />2. A list of my interests, or the interests of my immediate family, in real property <br />located in the City, or which may be competing with the interests of the City <br />located elsewhere, other than property occupied as a personal residence: <br /> <br />Date Signature of Public Official <br />