Form Center

2. Disclosure of Private Business Interests

4. Under the provisions of the Municipal Officers’ and Employees’ Ethics Act (Utah Code 10-3-1301 et seq.), the undersigned, under penalties of perjury, make the following statement regarding his/her private business interests.

   This statement must be filed by all volunteer members of special, regular, or full-time committees, agencies, or boards of the City who are officers, directors, agents, or employees or the owner of a substantial interest in any business entity which is subject to regulation of the City.

   After you file this disclosure, if your position in a business entity changes, or the value of your interest in a business entity changes significantly, you must file a new disclosure statement. For purposes of this disclosure, “substantial interest” means the ownership, either legally or equitably, by an individual, the individual’s spouse, or the individual’s minor children, of at least 10% of the outstanding shares of a corporation or 10% interest in any other business entity. Note: disclosure does not prohibit your involvement as a volunteer.

   The undersigned certifies that the following information is true and correct to the best of my knowledge:

6. 1*

   Do you, your spouse, or your minor children, in combination, have a ten percent (10%) or greater ownership interest in any limited partnership or other business entity that is regulated by the City?

   1. Yes
   2. No
7. 2*

   Do you, your spouse, or your minor children, in combination, have a ten percent (10%) or greater ownership interest in any limited partnership or other business entity that has a matter before the City Council, Planning Commission, or other city board, commission, or committee?

   1. Yes
   2. No

9. If you answered “Yes” to any of the above questions, please provide the following information for each business interest at the bottom of this form.

   1. The name of the business entity.
   2. The address of the business entity.
   3. The principal activity engaged in by the business activity.
   4. That nature of your position or the interest held in the business entity.
   5. Brief description of the transaction as to which service is rendered or is to be rendered and of the nature of the service performed or to be performed.

11. I swear and attest under penalty of perjury that the information provided by me in this disclosure statement is true and correct, and that all of my outside employment and outside business interests have been disclosed in writing on this statement.

13. Signature*
14. Date*

18. Notary Public required ONLY if you answered “Yes” to any of the above questions.

19. 

21. Please complete the rest of this form, print, and present to a Notary Public. Once notarized, scan and submit this form to volunteer@millcreek.us, or drop off at Millcreek City Hall.

25. This is a financial disclosure statement only. Additional disclosures or restrictions may apply if your financial, business or professional activities conflict with your City responsibilities.

27. Name of the business entity
29. Address of the business entity
31. Principal activity engaged in by the business activity
33. Nature of your position or the interest held in the business entity
35. Brief description of the transaction as to which service is rendered or is to be rendered and of the nature of the service performed or to be performed
39. Name of the business entity
41. Address of the business entity
43. Principal activity engaged in by the business activity
45. Nature of your position or the interest held in the business entity
47. Brief description of the transaction as to which service is rendered or is to be rendered and of the nature of the service performed or to be performed
51. Name of the business entity
53. Address of the business entity
55. Principal activity engaged in by the business activity
57. Nature of your position or the interest held in the business entity
59. Brief description of the transaction as to which service is rendered or is to be rendered and of the nature of the service performed or to be performed
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

* indicates a required field