Create a Website Account - Manage notification subscriptions, save form progress and more.
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:
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?
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?
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.
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.
Notary Public required ONLY if you answered “Yes” to any of the above questions.
Please complete the rest of this form, print, and present to a Notary Public. Once notarized, scan and submit this form to firstname.lastname@example.org, or drop off at Millcreek City Hall.
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.
This field is not part of the form submission.
* indicates a required field