Digital Financial Disclosure Form – Advisory

Please Confirm the Year you are filing for.*
- 2020

1. General Information
Enter your Full Name*
First Last
County Board*
County Agency Phone Number*
Email Address*
Enter Email Confirm Email
Department or Agency*
Please Select a Department or Agency.
- Community Services Board – Donald B. Smith (Building 2) 110 Old Route 6 Carmel, NY
- Emergency Services Safety Advisory Board – Training & Operations Bldg. 112 Old Route 6 Carmel, NY
- Region 3 Fish & Wildlife Management Board – David Bruen County Bldg 40 Gleneida Ave Carmel, NY
- Traffic Safety Board – Sheriff’s Dept. 3 County Center Carmel, NY
- Transportation Advisory Council – Planning Dept. 841 Fair St. Patterson, NY
- Veterans Memorial Park Advisory Board – County Park Office 223 Alms House Lane Kent, NY
- Youth Board – Donald B. Smith (Building 3) 110 Old Route 6 Carmel, NY

2. Spouse & Children
Provide the name of your spouse (if married) and the names of any dependent children
I have*
Check the items that apply to you.
- a Spouse
- Dependent Children
- This does not apply to me.
What is the name of your Spouse?*
First Last
What is the name(s) of your dependent Child(ren)?*

3. Financial Interests
*NOTE* Use the following Reporting Categories for the purpose of completing the Financial Disclosure form. No exact dollar amounts are to be included in the completion of the statements of financial disclosure; *IMPORTANT* Any section which does not apply to your circumstances MUST BE MARKED “N/A”or your statement will be returned to you to be so marked. ADDING MORE ENTRIES: To add more entries on the areas that apply to you click the (+) symbol to the right of the column.
a. Employment*
Describe any occupation, employment, trade, business or profession (other than employment with Putnam County) held by you, your spouse and your dependent children, if any. Please indicate whether such activities were regulated by any State or local agency, as well as any contract, promise or agreement for future employment or volunteer service with respect to your employment with Putnam County in the year 2020.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
a. List Employment*
Family Member Position Organization Gov't Agency
b. Outside Leadership*
List any office, trusteeship, directorship, partnership, board membership, or other leadership position in any association or not-for-profit organization (other than those listed in 3a. above) for you, your spouse and your dependent children, if any, and indicate whether these organizations were involved with the County of Putnam in any manner.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
b. List Leadership Positions*
Family Member Position Organization Gov't Agency
c. Real Estate (Home Address)*
List the location of your home address if it is within the County, or within five (5) miles of the County, and if you, your spouse or your dependent children personally own such home.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
c. List Real Estate (Home Address)*
For the Category Column Select the total value for the listed Real Estate (Home Address) from the reporting category box
Family Member Owning the Home Home Address Category¹

¹This is your Reporting Category for Value. Only enter the letter that corresponds to this area.

A = Up To $5000	B = $5001 to $20000	C = $20001 to $60000
D = $60001 to $100000	E = $100001 to $250000	F = $250001 or over,
	V = Volunteer or unpaid position

4. Interest in Contracts.
Describe any interest that you, your spouse or your dependent children had in any contract involving the County, or any municipality within the County.ADDING MORE ENTRIES: To add more entries on the areas that apply to you click the (+) symbol to the right of the column.
4. Does Interest in Contracts apply to you?*
For the Category Column Select the total value for the listed Interest in Contacts from the reporting category box
- Yes
- No. This does not apply to me.
List any Interest in Contracts*
Family Member Contract Description Category¹

¹This is your Reporting Category for Value. Only enter the letter that corresponds to this area.

A = Up To $5000	B = $5001 to $20000	C = $20001 to $60000
D = $60001 to $100000	E = $100001 to $250000	F = $250001 or over,
	V = Volunteer or unpaid position

5. Political Parties*
List any position you held within the last five (5) years as an officer of any political party, political committee, or political organization. The term "political organization" includes any independent body or any organization that is affiliated with, or a subsidiary of, a political party.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
List the Political Parties that you are affiliated with.*
Disclaimer*
I hereby certify, under penalty of perjury, that the information disclosed on this form is true and complete. I also acknowledge that I have a continuing duty to disclose conflicts of interest and am subject to the other requirements of the Putnam County Code of Ethics.
- Yes

Family Member	Position	Organization	Gov't Agency

Family Member	Position	Organization	Gov't Agency

Family Member Owning the Home	Home Address	Category¹

Family Member	Contract Description	Category¹

Digital Financial Disclosure Form – Advisory

FINANCIAL DISCLOSURE FORM - Advisory

1. General Information

2. Spouse & Children

3. Financial Interests

4. Interest in Contracts.