Digital Financial Disclosure Form – Policy

FINANCIAL DISCLOSURE FORM - Policy

ANNUAL STATEMENT OF FINANCIAL DISCLOSURE FOR THE YEAR 2020 P [Policy] COUNTY OF PUTNAM Officers and employees are reminded that they have a continuing duty to disclose conflicts of interest and are subject to the other requirements of the Putnam County Code of Ethics and Financial Disclosure Law.

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

1. General Information
Enter your Full Name*
First Last
County Agency Title*
Co. Agency Work Number*
Work Email*
Enter Email Confirm Email
Department or Agency*
Please Select a Department or Agency.
- Agriculture & Farmland Protection Board 841 Fair St. Patterson, NY
- Auditing -David Bruen County Bldg. 40 Gleneida Ave. Carmel, NY
- Board of Elections -Board of Elections 25 Old Rt 6 Carmel, NY
- Board of Electrical Examiners – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Board of Ethics – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Board of Health - Health Dept. 1 Geneva Rd. Brewster, NY
- Bureau of Emergency Services - Training & Operations Bldg. 112 Old Rt. 6, Carmel, NY
- Consumer Affairs– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- County Clerk -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- County Coroner - Training & Operations Bldg. 112 Old Rt. 6, Carmel, NY
- County Executive -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- County Historian – 68 Marvin Ave Brewster, NY
- County Legislature -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- District Attorney -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- East of Hudson Watershed Corporation, 2 Route 164, Patterson, NY
- Finance -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- Health Department – Health Dept. 1 Geneva Rd. Brewster, NY
- Highways & Facilities – Highway Dept., 842 Fair St. Patterson, NY
- Home Improvement Board – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Information Technology/GIS– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Law Dept. – Law Dept. 48 Gleneida Ave. Carmel, NY
- Office for Senior Resources – Donald B. Smith Gov’t Campus (Building 1) 110 Old Route 6 Carmel, NY
- Office for People with Disabilities– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Off-Track Betting Board – Planning Dept 841 Fair St. Patterson, NY
- Personnel– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Planning, Dev. & Public Transp. – Planning Dept. 841 Fair St. Patterson, NY
- Plumbing Board – Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Probation -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- Purchasing -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- Putnam County Industrial Development Agency – 2 Route 164, suite 2B, Patterson, NY 12563.
- Real Property -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- Sheriff’s Dept. – Sheriff’s Dept. 3 County Center Carmel, NY
- Social Services & Mental Health – Donald B. Smith Gov’t Campus (Building 2) 110 Old Route 6 Carmel, NY
- Soil & Water–Planning Dept. 841 Fair St. Patterson, NY
- Tourism -David Bruen County Bldg. 40 Gleneida Ave Carmel, NY
- Putnam County Veterans Service Agency– Donald B. Smith Gov’t Campus (Building 3) 110 Old Route 6 Carmel, NY
- Youth Bureau – Donald B. Smith Gov’t Campus (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*
In the Category Column, List the amount “if any” of compensation you have received for the calendar year of 2019.
Family Member Position Organization Gov't Agency Category¹

¹This is your Reporting Category for Compensation. 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

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*
In the Category Column, List the amount “if any” of compensation you have received for the calendar year of 2020.
Family Member Position Organization Gov't Agency Category¹

¹This is your Reporting Category for Compensation. 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

c. Other Income*
Other Income. Identify the source and nature of any other income from any source not described above, including teaching income, lecture fees, consultant fees, contractual income or income which you continued to receive from past employment or other income of any nature, for you, your spouse and your dependent children, if any.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
c. List Other Income*
In the Category Column, List the amount “if any” of compensation you have received for the calendar year of 2020.
Family Member Name & Address of Income Nature of Income Category¹

¹This is your Reporting Category for Compensation. 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

d. Investments*
Itemize and describe all investments or capital stock above a 5% share of ownership in any business, corporation or partnership, for you, your spouse and your dependent children, if any.
- The item above DOES apply to me.
- This item DOES NOT apply to me.
d. List Investments*
In the Category Column, List the amount “if any” of compensation you have received for the calendar year of 2020.
Family Member Name & Address of Business Description of Investment Category¹

¹This is your Reporting Category for Compensation. 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

e. 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.
e. 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