Form Center • Clinton Township, MI • CivicEngage

Personal Disclosure Statement for Public Officials

In accordance with the Charter Township of Clinton Ethics Policy, Public Officials must complete this form in full and file it with the Human Resources Department within 30 days of taking office.
Questions should be directed to the Human Resources Department, 40700 Romeo Plank Rd., Clinton Township, MI 48038, Telephone 586-286-9341.
FORM MUST BE FILED WITH THE HUMAN RESOURCES DEPARTMENT WITHIN 30 DAYS OF TAKING OFFICE
Date of Statement
Date of Statement
GENERAL INFORMATION
First Name
Last Name
Street Address
City
State
Zip
Township Position
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PART A - CURRENT EMPLOYER(S) - SOURCES OF EARNED INCOME
List the name and address of each full and part-time employer(s) with which the filer currenly holds a position. Include all public and private sector employment other than your employment with Clinton Township. For the purpose of this section, an employer is one who provides you with a W-2 or 1099NEC.
Employer Name
Title/Position
Employer Address
Employer Name
Title/Position
Employer Address
Employer Name
Title/Position
Employer Address
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PART B - CORPORATE & NON-PROFIT POSITIONS
List the name and address of any entity on which the filer serves as an officer, director, member, or partner, and receives compensation.
Organization's Name
Title/Position
Address
Organization's Name
Title/Position
Address
Organization's Name
Title/Position
Address
Organization's Name
Title/Position
Address
Organization's Name
Title/Position
Address
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PART C - OTHER INCOME SOURCES
List the name and a general description of each source of income generated by the filer. The Internal Revenue Service definition of “income” for the filing of Federal tax returns is the definition of “income under this Policy. General description can include: stocks, mutual funds, bank accounts, etc.
Name of Issuing Company
Description
Name of Issuing Company
Description
Name of Issuing Company
Description
Name of Issuing Company
Description
Name of Issuing Company
Description
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PART D - DIRECT OWNERSHIP INTERESTS IN BUSINESS ENTITY
List each business in which the filer holds a direct ownership interest worth at least 5% or $50,000.
Name of Business
Address
Name of Business
Address
Name of Business
Address
Name of Business
Address
Name of Business
Address
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PART E - PROPERTY OWNERSHIP
List all real property owned by the filer located within Clinton Township and/or contiguous to the Township.
Address
Address
Address
Address
Address
Address
Address
Address
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ATTESTATION
I hereby acknowledge that the information contained herein is to the best of my knowledge true, correct and complete. I further certify that I have not and will not transfer any asset or interest for the purpose of concealing it from disclosure while retaining an equitable interest therein.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date:
Date:

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