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Chapter 20 ETHICS CODE FOR OFFICIALS AND EMPLOYEES

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Appendix 1 STATEMENT OF ECONOMIC INTEREST AND FINANCIAL DISCLOSURE

DUE DATE:

Disclosure form shall be filed with the Kenosha County Clerk as a public record prior to January 7 of each year. In case of a person holding or seeking elective office, the form shall be so filed prior to the end of business on the last day for filing nomination papers for an election. In non-election years the form shall be filed with the County Clerk prior to January 7.

RETURN TO: Kenosha County Clerk Kenosha County Administration Building, 1010 – 56th Street, Kenosha WI 53140. Provide additional information and explanations as required. If the answer to any question is “yes” please explain below with specificity.

THESE QUESTIONS SHOULD BE ANSWERED

TO THE BEST OF YOUR KNOWLEDGE.

Definitions are found in Section 20.14(1) of the Municipal Code of Kenosha County.

“Immediate Family” means either a wife, husband, or any other person, including a domestic partner, who is a member of the immediate household or receives more than 50% of their support from such employee or official.

1. Are you or your spouse related to any Kenosha County employee?

□ YES □ NO

If yes, please explain to whom, what the relationship is and where that employee works.______________________________________________________________________________ ________________________________________________.

2. To the best of your knowledge, does your or your spouse’s employer or the employer of a member of your immediate family do business with Kenosha County?

□ YES □ NO

If yes, please explain who the employer is, the nature of the business, the dollar amount of the business and whether the business is continuous.______________________________________________________________________________ ________________________________________________.

3. To the best of your knowledge, is your or your spouse’s employer or the employer of any member of your immediate family regulated by Kenosha County [for example, by zoning, health, cabaret etc regulations or licensing]?

□ YES □ NO

If yes, please explain who the employer is and the nature of the regulation.______________________________________________________________________________ ________________________________________________.

4. To the best of your knowledge, do you know of any debt incurred by you, your spouse or member of your immediate family that is owed to any entity doing business with Kenosha County or is regulated by Kenosha County?

□ YES □ NO

If yes, please explain who the entity is. ______________________________________________________________________________ ________________________________________________.

5. To the best of your knowledge, are you, your spouse or any member of your immediate family on the Board of Directors of any entity [including a non-profit or not for profit corporation] that does business with Kenosha County?

□ YES □ NO

If yes, please identify the entity, the business that is associated with Kenosha County, the dollar amount of the business, whether the entity is for profit, non-profit or not-for-profit. ____________________________________________________________________________________ ________________________________________________.

6. To the best of your knowledge, do you, your spouse or any member of your immediate family own stock or have any equity in any local [ie., Kenosha County] entity doing business with Kenosha County? If yes, with who and what is the value?

□ YES □ NO

If yes, please explain.__________________________________________________________ ________________________________________________.

7. To the best of your knowledge, have you, your spouse or any member of your immediate family received anything of value as defined in this Code from any party doing business with Kenosha County or regulated by Kenosha County?

□ YES □ NO

If yes, please explain.____________________________________________________ ______________________________________________________________________________ ________________________________________________.

8. To the best of your knowledge, have you reported all campaign contributions as required by Federal and State law?

□ YES □ NO

If not, please explain.____________________________________________________ ______________________________________________________________________________ ________________________________________________.

9. To the best of your knowledge, do you or your spouse, member of your immediate family, business associates own any real property that is regulated by Kenosha County land use, health or cabaret etc regulations? Have you or your spouse been compensated or expect to be compensated for advocating on behalf of anyone, including clients, for the purpose of obtaining for them a permit or privilege or eligibility for anything of value from Kenosha County or a settlement of a claim or disposition of a criminal or municipal ordinance violation?

□ YES □ NO

If yes, please explain who or what is regulated and how, and who you advocated for and how________________________________________________________________________________ ______________________________________________________________________________ ________________________________________________.

10. To the best of your knowledge, do you or your spouse or any member of your immediate family have any claim against Kenosha County?

□ YES □ NO

If yes, please explain.__________________________________________________________ ______________________________________________________________________________ ________________________________________________.

11. Are any delinquent taxes owed by you, your spouse or member of your immediate family to any federal, state or local gov?

□ YES □ NO

If yes, please explain to whom, how much and how long the taxes have been delinquent. ____________________________________________________________________________________ ______________________________________________________________________________ ________________________________________________.

12. To the best of your knowledge, do you have any unpaid judgments?

□ YES □ NO

If yes, please explain to whom and how much. ____________________________________________________________________________________ ______________________________________________________________________________ ________________________________________________.

Executed this _____ day of ______________. 20__

_____________________________________

This document must be signed AND SWORN TO before a notary.

STATE OF WISCONSIN

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COUNTY OF KENOSHA

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The undersigned, a notary public in and for said COUNTY, in the State aforesaid, DO HEREBY CERTIFY that _____________________ personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he or she signed and delivered said instrument as his or her free and voluntary act, for the uses and purposes therein set forth AND FURTHER THAT SAID INDIVIDUAL HAS SWORN TO THE VERACITY OF THE STATEMENTS CONTAINED THEREIN..

GIVEN under my hand and official seal this _____ day of _______________, 20____.

_____________________ (SEAL)

Notary Public. My Commission expires ___________________ [is permanent].