§ 16A-8. Annual statement of financial disclosure., Chapter 16A. Ethics, Code of, Code of Ordinances, North Hempstead

NAME AND ADDRESS.


Last Name	Middle Initial	First Name

Title

Department or Agency

Department or Agency Address		Telephone No.

Residence Address		Telephone No.

SPOUSE AND CHILDREN.

	Provide the name of your spouse (if married) and the names of any dependent children:


	Spouse


	Child/Age


	Child/Age


	Child/Age

	NOTE: FOR QUESTIONS 3 TO 6: DO NOT REPORT EXACT DOLLAR AMOUNTS. INSTEAD, REPORT CATEGORIES OF AMOUNTS, USING THE FOLLOWING:
	Category	Dollar Amount Range
	A	Under $5,000
	B	$5,000 to under $20,000
	C	$20,000 to under $60,000
	D	$60,000 to under $100,000
	E	$100,000 to under $250,000
	F	$250,000 or over

FINANCIAL INTERESTS.

Business positions. List any office, trusteeship, directorship, partnership or other position in any business, association, proprietary or not-for-profit organization held by you and your spouse and dependent children, if any, and indicate whether these businesses are involved with the Town of North Hempstead in any manner.

	Name of Family Member	Position	Organization	Town Department or Agency and Nature of Involvement

Outside employment. Describe any outside occupation, employment, trade, business, or profession providing more than $1,000 per year for you and your spouse and dependent children, if any, and indicate whether such activities are regulated by any state or local agency.

	Name of Family Member	Position	Name, Address, and Description of Organization	State or Local Agency	Category of Amount

Future employment. Describe any contract, promise or other agreement between you and anyone else with respect to your employment after leaving your Town office or position.

Past employment. Identify the source and nature of any income in excess of $1,000 per year from any prior employer, including deferred income, contributions to a pension or retirement fund, profit sharing plan, severance pay, or payments under a buyout agreement.

	Name and Address of Income Source	Description of Income (e.g., pension, deferred, etc.)	Category of Amount

Investments. Itemize and describe all investments in excess of $1,000, or 5% of the value in any business, corporation, partnership or other assets, including stocks, bonds, loans, pledged collateral and other investments, for you and your spouse and dependent children, if any. List the location of all real estate within the Town of North Hempstead, or within five miles thereof, in which you, your spouse or dependent children, if any, have an interest, regardless of its value.

	Name of Family Member	Name and Address of Business or Real Estate	Description of Investment	Category of Amount

Trusts. Identify each interest in a trust or estate or similar beneficial interest in any assets in excess of $1,000, except for IRS eligible retirement plans or interests in an estate or trust of a relative, for you and your spouse and dependent children.

	Name of Family Member	Trustee/Executor	Description of Trust/Estate	Category of Amount

Other income. Identify the source and nature of any other income in excess of $1,000 per year from any source not described above, including teaching income, lecture fees, consultant fees, contractual income or other income of any nature, for you and your spouse and your dependent children, if any.

	Name of Family Member	Name and Address of Income Source	Nature of Income	Category of Amount

Relatives employed with the Town of North Hempstead. Identify whether any relative is employed by the Town of North Hempstead.

[Added 3-22-2016 by L.L. No. 4-2016]

	Name of Relative	Name and Address of Income Source	Nature of Income	Category of Amount

GIFTS AND HONORARIUMS.

List the source of all gifts aggregating in excess of $1,000 received during the last year by you, your spouse or dependent child, excluding gifts from a relative. The term "gifts" includes gifts of cash, property, personal items, payments to third parties on your behalf, forgiveness of debt, honorariums and any other payments that are not reportable as income.

	Name of Family Member	Name and Address of Donor	Category of Amount

THIRD-PARTY REIMBURSEMENTS.

Identify and describe the source of any third-party reimbursement for travel-related expenditures in excess of $1,000 for any matter that relates to your official duties. The term "reimbursement" includes any travel-related expenses provided by anyone other than the Town of North Hempstead for speaking engagements, conferences, or fact-finding events that relate to your official duties.

	Source	Description	Category of Amount

DEBTS.

Describe all debts of you, your spouse and dependent children in excess of $5,000.

	Name of Family Member	Name and Address of Creditor	Category of Amount

INTEREST IN CONTRACTS.

Describe any interest of you, your spouse or your dependent children in any contract involving the Town of North Hempstead or any municipality located within the Town.

	Name of Family Member	Contract Description

POLITICAL PARTIES.

	List any position you held within the last five 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.


	Signature	Date