Public Disclosure Forms /"�
City of Fridley
Public Disclosure Statement
By Members of Advisory Bodies
Name: u`U! 1 L-i�.yt d L�vI Date ,2
Position Title: C 0 MM ISS;aA.2,11-:R }-. I+
ME,M6&R, C f� a4TE� C, IIID II S slb✓t,
In conformance with Section 5.05 of the Fridley City Code,I hereby make the following
declarations regarding my financial and personal interests:
1. Names of all business corporations,partnerships, other business enterprises,or governmental
agencies doing business with the City of Fridley or located within the City of Fridley.
a) With which I have a financial interest.
(As used in Chapter 5,the term financial interest shall be deemed to include ownership of
more than 10%of. the outstanding stock in a corporation,an interest in a partnership,
proprietorship,or other business entity,or an interest in real property. Financial interest
shall apply to real or personal properties owned by one person making the disclosure and by
said person's spouse.)
b) With which I have a personal interest.
(As used in Chapter 5,the term personal interest shall be deemed to apply whenever a
person required to make a disclosure under this code of ethics shall be associated with a
business as an employee, officer, director,trustee,partner, advisor or consultant.)
Name of Business, Address Financial Interest Personal Interest
Partnership,Etc.
(use additional paper if necessary)
2. A list of the non-homestead real property located within the City of Fridley in which I currently
have a financial interest:
��.
Non-Homestead Real Property Address
A)o N
(use additional paper if necessary)
I do swear(or affirm)that this report is a full and true statement pursuant to Section 5.05 of the
Fridley City Code.
(Signature)
Note: This statement must be filed upon appointment or reappointment to an advisory committee or material changes
in financial interest while on an advisory committee.