Disclosure of Appointee Interest in State Contracts to be filed with the Secretary of State Secretary of State Index Department, Ethics Section 111 E. Monroe Springfield, IL 62756 217-782-0643 217-524-0930 (fax) www.cyberdriveillinois.com Appointee's Name: _______________________________________________________________________ Mailing Address: ________________________________________________________________________ City, State, ZIP: _________________________________________________________________________ Name and type of organization for which this disclosure is being filed: _____________________________________________________________________________________ Board Commission Authority Task Force Date of Appointment: _____________________________ (This date must be completed.) GENERAL DIRECTIONS Pursuant to 5 ILCS 420/3A.30, upon appointment to a board, commission, authority or task force authorized or created by State law, a person must file with the Secretary of State a disclosure of all contracts the person, or his or her spouse or immediate family members living with the person, have with the State and all contracts between the State and any entity in which the person, or his or her spouse or immediate family members living with the person, have a majority financial interest. List all contracts with the State of Illinois in effect on or after the date of appointment: (If additional space is needed, please attach a supplemental listing.) Name of individual or entity contracting with the State of Illinois: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Name of State agency or department contract is with: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ VERIFICATION "I declare that this disclosure statement (including any supplemental listing) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of any contracts that I am required to identify pursuant to the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a business offense punishable by a fine of $1,001. It is further understood that an unlawful conflict of interest may arise if, as an appointee, I, my spouse, or immediate family member living in my residence has or acquires a contract or has or acquires a direct pecuniary interest in a contract with the State that relates to the board, commission, authority or task force of which I am an appointee during and for one year following the conclusion of my term of office." ________________________________________________________ Signature of Appointee Making Statement (Source: Added at 29 Ill. Reg. 8908, effective June 10, 2005.) Printed by authority of the State of Illinois. December 2005 - 1 - I-205 American LegalNet, Inc. www.USCourtForms.com ________________________________________ Date