49 Neisen Kasdin 11/8/00 R7F
FORM 88 MEMORANDUM OF VOnNG CONFLICT FOR
COUNTY, MUNICIPAL, AND OTHER LOCAL PUBLIC OFFICERS
NAME OF BOARD. COUNCIL COMMISSION. AUTHORITY. OR. COMMllIEE
'-
Wi 10 I
THE BOAR.D. COU1lCIl.. COM ISSION. AUTHOKITY. OR COMMITTEE ON
WHI('H I SERVE IS A UNIT OF:
KelTY . . COUNTY . . OTHER LOCAt AGENCY
H
APPOINTIVE
WHO MUST flU FORM II
This form is for use by any person serving at the county. city. or other loca.Ilevel of government on an appointed or elected board.
council. commission. authority. or committee. It applies equally to members of advisory and non-advisory bodies who are presented
with a voting contlict of interest under Section 112.3143. Rorida Statutes. .
Your responsibilities under the law when faced with a measure in which you have a contlict of interest will vary greatly depending
on whether you hold an elective or appointive position. For this teaSOD, please pay close attention to the instructions on this form
before completing the reverse side and filing the form.
INSTRUCTIONS FOR COMPUANCE WITH SEcrtON 112.3143, FLORIDA STATUTES
ELECTED OFFICERS:
A person holding elective COUnty. municipal. or other local public office MUST ABSTAIN from voting on a measure which inures
to his special private gain. Each local officer also is prohibited from knowingly voting on a measure which inures to the special
gain of a principal (other .than a government agency) by whom he is retained.
In either case, you should disclose the contlict:
PRIOR TO THE VOTE BEING TAKEN by publicly stating to the assembly the nature of your interest in the measure on
which you are abstaining from voting; and
WITHIN 15 DAYS AFTER THE VOTE OCCURS by completing and filing this form with the person responsible for recording
the minutes of the meeting. who should incorporate the form in the minutes.
APPOINTED OFFICERS:
A person holding appointive county, municipal. or other local public office MUST ABSTAIN from voting on a measure which
inures to his special private gain. Each local officer also is prohibited from knowingly voting on a measure which inures to the
special gain of a principal (other than a government agency) by whom he is retained.
A person holding an appointive local office otherwise may participate in a maner in which h" has a conniet 0' interest, bUl must
disclose the nature of the contlict before making any anemptto influence the decision by ora! or written oomrr;Lnic2tion. whether
made by the officer or at his direction.
IF YOU INTEND TO MAKE ANY ATTEMPT TO INFLUENCE THE DECISION PRIOR TO THE >..fEElING AT WHICH
THE VOTE WILL BE TAKEN:
. You should complete and file this form (before making any anemptto influence the decision) with the person r
recording the minutes of the meeting. who will incorporate the form in the minutes.
. A copy of the form should be provided immediately to the other members of the agency.
. The form should be read publicly at the meeting prior to consideration of the maHer in which you have a contlict
If)"'\t...l! 11).>1110
..~'.
IF YOU MAKE NO ATrEMPTTO INFLUENCE THE DECISION EXCEPT BY DISCUSSION
AT THE MEETING;
· You should disc:lose orally the nature of your conflict in the measure before participating.
· You should complete the form and file it within 15 days after the vote occurs with the person responsible for recording the minutes
of the meeting. who should incorporate the form in the minutes.
I.
Mo~ ~A
DISCLOSURE OF LOCAL OFFICER'S INTEREST
. hereby disclose that OD -1l[ da7
.~:
(a) A measure came or will come before my aaency which (check one)
_ inured to my special private gain: or
~red to the special gain of J+ 171\0\:
. by whom I am retained.
(b) The measure before my agency and the nature of my interest in the measure is as follows: \ I J ,I
(K .j--F - C(~~V\~A- l",vv~l'W\t7\IL vWW'e~~~
Date Filed
Signature
NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES ~1I2.317 (1985). A FAILURE TO MAKE ANY REQUIRED
DISCLOSURE CONSTITUTES GROUNDS FOR AND MAYBE PUNISHED BY ONE OR MORE OF THE FOLLOWING:
IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN
SALARY, REPRIMAND. OR A CIVIL PENALTY NOT TO EXCEED $5.000.
FORM 88 . 10.86