WORKSHEET FOR FILING DISCLOSURE OF FINANCIAL INTEREST

NOTICE: It is a condition of commencing and continuing employment or appointment that persons subject to the Code of Conduct file a full disclosure of Financial Interests in Any Private Enterprise Which Is Subject to the Regulatory Jurisdiction of, or Does Business With, the Government Entity by which they are employed or appointed. EX: State employees/officials file if they do business with or are regulated by the State; local government employees/officials file if they do business with or are regulated by their local government. 29 Del. C. § 5806(d). This Worksheet is an Aid in completing disclosure, and does not guarantee the absence of a conflict. The disclosure is so the Public Integrity Commission can decide if there is a conflict.

QUESTIONS ON THE LAW OR THE FORM? CALL THE COMMISSION - 302-739-2399.

INSTRUCTIONS: Check Blocks Which Apply and Add Information Where Indicated. If a block is not checked, give the reason in Block 11. EX: Block 7 is not checked; explain in Block 11 why it is not completed. If the first block in items 5 through 7 or 9 through 10 is checked, explain in Block 11 when you engaged in that conduct.

DEFINITIONS: "Private enterprise" means any activity by any "person", whether for profit or not for profit. 29 Del. C. § 5804(8). "Person" means an individual, partnership, corporation, trust, joint venture and any other association of individuals or entities. 29 Del. C. § 5804(7). "Financial interest" means (a) a legal or equitable ownership interest of more than 10% (1% or more if the stock is regularly traded on an established securities market); (b) an employee, officer, director, trustee or independent contractor of the private enterprise who received or expects to receive income exceeding $5,000 annually; or (c) creditor of 10% or more of the enterprise's debt (1% or more if the enterprise's securities are regularly traded on an established securities market).

1. My government position is with:

2. I have a financial interest in a private enterprise which is subject to the regulatory jurisdiction of , or does business with a government agency.

3. Name of the private enterprise:

4. Name of the government agency the private enterprise is regulated by or doing business with:

5. In my official capacity, I did / did not review or dispose of the decision which resulted in the private enterprise's dealings with the government entity. 29 Del. C. § 5805(a).

6. I have reason /have no reason to believe that the private enterprise may be directly involved in decisions to be made by me in my official capacity. 29 Del. C. § 5806(c).

7. I did /did not represent or assist the private enterprise before the governmental entity with which I am associated by employment, elective office, or appointment. 29 Del. C. § 5805(b).

8 (a). The contract with the government was for more than $2,000 and was publicly noticed and bid. 29 Del. C. § 5805(c). Amount of each contract:

OR

8 (b). The contract with the government was for less than $2,000 and there was arms' length negotiations. 29 Del. C. § 5805(c). Amount of each contract:

9. I did /did not use my public office to secure any business dealings for the private enterprise. 29 Del. C. § 5806(e).

10. I did / did not disclose or otherwise use confidential information gained from my public position in the business dealings, or for personal gain or benefit. 29 Del. C. § 5806(f) and (g).

11. DETAILS OF THE BUSINESS DEALING/REGULATION

The substance of the business dealing or regulation is: (attach documents such as a written contract or describe the business dealing, i.e., is it a contract, lease, etc., what specific agency is it with, what is the duration; how was the price determined, etc.?).

If a worksheet item cannot be complied with because of an "undue hardship," the individual or the agency they seek to deal with may ask for a waiver. 29 Del. C. § 5807(a). EX: A contract is for more than $2,000 but cannot be publicly noticed and bid because of an emergency, e.g., water line breaks and must be fixed immediately, provide that information.

NAME:

ADDRESS:

                      

City: | State:   Zip:

Phone:

RETURN THIS FORM AND ANY ADDITIONAL INFORMATION TO:

State Public Integrity Commission

Margaret O'Neill Bldg., Suite 3

410 Federal St., 2d Floor

Dover, DE 19901

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