City of Ann Arbor - File #: 18-1916

Date	Ver.	Action By	Action	Result	Action Details	Meeting Details	Video
11/8/2018	1	Housing and Human Services Advisory Board			Action details	Meeting details	Not available

CITY OF ANN ARBOR

HOUSING & HUMAN SERVICES ADVISORY BOARD

2019 ANNUAL DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST

Name: ______________________________________________________________________________

Phone Number: ______________________________________________________________________

E-mail Address: _____________________________________________________________________

I understand that I am providing information regarding myself and members of my immediate family, and any organizations with which I am (or any one of them is) affiliated. If the disclosure relates to a person other than you, please indicate that person’s name and their relationship to you.

Organization/Agency Affiliation, or Capacity In Which I Serve

______________________________________ ______________________________________

I agree to provide written updates to this Disclosure at any time when such affiliations change throughout the year. I further agree to update this information annually for the duration of my term.

In order to avoid any potential conflict of interest, I, the undersigned, agree not to participate in any discussion, or make any recommendations or decisions regarding any organization(s) or entity(ies) disclosed on this form.

Signature_________________________ Date_________________________