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UNIFORM CONFLICT OF INTEREST ETHICS DISCLOSURE STATEMENT
State Form 53345 (7-08)

OFFICE OF THE INSPECTOR GENERAL IC 4-2-6-10.5

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A state officer, employee, or special state appointee may not knowingly have a financial interest in a contract made by an agency. The term financial interest is defined in IC 4-2-6-1. This prohibition, however, does not apply to an officer, employee, or special state appointee who (1) does not participate in or have official responsibility for any of the activities of the contracting agency and (2) meets the criteria in IC 4-2-6-10.5 (b)(1)(A) - (D). One criterion is that the officer, employee, or special state appointee must file with the State Ethics Commission ("Commission") a statement making full disclosure of all related financial interests in the contract.



The foregoing consists only of excerpts from IC 4-2-6-10.5. Care should be taken to review I.C. 4-2-6-10.5 in its entirety to ensure compliance with all criteria set forth in the statute.

PART 1 ­ CONTRACT(S)
Name of State Officer, Employee, or Special State Appointee submitting Statement: Address: (number and street, city, state and ZIP code) Title or Position within Agency: Name(s) of Contractor(s) or Vendor(s): Agency:

Description(s) of Contract(s): (Describe the kind of contract involved and the effective date and term of the contract if reasonably determinable.)

Description of the Financial Interest: (Describe in what manner the state officer, employee, or special state appointee expects to derive a financial interest from or otherwise has a pecuniary interest in, the above contract(s). State the approximate dollar value of the interest if reasonably determinable. Attach extra pages if additional space is needed.)



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PART 2 ­ AGENCY CERTIFICATION
Approval of Appointing Authority: (To be completed in the case of a contract for professional services only.) Being the _______________________________________________________________________________________
(Title of Appointing Authority)

ONLY COMPLETE PART 2 IF CONTRACT IS FOR PROFESSIONAL SERVICES

of _____________________________________________________________________________________________
(Name of Contracting Agency)

and having the duty to file a written certification with the Commission, I hereby affirm that no other state officer, employee, or special state appointee of ______________________________________________ is available to perform those services as part of the regular
(Name of the Contracting Agency)

duties of the state officer, employee, or special state appointee. _____________________________________
(Appointing Authority)

________________________________________________________
(Signature)

PART 3 ­ AFFIRMATION
Affirmation of State Officer, Employee, or Special State Appointee: This Statement was submitted to the Commission pursuant to 42 IAC 1-5-7 (IC 4-2-6- 10.5) to disclose my financial interest in a contract with an agency. I affirm, under penalty of perjury, the truth and completeness of the statements made above and that I am the above named state officer, employee, or special state appointee. Signed: ___________________________________ Date: (month, day, year) ______________________________

Mail or deliver to: Office of the Inspector General 150 West Market Street, Room 414 Indianapolis, IN 46204 317.232.3850

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