1-Attachment D-1 Affidavit of Disclosure of Interests.pdf

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AFFIDAVIT OF DISCLOSURE OF INTERESTS

Instructions. Completing and submitting this disclosure affidavit fulfills the disclosure requirements of Section 2-

106.2 of the 2012 Detroit City Charter and Section 2-5-34 of the 2019 Detroit City Code of Ordinances, as well as Sections 200.212, .318(c) of the Uniform Guidance found at 2 C.F.R. 200 et seq. Please complete all applicable sections by typing or legibly printing. Where a section does not apply, please check the appropriate box and skip to the next section. If necessary, provide additional information on page 4 or attach additional documents to this disclosure affidavit. This disclosure affidavit must be signed, notarized, and filed with the applicable bid or response to a Notice of Funds Availability (NOFA), as well as with the City of Detroit Board of Ethics, 7737 Kercheval, Suite #213, Detroit, MI 48214 (City Code § 2-5-34(b)).

Note: An “immediate family member” of a person is that person’s spouse, domestic partner, an individual living in the person’s household, or an individual claimed as a dependent or spouse’s dependent under the Internal Revenue Code at 26 USC 1, et seq. (City Charter § 2-105.A.20; City Code § 2-5-3)

Section 1 - Identity of Disclosing Filer (Individual/Contractor/Vendor) (Charter § 2-106.2.2; Code § 2-5-34)

Provide the complete name of the filer (individual or business entity/organization seeking to do business with the City of Detroit) making this disclosure:

Name Street Address City State Zip code Telephone Fax Email

If the filer is a business entity, print the name, title, and contact information of the authorized individual making the disclosure and signing for the business entity, and include the certificate or resolution of authority authorizing the individual as an attachment to this affidavit.

Name Title

Telephone Fax Email

Section 2 - Financial Interests in Contracts or Matters Pending Before City (Charter § 2-106.2.1(a), (b); Code § 2-5- 34(a)(1), (2))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City

Matter

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship https://detroitmi.gov/sites/detroitmi.localhost/files/2018-05/2_29_2012_CharterDocument_2_1_WITHOUT_COMMENTARY_1.pdf https://library.municode.com/mi/detroit/codes/code_of_ordinances?nodeId=PAIVCOCH1--20_CH17FI_ARTVPUSU_DIV1GOSE_SDBPUGOSE_S17-5-17REMACO

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Nature of financial interest

Estimated value of the financial interest

Section 3 - Interests in Property Subject to Decision by City (City Charter § 2-106.2.1(c); City Code § 2-5-34(a)(3))

The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof has (if checked, complete rest of section below) does not have (if checked, skip to next section) an interest in real or personal property that is subject to a decision by the City regarding the purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name

Street Address

City State Zip code

Telephone Relationship

Description of real or personal property

Nature of interest

Estimated value of the interest

Section 4 - Immediate Family Members Employed by or Seeking Employment with City (City Charter § 2- 106.2.1(e); City Code § 2-5-34(a)(5))

Please identify any immediate family member of the filer, including any immediate family members of a direct or indirect owner, officer, director, or manager thereof, who is currently employed by or applying for employment with the City of Detroit.

If none, check here and skip to next section; otherwise, complete rest of section below:

Name

Street address

City State Zip code

Phone

Nature of relationship to filer

Department/agency employed by or seeking employment with

Position held or sought

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Section 5 - Persons with Financial Interest in Contractor’s/Vendor’s Matters Pending Before City (City Charter § 2-106.2.2; City Code § 2-5-34(a)(6), (7))

Please identify all persons or entities having a direct or indirect financial interest in any matter the contractor or vendor has pending before the Detroit City Council or before any office, department, or agency of the City. Note that the term “financial interest” includes, but is not limited to receipt of a thing of value (either presently or in the future).

Complete on additional page(s), if necessary.

If none, check here and skip to next section; otherwise, complete rest of section below Name Street Address City State Zip code Contract or matter in which the person or entity named has a direct or indirect financial interest in the following matters that are pending before the Detroit City Council or the following office, department, or agency of the City:

Nature of financial interest Estimated value of the financial interest

Section 6 – Contractor/Vendor’s Role In The Solicitation Please identify whether the Contractor/Vendor contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project.

Complete on additional page(s), if necessary.

If the Vendor answers this question in the negative, please check here and skip to the next section; otherwise, complete the rest of the section below. Please use extra sheets if necessary.

Describe the nature and extent of the Vendor’s contribution:

List the City employees with whom the Vendor assisted with the Solicitation:

Please list any of Vendor’s subcontractors or proposed subcontractors that contributed information, expertise or in any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project, the requirements of the project, or the budget required for the project, along with the nature and extent of the subcontractor’s contribution:

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Section 7 - Affirmation of Accuracy of Disclosure (City Charter § 2-106.2.3; City Code § 2-5-34(b))

I understand that the information provided in this disclosure will be relied upon by the City of Detroit in evaluating the proposed bid, solicitation, contract, or lease. I swear [or affirm] that the information provided is accurate. If I am signing on behalf of an entity, I swear [or affirm] that I have made a good faith and reasonable effort to verify the information provided herein, and further, that I have the authority to provide this disclosure on behalf of the entity.

Sign name:

Print name:

Sworn and subscribed to before me on , 20 by , the [name] [title] of the and am an authorized representative of that entity.

[legal entity/company]

Sign:

Print:

Notary Public, County, Michigan, Acting in County

My Commission Expires:

Notary Seal

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ADDITIONAL INFORMATION

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REFERENCES FOR DISCLOSURES BY CONTRACTORS AND VENDORS

2012 Detroit City Charter

Sec. 2-105. - Definitions and Rules of Construction.

A. As used in this Charter:

20. Immediate family member means a Public Servant’s spouse, domestic partner, individual who lives in the Public Servant’s household or an individual claimed by a Public Servant or a Public Servant’s spouse as a dependent under the United States Internal Revenue Code at 26 USC 1, et seq.

Sec. 2-106.2. - Disclosures.

1. Except as otherwise provided by applicable law, a Public Servant who exercises significant authority shall disclose:

a. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before City Council.

b. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City.

c. Any interest that he or she, or an immediate family member has in real and personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement or a development agreement.

d. Campaign contributions and expenditures, in accordance with applicable laws.

e. The identity of any immediate family member employed by the City or who is making application to the City.

2. In addition to compliance with subsection (1) above, contractors and vendors shall disclose:

a. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before City Council.

b. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before or within any office, department, or agency of the City.

3. The above disclosures shall be made in writing and be made by sworn, notarized affidavit, in accordance with City ordinance and applicable laws.

https://detroitmi.gov/sites/detroitmi.localhost/files/2018-05/2_29_2012_CharterDocument_2_1_WITHOUT_COMMENTARY_1.pdf

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2019 Detroit City Code of Ordinances

Sec. 2-5-3 – Definitions.

Immediate family member means:

(1) A public servant’s spouse;

(2) A public servant’s domestic partner;

(3) An individual claimed by a public servant or a public servant’s spouse as a dependent under the United States Internal Revenue Code, being 26 USC 1 et seq.; or

(4) An individual who lives in the household of a public servant.

Sec. 2-5-34. - Disclosure of interests by contractors and vendors.

(a) Except as otherwise provided for by applicable law, all contractors and vendors doing business with the City of Detroit shall disclose the following:

(1) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before City Council;

(2) Any financial interest, direct or indirect, that the contractor or vendor or an immediate family member has in any contract or matter pending before or within any office, department or agency of the City;

(3) Any interest that the contractor or vendor, or an immediate family member, has in real or personal property that is subject to a decision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or abatement, or a development agreement;

(4) Campaign contributions and expenditures in accordance with applicable law;

(5) The identity of any immediate family member employed by the City or who is making application to the City;

(6) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before City Council;

(7) The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter that the contractor or vendor has pending before or within any office, department, or agency of the City.

(b) All disclosures that are required under Subsection (a) of this section shall be made, in writing, on a form that is created by the Law Department and sworn to in the presence of a notary public. After completion, the form shall be filed with the Board of Ethics, which shall forward a complete copy of the form to the applicable department director or agency head.

https://library.municode.com/mi/detroit/codes/code_of_ordinances?nodeId=PAIVCOCH1--20_CH17FI_ARTVPUSU_DIV1GOSE_SDBPUGOSE_S17-5-17REMACO