TOWN OF CLARKSTOWN OFFICE OF THE SUPERVISOR I GROMACK - . . Supervisor iilSeptember 29, 2015 Via hand delivery Ms. Jody Sherman Confidential Secretary Rockland County Board of Ethics Allison-Paris County Office Building 11 New Hempstead Road New City, New York 10956 Re: Amendment to 2012 and 2013 Financial Disclosure Statements Dear Ms. Sherman: It has been brought to my attention that there was an error on my 2012 and 2013 Financial Disclosure Forms for the Rockland County Solid Waste Authority and the Rockland County Sewer Commission. Attached is a revised Question 1 ?Outside Employment and Business? for both years for each entity. Kindly file accordingly. Very truly yours, AC Supervisor 10 Maple Avenue, New City, New York 10956 Telephone 845.639.2050 Fax 345.634.5456 - a.gromack@cla.rkstown.org CERTIFICATION T0 AMENDED FINANCIAL DISCLOSURE FORMS I certify that the responses to the attached amended Financial Disclosure Forms, Question 1, is true to the best of my knowledge. Dated: September 29, 2015 SignatUre NEH-MELE Notary Public, State of New York Hookiand County No. 02WA6246608 Commission Expires August 15. 2019 1. Outside Employment and Business List the name of every employer or business from which you were paid more than $2,500.00 for services performed or for goods sold or produced, whether you were a paid member, of?cer, director, or employee during the reporting period. Do not list the County of Rocldand as an employer (this information is covered in question 3 below) or individual customers or clients of the business. Do not list businesses in which you were an investor only (these are identi?ed in question 2 below). Identify the nature and type of the business, such as a partnership, corporation, limited liability company, or sole proprietorship, and list your relationships(s) to the employer or business (Le. owner, partner, of?cer, director, member, employee and/or shareholder) and state your position with the employer. Provide the same information for your Spouse. . Name Relationship to Name of Nature of Type of Position Held you Employer or Business Business Business eg. John Doe Hioboiid ABC Realty Reo/ Estate Porn-23min}; Employee 3a5 m: ?7er ?new Gs masth fauna RTB vft-?Ma? match-mm 63.. a Inc UL Mam-x? My; Winn? Mt}; 2. Privately Held Businesses List the name of any privately held entity in which, during the reporting period, you had an ownership interest of at least 20% of the entity or an investment with a total value of at least $50,000.00 in the entity. Do not list any entity listed in response to question 1 above or any publicly traded entity. Identify the nature of the business and the type of business corporation, limited liability company, partnership). Provide the same information For your spouse or children under 21 living with you at home. Name Relationship to You Name of Entity Nature of Business Type of Business eg. Moi}: Doe Self Investigations Private Corporation Investigations his? to ?ex. 3. Rockland County Employment List any and all relatives, de?ned with respect to this question only as your Spouse, children, siblings, parents or in- Iaws, including yourself, who were employed by the County of Rockland in a permanent, full-time capacity during the reporting period. Please include the position or title and the department. Name Relationship Position/Title Department Motive. Outside Employment'and'Business I List the name of every or business item which yen were paid more than $2,500 for services perfomled-' or for geods solder produced, whether you were a paid member, or employee during the reporting period. Do not list the County of Roekland as an employer. (this information is coyered in question 3. below)_or individual customers or clients of the business. Do- not list businesses in which you were an hivestOr only (these are identi?ed in question-2 below). Identify the nature of the business, such as a partnership, Corpom'tion, - limited liability. company, or sole preprietor'sliip, and list year the employer or business owner, partner,-oflieer, director, member, employee and/or shareholder) and state your position With the employer. - Provide the same inferential: for your :5pouseNanae - Relationshipto Name of Nature of - Type of .. FositionHeld- .- syou. - '?Employer or - Business "Business . __Business I Husband . Keely lites? Estate Employee Qf'romsde ?fame Sahel Deer1?T~ Emitter" 41cm, thivgrf . ?ritiw 2. PrivatelyeI-Ield Businesses List the name .ofany privately held entity in which, during the reporting period, you had an ownership interest of at. least 20% of the entity or an investment with a total value of at least $50,000 in the entity. Do not list any entity'- listed in response toque'stion i above or any publicly traded entity. Identify the nature of the business and the type of business (eg. corporation, limited liability company, partnership). Provide the same information for your spouse or children under 21 living With you at home. . Name of Entity Name Relationship to You Nature of BusineSS Type of Business e. g. Mary Doe I . Self Investigations Private Commotion - - Investigations 3. Roekland County Employment List any and all relatives, de?ned with respect to this question only as your Spouse, children, siblings, parents or in- laws, including yourself, who were employed by the County of Rocltland in a pennanent, ?sh-time capacity during the reporting period. Please include the position or title and the department. Name Relationship to you Position Held/Title County Department e.g. Ralph Roe Father-debt! Attorney Law Depamnem 'Neme 1. Outside Employment and Business List the name of every employer or business from which you were paid more than $2,5 00.00 for services performed or for goods sold or produced, whether you were a paid member, of?cer, director, or employee during the reporting period. Do not list the County of Rockland as an employer (this information is covered in question 3 below) or individual customers or clients of the business. Do not list businesses in which you were an investor only (these are identi?ed in question 2 below). Identify the nature and type of the business, such as a partnership, corporation, limited liability company, or sole proprietorship, and list your relationships(s) to the employer or business (Le. owner, partner, of?cer, director, member, employee and/'or shareholder) and state your position with the employer. Provide the same information for your Spouse. - Name Relationship to Name of Nature of Type of Position Held you Employer or Business Business Business ag. John Doe Husband ABC Realty Real Estate Partnership Employee 5 some RTE ?gremlins momma ta. est: a on.ng A as secure: GEO M?ck?. ML pwwr?i'm) Mdrtu?'rumwep Q. Pad?1"? 2. Privately Held Businesses List the name of any privately held entity in which, during the reporting period, you had an ownership interest of at least 20% of the entity or an investment with a total value of at least $50,000.00 in the entity, Do not list any entity listed in response to question 1 above 01' any publicly traded entity. Identify the nature of the business and the type of business (eg. corporation, limited liability company, partnership). Provide the same information for your spouse or children under 21 living with you at home. Name Relationship to You Name of Entity Nature of Business Type of Business ag. Mary Doe 5er Edit) Investigations Private Corporation Investigations hone; 3. Rockland County Employment List any and all relatives, de?ned with reSpect to this question only as your spouse, children. siblings, parents or in- laws, including yourself, who were employed by the County of Rockland in a permanent, full-time capacity during the reporting period. Please include the position or title and the department. Name [Relationship PositionfT'itle Department [slow-E, 3 - I List the name of eVery employer'or business ?om'which you were-paid'mo're than $2,500 for services performed or for goods solder produced, whether you Were .a paid member, of?cer, employee during the reporting period. . Do not list the County of Roekland-as an employer {this information is severed in question 3 below) or . - }'individual customers or clients of the business. Donor Iis't busines'Se's iambic}: you Were an investor only (these are identi?ed in-questionzz below); 'Id'eiitif'y the tore and type-of the" bhsineSs, such as a partnership, corporation, limited -.iia_bi1ity compeiry, or. sole proprietorship?nd list to: the'employe'r or of?oer, employee sewer-shareholder) and state-your position With the empIOyer. Provide-the some infatuation-foryourspodseName . hshipso - I Me'on I . Position Held - . you - - - Employer or . - . Business . Business - .. Business II I . . I ReoZEstare Per-fresher}; . - .. I {Is-smear:- rs'spemgg' - - '3 .. -- Mam-kmwarsw- . . Stbgai'f?ereigir ?ou?T- - Q'znmsek' 1311; Prowi-w I . - 1395??- 2. Privatehy Held Businesses - List the name of anyprivarely held entity in which, during the reporting period, you had an ownership interest of 'at least 20% of the entity or an investment With a total value of at least $50,000 in the entity. Do not list any entity' iisted- in response to Question 1 above or any publicly traded entity. Identify the nemeof the business and the type of busineSS (eg. Corporation, liability company, partnership). Provide'the Same infometion for your'Spouse . or children under 21 living with you at homeName Relationship to You Name of Entity - I Nature of Business . "Type of Business Mary Doe . Seb? - Ri?e!) Investigations Private - Corporation" - . - Investigations Me Me 3. Rockland County Employment List any and all relatives, de?ned with respect to this question only as your spouse, children, siblings, parents or laws, including yourself, who were employed by the County of Rockiand in a permanent, full-time capacity during the reporting period. Please include the position or title and the department. Name Relationship to you Position Held/Title County Department 8.3.: Ralph Roe Father-in-?lrrw - Attorney Law Department News