COUNTY OF ROCKLAND BOARD OF ETHICS Allison?Paris County Of?ce Building 11 New Hempstead Road New City, New York 10956 (845) 708?7137 . - C.SCOTT VANDERHOEF Fax: (345) 63 85356 . IRA E. OUSTATCHER, . County Executive Chairperson 66-112 No Con?icting Interest Or Activity Af?davit DISCLOSURE, ACKNOWLEDGMENT AND AFFIRMATION OF NO CONFLICTING INTEREST OR ACTIVITY, WHICH WOULD CONSTITUTE A PERSONAL GAIN OR A CONFLICT OF INTEREST (Short Form Disclosure Af?miation) ALL ORNIS TO BE SUBMITTED BY MAY 15.. 2013 With full knowledge and awareness I af?rm that I do not have, I have not engaged in, and I will not engage in any activity that would provide a personal or pecuniary gain to myself, my spouse, or. my dependent(s) from the activity (activities) in which I now give (or am about to give) my services, to the County of Rockland or any affiliated or associated board, commission or'agency thereof. Dated: a 2,213 [i Printed Name goli? Nae-Te Aunde m? york Board or Activity . Quali?ed in Rockland County COMMISSIOH a, . '20? a I Email Address 3H1 .40 aauigm h? '17 6 Wm th Bic-How FORM B: The annual statement of ?nancial disclosure shall contain the information and shall be in the form set forth below. Answer each of the questions completely and if additional Space is needed, attach additional pages. ROCKLAND COUNTY ANNUAL STATEMENT OF FINANCIAL DISCLOSURE CALENDAR YEAR 2012 ROM Pick: armada? I?ll?. Last Name First Name Middle Initial ?Sm eer- vt sm- Title/Position mer Pilwrl?sraw in: Current Emplover/Business Mince} Calm-l5: Salsd/ Was-la- dinners?97y Advisory Nam Ci?l?y, l0 Maple see. Work Address M, V. 106 as 01716 one 0. Marital Status: If married, please give spouse?s full name, including maiden name where applicable 13% 6? '20 Manet List the names of all children under 21 living with you at home: Email Address: The purpose of this disclosure statement is to identify potential con?icts that may exist between private and public life with reSpect to your duties while an elected of?cial, of?cer, employee, political paity of?cial, candidate for County elected of?ce or serving on a voluntary Rockland County board, commission or advisory council. Please follow all directions carefully and attach additional pages if necessary. Disclosure of the information on this form is required for-compliance with the Rockland County Code of Ethics and New York General Municipal Law. Mimi)? 3H1 :lO hi] If Am in]: .- i, 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 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 identified in question 2 below). Identify the nature and type of the business, such as a partnership, corporation, limited liability company, or sole preprietorship, and list your relationships(s) to the employer or business 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 Employer or Business Business Business e. g. John Doe Husband ABC Realty Real Estate Partnership Employee 3'09?: Sec-vie: Van-T ?hm no m. at 5 Qmwm? Min Weak: Co. in?: e" w- {Piuon 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 8. g. Mary Doe Self Investigations Private Corporation Investigations luv: we; 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 PositionfTitle Department Mom-e. 4. Government and Not-for-Profit Positions List each of?ce or position, whether paid or unpaid, that you held during the reporting period with any federal, state or municipal government entity or with any not?for-pro?t organization. Do not list entities where you were only a member but had no of?ce or position. Do not list entities where you only volunteered in a non-policymaking, non- administrative capacity, such as a neighborhood Girl Scout leader or a Little League coach. Do not list any of?ce or position reported elsewhere on this form. Entity or Organization Position Home. 5. Gifts List each gift worth $75.00 or more that you or your spouse received from any person, ?rm or entity that has or had a matter pending during the reporting period before you, your department or the board, commissiop or counsel upon which you serve. For purposes of this question, ?matter pending," means a formal request for a contract, goods, services, funding, license or permit. A ?gift? means anything of value fOr which you or your spouse paid nothing or paid less than the fair market value and may be .in the form of money, services, reduced interest on a loan, travel, travel reimbursements, entertainment, hospitality, or on any other form. Note that separate gifts from the same or af?liated donor during the reporting period must be added together for purposes of the $75 threshold. Name Relationship to you Donor of Gift Nature of Gift eg. Mary Doe self XYZ Corp. Free trip to Atlantic it); no we. The reporting of information in this statement is required by the New York State General Municipal Law and the Laws of Rockland County. Improper use of the information contained in this statement by any third person or entity in violation of privacy or other rights is separately punishable in accordance with the law. Please be advised that, pursuant to New York State law, this statement is available in its entirety for public inspection and reproduction, but any information within the statement deemed exempt by New York State law or the Laws of Rockland County shall be redacted accordingly. I certt?) that all ofthe above information is true to the best ofmy knowledge and that within the past two weeks; I have read the attached summary of the Rockland County Board of Er}; ics. Dated thief-ll 124?, 29 3 Signature I. Summary of the Rockland County Board of Ethics ?66~ll (C) shall now be created: as follows ?66?11 (C) 1: All members of Rockland County boards which are not identi?ed as persons who shall file either form A or ?nancial disclosure forms shall annually ?le with the county ethics board by the date set forth for ?ling annual ?nancial disclosure forms the ?no con?icting interest or activity affidavit? of the county. Failure to file shall be subject to sanctions as set forth in the law. {$66-11 (C) 2: Chairpersons of the county boards shall ?le the Form (Short Form) ?nancial disclosure affidavit, except when all board members of a board are required to file Form A (Long Form) per the annual list of policy making or in?uencing positions. 5566-11 (C) 3: All board members and employees of public authorities in Rookland County identi?ed in New York State Public Authorities Law Section 2825 (3) shall ?le the Rockland County Form (short form) as set forth in ?66-11 (B) ?nancial disclosure law. Section 3. Separability If any section, subsection, sentence, clause, phrase Or other portion of this local law is for any reason, declared unconstitutional or invalid, in whole or in part, by any court of competent jurisdiction such portion shall be deemed severable, and such unconstitutionality or invalidity shall not affect the validity of the remaining portions of this law, which remaining portions shall continue in full force and effect. Section 4. Effective date This local law shall take effect January 1, 2008. COUNTY OF ROCKLAND BOARD OF ETHICS Allison-Paris County Of?ce Building 11 New Hempstead Road New City, New York 10956 (845) 708?7137 C.SCOTT VANDERHOEF Fax: (845) 63 8?5856 County Executive Chairperson 66?1 1.2 No Con?icting Interest Or Activity Af?davit DISCLOSURE, ACKNOWLEDGMENT AND AFFIRMATION OF NO CONFLICTING INTEREST OR ACTIVITY, WHICH WOULD CONSTITUTE A PERSONAL GAIN OR A CONFLICT OF INTEREST (Short Form Disclosure Af?rmation) ALL FORMS TO BE SUBMITTED BY MAY 15. 2013 With full knowledge and awareness I af?rm that I do not have, I have not engaged in, and I will not engage in any activity that would provide a personal or pecuniary gain to myself, my spouse, or my dependent(s) from the activity (activities) in which I now give (or am about to give) my services, to the County of Rockland or any af?liated or associated board, commission or'agency thereof. Dated: 24/ 208 Printed Name Eacktm? 90w 5; M1 9;an? Board or Activity 5W Notary Public, State of New?? No. 010765232953 Qualified in Hockland . County ExpireaDeoa Us 30 3315.camaoaa a. . a [Ech?ckza 02?? Email Address IRA E. OUSTATCHER, FORM B: The annual statement of ?nancial disclosure shall contain the information and shall be in the form set forth below. Answer each of the questions completely and if additional space is needed, attach additional pages. ROCKLAND COUNTY ANNUAL STATEMENT OF FINANCIAL DISCLOSURE CALENDAR YEAR 2012 I Ramada Naxmdar? Last Name First Name Middle Initial 0-13- :0 Sm ear Vt sm- Current Employer/Business TitleIPosition Q?aHr-m? Cauchy 92/? an; Cc: M: 95: mo Advisom 1 l0 Marple Prue. Neva my, my. mu. 5362??st Work Address Work Phone No. Home Address Home Phone No. Marital Status: If married, please give spouse?s full name, including maiden name where applicable 35W linear-A to List the names of all children under 21 living with you at home: Email Address: The purpose of this disclosure statement is to identify potential conflicts that may exist between private and public life with respect to your duties while an elected of?cial, of?cer, employee, political party official, candidate for County elected of?ce or serving on a voluntary Rockland County board, commission or advisory council. Please follow all directions carefully and attach additional pages if necessary. Disclosure of the information on this form is required for compliance with the Rockland County Code of Ethics and New York General Municipal Law. 3A11?33?a Alanna 331330 an. ?ltll {l?Z 1. Outside Employment and Business List the name of every employer or business from which you were paid more than $2,500.00 for services performed or for goods sold or produced, whether you were a paid member, officer, director, or employee during the reporting period. Do not list the County of Rockland as an employer (this information is covered in question 3 below) or individual customers or clients of the business. Do not list businesses in which you were an investor only (these are identi?ed in question 2 below). Identify the nature and type of the business, such as a partnership, corporation, limited liability company, or sole proprietorship, and list your relationships(s) to the employer or business owner, partner, of?cer, director, member, employee and/or shareholder) and state your position with the employer. Provide the same information for your spouse. . Name Relationship to Name of Nature of Type of Position Held you Employer or Business Business Business eg. John Doe Husband ABC Realty Real Estate Partnership Employee 339$ set-Vic; th'T THU-9 Ronnie. 5 99W RTE vat-?? Mann-mpg; as, La; w. gem 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 e. g. Mary Doe Self Investigations Private Corporation Investigations the, 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 Position/Title Department Mow-e 4. Government and Not-for-Pro?t Positions List each of?ce or position, whether paid or unpaid, that you held during the reporting period with any federal, state or municipal government entity or with any not-for-pro?t organization. Do not list entities where you were only a member but had no of?ce or position. Do not list entities where you only volunteered in a non?policymaking, non- administrative capacity, such as a neighborhood Girl Scout leader or a Little League coach. Do not list any of?ce 01' position reported elsewhere on this form. Entity or Organization Position Home 5. Gifts List each gift worth $75.00 or more that you or your spouse received from any person, ?rm or entity that has or had a matter pending during the reporting period before you, your department or the board, commission or counsel upon which you serve. For purposes of this question, ?matter pending," means a formal request for a contract, goods, services, funding, license or permit. A ?gift? means anything of value for which you or your spouse paid nothing or paid less than the fair market value and may be in the form of money, services, reduced interest on a loan, travel, travel reimbursements, entertainment, hospitality, or on any other form. Note that separate gifts from the same or af?liated donor during the reporting period must be added together for purposes of the $75 threshold. Name Relationship to you Donor of Gift Nature of Gift eg. Mary Doe set)? XYZ Corp. Free trip to Atlantic City no we. The reporting of information in this statement is required by the New York State General Municipal Law and the Laws of Rockland County. Improper use of the information contained in this statement by any third person or entity in violation of privacy or other rights is separately punishable in accordance with the law. Please be advised that, pursuant to New York State law, this statement is available in its entirety for public inSpection and reproduction, but any information within the statement deemed exempt by New York State law or the Laws of Rockland County shall be redacted accordingly. I certi?/ that all of the above information is true to the best of my knowledge and that within the past two weeks; I have read the attached summary of the Rockland County Board of Ethics. Dated h. rec-H 20 3 Signature Summary of the Rockland County Board of Ethics ?66-11 (C) shall now be created: as follows ?66?11 (C) 1: All members of Rockland County boards which are not identi?ed as persons who shall ?le either form A or ?nancial disclosure forms shall annually ?le with the county ethics board by the date set forth for ?ling annual ?nancial disclosure forms the ?no con?icting interest or activity af?davit" of the county. Failure to ?le shall be subject to sanctions as set forth in the law. ?66-11 (C) 2: Chairpersons of the county boards shall ?le the Form (Short Form) ?nancial disclosure af?davit, except when all board members of a board are required to ?le Form A (Long Form) per the annual list of policy making or in?uencing positions. ?66-11 (C) 3: All board members and employees of public authorities in Rockland County identi?ed in New York State Public Authorities Law Section 2825 (3) shall ?le the Rockland County Form (short form) as set forth in ?66?ll (B) ?nancial disclosure law. Section 3. Separability If any section, subsection, sentence, clause, phrase or other portion of this local law is for any reason, declared unconstitutional or invalid, in whole or in part, by any court of competent jurisdiction such portion shall be deemed severable, and such unconstitutionality or invalidity shall not affect the validity of the remaining portions of this law, which remaining portions shall continue in full force and effect. Section 4. Effective date This local law shall take effect January I, 2008. .