Copy-ready · one page · not stored here

Covered-person self-disclosure — municipal bond holdings

Sworn statement to the clerk. Yes or no, plus an amount band. Copy-ready. This page does not collect, store, or transmit a completed filing.

Issuer: {{COUNTY}}
Project: {{PROJECT}}
Series: {{SERIES}}
Year: {{YEAR}}

Threshold

You must file if, in a fiscal year, you have more than $5,000 of interest in these bonds, or you own 5% or more of an entity that holds the bonds.

Covered persons

Elected officials who voted on the borrowing
County manager
Finance director
Project vendors and their principals
Spouse and dependent children of the above

When to file

At issuance
At material amendment
Annually while the bonds are outstanding

Statement

Name (as on the public roster)Seat or role

Do you, your spouse, or a dependent child have an interest in these bonds above the threshold, directly or through an entity?

Yes No

Amount band (if Yes)

I certify that the answers above are true to the best of my knowledge. I understand that a false statement, or a failure to file when required, is an ethics matter for the existing commission — not a missing world owner registry.

SignatureDate

Print and file with the clerk. This website does not receive the completed form. No Social Security number, account number, or exact position size belongs on this page.