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(Name of Volunteer Board) (Insert Address) (ZIP) (Describe Position) (Name of Business) (Insert Address) (Name of Business) (Describe Work) my spouse, my children) (Name of Business) (Description) (Name of Board, Commission, Council or Committee) (Officer, Director, Agent, Employee or Owner) (Description) A Utah municipal corporation Office of the Mayor 3330 South 1300 East Millcreek, Utah 84106 (801) 214-2700 DISCLOSURE OF PRIVATE BUSINESS INTERESTS Under the provisions of the Municipal Officer’s and Employee’s Ethics Act (Utah Code Ann 10-3-1301 et seq.), I, the undersigned, under criminal penalties of perjury, make the following statement regarding my private business interests. Please complete all sections that apply. 1. I am a member of the and my address is Millcreek, Utah 2. I am a(n) of located at 3. I receive compensation from for 4. own of 5. I have a personal interest or business interest in which is a matter before the 6. I am a(n) of a substantial interest in which is subject to regulation by the City. ---PAGE BREAK--- (Signature) (Printed Name) 7. Describe any other interests or relationships to be disclosed: DATED this day of 20___ and signed under criminal penalties of perjury pursuant to the laws of the state of Utah. www.millcreek.us