Form F-3 F-4, Employee Disclosure/Certification and Employment of Family Members Form - Arkansas

Form F-3 or the "F-4, Employee Disclosure/certification And Employment Of Family Members Form" is a form issued by the Arkansas Department of Finance & Administration.

The form was last revised in September 22, 2015 and is available for digital filing. Download an up-to-date Form F-3 in PDF-format down below or look it up on the Arkansas Department of Finance & Administration Forms website.

ADVERTISEMENT
STATE OF ARKANSAS
Department of Finance and Administration
E
D
/C
E
F
M
F
MPLOYEE
ISCLOSURE
ERTIFICATION AND
MPLOYMENT OF
AMILY
EMBERS
ORM
This form is to be completed by all interviewed applicants for a position.
Definitions for the symbols in questions 1 – 9 below. Please read before continuing.
A State Employee any employee of any state agency employed in a regular salary position or extra-help position not to include contract labor.
B Former is defined as within the last 24 months.
C Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner, General Assembly
member.
D General Assembly member: member of the Arkansas Senate or the Arkansas House of Representatives.
E Relative includes: husband, wife, mother, father, stepmother, stepfather, mother-in-law, father-in-law, sister, brother, stepsister, stepbrother, half-
sister, half-brother, sister-in-law, brother-in-law, daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, aunt, uncle, first cousin, niece
or nephew.
F
Public Official: constitutional officers; members of the Arkansas General Assembly; the executive head of any agency, department, board,
commission, institution, bureau, or council of the state.
G Agency or State Agency: every agency, board, commission, department, division, institution, and other office of state government located within
the executive branch of government and under the control of the Governor.
A
Are you a current state employee
?
1.
Yes
No
B
A
Are you a former
state employee
?
2.
Yes
No
C
3.
Yes
No
Are you a current Constitutional Officer
?
If “Yes”, were you employed prior to your election into office?
3a.
Yes
No
► If “Yes,” give
3b.
date elected
C
4.
Yes
No
Are you the spouse of a current Constitutional Officer
?
► If “Yes,” give
spouse’s name
4a.
position/office
If “Yes”, is your expected salary above $37,649 annually or above $18.10 per hour?
4b
Yes
No
.
B
C
Are you the spouse of a former
Constitutional Officer
?
5.
Yes
No
► If “Yes,” give
spouse’s name
5.a
position/office
B
D
Are you or your spouse a former
General Assembly member
?
6.
Yes
No
► If “Yes,” give
6a.
spouse’s name
position/office
If “Yes”, within the 24 months prior to your leaving office or your spouse leaving office, was the position for
6b.
Yes
No
which you are being considered created by legislative action, or if the maximum salary level increased by
more than 15%, was this authorized by legislative action?
E
F
G
Are you a relative
of the Public Official
in charge of the agency
in which you are applying?
7.
Yes
No
E
► If “Yes,” give
7a.
relative’s
name
position/office
relationship
8.
Yes
No
E
A
E
Are you a relative
of a state employee
, state board or commission member or are you a relative
(other
C
D
than the spouse) of a Constitutional Officer
or an Arkansas General Assembly member
?
► If “Yes,” give
E
8a.
relative’s
name
position/office
relationship
9.
Yes
No
If you checked “Yes” in #8 above, does this relative
E
G
work within the state agency
in which you are
applying?
9a.
Yes
No
If “Yes”, is the position for which you are applying in the direct line of supervision of your relative
E
or will the
E
position be a supervisory employee of the relative
.
I understand to be eligible for employment with the State of Arkansas, I must comply with Governor’s Executive Order 98-04, ACA §21-1-401-408, and
ACA §25-16-1001-1007. I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a
relative specifically under ACA §25-16-1002. If I am hired and it can be proven I falsely disclosed or failed to disclose information I could be subject to
criminal, civil and/or administrative remedies. I assert that I have answered the above questions to the best of my knowledge.
Applicant Name (Please Print)
Applicant Signature
Date
F-3/F-4
Rev. 09/22/15
STATE OF ARKANSAS
Department of Finance and Administration
E
D
/C
E
F
M
F
MPLOYEE
ISCLOSURE
ERTIFICATION AND
MPLOYMENT OF
AMILY
EMBERS
ORM
This form is to be completed by all interviewed applicants for a position.
Definitions for the symbols in questions 1 – 9 below. Please read before continuing.
A State Employee any employee of any state agency employed in a regular salary position or extra-help position not to include contract labor.
B Former is defined as within the last 24 months.
C Constitutional Officer: Governor, Lt. Governor, Secretary of State, Attorney General, Auditor, Treasurer, Land Commissioner, General Assembly
member.
D General Assembly member: member of the Arkansas Senate or the Arkansas House of Representatives.
E Relative includes: husband, wife, mother, father, stepmother, stepfather, mother-in-law, father-in-law, sister, brother, stepsister, stepbrother, half-
sister, half-brother, sister-in-law, brother-in-law, daughter, son, stepdaughter, stepson, daughter-in-law, son-in-law, aunt, uncle, first cousin, niece
or nephew.
F
Public Official: constitutional officers; members of the Arkansas General Assembly; the executive head of any agency, department, board,
commission, institution, bureau, or council of the state.
G Agency or State Agency: every agency, board, commission, department, division, institution, and other office of state government located within
the executive branch of government and under the control of the Governor.
A
Are you a current state employee
?
1.
Yes
No
B
A
Are you a former
state employee
?
2.
Yes
No
C
3.
Yes
No
Are you a current Constitutional Officer
?
If “Yes”, were you employed prior to your election into office?
3a.
Yes
No
► If “Yes,” give
3b.
date elected
C
4.
Yes
No
Are you the spouse of a current Constitutional Officer
?
► If “Yes,” give
spouse’s name
4a.
position/office
If “Yes”, is your expected salary above $37,649 annually or above $18.10 per hour?
4b
Yes
No
.
B
C
Are you the spouse of a former
Constitutional Officer
?
5.
Yes
No
► If “Yes,” give
spouse’s name
5.a
position/office
B
D
Are you or your spouse a former
General Assembly member
?
6.
Yes
No
► If “Yes,” give
6a.
spouse’s name
position/office
If “Yes”, within the 24 months prior to your leaving office or your spouse leaving office, was the position for
6b.
Yes
No
which you are being considered created by legislative action, or if the maximum salary level increased by
more than 15%, was this authorized by legislative action?
E
F
G
Are you a relative
of the Public Official
in charge of the agency
in which you are applying?
7.
Yes
No
E
► If “Yes,” give
7a.
relative’s
name
position/office
relationship
8.
Yes
No
E
A
E
Are you a relative
of a state employee
, state board or commission member or are you a relative
(other
C
D
than the spouse) of a Constitutional Officer
or an Arkansas General Assembly member
?
► If “Yes,” give
E
8a.
relative’s
name
position/office
relationship
9.
Yes
No
If you checked “Yes” in #8 above, does this relative
E
G
work within the state agency
in which you are
applying?
9a.
Yes
No
If “Yes”, is the position for which you are applying in the direct line of supervision of your relative
E
or will the
E
position be a supervisory employee of the relative
.
I understand to be eligible for employment with the State of Arkansas, I must comply with Governor’s Executive Order 98-04, ACA §21-1-401-408, and
ACA §25-16-1001-1007. I also understand that as an employee of the State of Arkansas I am restricted from supervising or being supervised by a
relative specifically under ACA §25-16-1002. If I am hired and it can be proven I falsely disclosed or failed to disclose information I could be subject to
criminal, civil and/or administrative remedies. I assert that I have answered the above questions to the best of my knowledge.
Applicant Name (Please Print)
Applicant Signature
Date
F-3/F-4
Rev. 09/22/15
STATE OF ARKANSAS
Department of Finance and Administration
Employee Disclosure Requirements/Restrictions Notice
Employee Disclosure Requirements Notice
Employees must report any benefit obtained from a state contract by a business in which the employee has a financial interest.
Ark. Code Ann. § 19-11-706. The employee must report this benefit to the Director of the Department of Finance and Administration.
A state employee has a “financial interest” in a business if he/she:
has received within the past year, or is presently or in the future entitled to receive, more than one thousand dollars
($1000) per year, as a result of ownership of any part of the business or any involvement in the business; or
owns more than a five percent (5%) interest in the business; or
holds a position in the business such as an officer, director, trustee, partner, employee, or the like, or holds any position of
management.
Any employee who knows or should have known of such benefit and fails to report the benefit to the director is in breach of the
ethical standards of Ark. Code Ann. § 19-11-706.
Employee Disclosure Restriction Notice
State employees are restricted from employment under certain conditions, both during the time they are employed by the state and
after they leave state employment. Ark. Code Ann. § 19-11-709. These restrictions include:
employment of a current state employee involved in procurement by any party contracting with the state;
former employees from representing anyone other than the state under certain conditions in matters which the employee
participated personally and substantially or which were within the former employee’s official responsibility;
partners of a current or former state employee from representing anyone other than the state under certain conditions;
selling to the state after termination of employment under certain conditions.
Any current or former state employee who violates any of these employment restrictions is in breach of the ethical standards of
Ark. Code Ann. § 19-11-709.
Penalties for Non-Compliance with Ark. Code Ann. § 19-11-706 or § 19-11-709
In addition to civil and administrative remedies, Ark. Code Ann. § 19-11-712 allows the Director of the Department of Finance and
Administration to impose against any employee who fails to comply with Ark. Code Ann. § 19-11-706 or § 19-11-709, after notice and an
opportunity for a hearing, any one or more of the following:
oral or written warnings or reprimands;
forfeiture of pay without suspension;
suspension with or without pay for specified periods of time; and
termination of employment.
Pursuant to Arkansas Code Annotated § 19-11-702, any employee who shall knowingly violate either of these restrictions shall be guilty of a felony and upon
conviction shall be fined in any sum not to exceed ten thousand dollars ($10,000) or shall be imprisoned not less than one (1) nor more than five (5) years, or shall
be punished by both.
I certify that I have read this Notice and the Ark. Code Ann. §§ 19-11-706, 19-11-702, 19-11-709 and 19-11-712 on the reverse side. The Rule promulgated to enforce
Executive Order 98-04 contain additional information regarding this reporting requirement at Section 13 & 14, posted by the agency in a conspicuous place. I
understand that it is my responsibility to comply with the requirement to report as explained in Ark. Code Ann §§ 19-11-706 & 19-11-709, this Notice and the rule.
Agency Name
Hiring Official
Name of Applicant/Employee (Please Print)
Applicant/Employee Signature
Date
See back for Arkansas Code Annotated §§ 19-11-702, 19-11-706, 19-11-709 and 19-11-712
F-5/F-6
Rev. 02/03/15
EXCERPTS FROM ARKANSAS CODE ANNOTATED §19-11
knowingly to act as a principal or as an agent for anyone other
SUBCHAPTER 7
than the state in connection with any:
19-11-702. Penalties.
(A) Judicial or other proceeding, application,
request for a ruling, or other determination;
Any employee or nonemployee who shall knowingly violate any of the
(B) Contract;
provisions of this subchapter shall be guilty of a felony and upon
(C) Claim; or
conviction shall be fined in any sum not to exceed ten thousand dollars
(D) Charge or controversy
($10,000) or shall be imprisoned not less than one (1) nor more than
in which the employee either participates
five (5) years, or shall be punished by both.
personally and substantially through
decision, approval, disapproval,
19-11-706. Employee disclosure requirements.
recommendation, the rendering of advice,
investigation, or otherwise, or which is the
(a) Disclosure of Benefit Received from Contract. Any employee
subject of the employee's official
who has or obtains any benefit from any state contract with a
respons bility, where the state is a party
business in which the employee has a financial interest shall
or has a direct and substantial interest.
report such benefit to the Director of the Department of Finance
and Administration. However, this section shall not apply to a
(2) When a Partner Is a Former State Employee. It shall be a
contract with a business where the employee's interest in the
breach of ethical standards for a partner of a former employee
business has been placed in a disclosed blind trust.
knowingly to act as a principal or as an agent for anyone other
than the state where such former employee is barred under
(b) Failure to Disclose Benefit Received. Any employee who knows
subsection (b) of this section.
or should have known of such benefit and fails to report the
benefit to the director is in breach of the ethical standards
(d) (1) Selling to State After Termination of Employment Is
of this section.
Prohibited. It shall be a breach of ethical standards for any
former employee, unless the former employee's last annual
19-11-709. Restrictions on employment of present and former
salary did not exceed ten thousand five hundred dollars
employees.
($10,500), to engage in selling or attempting to sell
commodities or services to the state for one (1) year following
(a) Contemporaneous Employment Prohibited. It shall be a
the date employment ceased.
breach of ethical standards for any employee who is involved in
(2) The term "sell", as used in this subsection, means signing a
procurement to become or be, while such an employee, the
bid, proposal, or contract; negotiating a contract; contacting
employee of any party contracting with the state agency by which
any employee for the purpose of obtaining, negotiating, or
the employee is employed.
discussing changes in specifications, price, cost allowances,
or other terms of a contract; settling disputes concerning
(b) Restrictions on Former Employees in Matters Connected
performance of a contract; or any other liaison activity with
with Their Former Duties.
a view toward the ultimate consummation of a sale although
the actual contract therefore is subsequently negotiated by
(1) Permanent Disqualification of Former Employee
another person.
Personally Involved in a Particular Matter. It shall be a
breach of ethical standards for any former employee
(e) (1) This section is not intended to preclude a former employee
knowingly to act as a principal or as an agent for anyone
from accepting employment with private industry solely
other than the state in connection with any:
because his employer is a contractor with this state.
(A) Judicial or other proceeding, application,
(2) This section is not intended to preclude an employee, a former
request for a ruling, or other determination;
employee, or a partner of an employee or former employee
(B) Contract;
from filing an action as a taxpayer for alleged violations of this
(C) Claim; or
subchapter.
(D) Charge or controversy
in which the employee participated personally
19-11-712. Civil and administrative remedies against employees
and substantially through decision, approval,
who breach ethical standards.
disapproval, recommendation, rendering of
advice, investigation, or otherwise while an
(a) Existing Remedies Not Impaired. Civil and administrative
employee, where the state is a party or has a
remedies against employees which are in existence on July 1,
direct and substantial interest.
1979, shall not be impaired.
(2) One-Year Representation Restriction Regarding Matters
(b) Supplemental Remedies. In addition to existing remedies for
for Which a Former Employee Was Officially
breach of the ethical standards of this subchapter, or regulations
Responsible. It shall be a breach of ethical standards for
promulgated thereunder, the Director of the Department of Finance
any former employee, within one (1) year after cessation of
and Administration may impose any one (1) or more of the
the former employee's official responsibility in connection
following:
with any:
(1) Oral or written warnings or reprimands;
(A) Judicial or other proceeding, application,
(2) Forfeiture of pay without suspension;
request for a ruling, or other determination;
(3) Suspension with or without pay for specified periods of time; &
(B) Contract;
(4) Termination of employment.
(C) Claim; or
(D) Charge or controversy
(c) Right to Recover from Employee Value Received in Breach of
knowingly to act as a principal or as an agent
Ethical Standards. The value of anything received by an
for anyone other than the state in matters
employee in breach of the ethical standards of this subchapter,
which were within the former employee's
or regulations promulgated thereunder, shall be recoverable by the
official responsibility, where the state is a
state as provided in § 19-11-714, which refers to recovery of value
party or has a direct or substantial interest.
transferred or received in breach of ethical standards.
(d) Due Process. Notice and an opportunity for a hearing shall be
(c) Disqualification of Partners.
provided prior to imposition of any of the remedies set forth in
(1) When Partner Is a State Employee. It shall be a breach of
subsection (b) of this section
.
ethical standards for a person who is a partner of an employee
STATE OF ARKANSAS
Department of Finance and Administration
Employee Disclosure Requirements
In Compliance with Governor’s Executive Order 98-04
Arkansas Code Annotated § 19-11-706
Pursuant to Arkansas Code Annotated § 19-11-706, employees are required to disclose any benefit received from any
state contract. Specifically:
(a) Any employee who has or obtains any benefit from any state contract with a
business in which the employee has a financial interest shall report such benefit
to the Director of the Department of Finance and Administration. However, this
section shall not apply to a contract with a business where the employee’s interest
in the business has been placed in a disclosed blind trust.
(b) Any employee who knows or should have known of such benefit and fails to
report the benefit to the director is in breach of the ethical standards of this
section.
This employee disclosure shall be made within 30 days after the employee has actual or constructive
notice of a benefit received or to be received. Such disclosure shall be made by completing this Employee Disclosure
Requirements form and forwarding this completed form to:
Director
Department of Finance and Administration
P. O. Box 3278
Little Rock, AR 72203-3278
Applicant/Employee Name:
Agency Name/Division where employed:
Name of Person/Business involved with State Contract:
Name of Government Body with which the Business has a Contract:
Dollar Amount and Nature of Contract:
Nature and extent of the benefit received or to be received:
Applicant/Employee Signature
Date
F-7
Rev. 02/03/15

Download Form F-3 F-4, Employee Disclosure/Certification and Employment of Family Members Form - Arkansas

325 times
Rate
4.3(4.3 / 5) 20 votes
ADVERTISEMENT
Page of 6