Form I-205 "Disclosure of Appointee Interest in State Contracts to Be Filed With the Secretary of State" - Illinois

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Disclosure of Appointee Interest in State Contracts
to be filed with the Secretary of State
Secretary of State Index Department, Ethics Section
111 E. Monroe
Springfield, IL 62756
Appointee’s Name: _______________________________________________________________________
217-524-0309
217-524-0930 (fax)
Mailing Address: ________________________________________________________________________
www.cyberdriveillinois.com
City, State, ZIP: _________________________________________________________________________
Name and type of organization for which this disclosure is being filed:
_____________________________________________________________________________________
❑ Board
Date of Appointment:
❑ Commission
❑ Authority
_____________________________
(This date must be completed.)
❑ Task Force
GENERAL DIRECTIONS
Pursuant to 5 ILCS 420/3A.30, upon appointment to a board, commission, authority or task force authorized or created by State law,
a person must file with the Secretary of State a disclosure of all contracts the person, or his or her spouse or immediate family mem-
bers living with the person, have with the State and all contracts between the State and any entity in which the person, or his or
her spouse or immediate family members living with the person, have a majority financial interest.
List all contracts with the State of Illinois in effect on or after the date of appointment:
(If additional space is needed, please attach a supplemental listing.)
Name of individual or entity contracting with the
Name of State agency or department contract is with:
State of Illinois:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
VERIFICATION
“I declare that this disclosure statement (including any supplemental listing) has been examined by me and to the best of my knowl-
edge and belief is a true, correct and complete statement of any contracts that I am required to identify pursuant to the Illinois
Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a business offense
punishable by a fine of $1,001.
It is further understood that an unlawful conflict of interest may arise if, as an appointee, I, my spouse, or immediate family mem-
ber living in my residence has or acquires a contract or has or acquires a direct pecuniary interest in a contract with the State that
relates to the board, commission, authority or task force of which I am an appointee during and for one year following the conclu-
sion of my term of office.”
________________________________________________________
________________________________________
Signature of Appointee Making Statement
Date
(Source: Added at 29 Ill. Reg. 8908, effective June 10, 2005.)
Printed by authority of the State of Illinois. October 2007 - I-205.1
Disclosure of Appointee Interest in State Contracts
to be filed with the Secretary of State
Secretary of State Index Department, Ethics Section
111 E. Monroe
Springfield, IL 62756
Appointee’s Name: _______________________________________________________________________
217-524-0309
217-524-0930 (fax)
Mailing Address: ________________________________________________________________________
www.cyberdriveillinois.com
City, State, ZIP: _________________________________________________________________________
Name and type of organization for which this disclosure is being filed:
_____________________________________________________________________________________
❑ Board
Date of Appointment:
❑ Commission
❑ Authority
_____________________________
(This date must be completed.)
❑ Task Force
GENERAL DIRECTIONS
Pursuant to 5 ILCS 420/3A.30, upon appointment to a board, commission, authority or task force authorized or created by State law,
a person must file with the Secretary of State a disclosure of all contracts the person, or his or her spouse or immediate family mem-
bers living with the person, have with the State and all contracts between the State and any entity in which the person, or his or
her spouse or immediate family members living with the person, have a majority financial interest.
List all contracts with the State of Illinois in effect on or after the date of appointment:
(If additional space is needed, please attach a supplemental listing.)
Name of individual or entity contracting with the
Name of State agency or department contract is with:
State of Illinois:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
VERIFICATION
“I declare that this disclosure statement (including any supplemental listing) has been examined by me and to the best of my knowl-
edge and belief is a true, correct and complete statement of any contracts that I am required to identify pursuant to the Illinois
Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a business offense
punishable by a fine of $1,001.
It is further understood that an unlawful conflict of interest may arise if, as an appointee, I, my spouse, or immediate family mem-
ber living in my residence has or acquires a contract or has or acquires a direct pecuniary interest in a contract with the State that
relates to the board, commission, authority or task force of which I am an appointee during and for one year following the conclu-
sion of my term of office.”
________________________________________________________
________________________________________
Signature of Appointee Making Statement
Date
(Source: Added at 29 Ill. Reg. 8908, effective June 10, 2005.)
Printed by authority of the State of Illinois. October 2007 - I-205.1
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