Financial Disclosure and Affiliation Statement Documents

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Position/ Board or Commission
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Name
Financial Disclosure and Affiliation Statement
The City of Evanston recognizes that government functions best when there is public
trust. As one means of ensuring this essential public trust, the Council has adopted a Code of
Ethics which requires all Officers and Employees to file this Financial Disclosure and Affiliation
Statement.
The completed statement shall be presented to the City Clerk for transmittal.
Statements shall be destroyed annually upon receipt of a newly filed statement or no
later than July 31st following the completion of a term of service.
This information is required from all elected Officials, City Manager, Assistant City
Manager, Department Heads, and members and executive staff of all Boards, Commissions,
Special Committees, and other positions as specifically designated by the City Council or City
Manager. 1-10-3
The Disclosure Statements of elected officials and the City Manager will be maintained
on file with the City Clerk and Board of Ethics. These statements are available for review by the
general public upon specific request to the City Clerk during regular business hours. When a
request for viewing of an Ethics Statement is made, the person whose Ethic Statement is
requested shall be notified and the person viewing the statement named.
The Disclosure Statement of members of Boards, Commissions, and Committees shall
be filled with the City Clerk and reviewed and maintained in confidence by the Board of Ethics.
The Disclosure Statement of the Assistant City Manager, Department Heads, and
Executive Staff of Boards, Commissions, and Committees shall be filed with and reviewed and
maintained in confidence by the City Manager. Upon request, the Board of Ethics may review in
confidence these statements.
All Officers and Employees of the City are expected to read the Code of Ethics. Copies
may be obtained from the City Clerk. 1-10-4.
Please answer every question. If no answer is available, please write "none" or "n/a."

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Section 1-10-4.(D) Prohibition Against Interests Which Are in Conflict With or Appear To Be in Conflict
with the Performance of Official Duties. “No covered person shall directly or indirectly engage in any
business or transaction or shall directly or indirectly have a financial or other personal interest in a
business or transaction that is in conflict with or gives the appearance of being in conflict with the proper
discharge of their official duties or that impairs or may give the appearance of impairing their independent
judgment and/or independent action in the performance of their official duties. For purposes of this
Section, "personal interest" shall include the financial interest of a spouse, minor child or other household
member of the covered person.”
1. 	Please list the addresses of all Evanston real estate, or the titles of Evanston land trusts, of
which you and/or spouse or cohabitating partner and/or any relative living with you have
financial ownership or interest.
If none, please state “None” or “n/a.”
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Is any application pending for zoning or rezoning of any of the above real estate? If so, indicate the
address of this real estate.
If none, please state “none” or “n/a.”
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_____________________________________________________________________________________
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2. 	Please list the name(s) of any entity(ies) doing business with the City of Evanston or the
Evanston Township.
(A) In which you and/or spouse or cohabitating partner and/or any relative living with you are
employed or from which you receive income, including pension or retirement income, except for
Social Security Payments.
(B) In which you and/or spouse or cohabitating partner and/or any relative living with you have an
element of ownership, or have an investment having a fair market value in excess of $5,000,
excepting, however, investment in securities traded on a recognized exchange need not be
disclosed unless it fair market value on the date of filing exceeds $20,000.
If none, please state “none” or “n/a.”
Business
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Relationship
(employee, owner. Lender, stockholder,
consultant, pensioner, etc.)
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________________________________________
________________________________________
________________________________________

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3. 	Please list the name(s) of those organizations, and/or institutions that receive funds or direct
services from the City in which you and/or spouse or cohabitating partner and/or any relative
living with you, in which you are an employee, officer, board member, or trustee.
If none, please state “none” or “n/a.”
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. 	Please indicate the nature of any professional or occupational licenses or franchises issued
by the City of Evanston to you and/or spouse or cohabitating partner and/or any relative
living with you, in which you are an employee, officer, board member, or trustee.
If none, please state “none” or “n/a.”
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(Activity licensed or franchised)
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5. 	Please state whether you and/or spouse or cohabitating partner and/or any relative living
with you owns any property, receives any gifts or income, or has any economic interest or
association which creates or could give rise to a conflict of interest with the City. Describe
briefly the nature of the potential conflict.
If none, please state “none” or “n/a.”
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
6. 	Please list the following information for you and/or spouse or cohabitating partner and/or any
relative living with you.
If none, please state, “none” or “n/a.”
A. Your place of employment:
____________________________________________________________________________
Name of employer 	Nature of business of the employer
____________________________________________________________________________
Street address
____________________________________________________________________________
City or town, state, and zip 	Your job title
B. Spouse or significant other’s place of employment
____________________________________________________________________________
Name of employer 	Nature of business of the employer
____________________________________________________________________________
Street address
____________________________________________________________________________
City or town, state, and zip 	Spouse’s job title

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C. Relative’s place of employment
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Name of relative 	Relationship
____________________________________________________________________________
Name of employer 	Nature of employment
____________________________________________________________________________
Street address
____________________________________________________________________________
City or town, state, and zip 	Relative’s job title
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
7. 	Please indicate additional information relevant to the Disclosure regarding the Code of
Ethics. Attach additional pages if necessary.
If none, please state, “none” or “n/a”
____________________________________________________________________________
____________________________________________________________________________
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Verification
I swear (or affirm) that I have read the Code of Ethics.
I further swear (or affirm) that the information listed above (including information
attached) has been examined by me and is true, correct, and complete to the best of my
knowledge.
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Signature
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Date
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This Financial Disclosure and Affiliation Statement shall be filled prior to the person being seated as a member of a Board,
Committee, or Commission, and shall be filed annually thereafter on July 1st of each year.
Rev. 7/2022

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