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Written Disclosure of Conflict of Interest

  1. Relationship to the City of Madison*

  2. enter your full name

  3. Disclosure Statement
    I, the above named person, being duly elected to the City of Madison, Georgia position named above, officially recuse myself from participation in the presentation, deliberation, and decision-making, other than in the limited capacity as a representative agent as expressly allowed in the City’s Ethics Ordinance, regarding the matter described below.*

  4. Disclosure Statement
    I, the above named person, being duly appointed to the City of Madison, Georgia position named above, officially recuse myself from participation in the presentation, deliberation, and decision-making, other than in the limited capacity as a representative agent as expressly allowed in the City’s Ethics Ordinance, regarding the matter described below.*

  5. Disclosure Statement
    I, the above named person, being a duly appointed member of the City of Madison, Georgia board named above, officially recuse myself from participation in the presentation, deliberation, and decision-making, other than in the limited capacity as a representative agent as expressly allowed in the City’s Ethics Ordinance, regarding the matter described below.*

  6. Disclosure Statement
    I, the above named person, being duly hired to the City of Madison, Georgia position named above, officially recuse myself from participation in the presentation, deliberation, and decision-making, other than in the limited capacity as a representative agent as expressly allowed in the City’s Ethics Ordinance, regarding the matter described below.*

  7. Type of Conflict*

  8. describe type of conflict

  9. Leave This Blank:

  10. This field is not part of the form submission.