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2. Relationship to the City of Madison*

   1. Elected Official
   2. Appointed Official
   3. Appointed Board Member
   4. Hired Official
4. Name*
   enter your full name
6. Elected Position*
   -- Select One --MayorCity Council Member
8. 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.*

   1. I affirm the Disclosure Statement
10. Appointed Posistion*
    -- Select One --Municipal Court JudgeCity Attorney
12. 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.*

    1. I affirm the Disclosure Statement
14. Appointed Board*
    -- Select One --Audit CommitteeCemetery Stewardship CommissionCorridor Design CommissionDowntown Development AuthorityGreenspace CommissionHistoric Preservation CommissionHousing Opportunity CommissionMain Street Advisory BoardPlanning & Zoning CommissionOther Board, Authority, Commission, or Committee
16. Other Board, Authority, Commssion, or Committee*
18. 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.*

    1. I affirm the Disclosure Statement
20. Hired Position*
    -- Select One --City ManagerAssistant City ManagerCity ClerkDeputy City Clerk
22. 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.*

    1. I affirm the Disclosure Statement
24. Recusal Matter*
26. Type of Conflict*

    1. Substantial Interest (direct or indirect pecuniary interest)
    2. Familial Relationship (nuclear degree of consanguinity)
    3. Personal Involvement or Bias (positive or negative)
    4. Other Conflict
28. Other type of Conflict
    describe type of conflict
30. Date*
    Date
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32. 1. Receive an email copy of this form.
33. Email address

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34. Submit Submit and Print

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