HomeMy WebLinkAbout1/22/2018 - Municipal Elected Official Outside Concurrent Employment Annual Disclosure FormBROWARD COUNTY ELECTED OFFICIAL CODE OF ETHICS OUTSIDE/CONCURRENT EMPLOYMENT
DISCLOSURE FORM FOR MUNICIPAL ELECTED OFFICIALS
Name of Elected Official:
Calendar year covered by disclosure form:
Name of outside or concurrent
Remuneration received
Direct employer contributions to
employer
during covered year
retirement
Please state exact amount or check applicable box
El Under $1,000
Did you receive any direct employer
$1,000 - $5,000
contribution to retirement from this
$5,001 - $10,000
employer during the reporting period?
$10,001 - $25,000
ElYes ® No
$25,001 - $50,000
If yes, was this amount incuded in the
$50,001 - $100,000
exact remuneration amount or range
cis
Over $100,000
disclosed in the prior column?
®Exact Amount
®Yes ®No
Under $1,000
$1,000 - $5,000
Did you receive any direct employer
contribution to retirement from this
!I
$5,041 - $10,400
employer during the reporting period?
El $10,001 - $25,000
®Yes 9<0
® $25,001 - $50,000
If yes, was this amount incuded in the
$50,001 - $100,000
exact remuneration amount or range
ever $100,000
disclosed in the prior column?
Exact Amount
[]Yes El No
Under $1,000
Did you receive any direct employer
Q $1,000 - $5,000
contribution to retirement from this
$5,001 - $10,000
employer during the reporting period?
0 $10,001 - $25,000
®Yes No
$25,001 - $50,000
If yes, was this amount incuded in the
$50,001 - $100,000
exact remuneration amount or range
Over $100,000
disclosed in the prior column?
El Exact Amount
EjYes El No
Signature of Elected Official:
If this form amends a previously filled form, please check this box
Date: