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• • <br />Name of OWASA Board member: <br />Name of spouse or domestic partner: <br />Orange Water and Sewer Authority (OWASA) <br />Board Member Disclosure Form <br />(please print) <br />(please print) <br />Please fill in the following information pursuant to the Ethics Policy for the OWASA Board of Directors: <br />A. All employers of the OWASA Board member and those of his or her spouse <br />or domestic partner, or the nature of their business or professions if self- <br />employed. <br />B. .Position of Board member. <br />C. Position of Spouse or domestic partner. <br />a. <br />b. <br />a. <br />a. <br />b. <br />D. Acreage, location, degree of interest and use of all real property which is <br />owned, leased, or under option to purchase or lease by a Board member, <br />his or her spouse or domestic partner, which is in Orange County and/or in <br />northern Chatham County; and <br />(1) under existing agreements might, in the future, be served by <br />OWASA and/or <br />(2) may be developed or subdivided upon receipt of subdivision approval <br />or special use or conditional use approval by the local government <br />within whose jurisdiction the land is located. <br />E. Ownership interest of the Board member or his or her spouse or domestic <br />partner, in any company which contracts to perform services for OWASA. <br />a <br />b. <br />c. <br />d. <br />e. <br />a. <br />b. <br />c. <br />Page 1 of 2 <br />w <br />