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f~°t....l~i~~'H~~E'~dT l~ <br />fiC~~Ri} C1F' Ct~I.~T'1' C0~1?1~1ISS1C3''0'~RS <br />t1R.~1'~~GE C~C)C3~~3 tiC}RTI~ C~R.€)LI~~ <br />QRAN~E GQUNTY ~QMMISSIUNERS <br />DESCL~SURE STATEMENT <br />The minimal requirements far completion of this farm are that it be completed at ar during the annual <br />Qrganizational Meeting of the County Commissioners after the election.. or appointment and all <br />subsequent elections or appointments to the office of County Gomrnissioner of each commissioner. <br />However, it is recommended that commissioners eornplete this form annually during each C~rganizationai <br />Meeting. <br />Please answer ail questions and where your answer is Wane or not applicable so state. ANSWERS <br />SHOULD BE PRINTED C7R TIPPED, and additional sheets may be used if mare space is needed. For <br />clarification of any question, please refer to the County Attorney. Upon completion this Disclosure <br />Statement shall be fried with the Clerk to the Board of County Commissioners. <br />Nate: The failure to file this Disclosure Statement is a violation of the Cade of Ethics and may subject you <br />to censure or other penalties.. <br />~l . <br />2 <br />NAME iJF QFFICIAL {LAST} (FIRST} {IN1TlAL} TITLE <br />HOME ADDRESS (STREET} {CITI'(fOWN} (ZlP CODE} <br />It11AILING ADDRESS {If different from home address} <br />3. I was elected on C was appointed an <br />4. List the following: NAME OF SPOUSE <br />5. List the address or legal description of any real estate; including your principal residence, in which you <br />or your spouse, have a financial interest. <br />NATURE OF INTEREST ADDRESS OR DESCRIPTION <br />