DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE, COUNTY OR MUNICIPAL ELECTED OFFICIALS. Check the box that applies and provide related information where needed D The Person Doing Business with the County is an individual and there is no familial relationship between this individual and any Cook County employee or any person holding elective office in the State of Illinois, Cook County, or any municipality within Cook County. DX The Person Doing Business with the County is a business entity and there is no familial relationship between any member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity or employees directly engaged in contractual work with the County on behalf of the business entity, and any Cook County employee or any person holding elective office in the State of Illinois, Cook County, or any municipality within Cook County. D The Person Doing Business with the County is an individual and there is a familial relationship between this individual and at least one Cook County employee and/or a person or persons holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County. The familial relationships are as follows: Name of Individual Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one Cook County employee and/or a person holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County, on the other. The familial relationships are as follows: Name of Member of Board of Director for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Officer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Employee of Business Entity Directly Engaged in Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. VERIFICATION: To the best of my knowledge, the information I have provided on this disclosure form is accurate and complete. I acknowledge that an inaccurate or incomplete disclosure is punishable by law, including but not limited to fines and debarment. 4/24/2020 Signature of Recipient Date SUBMIT COMPLETED FORM TO: Cook County Board of Ethics 00 Xxxx Xxxxxxxxxx Xxxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx 00000 Office (000) 000-0000 – Fax (000) 000-0000 XxxxXxxxxx.Xxxxxx@xxxxxxxxxxxx.xxx
Appears in 1 contract
Samples: opendocs.cookcountyil.gov
DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE, COUNTY OR MUNICIPAL ELECTED OFFICIALS. Check the box that applies and provide related information where needed D The Person Doing Business with the County is an individual and there is no familial relationship between this individual and any Cook Xxxx County employee or any person holding elective office in the State of Illinois, Cook Xxxx County, or any municipality within Cook Xxxx County. DX The Person Doing Business with the County is a business entity and there is no familial relationship between any member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity or employees directly engaged in contractual work with the County on behalf of the business entity, and any Cook Xxxx County employee or any person holding elective office in the State of Illinois, Cook Xxxx County, or any municipality within Cook Xxxx County. D EDS-11 March/2017 CONTRACT NO.1753-16842 XXXX COUNTY BOARD OF ETHICS FAMILIAL RELATIONSHIP DISCLOSURE FORM The Person Doing Business with the County is an individual and there is a familial relationship between this individual and at least one Cook Xxxx County employee and/or a person or persons holding elective office in the State of Illinois, Cook Xxxx County, and/or any municipality within Cook Xxxx County. The familial relationships are as follows: Name of Individual Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one Cook Xxxx County employee and/or a person holding elective office in the State of Illinois, Cook Xxxx County, and/or any municipality within Cook Xxxx County, on the other. The familial relationships are as follows: Name of Member of Board of Director for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Officer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* EDS-12 March/2017 CONTRACT NO.1753-16842 Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Employee of Business Entity Directly Engaged in Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. VERIFICATION: To the best of my knowledge, the information I have provided on this disclosure form is accurate and complete. I acknowledge that an inaccurate or incomplete disclosure is punishable by law, including but not limited to fines and debarment. 4/24/2020 Signature of Recipient 10/15/2020 Date SUBMIT COMPLETED FORM TO: Cook Xxxx County Board of Ethics 00 Xxxx Xxxxxxxxxx Xxxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx 00000 Office (000) 000-0000 – Fax (000) 000-0000 XxxxXxxxxx.Xxxxxx@xxxxxxxxxxxx.xxxXxxxXxxxxx.Xxxxxx@xxxxxxxxxxxx.xxx * Spouse, domestic partner, civil union partner or parent, child, sibling, aunt, uncle, niece, nephew, grandparent or grandchild by blood, marriage (i.e. in laws and step relations) or adoption. EDS-13 March/2017 EDS 10-13
Appears in 1 contract
Samples: opendocs.cookcountyil.gov
DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE, COUNTY OR MUNICIPAL ELECTED OFFICIALS. Check the box that applies and provide related information where needed D □ The Person Doing Business with the County is an individual and there is no familial relationship between this individual and any Cook Xxxx County employee or any person holding elective office in the State of IllinoisofTllinois, Cook Xxxx County, or any municipality within Cook Xxxx County. DX The Person Doing Business with the County is a business entity and there is no familial relationship between any member of this ofthis business entity’s 's board of directorsofdirectors, officers, persons responsible for general administration of the ofthe business entity, agents authorized to execute documents on behalf of the behalfofthe business entity or employees directly engaged in contractual work with the County on behalf of the behalfofthe business entity, and any Cook Xxxx County employee or any person holding elective office in the State of ot' Illinois, Cook Xxxx County, or any municipality within Cook Xxxx County. EDS-10 XXXX COUNTY BOARD OF ETHICS FAMILIAL RELATIONSHIP DISCLOSURE FORM CONTRACT#: 1812-17304 D The Person Doing Business with the County is an individual and there is a familial relationship between this individual and at least one Cook Xxxx County employee and/or a person or persons holding elective office in the State of Illinois, Cook Xxxx County, and/or any municipality within Cook Xxxx County. The familial relationships are as follows: Name of Individual offndividual Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position ofRelated County Employee or State. County or Municipal Elected Official Nature ofFamilial Relationship• N/A ifmore space is needed, allach an additional sheetfollowing the aboveformat. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member ofthis business entity's board ofdirectors, officers, persons responsible for general administration ofthe business entity, agents authorized to execute documents on behalfof the business entity and/or employees directly engaged in contractual work with the County on behalfofthe business entity, on the one hand, and at least one Xxxx County employee and/or a person holding elective office in the State oflllinois, Xxxx County, and/or any municipality within Xxxx County, on the other. The familial relationships are as follows: Name ofMember of Board of Director for Business Entity Doing Business with the County Name ofOfticer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Name of Related County Employee or State, County or Municipal Elected Otlicial Title and Position ofRelated County Employee or State, County or Municipal Elected Oflicial Title and Position ofRelated County Employee or State, County or Municipal Elected Otlicial Nature ofFamilial Relationship' Nature ofFamilial Relationship' N/A EDS-11 Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one Cook County employee and/or a person holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County, on the other. The familial relationships are as follows: Name of Member of Board of Director for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, . County or Municipal Elected Official CONTRACT#: Nature of Familial Relationship• Nature of Familial Relationship* Name of Officer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* ' 1812-17304 N/A Name of Employee of Business Entity Directly Engaged in Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more ' Ifmore space is needed, attach an additional sheet following sheetfollowing the above formataboveformat. VERIFICATION: To the best of my knowledge, the information I have provided on this disclosure form is accurate and complete. I acknowledge that an inaccurate or incomplete disclosure is punishable by law, including but not limited to fines and debarment. 4/24/2020 Signature of Recipient Date SUBMIT COMPLETED FORM TO: Cook County Board of Ethics 00 Xxxx Xxxxxxxxxx Xxxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx 00000 Office (000) 000-0000 – Fax (000) 000-0000 XxxxXxxxxx.Xxxxxx@xxxxxxxxxxxx.xxx.
Appears in 1 contract
Samples: opendocs.cookcountyil.gov
DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE, COUNTY OR MUNICIPAL ELECTED OFFICIALS. Check the box that applies and provide related information where needed D □ The Person Doing Business with the County is an individual and there is no familial relationship between this individual and any Cook County employee or any person holding elective office in the State of IllinoisofTllinois, Cook County, or any municipality within Cook County. DX The Person Doing Business with the County is a business entity and there is no familial relationship between any member of this ofthis business entity’s 's board of directorsofdirectors, officers, persons responsible for general administration of the ofthe business entity, agents authorized to execute documents on behalf of the behalfofthe business entity or employees directly engaged in contractual work with the County on behalf of the behalfofthe business entity, and any Cook County employee or any person holding elective office in the State of ot' Illinois, Cook County, or any municipality within Cook County. EDS-10 COOK COUNTY BOARD OF ETHICS FAMILIAL RELATIONSHIP DISCLOSURE FORM CONTRACT#: 1812-17304 D The Person Doing Business with the County is an individual and there is a familial relationship between this individual and at least one Cook County employee and/or a person or persons holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County. The familial relationships are as follows: Name of Individual offndividual Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position ofRelated County Employee or State. County or Municipal Elected Official Nature ofFamilial Relationship• N/A ifmore space is needed, allach an additional sheetfollowing the aboveformat. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member ofthis business entity's board ofdirectors, officers, persons responsible for general administration ofthe business entity, agents authorized to execute documents on behalfof the business entity and/or employees directly engaged in contractual work with the County on behalfofthe business entity, on the one hand, and at least one Cook County employee and/or a person holding elective office in the State oflllinois, Cook County, and/or any municipality within Cook County, on the other. The familial relationships are as follows: Name ofMember of Board of Director for Business Entity Doing Business with the County Name ofOfticer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Name of Related County Employee or State, County or Municipal Elected Otlicial Title and Position ofRelated County Employee or State, County or Municipal Elected Oflicial Title and Position ofRelated County Employee or State, County or Municipal Elected Otlicial Nature ofFamilial Relationship' Nature ofFamilial Relationship' N/A EDS-11 Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more space is needed, attach an additional sheet following the above format. D The Person Doing Business with the County is a business entity and there is a familial relationship between at least one member of this business entity’s board of directors, officers, persons responsible for general administration of the business entity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one Cook County employee and/or a person holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County, on the other. The familial relationships are as follows: Name of Member of Board of Director for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, . County or Municipal Elected Official CONTRACT#: Nature of Familial Relationship• Nature of Familial Relationship* Name of Officer for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Person Responsible for the General Administration of the Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* Name of Agent Authorized to Execute Documents for Business Entity Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* ' 1812-17304 N/A Name of Employee of Business Entity Directly Engaged in Doing Business with the County Name of Related County Employee or State, County or Municipal Elected Official N/A Title and Position of Related County Employee or State, County or Municipal Elected Official Nature of Familial Relationship* If more ' Ifmore space is needed, attach an additional sheet following sheetfollowing the above formataboveformat. VERIFICATION: To the best of my knowledge, the information I have provided on this disclosure form is accurate and complete. I acknowledge that an inaccurate or incomplete disclosure is punishable by law, including but not limited to fines and debarment. 4/24/2020 Signature of Recipient Date SUBMIT COMPLETED FORM TO: Cook County Board of Ethics 00 Xxxx Xxxxxxxxxx Xxxxxx, Xxxxx 0000, Xxxxxxx, Xxxxxxxx 00000 Office (000) 000-0000 – Fax (000) 000-0000 XxxxXxxxxx.Xxxxxx@xxxxxxxxxxxx.xxx.
Appears in 1 contract
Samples: opendocs.cookcountyil.gov
