Conflict of Interest Disclosure Statement Form
The Madison County Compliance Policy for Conflict of Interest includes a provision setting forth the standards of conduct expected and required of Affected Individuals to disclose all interests which could result in a conflict.
Please be assured that the disclosure requirements are intended to provide Madison County with a systematic and ongoing method of disclosing and ethically resolving potential conflicts of interest. Although it is impossible to list every circumstance giving rise to a possible conflict of interest, the following will serve as a guide to the types of activities that might cause conflicts and that should be fully reported.
To render directive, managerial, or consultative services to any outside concern that does business with, or competes with the services of the County, or to render other services in competition with the County.
To disclose or use information relating to the County’s business for the personal profit or advantage of the individual or his/her immediate family.
To accept gifts, excessive entertainment, or other favors from any outside concern that does, or is seeking to do, business with, or is a competitor of, the County – under circumstances from which it might be inferred that such action was intended to influence or possibly would influence the individual in the performance of his/her duties.
I hereby state that I, or members of my immediate family, have the following affiliations or interest and have taken part in the following transactions that, when considered in conjunction with the position with or relation to the County, might possibly constitute a conflict of interest (check “None” or “I have no conflict of interest to report” where applicable, attach additional page as necessary):
If there are none, type "None".
By checking the "I agree" box below, you agree and acknowledge that 1) your disclosure statement form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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