State Authorities/Boards/Commissions - Annual Disclosure Form ANNUAL DISCLOSURE FOR AUTHORITY/BOARD/COMMISSION MEMBERPURSUANT TO SDCL CHAPTER 3-23 THIS IS A PUBLIC DOCUMENT Name of Member: Name of Board, Authority or Commission: The Member shall disclose below any contract in which the Member has an interest or from which the Member derives a direct benefit if the contract is: With the state agency to which the Member�s board, authority or commission is attached for reporting or oversight purposes and which contract requires the expenditure of government funds; With the state and which contract requires the approval of the Member�s board, authority or commission and the expenditure of government funds; or With a political subdivision of the state if the political subdivision approves the contract and: Is under the regulatory oversight of the authority, board, or commission, or Is under the regulatory oversight of the agency to which the Member�s board, authority or commission is attached. The Member shall disclose the contract even though no additional authorization is needed from the Member�s board, authority or commission to have an interest or derive a benefit from the contract. The Member shall also identify every entity in which the Member possesses an ownership interest of five percent or greater if: The entity receives grant money from the State, either directly or by a pass-through grant or The entity contracts with the State or any political subdivision for services. 1. Contracts in which you have an interest pursuant to SDCL Chapter 3-23 and which do not violate any other provision of law - Provide the following for each contract in which you have, or will have, an interest. For further information see SDCL 3-23-2.1 and 3-23-3.1. Description of the contract Parties Description of your interest/role in the contract Date contract was previously disclosed; if applicable add row 2. Contracts in which you have a direct benefit pursuant to SDCL Chapter 3-23 - Provide the following for each contract from which you derive, or will derive, a direct benefit. For more information see SDCL 3-23-2, 3-23-2.2 and 3-23-3.1. Description of the contract Parties Description of the direct benefit Date contract was authorized add row 3. Entities in which you possess an ownership interest of five percent or more that receive grant money from the State, either directly or by a pass-through grant, or that contract with the State or any political subdivision for services � Provide the following for each such entity. See SDCL 3-23-3.1. Description of the contract or grant Party in which you possess the interest State agency or subdivision add row The member shall complete a separate authorization request for any contract identified above that requires authorization from the Member�s board, authority or commission in order for the Member to legally derive a direct benefit. Signature of Member: Date:
State Authorities/Boards/Commissions - Annual Disclosure Form ANNUAL DISCLOSURE FOR AUTHORITY/BOARD/COMMISSION MEMBERPURSUANT TO SDCL CHAPTER 3-23 THIS IS A PUBLIC DOCUMENT Name of Member: Name of Board, Authority or Commission: The Member shall disclose below any contract in which the Member has an interest or from which the Member derives a direct benefit if the contract is: With the state agency to which the Member�s board, authority or commission is attached for reporting or oversight purposes and which contract requires the expenditure of government funds; With the state and which contract requires the approval of the Member�s board, authority or commission and the expenditure of government funds; or With a political subdivision of the state if the political subdivision approves the contract and: Is under the regulatory oversight of the authority, board, or commission, or Is under the regulatory oversight of the agency to which the Member�s board, authority or commission is attached. The Member shall disclose the contract even though no additional authorization is needed from the Member�s board, authority or commission to have an interest or derive a benefit from the contract. The Member shall also identify every entity in which the Member possesses an ownership interest of five percent or greater if: The entity receives grant money from the State, either directly or by a pass-through grant or The entity contracts with the State or any political subdivision for services. 1. Contracts in which you have an interest pursuant to SDCL Chapter 3-23 and which do not violate any other provision of law - Provide the following for each contract in which you have, or will have, an interest. For further information see SDCL 3-23-2.1 and 3-23-3.1. Description of the contract Parties Description of your interest/role in the contract Date contract was previously disclosed; if applicable add row 2. Contracts in which you have a direct benefit pursuant to SDCL Chapter 3-23 - Provide the following for each contract from which you derive, or will derive, a direct benefit. For more information see SDCL 3-23-2, 3-23-2.2 and 3-23-3.1. Description of the contract Parties Description of the direct benefit Date contract was authorized add row 3. Entities in which you possess an ownership interest of five percent or more that receive grant money from the State, either directly or by a pass-through grant, or that contract with the State or any political subdivision for services � Provide the following for each such entity. See SDCL 3-23-3.1. Description of the contract or grant Party in which you possess the interest State agency or subdivision add row The member shall complete a separate authorization request for any contract identified above that requires authorization from the Member�s board, authority or commission in order for the Member to legally derive a direct benefit. Signature of Member: Date:
