3979 APPENDIX A Disclosure StatementSchedule 'A' - Disclosure Statement
Section 13 of the Code of Conduct regarding the acceptance of gifts and benefits, requires Members to
disclose the receipt of certain gifts and benefits if the dollar value of a single gift or benefit exceeds $200 or if
the total value of gifts and benefits received from one source in a calendar year exceeds $500. This Disclosure
Statement is to be used to report on such gifts and benefits and shall be filed with the Clerk within 30 days of
receipt of such gift or benefit, or upon reaching the annual limit.
Disclosure Statements are a matter of public record.
Nature of Gift or Benefit received:
________________________________________________________________________________________
________________________________________________________________________________________
Source of Gift or Benefit:
________________________________________________________________________________________
________________________________________________________________________________________
Circumstances under which Gift or Benefit received:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Intended use of the Gift or Benefit (i.e. will be donated/provided to the Town):
________________________________________________________________________________________
________________________________________________________________________________________
Estimates Value of Gift or Benefit: $___________________________
Date Gift or Benefit was received: ____________________________(MM/DD/YR)
______________________________ _____________________________ Signature of Member Date