STATE OF OKLAHOMA
INDEPENDENT SCHOOL OR TECHNOLOGY CENTER DISTRICT OF
_
__________________________
(Name of District)
PFD Elected ISD/TCDI Officers
Version 2016.1
FINANCIAL DISCLOSURE STATEMENT
FOR ELECTED OFFICERS
Amended:
Full Name of Elected Officer
Filing Year
Name of Elective Office
Electronic Mail Address
Work Phone Number
“Elected officer” shall mean a school or technology center officer who is subject to election or retention.
I understand that as an elected officer, as defined above, I am required to comply with the Rules of the
Oklahoma Ethics Commission applicable to non-state officers concerning filing and contents of Financial
Disclosure Statements, and that, according to the Oklahoma Supreme Court, those Rules have the “weight
of statutes.”
I understand the purpose of Financial Disclosure is to assist elected officers in identifying and disclosing
potential conflicts of interest between their public duties and private economic interests.
I understand the Ethics Commission rules are available in the Oklahoma Statutes at Title 74, Chapter 62,
Appendix I, and on the Ethics Commission website at www.ethics.ok.gov.
I understand the Ethics Commission provides the forms that are required to be filed on the Ethics
Commission website at www.ethics.ok.gov and is available to answer questions concerning financial
disclosure.
I understand an initial Financial Disclosure Statement is required to be filed with the School Board Clerk
within thirty (30) days of assuming office for a full or partial term covering the prior calendar year if a
Financial Disclosure Statement covering the prior year has not already been filed.
I understand that an annual Financial Disclosure Statement is required to be filed with the School Board
Clerk annually between January 1 and May 15 covering the prior calendar year if a Financial Disclosure
Statement covering the prior year has not already been filed.
I understand that, pursuant to Title 19 O.S. § 215.5, I may seek advice from the district attorney or his
or her assistants concerning my duties as an elected officer.
Material Financial Interest.
I understand I must disclose, on this form, any material financial interest as defined below, that I, my
spouse or my dependent(s) had in the preceding calendar year covering January 1, 20xx through
December 31, 20xx.
A material financial interest shall mean one or more of the interests identified below:
an ownership interest in a private business, including but not limited to, a closely held corporation,
limited liability company, Subchapter S corporation or partnership for which I, my spouse or my
dependent(s) is a director, officer, owner, manager, employee, or agent or any private business, closely
held corporation or limited liability company in which I, my spouse or my dependent(s) owns or has
Term of Office
Mailing Address, City, State, Zip Code
2
PFD Elected ISD/TCDI Officers
version 2016.1
owned stock, another form of equity interest, stock options, debt instruments, or has received dividends
or income worth $20,000.00 or more;
an ownership interest of 5% or more in a publicly traded corporation or other business entity;
an ownership interest in a publicly traded corporation or other business entity from which dividends or
income, not to include salary, of $50,000.00 or more were derived during the preceding calendar year;
an interest that arises as a result of service as a director or officer of a publicly traded corporation or
other business entity;
income derived from employment, other than compensation pertaining to the office subject to election
or retention, in the amount of $20,000.00 or more.
Disclose in the table below the name and address of all entities in which you, your spouse or your dependents had a
material financial interest in the preceding calendar year, and who has the interest.
Name and Address of Entity
Description (optional)
Filer / Spouse / Dependent
Name and Address of Entity
Description (optional)
Filer / Spouse / Dependent
Name and Address of Entity
Description (optional)
Filer / Spouse / Dependent
Name and Address of Entity
Description (optional)
Filer / Spouse / Dependent
Name and Address of Entity
Description (optional)
Filer / Spouse / Dependent
Amended Financial Disclosure Statement Certification. I certify this amendment is not made for the
purpose of reporting information that was intentionally omitted or misstated on the original or previously
filed Financial Disclosure Statement.
Acknowledgement: By signing, electronic or otherwise, my name below, I, acknowledge that the information
submitted is complete, true and accurate as of the date submitted. I understand the failure to provide such
information is a violation of the laws of Oklahoma. I understand that I can update the information above at any
time by filing an amended Financial Disclosure Statement.
_____________________________ _____________________________
Date Signature