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Date:
STATEMENT OF INTEREST
Name (Printed or typed)
IF NONE, CHECK HERE
Signature
(You must sign this statement even if you checked the "none" box.)
School District or Educational Service Center
OHIO ETHICS COMMISSION
(614) 466-7090
Page 1 of 2
Before completing this statement, please read the instructions on the back.
CONFIDENTIAL
The following sources of income, investments, or other interests identified on my 2014
Financial Disclosure Statement are regulated by, do business or seek to do business with, or are
interested in matters pending before, the school district or educational service center that I
serve or served.
[
EXAMPLE:
I am president of XYZ Company, which is regulated by or does business
with the school district or educational service center that I serve or served.]