Landowner Contract with Employee

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Landowner Contract with Employee Powered By Docstoc
					                                Village of Southampton
                                     BUILDING DEPARTMENT                                                 631-204-2146
                                        71 Hill Street, Suite #1                                         631-204-2147
                                        Southampton, NY 11968                                       Fax: 631-283-0649



                                              Disclosure Affidavit
                                           General Municipal Law §809
STATE OF NEW YORK )
                                   )ss.:
COUNTY OF SUFFOLK )

               _____________________________________, being duly sworn, deposes and says that:

          1.         (a)    An application has been made by __________________________
                                                                          name of applicant
to the _________________________________________________________ of the
                   name of Village agency
 Village    of   Southampton    with    respect to property situate at

_______________________________________, Southampton, New York. I am the
         street address
__________________________________________________________. I reside at
                                   applicant or agent for applicant

______________________________________________________________.

                  (b)       The shareholders, partners or members of the applicant corporation, partnership or limited
liability company are (if applicable):

                     (1)________________________     (3)_________________________

                     (2)________________________     (4)_________________________

     2.        (a)     The landowner’s name and address are:
                     _________________________________________________________

                     _________________________________________________________

          (b) The shareholders, partners or members of the landowner corporation, partnership or limited liability
company are (if applicable):

                     (1)________________________     (3)_________________________

                     (2)________________________     (4)_________________________

    3.     (a)       The contract vendee’s name and address are (if applicable):
                     _________________________________________________________

                     _________________________________________________________

        (b)      The shareholders, partners or members of the contract vendee corporation, partnership or limited liability
company are (if applicable):

                     (1)________________________     (3)_________________________
                  (2)________________________         (4)_________________________


        4.    Does any officer or employee of the Village of Southampton have an interest in the
                     applicant or in the landowner or in the contract vendee?

                                    _____ YES                  _____ NO

  If yes, state the name and residence of such officer or employee and the nature and extent of such interest.


   For the purpose of this disclosure, an officer or employee of the Village of Southampton shall be deemed to
   have an interest in the applicant or in the landowner or in the contract vendee when he, his spouse, or their
                  brothers, sisters, parents, children, grandchildren, or the spouse of any of them:
                  (a)      is the applicant or landowner or contract vendee; or
                  (b)      is an officer, director, partner, member or employee of the applicant or landowner or contract
vendee; or
                  (c)      legally or beneficially owns or controls stock of a corporate applicant or landowner or contract
vendee, or is a partner or member of a partnership or limited liability company applicant or landowner or contract vendee;
or
                (d)    is a party to an agreement with such an applicant or landowner or contract vendee, express
     or implied, whereby he may receive any payment or other benefit, whether or not for services rendered,
                      dependent or contingent upon the favorable approval of such application.
   A person who knowingly and intentionally fails to make such disclosure shall be guilty of a misdemeanor as
                                        provided in General Municipal Law §809.

   5.  Does any officer or employee of the Town of Southampton, County of Suffolk or State
of New York have an interest in the applicant or in the landowner or in the contract vendee?

                           _____ YES                  _____ NO

If yes, state the name and residence of such officer or employee, the name of such governmental entity (Town,
                           County, State) and the nature and extent of such interest.



         For the purpose of this disclosure, an officer or employee of the Town of Southampton, County of Suffolk or State
of New York shall be deemed to have an interest in the applicant or in the landowner or in the contract vendee when he, his
spouse, or their brothers, sisters, parents, children, grandchildren, or the spouse of any of them:
                   (a)       is the applicant or landowner or contract vendee; or
                   (b)       is an officer, director, partner, member or employee of the applicant or landowner or contract
vendee; or
                   (c)       legally or beneficially owns or controls stock of a corporate applicant or landowner or contract
vendee, or is a partner or member of a partnership or limited liability company applicant or landowner or contract vendee;
or
                  (d) is a party to an agreement with such an applicant or landowner or contract vendee, express
     or implied, whereby he may receive any payment or other benefit, whether or not for services rendered,
                       dependent or contingent upon the favorable approval of such application.
   A person who knowingly and intentionally fails to make such disclosure shall be guilty of a misdemeanor as
                                          provided in General Municipal Law §809.



                                                              __________________________________
                                                                        Signature
Sworn to before me this _________

day of _______________, 200___.

_______________________ Notary Public

				
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Description: Landowner Contract with Employee document sample