This form is for all individuals receiving any Shelby County Government contract, subcontract, land use approval or financial grant of money to report any gratuity that has been given, directly or indirectly, to any elected official, employee or appointee (including their spouse and immediate family members) who is involved in the decision regarding the contract, land use approval or financial grant of money

Name*

E-Mail address*

Date of Gratuity*

Nature and Purpose of the Gratuity*

Name of the Official, Employee, Appointee or Family Member who received the gratuity*

Name of the person or entity that provided the gratuity*

Address of the person or entity that provided the gratuity*

Description of the gratuity*

Cost of the Gratuity (If cost is unknown and not reasonably discernible by the person giving the gratuity, then the person giving the gratuity shall report a good faith estimate of the cost of the gratuity.)

The information contained in this Gratuity Disclosure Form, and any supporting documentation or materials referenced herein or submitted herewith, is true and correct to the best of my knowledge, information and belief and I affirm that I have not given, directly or indirectly, any gratuity to any elected official, employee or appointee (including their spouse and immediate family members) that has not been disclosed and I affirm that I have not violated the provisions of the Shelby County Government Code of Ethics.*

Yes

No

Print Name*

Signature*

Date*