Disclosure Form

Docusign Envelope ID: 1D87A011-546E-4BED-913F-3918B5C13ACA

venture, corporation, limited liability company, firm, trust, foundation, or other organization or entity used in carrying on a business.

Name of Business Entity or Person: * (Write NA if not applicable.)

Address of Business Entity or Person:

Position Held with Entity:

Nature of the regulation of the Entity by the Duchesne County (including any licenses, permits, etc.)

Nature of the business which the Entity or Person does or anticipates doing with the Duchesne County:

Nature of the transaction involving the Duchesne County for which you may receive or agree to receive compensation from the Entity or Person for assisting, including a description of the services to be performed and the compensation to be rendered:

DISCLOSURE OF SUBSTANTIAL BUSINESS INTERESTS

Please disclose any ownership of a substantial interest in any business entity which may be subject to the regulation of the City or which does or anticipates doing business with the City. As used herein, "substantial interest" means the ownership, either legally or equitably, by you or your spouse or minor children, of at least 10% of the outstanding shares of a corporation or 10% interest in any other business entity. This section shall not require the disclosure of interests that do not exceed $2,000.00. Life insurance policies and annuities need not be considered in determining the value of any such interest.

Name of Business Entity: * (Write NA if not applicable.)