Please list any full-time and/or part-time employment or business presently engaged in by you and each member of your immediate family. A member of your immediate family means a spouse/civil union partner, domestic partner, or child, parent, or sibling residing in your household. Indicate positions held, names of employers and/or businesses, and commencement and termination dates of employment, if applicable.

If you hold a license issued by a State agency that entitles you to engage in a particular business, profession, trade, or occupation (for example, law, medicine, nurse, pharmacist, engineer, real estate, insurance, private detective, teacher), click "Yes" and list the type of license. Choose from the drop-down menu whether the license is active or inactive. Completing this section satisfies your obligation to report under N.J.S.A. 52:13D-23(e)(2).

The Conflicts of Interest law, N.J.S.A. 52:13D-21.2(b)(1), provides that “[a] relative of an appointed member of a governing or advisory body of an independent authority, board, commission, agency or instrumentality of the State shall not be employed in an office or position in that independent authority, board, commission, agency, or instrumentality.” Furthermore, the statute provides that “[a] State officer or employee or a Special State Officer or employee in the Executive Branch shall not supervise, or exercise authority with regard to personnel actions over, a relative of the officer or employee.” 

If you have a relative who is employed in an office or position in the unclassified service of the civil service of the State, click “Yes” and provide the name, relationship to you, and the employing agency of that relative. Note that for purposes of this section, relative means your spouse/civil union partner, or your or your spouse’s/civil union partner’s parent, child, brother, sister, aunt, uncle, niece, nephew, grandparent, grandchild, son-in-law, stepparent, stepchild, stepbrother, stepsister, half-brother or half-sister, whether the relative is related to you or your spouse/civil union partner by blood, marriage or adoption.

In #2, indicate whether you exercise authority, supervision or control with regard to personnel actions regarding relatives. If the answer is “Yes,” indicate Name, Job Title, and Work Unit of the relative.

For item #1, please provide the date of the most recent list provided to you of entities that do business with the college or university where you serve as a governing board member.

For item #2, please indicate if you or an immediate family member (spouse/civil union partner, domestic partner, child, parent, or sibling residing in your household) do business with the college or university where you serve as a governing board member. Use the space provided to note details, including the name and nature of the business for you or your immediate family member.

For item #3, please disclose all compensated employment, directorships or fiduciary positions, contractual arrangements producing or expected to produce compensation, capital gains, and honoraria and other sources of income. You will provide more details on these disclosures as you continue with the form.

For item #4, disclose interests in public and closely held corporations, partnerships, sole proprietorships, or similar business entities. Indicate whether you own or control more than one percent of the profits or assets of any firm, association, or partnership that does business with your university or college. Also provide the name of firm, association, or partnership.

For item #5, indicate whether a member of your immediate family owns or controls more than one percent of the profits or assets of any firm, association, or partnership that does business with your university or college. If “yes,” provide the family member’s name, relationship to you, and the firm, association, or partnership.

For items #6 and #7, please disclose compensated or uncompensated offices, trusteeships, directorships, or positions of any nature held by you, your spouse/civil union partner or domestic partner, or dependent children, with any firm, corporation, association, partnership, or business. List all applicable positions and indicate in the space provided whether the firm, corporation, association, partnership, or business does business with your college/university.

For item #8, please provide details regarding any debts you owe to your university or college.

For item #9, please provide details of any liabilities or debts, held by you or your immediate family members, with creditors doing business with your university. In the space provided, provide the family member’s name and relationship to you, the creditor or institution doing business with your university or college with whom you or your immediate family member has a debt or liability, as well as the nature of the liability. Liabilities include, but are not limited to, notes, accounts payable, past due taxes, mortgages or liens, and loans on life insurance. Include all liabilities that have been forgiven within the last twelve months, stating the names of all the creditors to whom the liability was owed.

Identify the stocks or bonds held by you, your spouse/civil union partner or domestic partner, or immediate family members with companies, mutual/holding funds, or government agencies doing business with your college or university. List whether such person owns more than one percent of the profits or assets in the entity listed.

List and describe any interest you or a member of your immediate family has in any contract made or executed by your university or college. Contractual arrangements include, but are not limited to, a buyout agreement, severance payments, a purchase contract, contract of sale, or lease or rental agreement of any goods or services, or license.

In this section, you will also disclose any contractual or business relationships with university/college officers/employees. Be sure to indicate the name and title of the officer, employee or special State officer. Note that under the Uniform Ethics Code, an agency head, deputy head or assistant head is prohibited from engaging in any private business transactions with any employee of his/her agency.

Please indicate in the space provided any interest you or an immediate family member has in real estate owned by your university or college. Real estate interests can include those arising from sales, purchases, rental agreements, leases, contingent interests, or deeds. Be sure to provide the information required for each interest held.

Please list any interest you, or an immediate family member, holds in any closely held corporation, partnership, sole proprietorship, or similar business entity that does business with your university or college. Interest is defined as more than one-percent ownership or control of any profits or assets of such a business entity.

Please list and describe any exceptions granted to you by the State Ethics Commission under paragraph 5 of Executive Order No. 14. Please indicate the date on which the exception was granted.

Please indicate whether there are individuals, agencies, private sector entities, non-profit organizations, trade, or professional organizations that you now or expect in the future, to represent, appear for, or make inquiries before your university or college. Note, under the Conflicts of Interest law, N.J.S.A. 52:13D-16a “[a] Special State officer is prohibited from representing, appearing for or negotiating on behalf of any person or party other than the State in connection with any cause, proceeding, application or other matter pending before the particular office, bureau, board, council, commission, authority, agency, fund or system in which such special State Officer or employee holds office or employment.” This prohibition also extends to any partnership, firm, or corporation in which the special State officer has an interest.

A capital gain is a profit realized on the sale or exchange of a capital asset (stocks, bonds, house, property, car, etc.). Please indicate the item sold, the description of the item, and the recipient of the gain.

Honoraria, lecture fees, gifts not included above, and other miscellaneous sources of income must be disclosed here, including but not limited to Social Security, pensions, bank interest, dividends, rental income, accounts and notes receivable, and royalties over $1,000. List each type of income, source of income, and recipient of income in the spaces provided. Note: State officers are not permitted to accept honoraria in connection with matters related to their official duties.

If you have any additional information to append to your form, please click “Yes” and “Select files.” You may only attach a PDF document. Also, please ensure that any documents you attach do not include any personal identifiers, such as your address, account numbers, Social Security number, and/or telephone numbers.

Electronically sign the form by choosing from the options under the signature box. You may type, draw, or upload your signature. Note that your electronic signature is the legal equivalent of your written signature, and that you are subject to penalties for perjury if you falsely certify the COI. Indicate who completed the form on behalf of the filer. If you choose “Other,” a text box will appear for more information. You will be required to verify your information by clicking “I’m not a robot,” and following the instructions.