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40 <br />IF YOU MAKE NO ATTEMPT TO INFLUENCE THE DECISION EXCEPT BY DISCUSSION AT THE MEETING: <br />• You must disclose orally the nature of your conflict in the measure before participating. <br />• You must complete the form and file it within 15 days after the vote occurs with the person responsible for recording the minutes of <br />the meeting, who must incorporate the form in the minutes. A copy of the form must be provided immediately to the other <br />members of the agency, and the form must be read publicly at the next meeting after the form is filed. <br />DISCLOSURE OF LOCAL OFFICER'S INTEREST <br />) John W. T i p p i n , hereby disclose that on December 14, .19 S <br />(a) A measure came or will come before my agency which (check one) <br />inured to my special private gain; <br />inured to the special gain of my business associate, <br />_ inured to the special gain of my relative, <br />— inured to the special gain of <br />whom 1 am retained; or <br />inured to the special gain of <br />is the parent organization or subsidiary of a principal which has retained me. <br />(b) The measure before my agency and the nature of my conflicting interestin t e measure is as follows: <br />pc <br />Date F' dSign Lure <br />i_. Jokn/d. Tippin <br />, by <br />, which <br />NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317 (1991), A FAILURE TO MAKE ANY REQUIRED <br />DISCLOSURE CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: <br />IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT. DEMOTION, REDUCTION IN <br />SALARY, REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $5,000. <br />I <br />�.. , vn.}, an • ILLYI <br />PAGE 2 <br />