All information on this form is public information. Instructions and helpful hints will appear as you go through the form. Address questions to the City’s Ethics Officer at (612) 673-3230 or the City Clerk’s Department at (612) 673-2216.

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Personal Information

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Employment Information

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Period Coverage

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Sources of Compensation

Name of Source Relationship

Spouse or Domestic Partner - Sources of Compensation

Name of Source Relationship

Securities Held in Associated Businesses

Name of Security

Spouse or Domestic Partner - Securities Held in Associated Businesses

Name of Security

Real Property

County Address and city; Or section, township, range Ownership Type Acreage - if applicable

Spouse or Domestic Partner - Real Property

County Address and city; Or section, township, range Ownership Type Acreage - if applicable

Pari-Mutuel Horse Racing

Interest Type Description of Interest (horse, stable, etc.)
Official Direct Interest
Official Indirect Interest
Family Interest

Spouse or Domestic Partner - Pari-Mutuel Horse Racing

Interest Type Description of Interest (horse, stable, etc.)
Official Direct Interest
Official Indirect Interest
Family Interest

Loans

Name of Security

Spouse or Domestic Partner - Loans

Name of Security
Due to the required signature, you must print this form and sign it. After printing, be sure to press the submit button to complete the form.

Any person who signs and certifies to be true a report or statement which the person knows contains false information, or who knowingly omits required information, is subject to a civil penalty imposed by the Minnesota Campaign Finance & Public Disclosure Board of up to $3,000 and is subject to criminal prosecution for a gross misdemeanor.

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Type of Filing

  • Candidates must complete this form within 14 days of filing.
  • Elected officials must complete this form within 60 days of being sworn in and then annually by the last Monday in January.
  • City employees, or members of a board or commission - City management has determined that in your position, you have the authority to make or recommend major decisions regarding the use of City money. You must complete this form within 60 days of accepting employment or assuming the duties of the position and then annually by the last Monday in January. Even if you are considered part-time or "acting" or "interim", you must conplete this form in a timely manner.

Means the address at which you wish to receive mail from the City. You may list your business address, the address for your campaign, or your home address.

List a number at which you can be reached during the day.

Candidates or Board Members: Your occupation is your usual job. If you have employment, you need to list it here. If you are retired, a student, a homemaker, or unemployed, you should list that category as your occupation and then leave the box for the employer's name blank.

If you are employed, you should list the name of your employer. If you are self-employed and your business has an assumed name, list it here. If self-employed and your business is under your own name, list "self-employed".

If employed, list the address from which you conduct the employer’s business. If self-employed, list the main address where you conduct your business.

Original Statement must be completed by candidates within 14 days of filing or within 60 days of being sworn in or assuming the duties of your position.

Annual Supplementary Statement must be completed annually by the last Monday in January.

Amended Statement is for changes to be reported from the previously filed statement within the same year.

Termination Statement is required only if there are changes to a previously filed statement and the statement is due after your term ends and before the last Monday in January.

Sources of Compensation

This is the section where your report information about compensation you have received from Associated Businesses. An Associated Business is one of the following types of entities: Corporation, Partnership, Limited Liability Company (LLC), Limited Liability Partnership (LLP), Association (two or more people, not all from the same immediate family, acting together) or other organized legal entity (including a trust or mutual fund). This includes self-employment if your self-employment is organized as one of the listed types of entities. Compensation of $2,500 received as an independent contractor must also be reported. See exclusions (hover for more info). If you receive more than $50 in a month from an Associated Business for services as a Director, Officer, Owner, Member, Partner, Employer or Employee, the source of the compensation must be listed. Compensation includes honorariums of $50 or more. More details for first time filers (hover for more info) or second time or later filers (hover for more info). Special rules for honorarium and per diem (hover for more info).

Relationship

This is the reason you are receiving the compensation. Choose Director, Officer, Owner, Member, Partner, Employer or Employee. You may select more than one relationship. For example, you could be self-employed and have formed an S corporation in which you are an officer and an employee. You would list the S corporation as the Name of Source twice and, in the relationship drop-down, select "officer" for one entry and then "employee" for the second entry. Please note that if you own shares (worth $2,500 or more) in the S Corporation, you also will need to list the S corporation in the Securities section below.

Securities Held in Associated Businesses

Report only the name of the entity whose securities you own. You must report the actual name of the entity not the symbol used for the entity's stock on an exchange. For mutual funds, list the name of the fund and the fund provider but not the individual stocks or other assets in the mutual fund. Do not report the value of the securities you own. What are Securities (hover for more info)? What are Associated Businesses (hover for more info)? See exclusions (hover for more info). More details for first time filers (hover for more info) or second time or later filers (hover for more info).

Real Property

This is where you report information about land in Minnesota in which you own an interest either personally or in partnership. Report the county in which the property is located. Report the street address if the property has one. If the property does not have a street address, you must list the section, township and range of the proerty or its lot, block, and addition. You must list the acreage for any property that does not have a street address. Do not list property which you claim as a homestead. See a list of interests (hover for more info). More details for first time filer (hover for more info) or second time or later filers (hover for more info) or if you own a second home (hover for more info).

Pari-Mutuel Horse Racing

This is where you report any interest that you or an immediate family member has in property connected with horse racing in the United States and Canada. You must report direct interests, indirect interests and partial interests. If you bought or sold the interest during the reporting period, you may list the date of the transaction but you are not required to list any dates.

Loans

This is where you report sources of loans you have. DO NOT REPORT loans from financial lending institutions, negotiated by unrelated parties each acting in his/her own self-interest where the interest rate is at least market rate. DO NOT include amount of loan or interest rate. For example, a student loan or a mortgage issued by a financial institution does not need to be reported.

I certify that the information contained on this form is complete, true and correct.
Signature
Date
Any person who signs and certifies to be true a report or statement which the person knows contains false information, or who knowingly omits required information, is subject to a civil penalty imposed by the Minnesota Campaign Finance & Public Disclosure Board of up to $3,000 and is subject to criminal prosecution for a gross misdemeanor.
Due to the required signature, the completed statement must be signed and delivered to Minneapolis City Clerk’s Office, 350 South 5th Street, Room 304, Minneapolis, MN 55415, or it may be faxed to (612) 673-2756.