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Model Member Item Affidavit
Model Member Item Affidavit
Page 1 of 2
7. To the best of my knowledge, and upon reasonable diligence and review,
_________________ does not do business with nor is engaged contractually to transfer
any government funds, or to provide or receive goods and services, with any business or
entity owned in whole or in part by myself, members of my immediate family,
household companions or close relatives, or any business or entity owned in whole or in
part by members of my staff and/or their immediate family members, household
companions, or close relatives.
9. I intend and expect that these sponsored discretionary state funds will be used by the
organization for ___________________________________ during the year
______________ .
10. At no time in the past 6 years has _________________ performed any political
activities on my behalf or on behalf of any other member of the New York State
Legislature, including but not limited to, advertising, mailing, producing documents and
flyers, committing human resources to my campaigns, soliciting funds, or utilizing
office space or any other activities not previously disclosed to the NYS Board of
Elections- campaign finance board.
11. The proposed discretionary funding was not allocated lieu of any past or future political
activity (as defined in no. 10 above).
Signed: ____________________________
Legislator/Date
Notary:____________________________