Fillable Printable Client Business Relationship Form 12 6 12.Qxp
Fillable Printable Client Business Relationship Form 12 6 12.Qxp
Client Business Relationship Form 12 6 12.Qxp
NY
STATE
CLIENT
BUSINESS
RELATIONSHIP
FORM
Marking Instructions:
Please type or use blue or black ink pen.
Print legible numbers and block letters, no script.
Completely fill in one circle.
II
Name:
Permanent Business Address:
City:State:ZIP code:
Phone:
Fill in circle if amendment
FOR OFFICE USE ONLY
Reporting Information
I
Year:
Client Information
Continued on next page
Entity Name:
Entity Address:
City:State:ZIP code:
Phone:
State Person with the Requisite Involvement in the Entity:
Last name:First name:
State Person’s Agency or Legislative Body of Employment:
Public Office Address:
City:State:ZIP code:
Phone:
Check here if using addendum sheet for additional State Person(s) with the Requisite Involvement in the Entity:
Description of Business Relationship(s):
Compensation (Actual or Anticipated):$.00
Expenses (Actual or Anticipated):$.00
Total Compensation and Expenses (Actual or Anticipated): $.00
Beginning date of Business Relationship (Actual or Anticipated): Month:Year:
End date of Business Relationship (Actual or Anticipated)if applicable:Month:Year:
Check here if using addendum sheet for additional Relationship(s) with different Entity/Entities:
III
Instructions: Fill out this section onlyif the Relationship is with an Entity. If the Relationship is with a State Person, skip this section
and fill out Section IV.
Business Relationship with an Entity
Print Form
This Declaration must be signed by the Chief Administrative Officer. If the Chief Administrative Officer, for any
reason, does not sign, he/she must duly designate another person to sign this Declaration.) (See instructions.)
SIGNATURE: DATE:
PRINT NAME: LASTFIRST
Mark One:Chief Administrative OfficerDesignee(Attach Letter)
X
Declaration
V
I declare under penalty of perjury that the information contained in this report is true,
correct, and complete to the best of my knowledge and belief.
Business Relationship with a State Person
State Person Last Name:
IV
Agency or Legislative Body of Employment:
Public Office Address:
City:State:ZIP code:
Phone:
Description of Business Relationship(s):
Compensation (Actual or Anticipated):$.00
Expenses (Actual or Anticipated):$.00
Total Compensation and Expenses (Actual or Anticipated): $.00
Beginning date of Business Relationship (Actual or Anticipated): Month:Year:
End date of Business Relationship (Actual or Anticipated) if applicable: Month:Year:
Check here if using addendum sheet for additional State Person(s):
State Person FirstName:
Instructions: Fill out this section onlyif the Relationship is with a State Person. If the Relationship is with an Entity, skip this section
and fill out Section III.
Please use the following addendum pages as continuation for the specified sections. If additional space is needed, please
make a copy of this sheet.
Designated Addendum Sheet for Sections III and IV
III
Instructions: Fill out this section onlyif the Relationship is with an Entity. If the Relationship is with a State Person, skip this section
and fill out Section IV.
Business Relationship with an Entity
Continued on next page
III(a)
Fill out this section ONLY for additional Relationship(s) with different Entity/Entities.
Entity Name:
Entity Address:
City:State:ZIP code:
Phone:
State Person with the Requisite Involvement in the Entity:
Last name:First name:
State Person’s Agency or Legislative Body of Employment:
Public Office Address:
City:State:ZIP code:
Phone:
Check here if using addendum sheet for additional State Person(s) with the Requisite Involvement in the Entity:
Description of Business Relationship(s):
Compensation (Actual or Anticipated):$.00
Expenses (Actual or Anticipated):$.00
Total Compensation and Expenses (Actual or Anticipated): $.00
Beginning date of Business Relationship (Actual or Anticipated): Month:Year:
End date of Business Relationship (Actual or Anticipated) if applicable:Month:Year:
Entity Name:
Entity Address:
City:State:ZIP code:
Phone:
State Person with the Requisite Involvement in the Entity:
Last name:First name:
State Person’s Agency or Legislative Body of Employment:
Public Office Address:
City:State:ZIP code:
Phone:
III(b)
Fill out this section ONLY for additional State Person with the Requisite Involvement in an Entity previously listed.
Business Relationship with a State Person
State Person Last Name:
IV
Agency or Legislative Body of Employment:
Public Office Address:
City:State:ZIP code:
Phone:
Description of Business Relationship(s):
Compensation (Actual or Anticipated):$.00
Expenses (Actual or Anticipated):$.00
Total Compensation and Expenses (Actual or Anticipated): $.00
Beginning date of Business Relationship (Actual or Anticipated): Month:Year:
End date of Business Relationship (Actual or Anticipated) if applicable: Month:Year:
State Person FirstName:
Instructions: Fill out this section onlyif the Relationship is with a State Person. If the Relationship is with an Entity, skip this section
and fill out Section III.
Please use the following addendum pages as continuation for the specified sections. If additional space is needed, please
make a copy of this sheet.
Designated Addendum Sheet for Sections III and IV
