Annual Disclosure Report Request Form

NEW YORK CITY CONFLICTS OF INTEREST BOARD
ANNUAL DISCLOSURE REPORT REQUEST FORM

Pursuant to the Annual Disclosure Law, the Conflicts of Interest Board must give notice to the filer of the report of the production and of the identity of the person for whom the report was produced. In accordance with the notification requirement, your name and entity (where applicable) will be sent to the filer when the Board provides the requester with the report(s).

Filer's Name: *

Requester's Name: *

Affiliation (Person or entity on whose behalf you are obtaining this report) if any:

Affiliation's Address (Do not disclose your home address):

Date Requested: *

Requester's Telephone Number: *

Requester's E-mail Address: *

IN ORDER TO REQUEST AN ANNUAL DISCLOSURE REPORT, THE REQUESTER MUST PROVIDE GOVERNMENT-ISSUED IDENTIFICATION. PLEASE UPLOAD A CURRENT COPY OF YOUR GOVERNMENT-ISSUED ID (e.g.). A STATE DRIVER'S LICENSE, GOVERNMENT-ISSUED IDENTIFICATION CARD, OR MILITARY ID BELOW. YOU MUST UPLOAD ONE OF THESE FORMS OF IDENTIFICATION IN ORDER FOR YOUR REQUEST TO BE PROCESSED.

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