Disclosure of Substantial Interests by Trustees

1. In order to insure compliance with K.S.A. 75-4303 and 75-4305, each Trustee of Pratt Community College shall complete and file a written report (Statement of Substantial Interests) disclosing thereon, all substantial interests of said trustee as defined by K.S.A. 75-4301a and amendments thereto.

2. The Statement of Substantial Interests shall be filed by each Trustee within thirty (30) days after being sworn in as a Trustee. Each Trustee shall update the information disclosed on his or her Statement of Substantial Interests at least annually, on or before the 30th day of June each year.

3. Each Trustee shall file his or her Statement of Substantial Interests in the office of the President of Pratt Community College, and the President shall maintain the original Statement of Substantial Interests on file in the President’s office for as long as said Trustee serves as a Trustee of Pratt Community College and for a period of five (5) years from the date that said Trustee no longer serves as a Trustee of Pratt Community College.

PRATT COMMUNITY COLLEGE
STATEMENT OF SUBSTANTIAL INTERESTS

This Statement of Substantial Interests (including any accompanying pages and statements) is intended to report and disclose all substantial interests and other matters required by law (K.S.A. 75-4301a, K.S.A. 75-4302a, K.S.A. 75-4303a, K.S.A. 75-4304, K.S.A. 75-4305 and K.S.A. 75-4306) of the undersigned individual and the spouse of the undersigned individual.

1. Personal Identification Information:

Name (Last, First MI)

Spouse’s Name (Last, First MI)

Address (Number & Street Name)

Address (City, State, Zip Code)

Home Phone Business Phone

Current Position at Pratt Community College (Trustee, President, Vice-President, Etc.)

2. Ownership Interests: List any corporation, partnership, proprietorship, trust, joint venture and every other business interest, including land used for income, and specific stocks, mutual funds or retirement accounts in which either you or your spouse has owned within the preceding 12 months a legal or equitable interest exceeding $5,000 or 5%, whichever is less. Please attach additional pages if necessary to complete this section.
If you have nothing to report in Section "2.", check here ____.

Business Name and Address Type of Business Description of Interests Held Held by Whom
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

3. Gifts in the Form of Goods or Services: List any person, business or combination of businesses
from which you or your spouse either individually or collectively, have received in the preceding 12 months, without reasonable and valuable consideration, goods or services having an aggregate value of $500 or more.
If you have nothing to report in Section "3.", check here ____.

Name of Person or Business from Whom Gift Received Address Received by:
1.
2.
3.

4. Receipt of Compensation: List all places of employment in the last calendar year, and any other businesses from which you or your spouse received $2,000 or more in compensation (salary, thing of value, or economic benefit conferred on you or your spouse in return for services rendered, or to be rendered), which was reportable as taxable income on your federal income tax returns.

A. Your place(s) of employment or other business in the preceding calendar year.
If you have nothing to report in Section "4. A.”, check here ____.

Name of Business Address Type of Business
1.
2.

B. Spouse's place(s) of employment or other business in the preceding Calendar year.
If you have nothing to report in Section "4.B.”, check here ____.

Name of Business Address Type of Business
1.
2.

5. Officer or Director of an Organization or Business: List any organization or business in
which you or your spouse hold a position as officer, director, associate, partner or proprietor at the time of filing, irrespective of the amount of compensation received for holding such position. Please insert additional pages if necessary to complete this section.
If you have nothing to report in Section "5.", check here ____.

Business Name and Address Position Held Held by Whom
1.

2.

3.

4.

5.

6. Receipt of Fees and Commissions: List each client or customer who paid fees or commissions to a business or combination of businesses from which fees or commissions you or your spouse received an aggregate of $2,000 or more in the preceding calendar year. The phrase "client or customer" relates only to businesses or the combination of businesses. In the case of a partnership, it is the partner's proportionate share of the business, and hence of the fee, which is significant, without regard to the expenses of the partnership. An individual who receives a salary as opposed to portions of fees or commissions is generally not required to report under this provision. Please insert additional pages if necessary to complete this section.
If you have nothing to report in Section "6.", check here ____.

Name of Client / Customer Address Received by:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

7. Declaration:

I, , declare that this statement of substantial interests (including any accompanying pages and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of all of my substantial interests and other matters required by law. I understand that the intentional failure to file this statement as required by law or intentionally filing a false statement is a class B misdemeanor.

Date Signature of Person Making Statement

Number of additional pages attached hereto .