Conflict of Interest Statement - Ohio Department of ...



Rev. 07/2011CONFLICT OF INTEREST STATEMENTI, FORMTEXT [Insert Name of ODOT Employee] am currently employed by the Ohio Department of Transportation (ODOT), Division of FORMTEXT [Insert ODOT Division], in FORMDROPDOWN . I hereby disclose that I hold a FORMTEXT [Fee Simple, Leasehold, etc.] interest in certain real property that may be acquired or appropriated by ODOT. A legal description of the property is attached. This property may be acquired or appropriated in connection with the following project, FORMTEXT [Insert C/R/S], PID FORMTEXT [Insert PID Number]. Pursuant to 23 CFR 1.33 and Real Estate Policy and Procedures, Section 5322, I hereby declare as follows: 1) I have disclosed the fact that I have an interest in real property which may be acquired or appropriated to the appropriate employee or official of ODOT. 2)I have not participated in any project decision making activities or acquisition activities as defined in Real Estate Policy and Procedures, Section 5322. ________________________________Signature of Employee__________________DateI acknowledge receipt of this disclosure:_______________________________District Real Estate Administrator___________________DateCopies: Property owner, acquisition file, to District Deputy Director if person is a District employee, to Central Office Deputy Director if person is a Central Office employee ................
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