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BUSINESS RELATIONSHIP FORM Relationship with a State Person

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BUSINESS RELATIONSHIP FORM Relationship with a State Person NEW YORK STATE JOINT COMMISSION ON PUBLIC ETHICS 540 Broadway, Albany NY 12207 [email protected] BUSINESS RELATIONSHIP FORM Relationship with a State Person CALENDAR YEAR AND REPORTING PERIOD FOR OFFICE USE ONLY Calendar Year Check if amendment Amendment effective date of change SECTION I - INFORMATION ABOUT THE ORGANIZATION ORGANIZATION NAME Enter your Lobbyist, Contractual Client, Beneficial Client or Public Corporation name below. Do not use abbreviations. Name ORGANIZATION BUSINESS ADDRESS AND CONTACT INFORMATION Street Street 2 (optional) City State Country Zip code Business phone Ext. Additional phone Ext. Email address REVISED 12/14/2020 1 of 6 SECTION II - INFORMATION ABOUT THE REPORTABLE BUSINESS RELATIONSHIP INFORMATION ABOUT THE STATE PERSON Refer to the definition of ‘State Person’ on the first page of this form. Enter information regarding the State Person. Enter the name of the State entity or Legislative body the State Person is employed by and include the business address and other required contact information below. State Person Last name First name Name of State Entity or Legislative Body (See appendix) Business Street Address Street 2 (optional) City State Zip Code Business Phone Ext. (optional) DESCRIPTION OF THE BUSINESS RELATIONSHIP BETWEEN YOU AND THE THE STATE PERSON Enter a brief description of the goods, services or anything of value performed or provided (or intended to be performed or by provided) by the State Person for the Lobbyist/Client Organization. SUMMARY OF COMPENSATION AND EXPENSES Enter the amount of compensation and expenses (actual or anticipated) the Lobbyist/Client Organization has paid or will pay the State Person for the current filing period (calendar year). Do NOT include the total amount of compensation for relationships that span more than one calendar year. NOTE: Expense information is optional. Compensation Amount $ Check one: Anticipated Actual Expense Amount $ Check one: Anticipated Actual Was payment made to the State Person? Yes No Were services provided by the State Person? Yes No 2 of 6 SECTION III- START AND END DATE OF THE RELATIONSHIP START AND END DATES OF THE RELATIONSHIP Enter the date the Business Relationship between you and the State Person began within the Calendar Year (the time period of January 1 through December 31 of any given year). If known, enter the date the Relationship between you and the State Person will end. NOTE: For an adjunct professor, the start date would be the date classes begin (provided no payment is made prior to that date). If payment is made prior to that date, that would be the start date. If there is a break of a Calendar year or more, a new RBR form should be filed. If an adjunct professor teaches more than one semester in a calendar year for the same Lobbyist/Client, compensation and activity for both semesters must be disclosed on the same RBR form. If an RBR has already been submitted, submit an amendment to the RBR form that includes the new compensation amount and revised ‘End Date’. (See instructions) Beginning date (mm/dd/yyyy) If “unknown”, the end date will be reflected End date (mm/dd/yyyy) Check if unknown as the end of the current calendar year. SECTION IV - DECLARATION ATTESTATION This Attestation must be signed by the Chief Administrative Officer of the Organization. If the Chief Administrative Officer, for any reason, does not sign, he/she must duly designate another person to sign this Attestation by providing a designation letter. A sample Designation Letter is available on the JCOPE website. DECLARATION I declare that I am the person listed below and I declare under penalty of perjury that the information contained in this filing is true, correct, and complete to the best of my knowledge and belief. If I am the Chief Administrative Officer (“CAO”) of an organization that is a lobbyist or client, I further acknowledge that I am legally responsible for the veracity, accuracy and timeliness of all filings submitted on behalf of the organization to the Joint Commission on Public Ethics (“JCOPE”). Signature X Date Last First Select One: Chief Administrative Officer Designee (Attach Letter) 3 of 6 APPENDIX: STATE ENTITY/ LEGISLATIVE BODY SELECTIONS 511NY Industries) CUNY York College Adirondack Community College Corning Community College Department of Agriculture and Markets Adirondack Park Agency Council on Children and Families Department of Civil Service Affordable Housing Corporation Council on the Arts Department of Corrections and Agriculture and New York State CUNY Baruch College Community Supervision Horse Breeding Development Fund CUNY Bronx Community College Department of Education Albany Convention Center Authority CUNY Brooklyn College Department of Environmental Archives Partnership Trust CUNY City College of New York Conservation Authorities Budget Office CUNY College of Staten Island Department of Financial Services Battery Park City Authority CUNY College of Technology, NYC Department of Health Board of Elections CUNY Craig Newmark Graduate Department of Labor Bridge Authority School of Journalism Department of Motor Vehicles Broome Community College CUNY Graduate College Department of Public Service Buffalo Fiscal Stability Authority CUNY Guttman Community College Department of State Canal Corporation CUNY Hostos Community College Department of Taxation and Finance Capital District Transportation CUNY Hunter College Department of Transportation Authority CUNY John Jay College Development Authority of the North Cayuga Community College CUNY Kingsborough Community Country Central New York Regional College Developmental Disabilities Planning Transportation Authority CUNY Laguardia Community Council Central Pine Barrens Joint Planning College Division of Consumer Protection and Policy Commission CUNY Lehman College Division of Criminal Justice Services City University Construction Fund CUNY Macaulay Honors College Division of Homeland Security City University of New York Board of Trustees CUNY Manhattan Community Division of Human Rights College City University of New York Central Division of Military and Naval Affairs Office (CUNY) CUNY Medgar Evers College Division of State Police Clinton Community College CUNY Queens College Division of Tax Appeals and Tax Columbia-Greene Community CUNY Queensborough Community Appeals Tribunal College College Division of the Budget Commission of Correction CUNY School of Law Division of Veterans’ Affairs Commission on Judicial Conduct CUNY School of Professional Studies Dormitory Authority Corcraft Products (Department of CUNY School of Public Health Correctional Services, Division of Dutchess Community College 4 of 6 APPENDIX: STATE ENTITY/ LEGISLATIVE BODY SELECTIONS Empire State Development Hudson Valley Community College New York Local Government Assistance Corporation Environmental Facilities Jacob K. Javits Convention Center Corporation New York Power Authority Jamestown Community College Erie Community College Niagara County Community College Jefferson Community College Erie County Fiscal Stability Niagara Frontier Transportation Authority Joint Commission on Public Ethics Authority Erie County Medical Center Justice Center for the Protection of North Country Community College Corporation People with Special Needs North Country Power Authority Executive Chamber Law Revision Commission NYC 311 Fashion Institute of Technology Liquidation Bureau NYGov Financial Control Board Liquor Authority, Division of Alcoholic Beverage Control NYS Assembly Finger Lakes Community College Long Island Power Authority NYS Senate Fulton-Montgomery Community College Metropolitan Transportation Office for New Americans Authority Gaming Commission Office for People With Mohawk Valley Community College Developmental Disabilities Genesee Community College Monroe Community College Office for the Aging Geographic Information Systems (GIS) Clearinghouse MTA Inspector General Office for the Prevention of Domestic Violence Governor’s Office of Employee Municipal Assistance Corporation Relations for the City of Troy Office of Alcoholism and Substance Abuse Services Governor’s Traffic Safety Committee Nassau Community College Office of Attorney General Herkimer County Community Nassau County Interim Finance College Authority Office of Children and Family Services Higher Education Services Nassau Health Care Corporation Office of Counter Terrorism Corporation Natural Heritage Trust Office of Emergency Management Homeless Housing Assistance Nelson A. Rockefeller Empire State Corporation Plaza Performing Arts Center Office of Fire Prevention and Homes and Community Renewal Operating Corporation Control Housing Finance Agency New York City Off-Track Betting Office of General Services Corporation Housing Trust Fund Corporation Office of Indigent Legal Services New York Convention Center Hudson River Park Trust Operating Corporation Office of Information Technology Services Hudson River Valley Greenway New York Energy Research and Development Authority Office of Interoperable and Hudson River-Black River Emergency Communications Regulating District New York Foundation for Science, (OIEC) Technology and Innovation 5 of 6 APPENDIX: STATE ENTITY/ LEGISLATIVE BODY SELECTIONS Office of Medicaid Inspector General State of New York Municipal Bond SUNY Optometry Bank Agency Office of Mental Health SUNY Oswego State University Construction Fund Office of Parks, Recreation and SUNY Plattsburgh Historic Preservation State University of New York Board of Trustees SUNY Polytechnic Institute Office of State
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