MODEL MEMBER ITEM AFFIDAVIT

I _____________ representing the ___________________ District, having been sworn in on

______________, hereby swear/affirm/declare under penalty of perjury pursuant to NY CLS

Penal § 210.40 that:

1. I know ___________ to be a reputable organization providing __________ services to

my community and are deserving of $_________________ in discretionary funding,
commonly referred to as a “member item,” from NYS Budget for FY________.

2. To the best of my knowledge, and upon reasonable diligence and review,

______________ does not employ, nor was incorporated by, anyone who has been
convicted of a felony involving financial irregularities, tax crimes or been convicted of
defrauding government within the past five years.

3. To the best of my knowledge, and upon reasonable diligence and review,

________________ does not employ any of my immediate family members, household
companions or close relatives.

4. To the best of my knowledge, and upon reasonable diligence and review,

________________ does not employ any immediate family members, household
companions or close relatives of any member of my staff.

5. To the best of my knowledge, and upon reasonable diligence and review,

_________________ was not incorporated by, nor contains any current board members
who are either my immediate family members, household companions or close relatives.

6. To the best of my knowledge, and upon reasonable diligence and review,

_________________ was not incorporated by, nor contains any current board members
who are either members of the immediate family of, household companions of, or are
close relatives of, any member of my staff.

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 7. To the best of my knowledge, and upon reasonable diligence and review,
_________________ does not do business with nor is engaged contractually to transfer
any government funds, or to provide or receive goods and services, with any business or
entity owned in whole or in part by myself, members of my immediate family,
household companions or close relatives, or any business or entity owned in whole or in
part by members of my staff and/or their immediate family members, household
companions, or close relatives.

8. To the best of my knowledge, and upon reasonable diligence and review,

_________________ does not employ the immediate family members of any other New
York State Legislator whether are Members of the State Assembly or State Senate, nor
is _ barred from receiving discretionary funding known as “member items” due
to any of the conflicts enumerated in with paragraphs 2-7 above and 10 below with any
other New York State legislator, whether they are Members of the State Assembly or
State Senate.

9. I intend and expect that these sponsored discretionary state funds will be used by the
organization for ___________________________________ during the year
______________ .

10. At no time in the past 6 years has _________________ performed any political
activities on my behalf or on behalf of any other member of the New York State
Legislature, including but not limited to, advertising, mailing, producing documents and
flyers, committing human resources to my campaigns, soliciting funds, or utilizing
office space or any other activities not previously disclosed to the NYS Board of
Elections- campaign finance board.

11. The proposed discretionary funding was not allocated lieu of any past or future political
activity (as defined in no. 10 above).

Signed: ____________________________
Legislator/Date

Notary:____________________________