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<br />'> ( <br /> <br />( <br /> <br />For'm 3 <br /> <br />Model affidavit of official interest in claim <br />(under Minn. Stat. ~~ 471.88, subd. 5 and 471.89, subd. 3) <br /> <br />STATE OF MINNESOTA ) <br />COUNTY OF ) <br /> <br />I, (Name of interested officer), being duly sworn state the following:. <br /> <br />1) <br />2) <br /> <br />1 am (office held bv interested officiaf) of the city of <br /> <br />, Minnesota. <br /> <br />( <br /> <br />4) <br /> <br />On (day and date), the following (goods / merchandise / equipment / services) were furnished by <br />(name of business or individual with whom the contract was made) to the city of _: (specifY <br />the type of goods. merchandise. eQuipment. or services that were purchaseff). <br /> <br />The contract pricefol' such (goods / merchandise / equipment / services) was $_ and their <br />reasonable value was $_. <br /> <br />At the time such (goods / merchandise / equipment I services) were furnished to the city, 1 had the <br />following personal financial interest in this contract: (specifY the nature of the personal financial <br />interest) <br /> <br />To the best of my knowledge and belief the contract price is as low as, or lower than the price at which <br />the (goods I merchandise / equipment / services) could be obtained from other sources. <br /> <br />3) <br /> <br />1 further state that this affidavit constitutes a claim against the city for the contract price, that the claim is <br />just and correct, and that no part of the claim has been paid. <br /> <br />(signature of interested official) <br /> <br />Subscribed and sworn to before me this _ day of (Jnonth>, (vear). <br /> <br />(sif!l1ature Qf notary) <br /> <br />Official Conflict of Interest <br /> <br />41 <br />