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Form 3 <br />Model affidavit of official interest in claim <br />(under Minn. Stat. §§ 471.88, subd. 5 and 471.89, subd. 3) <br />STATE OF MINNESOTA ) <br />COUNTY OF ) <br />I, (Name ofintea ested oaces ), being duly sworn state the following: <br />1) I am (office he by interested o acial) of the city of , Minnesota. <br />2) On jday and date), the following (gQods / merchandise / equipment / services) were furnished by <br />(name ofbusiness or individual with whom the contract was made) to the city of_____.,_: (seci i <br />the type ofgoods merchandise, equipment, or sea -vices that were purchased). <br />3) The contract price for such (goods /merchandise/ equipment /services) was $ and their <br />reasonable value was $ <br />4) At the time such (goods/ merchandise / equipment /services were furnished to the city, I had the <br />following personal financial interest in this contract: �eci�y the nature o the personal financial <br />interest <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 / merchandise / equipment /services) could be obtained from other sources. <br />I 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 park of the claim has been paid. <br />{sigmatw•e ofinterested o ciao <br />Subscribed and sworn to before me this day of (month), &ear . <br />W277dture of notaay) <br />Official Conflict of Interest 41 <br />