New Jersey Administrative Code
Title 19 - OTHER AGENCIES
STATE ETHICS COMMISSION
Chapter 61 - STATE ETHICS COMMISSION
Subchapter 6 - ATTENDANCE AT EVENTS, ACCEPTANCE OF HONORARIA, ACCEPTANCE OF COMPENSATION FOR PUBLISHED WORKS, AND ACCEPTANCE OF THINGS OF VALUE
Section 19:61-6.10 - Annual disclosure for scholarly capacity employees
Current through Register Vol. 56, No. 24, December 18, 2024
(a) A State official serving in a scholarly capacity shall disclose annually to his or her department head any travel, subsistence or entertainment expenses, honoraria, academic prizes, or other things of value related to activities performed in his or her scholarly capacity received in the prior academic year (July 1st through June 30th). The sources of all such expenses and things of value shall be identified.
(b) A State official serving in a scholarly capacity shall use the following form for his or her annual disclosure. The completed forms shall be submitted to his or her department head, and the form shall be kept on file for a period of five years. Each State college and university shall forward copies of the forms to the Commission on an annual basis.
Annual College and University Disclosure Form
Date of Statement___________
For Academic Year July 1, ___ through June 30, ________
First Name _________________________________________________
Last Name _________________________________________________
Institution _________________________________________________
Department ________________________________________________
Position ___________________________________________________
Daytime Telephone __________________________________________
Email Address ______________________________________________
Instructions: This form must be submitted pursuant to N.J.A.C. 19:61-6.1 0(a), which requires a State official serving in a scholarly capacity to annually disclose to his/her Department head any travel, subsistence or entertainment expenses, honoraria, academic prizes or other things of value related to activities performed in a scholarly capacity received in the prior academic year (July 1st through June 30th). Any benefit received related to your State position, and any outside activity performed, while not acting in a scholarly capacity, must still be reported pursuant to your institution's procedures, and on the forms required by the State Ethics Commission. Enter "N/A" in any category in which you did not receive benefits while acting in scholarly capacity during the covered academic year.
Benefits Received
Date Received Type of Benefit Amount Source Interested Party*
1.
2.
3.
4.
Date Received Type of Benefit Amount Source Interested Party*
1.
2.
3.
4.
*Indicate whether the source of the benefit is an interested party to your institution. "Interested party" means: 1) any person or entity your institution regulates, licenses or supervises; 2) any grantee or grantor to your institution and any employee, representative or agent thereof; 3) any supplier/vendor to your institution; 4) any advocacy group that advocates or represents the positions of its members to your institution; 5) any organization a majority of whose members fall under 1-4 above.
Yes_____ No______
Yes_____ No______
Yes______ No______
__________________________________________________________
To the best of my knowledge and belief the information on this form is true and accurate.
EMPLOYEE: _____________________________ Date:____________
Signature
I have reviewed the information contained on this form.
DEPARTMENT HEAD: ______________________ Date:__________
Signature
ETHICS
LIAISON OFFICER: _______________________Date:____________
Signature
