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Appendix C: Sample Affidavit of Official Interest in Claim <br />Before using this sample, a city should be familiar with the contents of the League of <br />Minnesota Cities information memo, Official Conflict of Interest (October 2014). <br />When using this form as a template, insert appropriate city -specific language where indicated <br />and remove all explanations provided for your reference. <br />A city wishing to use this sample should review it with the city attorney to determine whether it <br />is suited to the city's circumstances. Because the sample implicates state and federal law, the city <br />attorney should review any modifications to ensure they conform to current law. <br />Additional samples are available through the LMC Research and Information Service upon <br />request. <br />SAMPLE AFFIDAVIT <br />OFFICIAL INTEREST IN CLAIM <br />STATE OF MINNESOTA ) <br />COUNTY OF ) <br />I, (Name of interested officer), being duly sworn state the following: <br />1) I am (office held by interested official) of the city of , Minnesota. <br />2) On (day and date), the following (goods / merchandise /equipment /services) were <br />furnished by (name of business or individual with whom the contract was made) to the <br />city of : (speck the type of goods merchandise, equipment, or services that were <br />purchased). <br />3) The contract price for such (goods / merchandise / equipment / services) was $ and <br />their reasonable value was $ <br />League of Minnesota Cities Information Memo: 10/17/2014 <br />Official Conflict of Interest Page 40 <br />