Michigan § 18.1364a - Legislatively directed spending items; disclosure form.

Legislatively Directed Spending Item Information

1. Sponsoring legislator's full name:

2. Cosponsoring legislators' names (if applicable):

3. Intended legislatively directed spending item recipient:

4. Physical address of legislatively directed spending item recipient and the intended location of the project or activity:

5. The recipient's employer identification number:

6. Requested amount of the legislatively directed spending item:

7. What is the purpose and how does the legislatively directed spending item provide a public benefit that is an appropriate use of taxpayer money?

8. Has the legislatively directed spending item previously received or been awarded any of the following types of funding in the past 5 years? If so, how much? Check all that apply.

[ ] Federal

[ ] State

[ ] Local

9. Estimated time frame for completion of the legislatively directed spending item project:

Additional Information For Nonprofit Corporations (if applicable)

The answer to questions 1 to 3 must be "Yes" for the nonprofit corporation to qualify for a legislatively directed spending item.

1. Has the nonprofit corporation continuously operated in this state for the preceding 36 months?

[ ] Yes

[ ] No

2. Has the nonprofit corporation had a physical office in this state for not less than the preceding 12 consecutive months?

[ ] Yes

[ ] No

3. Does the nonprofit corporation have a board of directors?

[ ] Yes

[ ] No

4. List all of the officers and active members on the board of directors:

Certification By Sponsoring Legislator

"I certify that my immediate family members, legislative staff members, and I have no direct or indirect pecuniary interest in the requested legislatively directed spending item."

"I certify that the intended recipient of this legislatively directed spending item is not a for-profit entity."

"I certify that the information in this form is true to the best of my knowledge."

Signature:____________________________________