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12-C C Government Official* Disclosure Form



This form must be answered by the grantee organization for any charitable contribution
requests. When completed, please sign the form and initial each page.

*According to an expanded definition used for grant purposes by Philip Morris International, a
government official is considered any officer or employee acting on behalf of any state-owned
or funded agency or entity at the federal, state or local level. Examples would include: police
officers; fire-fighters; employees at public schools, universities or hospitals; elected members
of parliament; ambassadors and embassy staff; political party officials; civil servants;
administrative, judicial and military officers; employees of international organizations, such as
the World Trade Organization, the World Health Organization, and the Asian Development
Bank; political candidates; employees of enterprises in which a government has an ownership
interest (which may include a minority interest) or exercises control. PLEASE RELY ON THE
DEFINITION PROVIDED ABOVE IN ANSWERING THE QUESTIONS WITHIN THIS
DISCLOSURE FORM.
Name of Charitable Organization:




Name of project:




Were government officials responsible for the establishment or formation of the grantee
organization (Yes/No)?




Do government officials or their spouses or family members serve on the Board of Directors of
the grantee organization (Yes/No)?




Do government officials or their spouses or family members serve as senior executives of the
grantee organization (Yes/No)?




Initial
___________

YES
YES
YES
Donation of used IT equipment
Elementary school "Dragomir Trajkovic"
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If Yes to any of the questions above, please identify them, their positions, and explain
involvement:








Statutory Representative Name: ___________________________

Position/Title: ___________________________

Date: ___________________________

Signed: ___________________________

Organization Stamp (if available)
Initial
___________
The Board of the Elementary School "Dragomir Trajkovic" consists of
the following members:
- 3 representatives of the city/municipal administration,
- 3 representatives of the parents' council and
- 3 representatives of the teachers' council.
Some members of the School Board are government officials as they are employed by public
institutions or they represent local administration, these include the following:
1. Dodic Dragan - board member employed in Veterinary Clinic - Bujanovac,
representative of the city/municipal administration,
2. Cvetkovic Sasa - board member employed in Veterinary Clinic - Zbevac,
representative of the parents' council,
3. Zafirovic Bora - board member, elementary school in Zbevac,
4. Mitic Djordje - board member, elementary school in Zbevac,
5. ordjevic Stance - board member, elementary school in Zbevac,
6. Nikolic Stojanca - board member, elementary school in Zbevac.
Bora Zafirovi
Headmaster
14.07.2014.