Office / Agency Information

Jurisdiction

Type of Statement

Assuming Office, Annual, Leaving Office

A-1: Investments

Stocks, including those held in an IRA or 401K. Each stock must be listed.

Insurance policies, government bonds, diversified mutual funds, funds similar to diversified mutual funds.

A-2: Business Entities/Trusts

Business entities, sole proprietorships, partnerships, LLCs, corporations, and trusts (e.g., Form 1099 filers)

Savings and checking accounts, and annuities.

B: Real Property

Rental property in filer’s jurisdiction, or within two miles of the boundaries of the jurisdiction.

A residence used exclusively as a personal residence (such as a home or vacation property).

C: Income

Non-governmental salaries. Note that filers are required to report only half of their spouse’s or partner’s salary.

Governmental salary (from school district, for example).

D: Gifts

Gifts from businesses, vendors, or other contractors (meals, tickets, etc.).

Gifts from family members.

E: Travel Payments

Travel payments from third parties (not your employer).

Travel paid by your government agency.

Cover

address, phone number, email address

A1

None

A2

address, real property parcel address

B

income sources, loan address

C

income address, loan address

D

address

E

address

Comments

None