Fill and Sign the Financial Disclosure House Committee on Ethics Housegov Form

Financial Statement page - 1 -Initials: ________ __________ PERSONAL FINANCIAL DISCLOSURE STATEMENT * * * To: Date: Individual Information Name: Address: City: State    Zip Occupation: Phone: Current Assets Current Liabilities Cash on Hand or in Banks Notes Payable (Secured)(Schedule F) Other Cash: Notes Payable (Unsecured)(Schedule G) Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H) Residence Auto Loans (Schedule I) Motor Vehicles (Schedule B) Unpaid Taxes and Interest US Government Securities (Schedule C) Due to Brokers Non-Marketable Securities (Schedule D) Open Accounts Stocks (Schedule E) Credit Cards (List): Other Personal Property Life Insurance Cash Value Business Interests Notes Receivable Other Assets: Other: Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES Total Assets NET WORTH Individual Income Information (Annual) Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent Liabilities Guarantor, Co-maker Lease or Contracts Legal Claims Other: Financial Statement page - 2 - SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Date Acquired Par Value Market Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “D” NON MARKETABLE SECURITIES Description Date Acquired Par Value Market Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “F” NOTES PAYABLE SECURED Description Date Balance Payment (m/yr) Financial Statement page - 3 - $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “G” NOTES PAYABLE UNSECURED Description Date Balance Payment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “H” REAL ESTATE MORTGAGES Description Date Balance Payment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “I” AUTO LOANS Description Date Balance Payment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ I certify this Statement to be true and correct as of the date indicated: _________________________________ Signature