FINANCIAL DISCLOSURE REPORT |
||||||||||||||||
Please Note: Section 1.3 of E.O. 12968 requires that employees complete this form as a condition of access to specific types of classified information as determined by the head of an agency. Before completing this form, read the instructions, which include the Privacy Act Statement located in the instructions for completion of this form and the sections below on Sensitive Personal Data and Public Reporting Burden. Type or print clearly in black or blue ink. |
||||||||||||||||
Sensitive Personal Data: After this form is completed, it will contain sensitive personal information, which is to be safeguarded pursuant to the Privacy Act, 5 U.S.C. 552a. This information is to be released only to authorized personnel having a need to know for official uses. The completed form should be stored in a locked file cabinet or secured room. When the completed form is no longer required, it should be destroyed by burning or shredding. |
||||||||||||||||
Public Reporting Burden for collection of information is estimated to average two hours per response, including the time for reviewing instructions, searching existing date sources, gathering and maintaining the data needed, and completing and reviewing the reported information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestion for reducing this burden to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503. |
||||||||||||||||
SECTION 1: EMPLOYEE IDENTIFICATION |
||||||||||||||||
1a. Name (Last, First , Middle Initial, Suffix) |
1b. Date of Birth (MM/DD/YYYY) |
1c. Social Security Number |
1d. Reserved for Agency Use
|
|||||||||||||
1e. Home Address (Number, Street, Apt. #, City, Sate, Zip Code, Country) |
1f. Marital Status
|
|||||||||||||||
1g. Employee Status |
1h. Daytime Telephone Number and Office e-mail Address |
1i. Company or Home Agency
|
||||||||||||||
SECTION 2: ANNUAL INCOME, U.S. AND FOREIGN |
||||||||||||||||
2a. Codes |
2b. Name of Country |
2c. Annual Salary & Wages |
2d.Interest Income |
2e. Dividend Income |
2f. Gross Rental Receipts |
2g. Other Income |
2h. Total Annual Income |
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
Totals |
|
|
|
|
|
|
|
|||||||||
SECTION 3: BANK ACCOUNTS, U.S. AND FOREIGN |
||||||||||||||||
3a. Codes |
3b. Institution |
3c. Name of Country |
3d. Total # of Accounts |
3e. Address |
3f. Year-End Balance |
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
SECTION 4: INVESTMENT ACCOUNTS, U.S. AND FOREIGN |
||||||||||||||||
4a. Codes |
4b. Institution |
4c. Name of Country |
4d. Total # of Accounts |
4e. Address |
4f. Year-End Fair Market Value |
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
SECTION 5: OWNED REAL ESTATE, U.S. AND FOREIGN |
||||||||||||||||
5a. Codes |
5b. Address (include Country) |
5c. Year Acquired |
5d. How Acquired |
5e. Purchase Price or Acquisition Value |
5f. Capital Improvement Costs |
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|||||||||||
SECTION 6: OWNED VEHICLES, BOATS, AIRPLANES, OTHER |
||||||||||||||||
6a. Codes |
6b. Type |
6c. Make |
6d. Model/Year |
6e. Plate or ID Number |
6f. Year Acquired |
6g. How Acquired |
6h. Purchase Price or Acquisition Value |
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
|||||||||
|
|
|
|
|
|
|
|
SECTION 7: REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S. AND FOREIGN |
|||||||||||||||||
7a. Codes |
7b. Address (include Country) |
7c. Month and Year of Initial Lease/Rental (MM/YYYY) |
7d. Monthly Lease/Rental Payment |
||||||||||||||
|
|
|
|
||||||||||||||
|
|
|
|
||||||||||||||
|
|
|
|
||||||||||||||
|
|
|
|
||||||||||||||
SECTION 8: LEASED VEHICLES, BOATS, AIRPLANES, OTHER |
|||||||||||||||||
8a. Codes |
8b. Type |
8c. Make |
8d. Model/Year |
8e. Plate or ID Number |
8f. Month and Year of Initial Lease (MM/YYYY) |
8g. Monthly Lease/Rental Payment |
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
SECTION 9: OTHER ASSETS, U.S. AND FOREIGN |
|||||||||||||||||
9a. Codes |
9b. Description |
9c. Name of Country |
9d. Year/Period Acquired |
9e. Purchase Price or Other Cost Basis |
9f. Year-End Fair Market Value |
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
SECTION 10: MORTGAGES, LOANS, AND OTHER LIABILITIES (except credit cards), U.S. AND FOREIGN |
|||||||||||||||||
10a. Codes |
10b. Type of Loan/Liability |
10c. Name of Creditor |
10d. Address of Creditor (include Country) |
10e. Original Balance |
10f. Year-End Balance |
10g. Monthly Payment |
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
SECTION 11: CREDIT CARDS, U.S. AND FOREIGN |
|||||||||||||||||
11a. Codes |
11b. Name of Creditor |
11c. Address of Creditor (include Country) |
11d. Year-End Balance |
11e. Last Payment Amount |
11f. Last Payment Date (MM/YYYY) |
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
SECTION 12: ADDITIONAL INCOME/BANKRUPTCY |
|||||||||||||||||
12a. Item Type |
12b. $ Amount |
12c. Explanation |
|||||||||||||||
|
|
|
|||||||||||||||
|
|
|
|||||||||||||||
|
|
|
|||||||||||||||
SECTION 13: SAFE DEPOSIT BOX |
|||||||||||||||||
13a. Name of Institution |
13b. Address of Institution |
||||||||||||||||
|
|
||||||||||||||||
SECTION 14: COMMENTS |
|||||||||||||||||
|
|||||||||||||||||
SECTION 15: CERTIFICATION BY PERSON COMPLETING THE FORM: I certify that the entries made by me are true, complete, and accurate to the best of my knowledge and belief and are made in good faith. I understand that knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See U.S. Code Title 18, Section 1001.) |
|||||||||||||||||
15a. Type Name (Last, First, Middle Initial, Suffix) |
15b. Signature |
15c. Date Signed (MM/DD/YYYY)
|
Name (Last, First, Middle Initial, Suffix) |
Social Security Number |
||||||||||||||
ADDITIONAL ENTRIES |
|||||||||||||||
SECTION 2: ANNUAL INCOME, U.S. AND FOREIGN |
|||||||||||||||
2a. Codes |
2b. Name of Country |
2c. Annual Salary & Wages |
2d.Interest Income |
2e. Dividend Income |
2f. Gross Rental Receipts |
2g. Other Income |
2h. Total Annual Income |
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
SECTION 3: BANK ACCOUNTS, U.S. AND FOREIGN |
|||||||||||||||
3a. Codes |
3b. Institution |
3c. Name of Country |
3d. Total # of Accounts |
3e. Address |
3f. Year-End Balance |
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
SECTION 4: INVESTMENT ACCOUNTS, U.S. AND FOREIGN |
|||||||||||||||
4a. Codes |
4b. Institution |
4c. Name of Country |
4d. Total # of Accounts |
4e. Address |
4f. Year-End Fair Market Value |
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
SECTION 5: OWNED REAL ESTATE, U.S. AND FOREIGN |
|||||||||||||||
5a. Codes |
5b. Address (include Country) |
5c. Year Acquired |
5d. How Acquired |
5e. Purchase Price or Acquisition Value |
5f. Capital Improvement Costs |
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
||||||||||
SECTION 6: OWNED VEHICLES, BOATS, AIRPLANES, OTHER |
|||||||||||||||
6a. Codes |
6b. Type |
6c. Make |
6d. Model/Year |
6e. Plate or ID Number |
6f. Year Acquired |
6g. How Acquired |
6h. Purchase Price or Acquisition Value |
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||||
SECTION 7: REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S. AND FOREIGN |
|||||||||||||||
7a. Codes |
7b. Address (include Country) |
7c. Month and Year of Initial Lease/Rental (MM/YYYY) |
7d. Monthly Lease/Rental Payment |
||||||||||||
|
|
|
|
||||||||||||
|
|
|
|
||||||||||||
|
|
|
|
||||||||||||
|
|
|
|
||||||||||||
|
|
|
|
||||||||||||
|
|
|
|
Name (Last, First, Middle Initial, Suffix) |
Social Security Number |
||||||||||||||||
ADDITIONAL ENTRIES |
|||||||||||||||||
SECTION 8: LEASED VEHICLES, BOATS, AIRPLANES, OTHER |
|||||||||||||||||
8a. Codes |
8b. Type |
8c. Make |
8d. Model/Year |
8e. Plate or ID Number |
8f. Month and Year of Initial Lease (MM/YYYY) |
8g. Monthly Lease/Rental Payment |
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
SECTION 9: OTHER ASSETS, U.S. AND FOREIGN |
|||||||||||||||||
9a. Codes |
9b. Description |
9c. Name of Country |
9d. Year/Period Acquired |
9e. Purchase Price or Other Cost Basis |
9f. Year-End Fair Market Value |
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
SECTION 10: MORTGAGES, LOANS, AND OTHER LIABILITIES (except credit cards), U.S. AND FOREIGN |
|||||||||||||||||
10a. Codes |
10b. Type of Loan/Liability |
10c. Name of Creditor |
10d. Address of Creditor (include Country) |
10e. Original Balance |
10f. Year-End Balance |
10g. Monthly Payment |
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|||||||||||
SECTION 11: CREDIT CARDS, U.S. AND FOREIGN |
|||||||||||||||||
11a. Codes |
11b. Name of Creditor |
11c. Address of Creditor (include Country) |
11d. Year-End Balance |
11e. Last Payment Amount |
11f. Last Payment Date (MM/YYYY) |
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
||||||||||||
SECTION 12: ADDITIONAL INCOME/BANKRUPTCY |
|||||||||||||||||
12a. Item Type |
12b. $ Amount |
12c. Explanation |
|||||||||||||||
|
|
|
|||||||||||||||
|
|
|
|||||||||||||||
|
|
|
|||||||||||||||
|
|
|
|||||||||||||||
SECTION 13: SAFE DEPOSIT BOX |
|||||||||||||||||
13a. Name of Institution |
13b. Address of Institution |
||||||||||||||||
|
|
||||||||||||||||
|
|
||||||||||||||||
SECTION 14: COMMENTS |
|||||||||||||||||
|
|||||||||||||||||
|
SF 714 (1-09) Page
File Type | application/msword |
File Title | FINANCIAL DISCLOSURE |
Author | NARAuser |
Last Modified By | NARAuser |
File Modified | 2009-05-15 |
File Created | 2009-05-15 |