4. List the identity (including the address or legal description of real estate) of any capital asset from which a capital gain
of $5,000 or more was realized during the preceding calendar year.
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5. List the name of any entity and the nature of the governmental action requested by any entity which has applied to a
unit of local government in relation to which the person must file for any license, franchise or permit for annexation,
zoning or rezoning of real estate during the preceding calendar year if the ownership interest of the person filing is in
excess of $5,000 fair market value at the time of filing or if income or dividends in excess of $1,200 were received by the
person filing from the entity during the preceding calendar year.
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6. List the name of any entity doing business with a unit of local government in relation to which the person is required
to file from which income in excess of $1,200 was derived during the preceding calendar year other than for professional
services and the title or description of any position held in that entity. No time or demand deposit in a financial
institution nor any debt instrument need be listed.
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7. List the name of any unit of government which employed the person making the statement during the preceding
calendar year other than the unit or units of government in relation to which the person is required to file.
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8. List the name of any entity from which a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in
excess of $500, was received during the preceding calendar year.
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VERIFICATION
“I declare that this statement of economic interests (including any accompanying schedules and statements) has been
examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic
interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or
incomplete statement shall be a fine not to exceed $1,000 or imprisonment in a penal institution other than the
penitentiary not to exceed one year, or both fine and imprisonment”.
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(Signature of person making the statement) (date)