Secretary of State Revision November 29, 2017 2
A. PERSONAL FINANCIAL INTERESTS
This section requires disclosure of your financial interests and/or the financial interests of the member(s) of your household.
1. Identification of Household Members and Business Interests
What to disclose: If you are married, is your spouse a member of your household? Yes No N/A (If not married/widowed, select N/A)
Are any minor children
members of your household? Yes (if yes, disclose how many ) No N/A (If no children, select N/A)
For the remaining questions in this Financial Disclosure Statement, the term “member of your household” or “household member” will be defined as
the person(s) who correspond to your “yes” answers above.
You are not required to disclose the names of your spouse or minor children when answering the questions below. Thus, you may identify your
household members as “spouse,” “minor child 1”, “minor child 2,” etc. Please note that if you choose to identify your spouse or minor children
by name, the Secretary of State’s Office or other local filing officer are not expected to redact that information when posting this Financial
Disclosure Statement on the internet or providing it in response to a public records request.
2. Sources of Personal Compensation
What to disclose: In subsection (2)(a), provide the name and address of each employer who paid you or any member of your household more than
$1,000 in salary, wages, commissions, tips or other forms of compensation (other than “gifts”) during the period covered by this report. Describe the
nature of each employer’s business and the type of services for which you or a member of your household were compensated.
In subsection (2)(b), if applicable, list anything of value that any other person (outside your household) received for your or a member of your
household’s use or benefit. For example, if a person was paid by a third-party to be your personal housekeeper, identify that person, describe the
nature of that person’s services that benefited you, and provide information about the third-party who paid for the services on your behalf.
You need not disclose income of a business, including money you or any member of your household received that constitutes income paid to
a business that you or your household member owns or does business as. This type of business income will be disclosed in Question 12 below.
If additional space is needed to report information on this Financial Disclosure Statement, please attach additional information as numbered exhibits.
Minor children include children 18 years old and younger over whom you have joint or sole legal custody.