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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
5. List the identity of any compensated lobbyist with whom the person making the statement maintains a close econom-
ic association, including the name of the lobbyist and specifying the legislative matter or matters that are the object of the
lobbying activity, and describing the general type of economic activity of the client or principal on whose behalf that per-
son is lobbying.
Lobbyist Legislative Matter Client or Principal
________________________________ ________________________________ ________________________________
________________________________ ________________________________ ________________________________
6. List the name of any entity doing business in the State of Illinois 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. (In the case of real estate, location thereof shall be listed by street address or, if none, by legal description.) No
time or demand deposit in a financial institution nor any debt instrument need be listed.
Entity Position Held
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
7. List the name of any unit of government that 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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
VERIFICATION
I declare that this Statement of Economic Interests (including any accompanying schedules and statements) has been exam-
ined 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 state-
ment 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.
___________________________________________________
(Signature of person making Statement) (Date)
NOTE: This statement must be filed in the Office of the Secretary of State, Index Department, Ethics Section, 111 E.
Monroe, Springfield, IL 62756.
Printed by authority of the State of Illinois. March 2012 — 1 — I 188.2
