Fillable Statement of Economic Interests to be Filed with (DeKalb County, Illinois)

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Statement of Economic Interests to be Filed with (DeKalb County, Illinois)

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Statement of Economic Interests to be Filed with the County Clerk
Your Name Was Submitted For Filing by an Entity That You Represent
Name:
Each Office or Position of Employment for which this Statement is Filed:
Full Post Office Address:
GENERAL DIRECTIONS
The interest (if constructively controlled by the person making the statement) of a spouse or any other party shall be considered to
be
the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If more
space is needed, please attach supplemental listing.
1.
List the name and instrument of ownership in any entity doing business with a unit of local government in relation to which the
person is required to file, in which the ownership interest held by the person at the date of filing is in excess of $5,000 fair mar
ket
value, or from which dividends in excess of $1,200 were received during the preceding calendar year: (In the case of real estate,
location thereof shall be listed by the street address, or if none, then by legal description.) No time or demand deposit in a financial
institution, nor any debt instrument shall be listed.
Business Entity Instrument of Ownership Position of Management
2.
List the name, address and type of practice of any professional organization in which the person making the statement was an officer,
director, associate, partner or proprietor, or served in any advisory capacity, from which income in excess of $1,200 was derived during
the preceding calendar year:
Name Address
Type of Practice
3.
List the nature of professional services rendered (other than to the unit or units of local government in relation to which the person is
required to file) to each entity from which income exceeding $5,000 was received for professional services rendered during
the
preceding calendar year by the person making the statement:
COMPLETE BUT DO NOT DETACH
This section will be returned to you when the
Statement is filed with the County Clerk.
Office or Position of Employment for which this statement is filed
Name
Address
City/State/ZIP Code
Receipt is hereby acknowledged of your
Statement of
Economic Interests, filed
pursuant to the Illinois
Governmental Ethics
Act. The Statement was filed on this date:
4.
List the identity (including 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 name of any entity and the nature of the governmental action requested by any entity that 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 pre
ceding
calendar year:
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.)
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
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 impris
onment.
Signature of Person Making Statement
Date
DO NOT DETACH
(WILL BE RETURNED AS YOUR RECEIPT)
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Statement of Economic Interests to be Filed with (DeKalb County, Illinois)

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Completed 11 June 2021

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