Ethics and Financial Disclosure Form

# Ethics and Financial Disclosure Form **Filing Date:** ___________ **Reporting Period:** ___________ to ___________ This Ethics and Financial Disclosure Form ("Disclosure") is submitted by: **Full Legal Name:** ___________ **Title/Position:** ___________ **Department/Agency:** ___________ **Office Address:** ___________ ## 1. Filing Type ___________ ## 2. Employment Income **Primary Position Compensation:** $___________ per ___________ **Other Employment Income During Reporting Period:** ___________ **Honoraria Received (speeches, appearances, articles):** ___________ ## 3. Financial Interests **Stocks, Bonds, and Securities (valued over $1,000):** ___________ **Real Estate Holdings (excluding primary residence):** ___________ **Business Ownership Interests (partnerships, LLCs, corporations):** ___________ **Trusts and Beneficial Interests:** ___________ ## 4. Liabilities