§ 51-321. Contents and form of Financial Disclosure Statement.

A.  The Financial Disclosure Statement shall contain the following information for the preceding two (2) calendar years or for the period since the most recent Financial Disclosure Statement was filed:

1.  Name or title of the office;

2.  Name of the person filing the Financial Disclosure Statement;

3.  Business address of the person;

4.  Residential address of the person;

5.  Occupation or business of the person prior to the election or employment for which the Financial Disclosure Statement is being filed;

6.  Prior positions held as a public official, regardless of whether a salary or reimbursement was received for such service;

7.  Names, business addresses, residential addresses and occupations of the spouse of the person and all living adult children if such spouse or children are doing business with the county;

8.  A list of categories or industries from which income is received without reference to amounts or frequency of receipt of income.  Provided, categories or industries from which less than One Thousand Dollars ($1,000.00) annually is received may be omitted.  Such persons shall list special areas of practice in general subjective terms;

9.  A list of categories or industries in which the person has had stock during the period for which the information on the Financial Disclosure Statement is required.  Provided, categories or industries in which the person has stock valued at less than One Thousand Dollars ($1,000.00) at the time of filing the Financial Disclosure Statement may be omitted;

10.  The name of any entity from which an honorarium or honoraria, valued at more than Two Hundred Dollars ($200.00) over and above actual expenses paid to the person, was received and the value of any such honorarium; and

11.  The name of any registered lobbyist with whom the person has engaged in business from which income of over One Thousand Dollars ($1,000.00) was received.

B.  The form for the Financial Disclosure Statement shall be as follows:

FINANCIAL DISCLOSURE STATEMENT

______________________________________________________________

NAME: (Last, First, Middle)                   Birth Date

______________________________________________________________

Business Address (Street or Box, City, State, Zip)

_______________________________________________________________

Residential Address (Street or Box, City, State, Zip)

CHECK YOUR FILING STATUS:  (mark only one box)

( )  An elected official.

( )  A candidate running in an election:

month_____________________ year_________

( )  A member of a board or commission.

Position you hold or have been appointed to:

(fill in all applicable blanks)

Position Title:_________________________________________

County or agency of the office:

_______________________________________________________________

Position number:_______________________________________________

Term begins:___________________ ends:___________________

Appointment date:__________________________________

Employment date:___________________________________

1.  OCCUPATION OR BUSINESS:  (current or prior to this election or appointment)

_______________________________________________________________

2.  PRIOR POSITIONS HELD AS A PUBLIC OFFICIAL:  (List most recent positions first)

_______________________________________________________________

3.  SPOUSE and ADULT CHILDREN:  Give the following information for your spouse and all living adult children (over 18 years of age) if your spouse or children are doing business with the county.

_________________________________________________________________

NAME       RESIDENTIAL ADDRESS      BUSINESS ADDRESS     OCCUPATION

Check here ( ) if continued on attached sheet

_______________________________________________________________

4.  INCOME:  List categories or industries from which you receive $1,000 or more annually:

Check here ( ) if continued on attached sheet

_______________________________________________________________

5.  STOCK:  List categories or industries in which you have owned stock which is valued at $1,000 or more during the period for which this Financial Disclosure Statement is required:

CATEGORY OR INDUSTRY

CATEGORY OR INDUSTRY

CATEGORY OR INDUSTRY

Check here ( ) if continued on attached sheet

_______________________________________________________________

6.  HONORARIA:  List names of any entities from which you received an honorarium or honoraria valued at more than $200 over and above actual expenses and list the value of such honorarium or honoraria:

DATE

ENTITY

VALUE

Check here ( ) if continued on attached sheet

_______________________________________________________________

7.  LOBBYISTS:  List any registered lobbyists with whom you have engaged in business from which income of over $1,000 was received:

LOBBYIST'S NAME

LOBBYIST'S NAME

Check here ( ) if continued on attached sheet

_______________________________________________________________

Report additional information on plain 8 1/2 x 11 paper using format of each question.  Attach pages to this report.  Put your name and the date on all attachments.

_______________________________________________________________

To the best of my knowledge and belief, the above is a true and correct compilation:

_______________________________________________________________

SIGNATURE: (Person Filing Statement)           Date

Added by Laws 1995, c. 343, § 35, eff. July 1, 1995.