Executive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT
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1 Eecutive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT Form Approved: OMB No of Appointment, Candidacy, Election, or Nomination (Month, Day, Year) Reporting Individual's Name Position for Which Filing Location of Present Office (or forwarding address) Position(s) Held with the Federal Government During the Preceding Months (If Not Same as Above) Presidential Nominees Subject to Senate Confirmation Certification I CERTIFY that the statements I have made on this form and all attached schedules are true, complete and correct to the best of my knowledge. Review (If desired by agency) Reporting Status (Check Appropriate Boes) Last Name Title of Position Incumbent Address (Number, Street, City, State, and ZIP Code) Title of Position(s) and (s) Held Name of Congressional Committee Considering Nomination Signature of Reporting Individual Signature of Reviewer Calendar Year Covered by Report New Entrant, Nominee, or Candidate First Name and Middle Initial Department or Agency (If Applicable) Yes Termination Filer Termination ( If Applicable) (Month, Day, Year) Telephone No. (Include Area Code) Do You Intend to Create a Qualified Diversified Trust? No Fee for Late Filing Any individual who is required to file this report and does so more than 0 days after the date the report is required to be filed, or, if an etension is granted, more than 0 days after the last day of the filing etension period, shall be subject to a $00 fee. Reporting Periods Incumbents: The reporting period is the preceding calendar year ecept Part II of Schedule C and Part I of Schedule D where you must also include the filing year up to the date you file. Part II of Schedule D is not applicable. Termination Filers: The reporting period begins at the end of the period covered by your previous filing and ends at the date of termination. Part II of Schedule D is not applicable. Nominees, New Entrants and Candidates for President and Vice President: Schedule A--The reporting period for income () is the preceding calendar year and the current calendar year up to the date of filing. Value assets as of any date you choose that is within days of the date of filing. Schedule B--Not applicable. Agency Ethics Official's Opinion On the basis of information contained in this report, I conclude that the filer is in compliance with applicable laws and regulations (subject to any comments in the bo below). Office o f Government Ethics Use Only Signature of Designated Agency Ethics Official/Reviewing Official Signature Schedule C, Part I (Liabilities)--The reporting period is the preceding calendar year and the current calendar year up to any date you choose that is within days of the date of filing. Schedule C, Part II (Agreements or Arrangements)--Show any agreements or arrangements as of the date of filing. Comments of Reviewing Officials (If additional space is required, use the reverse side of this sheet) (Check bo if filing etension granted & indicate number of days ) Schedule D --The reporting period is the preceding twot w ocalendar years and the current calendar year up to the date of filing. Agency Use Only (Check bo if comments are continued on the reverse side) OGE Use Only Supersedes Prior Editions, Which Cannot Be Used. 78- NSN
2 SCHEDULE A For you, your spouse, and dependent children, report each asset held for investment or the production of income which had a fair market value eceeding $,000 at the close of the reporting period, or which generated more than $00 in income during the reporting period, together with such income. For yourself, also report the source and actual amount of earned income eceeding $00 (other than from the U.S. Government). For your spouse, report the source but not the amount of earned income of more than $,000 (ecept report the actual amount of any honoraria over $00 of your spouse). (or less than $,00) (or less than $0) & ) Central Airlines Common Eamples Doe Jones & Smith, Hometown, State Law Partnership $0,000 Kempstone Equity Fund IRA: Heartland 00 Inde Fund
3 SCHEDULE A continued (Use only if needed) (or less than $,00) (or less than $0) & ) 7 8 9
4 SCHEDULE A continued (Use only if needed) (or less than $,00) (or less than $0) & ) 7 8 9
5 SCHEDULE A continued (Use only if needed) (or less than $,00) (or less than $0) & ) 7 8 9
6 SCHEDULE C Part I: Liabilities Report liabilities over $0,000 owed to any one creditor at any time during the reporting period by you, your spouse, or dependent children. Check the highest amount owed during the reporting period. Eclude Creditors (Name and Address) a mortgage on your personal residence unless it is rented out; loans secured by automobiles, household furniture or appliances; and liabilities owed to certain relatives listed in instructions. See instructions for revolving charge accounts. of Liability Incurred Rate Term if applicable $0,00 - $,000 $,00 - $0,000 $0,00 - $00,000 Category of or Value () $00,00- $0,000 $0,00 - $00,000 $00,00 - $,000,000 Over $,000,000* $,000,00- $,000,000 $,000,00 - $,000,000 $,000,00 - $0,000,000 Over $0,000,000 Eamples First District Bank, Washington, DC John Jones, J St., Washington, DC Mortgage on rental property, Delaware Promissory note % 0% yrs. on demand * This category applies only if the liability is solely that of the filer's spouse or dependent children. If the liability is that of the filer or a joint liability of the filer with the spouse or dependent children, mark the other higher categories, as appropriate. Part II: Agreements or Arrangements Report your agreements or arrangements for: () continuing participation in an employee benefit plan (e.g. pension, 0k, deferred compensation); () continuation of payment by a former employer (including severance payments); () leaves of absence; and () future employment. See instructions regarding the reporting of negotiations for any of these arrangements or benefits. Status and Terms of any Agreement or Arrangement Parties Eample Pursuant to partnership agreement, will receive lump sum payment of capital account & partnership share calculated on service performed through /00. Doe Jones & Smith, Hometown, State 7/8
7 SCHEDULE D Part I: Positions Held Outside U.S. Government Report any positions held during the applicable reporting period, whether compensated or not. Positions include but are not limited to those of an officer, director, trustee, general partner, proprietor, representative, employee, or consultant of any corporation, firm, partnership, or other business enterprise or any non-profit Eamples Organization (Name and Address) Nat'l Assn. of Rock Collectors, NY, NY Doe Jones & Smith, Hometown, State Non-profit education Law firm organization or educational institution. Eclude positions with religious, social, fraternal, or political entities and those solely of an honorary nature. of Organization President Position Held From (Mo., /9 To (Mo., Present Partner 7/8 /00 Part II: Compensation in Ecess of $,000 Paid by One Source Report sources of more than $,000 compensation received by you or your business affiliation for services provided directly by you during any one year of the reporting period. This includes the names of clients and customers of any corporation, firm, partnership, or other business enterprise, or any other Do not complete this part if you are an Incumbent, Termination Filer, or Vice non-profit organization when Presidential or Presidential Candidate. you directly provided the services generating a fee or payment of more than $,000. You need not report the U.S. Government as a source. Eamples Source (Name and Address) Doe Jones & Smith, Hometown, State Metro University (client of Doe Jones & Smith), Moneytown, State Legal services Legal services in connection with university construction Brief Description of Duties
Executive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT
SF 78 (Rev. 0/000) C.F.R. Part Eecutive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT Form Approved: OMB No. 09-000 of Appointment, Candidacy, Election, or Nomination (Month, Day, Year) Reporting
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R part 2634 Form Approved: OMB No. (3209-0001)(March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
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Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
Nominee Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
Nominee Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
Nominee Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R part 2634 Form Approved: OMB No. (3209-0001)(March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
Nominee Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
New Entrant Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
Nominee Report U.S. Office of Government Ethics; 5 C.F.R. part 2634 Form Approved: OMB No. (3209-0001) (March 2014) Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e) Filer's
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Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
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Executive Branch Personnel Public Financial Disclosure Report (OGE Form 278e)
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