Statement of Economic Interest
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Name: *
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List EACH Office or Position of Employment for which this Statement is filed: *
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Full Post Office Address: *
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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 $5,000.00 fair market value, or from which dividends in excess of $1,200.00 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. ******************************************************************IF APPLICABLE-MUST LIST the following for each qualifying answer: BUSINESS ENTITY, INSTRUMENT OF OWNERSHIP, POSITION OF MANAGEMENT. *
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List the name, address, and type 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. ******************************************************************IF APPLICABLE MUST LIST the following for each qualifying answer: NAME, ADDRESS, TYPE OF PRACTICE *
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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 $5,000.00 was received for professional services rendered during the preceding calendar year by the person making the statement: *
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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: *
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List the name of any entity and the nature of the governmental action requested by an entity that has applies 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 $5,000.00 fair market value at the time of filing, or if income or dividends in excess of $1,200.00 were received by the person filing from the entity the preceding calendar year: *
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List the name of any entity doing business with a unit of local government in relation to which the person if required to file, from which income in excess of $1,200.00 was derived during the preceding calendar year other than for professional services and the title or description of any position in that entity: (No time or demand deposit in a financial institution nor any debt instrument need be listed) *
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List the name of any unit of government that employed the person making the statement during the preceding calendar year, other than the unity or units of government in relation to which the person is required to file: *
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List the name of any entity from which a gift or gifts, or honorarium or honoraria, valued singly or in excess of $500.00 was received during the preceding calendar year: *
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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 $1,000.00, or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment.







Printed by authority of the State of Illinois. August 2007--80M--1-107.8
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