Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696589736232.pdf (United States)
78-995:78-995 3/1/13 4:11 AM Page 1 UNITED STATES HOUSE OF REPRESENTATIVES ETHICS IN GOVERNMENT ACT—FINANCIAL DISCLOSURE STATEMENT FORM B—For Use By Candidates and New Employees WHO MUST FILE AND WHEN: A candidate for the U.S. House of Representatives must file a Financial Disclosure Statement each year.
The candi- date’s first report is due within 30 days of becoming a candidate (by raising or spending more than $5,000) or by May 15th of the calendar year in which he or she becomes a candidate, whichever is later, but, in any event, at least 30 days before the primary or general election.

A clear post- mark is accepted as the filing date.

A covered new employee of the Legislative Branch must file a Financial Disclosure Statement within 30 days of beginning the job.
A $200 late filing fee shall be assessed against any individual who files more than 30 days after the due date of a report or amendment (or the date of any extension).

Any individual who knowingly and willfully falsifies or who knowingly and willfully fails to file the attached report may be subject to civil penalties and criminal sanctions.

See Section 104 of the Ethics in Government Act (5 U.S.C.

app.

4 §§ 101–111) and 18 U.S.C.

§ 1001.


REPORTING PERIOD: Information must be reported for the preceding calendar year and current year to date of filing.

Sources of compensation over $5,000 and positions must be reported for the two prior years (24 months).

Information regarding assets and liabilities must be current as of a date which is within 30 days of this form's filing date.
WHERE TO OBTAIN ASSISTANCE: Committee on Ethics, U.S. House of Representatives, 508 Ford House Office Building, Washington, DC 20515.

Telephone: (202) 225–7103.

Additional forms and instructions may be obtained from the Committee.

Requests for extensions of time for filing must be in writing and addressed to the Committee (or the relevant legislative branch agency).

An exten- sion request must be received (not postmarked) no later than the due date.
The maximum extension is 90 days, but no extension can be granted allowing a candidate to file less than 30 days before an election.

BEFORE FILING: Complete all parts.

Please type or print neatly using blue or black ink.

Do not use pencil.

Attach additional sheets if necessary, indicating the section being continued.

Type or print your name at the top of each page filed.

ANSWER EACH QUESTION ON THE PRELIMINARY INFORMATION PAGE and attach the appropriate schedule for each “Yes” response.
Sign and date the form.

Remove this cover page before filing.

Separate pages and file only those required.

Do not file blank schedules.

RETURN COMPLETED STATEMENT TO: The Clerk, U.S. House of Representatives Legislative Resource Center B–106 Cannon House Office Building Washington, DC 20515–6612 Filing Instructions for Candidates: File a signed original and two photocopies of your report, including all attachments.
Filing Instructions for Employees: File a signed original and one photocopy of your report, including all attachments .

78-995:78-995 3/1/13 4:11 AM Page 2 UNITED STATES HOUSE OF REPRESENTATIVES ETHICS IN GOVERNMENT ACT FINANCIAL DISCLOSURE STATEMENT — FORM B Please provide the following information.

Your address and signature WILL NOT be made available to the public.
(Print Full Name) (Daytime Telephone) (Complete Address – Office or Home) Filer Status Candidate New Employee CERTIFICATION – THIS DOCUMENT MUST BE SIGNED BY THE REPORTING INDIVIDUAL AND DATED The attached Financial Disclosure Statement is required by the Ethics in Government Act of 1978, as amended.

The Statement will be available for review by the public and will be reviewed by the Committee on Ethics or its designee.
Any individual who knowingly and willfully falsifies or who knowingly and willfully fails to file the attached report may be subject to civil penalties and criminal sanctions.

See Section 104 of the Ethics in Government Act (5 U.S.C.

app.

4 §§ 101-111) and 18 U.S.C.

§ 1001.

Certification I CERTIFY that the statements I have made on the attached Financial Disclosure Statement and all attached schedules are true, complete, and correct to the best of my knowledge and belief.
Signature of Reporting Individual Date Candidates must file a signed original and two photocopies thereof.

Employees must file a signed original and one photocopy thereof.

***FOR OFFICIAL USE ONLY – DO NOT WRITE BELOW*** Certification It is my opinion, based on the information contained in this Financial Disclosure Statement, that the reporting individual is in compliance with Title I of the Ethics in Government Act (5 U.S.C.

app.

4 §§ 101-111).
Signature of Certifying Official Date 78-995:78-995 3/1/13 4:11 AM Page 3 UNITED STATES HOUSE OF REPRESENTATIVES FINANCIAL DISCLOSURE STATEMENT Period covered: January 1, __ _____ - ____________________________ FORM B For use by candidates and new employees Page 1 of ____ Name: Filer Status Daytime Telephone: Candidate for the House of Representatives State: __________________ District: ________________ Date of Election: _________________ Check if Amendment New officer or employee Employing Office: _______________________________________ (Office Use Only) A $200 penalty shall be assessed against any individual who files more than 30 days late.
In all sections, please type or print clearly in blue or black ink.

PRELIMINARY INFORMATION — ANSWER EACH OF THESE QUESTIONS I.

Did you or your spouse have “earned” income (e.g., salaries or fees) of $200 or more from any source in the reporting period?

If yes, complete and attach Schedule I. II.

Did you, your spouse, or a dependent child receive “unearned” income of more than $200 in the reporting period or hold any reportable asset worth more than $1,000 at the end of the period?
If yes, complete and attach Schedule II.

III.

Did you, your spouse, or a dependent child have any report- able liability (more than $10,000) during the reporting period?

If yes, complete and attach Schedule III.

Yes Yes Yes No No No IV.

Did you hold any reportable positions on or before the date of filing in the current calendar year or in the prior two years?

If yes, complete and attach Schedule IV.

V. Did you have any reportable agreement or arrangement with an outside entity?
If yes, complete and attach Schedule V. VI.

Did you receive compensation of more than $5,000 from a single source in the two prior years?

If yes, complete and attach Schedule VI.

Yes Yes Yes Each question in this part must be answered and the appropriate schedule attached for each “Yes” response.
EXCLUSION OF SPOUSE, DEPENDENT, OR TRUST INFORMATION — ANSWER EACH OF THESE QUESTIONS TRUSTS—Details regarding “Qualified Blind Trusts” approved by the Committee on Ethics and certain other “excepted trusts” need not be disclosed.

Have you excluded from this report details of such a trust benefiting you, your spouse, or a dependent child?
EXEMPTION—Have you excluded from this report any other assets, “unearned” income, transactions, or liabilities of a spouse or dependent child EXEMPTION— because they meet all three tests for exemption?

Do not answer “yes” unless you have first consulted with the Committee on Ethics.
Yes Yes No No No No No 78-995:78-995 3/1/13 4:11 AM Page 4 SCHEDULE I — EARNED INCOME (INCLUDING HONORARIA) Name Page ____ of ____ List the source, type, and amount of earned income from any source (other than the filer’s current employment by the U.S. Government) totalling $200 or more during the preceding calendar year.

For a spouse, list the source and amount of any honoraria; list only the source for other spouse earned income exceeding $1,000.

See examples below.
See examples below.

Exclude: Military pay (such as National Guard or Reserve pay), federal retirement programs, and benefits received under the Social Security Act.
Source (include date of receipt for honoraria) Type Examples: XYZ Corporation, Houston, TX First Bank & Trust, Houston, TX XYZ Trade Association, Chicago, IL (Rec’d December 2) Harris County, Texas Public Schools Salary Director’s Fee Honorarium Spouse Salary Amount Current Year to Filing Preceding Year $6,300 $400 0 NA $28,450 $3,200 $1,000 NA This page may be copied if more space is required.
78-995:78-995 3/1/13 4:11 AM Page 5 SCHEDULE II — ASSETS AND “UNEARNED” INCOME BLOCK A Asset and/or Income Source BLOCK B Value of Asset Identify (a) each asset held for investment or production of income with a fair market value exceeding $1,000 at the end of the reporting period, and (b) any other reportable asset or sources of income which generated more than $200 in “unearned” income during the year.

Indicate value of asset at close of reporting year.
If you use a valuation method other than fair market value, please specify the method used.

Provide complete names of stocks and mutual funds (do not use ticker symbols).

For all IRAs and other retirement plans (such as 401(k) plans) provide the value for each asset held in the account that exceeds the reporting thresholds.

For rental or other real property held for investment, provide a complete address or a description, e.g., “rental property,” and the city and state.
For an ownership interest in a privately-held business that is not publicly traded, state the name of the busi- ness, the nature of its activities, and its geographic location in Block A.
Exclude: Your personal residence, including second homes and vacation homes (unless there was rental income during the reporting period); any deposits total- ing $5,000 or less in personal checking or savings accounts; and any financial interest in, or income derived from, a federal retirement program, including the Thrift Savings Plan.
If you so choose, you may indicate that an asset or income source is that of your spouse (SP) or depen- dent child (DC) or is jointly held with your spouse (JT), in the optional column on the far left.

For a detailed discussion of Schedule II requirements, please refer to the instruction booklet.
SP, SP Mega Corp. Stock DC, Examples: Simon & Schuster If an asset was sold during the report- ing year and is included only because it generated income, the value should be “None.” *This column is for assets solely held by your spouse or dependent child.
A B C D E F G H I J K L M 0 0 0 , 0 0 0 , 5 2 $ 0 0 0 , 0 0 0 , 5 $ – – 1 0 0 , 0 0 0 , 1 $ 1 0 0 , 0 0 0 , 5 $ 0 0 0 , 0 0 0 , 0 5 $ – 1 0 0 , 0 0 0 , 5 2 $ 0 0 0 , 0 0 0 , 0 5 $ r e v O 0 0 0 , 0 5 2 $ 0 0 0 , 0 0 5 $ 0 0 0 , 0 0 0 , 1 $ – – – 1 0 0 , 0 0 1 $ 1 0 0 , 0 5 2 $ 1 0 0 , 0 0 5 $ * 0 0 0 , 0 0 0 , 1 $ r e v o t e s s A C D / e s u o p S E N O N X 0 0 0 , 1 $ – 1 $ e n o N 0 0 0 , 0 0 1 $ 0 0 0 , 0 5 $ – – 1 0 0 , 5 1 $ 1 0 0 , 0 5 $ 0 0 0 , 5 1 $ – 1 0 0 , 1 $ X Indefinite JT 1st Bank of Paducah, KY accounts X For additional assets and unearned income, use next page.
Name Page of BLOCK D Amount of Income For assets for which you checked “Tax-Deferred” in Block C, you may check the “None’’ column.

For all other assets, indicate the category of income by checking the appropriate box below.

Dividends, interest, and capital gains, even if reinvested, must be disclosed as income.

Check “None” if no income was earned or generated.

* This column is for income derived from assets solely held by your spouse or dependent child.
BLOCK C Type of Income Check all columns that apply.

For retirement accounts that do not allow you to choose specific investments or that generate tax- deferred income (such as 401(k) plans or IRAs), you may check the “Tax-Deferred’’ column.

Dividends, interest, and capital gains, even if reinvested, must be dis- closed as income.

Check “None” if the asset generated no income during the reporting period. )

e m o c n I m r a F r o e m o c n I i p h s r e n t r a P , .

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e : y f i c e p S ( T S U R T D N I L B D E T P E C X E / e m o c n I f o e p y T r e h t O D E R R E F E D X A T - Royalties Current Year Preceding Year I II III IV V VI VII VIII IX X XI XII I II III IV V VI VII VIII IX X XI XII * 0 0 0 , 0 0 0 , 1 $ r e v o e m o c n I C D / e s u o p S 0 0 0 , 0 0 0 , 5 $ – 1 0 0 , 0 0 0 , 1 $ 0 0 0 , 0 0 0 , 1 $ – 1 0 0 , 0 0 1 $ 0 0 0 , 0 0 0 , 5 $ r e v O 0 0 0 , 0 0 1 $ 0 0 0 , 0 5 $ – – 1 0 0 , 5 1 $ 1 0 0 , 0 5 $ * 0 0 0 , 0 0 0 , 1 $ r e v o e m o c n I C D / e s u o p S 0 0 5 , 2 $ 0 0 0 , 5 $ 0 0 0 , 5 1 $ – – – 1 0 0 , 1 $ 1 0 5 , 2 $ 1 0 0 , 5 $ 0 0 0 , 0 0 1 $ 0 0 0 , 0 5 $ – – 1 0 0 , 5 1 $ 1 0 0 , 0 5 $ 0 0 0 , 0 0 0 , 5 $ – 1 0 0 , 0 0 0 , 1 $ 0 0 0 , 0 0 0 , 1 $ – 1 0 0 , 0 0 1 $ 0 0 0 , 0 0 0 , 5 $ r e v O 0 0 2 $ – 1 $ e n o N 0 0 0 , 1 $ – 1 0 2 $ X X X 0 0 0 , 1 $ – 1 0 2 $ 0 0 2 $ – 1 $ e n o N 0 0 5 , 2 $ 0 0 0 , 5 $ 0 0 0 , 5 1 $ – – – 1 0 5 , 2 $ 1 0 0 , 5 $ 1 0 0 , 1 $ 78-995:78-995 3/1/13 4:11 AM Page 6 SCHEDULE II — ASSETS AND “UNEARNED” INCOME Continuation Sheet (if needed) Name Page of BLOCK A BLOCK B BLOCK C BLOCK D Asset and/or Income Source Value of Asset Type of Income Amount of Income Current Year Preceding Year I II III IV V VI VII VIII IX X XI XII I II III IV V VI VII VIII IX X XI XII 0 0 0 , 0 0 0 , 5 $ – 1 0 0 , 0 0 0 , 1 $ 0 0 0 , 0 0 0 , 1 $ – 1 0 0 , 0 0 1 $ 0 0 0 , 5 1 $ – 1 0 0 , 5 $ 0 0 0 , 0 5 $ – 1 0 0 , 5 1 $ 0 0 0 , 0 0 1 $ – 1 0 0 , 0 5 $ 0 0 5 , 2 $ – 1
 0 0 , 1 $ 0 0 0 , 5 $ – 1 0 5 , 2 $ 0 0 0 , 1 $ – 1 0 2 $ 0 0 2 $ – 1 $ e n o N , * 0 0 0 0 0 0 1 $ , r e v o e m o c n I C D / e s u o p S 0 0 0 , 0 0 0 , 5 $ r e v O 0 0 5 , 2 $ – 1 0 0 , 1 $ 0 0 0 , 5 $ – 1 0 5 , 2 $ 0 0 0 , 1 $ – 1 0 2 $ 0 0 2 $ – 1 $ e n o N 0 0 0 , 0 0 0 , 5 $ – 1 0 0 , 0 0 0 , 1 $ 0 0 0 , 0 0 0 , 1 $ – 1 0 0 , 0 0 1 $ 0 0 0 , 5 1 $ – 1 0 0 , 5 $ 0 0 0 , 0 5 $ – 1 0 0 , 5 1 $ 0 0 0 , 0 0 1 $ – 1 0 0 , 0 5 $ , * 0 0 0 0 0 0 1 $ , r e v o e m o c n I C D / e s u o p S 0 0 0 , 0 0 0 , 5
 $ r e v O , .
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e : y f i c e p S ( - - e m o c n I f o e p y T r e h t O ) / D E R R E F E D X A T - SP, JT, DC A B C D E F G H I J K L M * 0 0 0 , 0 0 0 , 1 $ r e v o t e s s A C D e s u o p S / E N O N 0 0 0 , 0 0 0 , 5 2 $ 0 0 0 , 0 0 0 , 5 $ – – 1 0 0 , 0 0 0 , 1 $ 1 0 0 , 0 0 0 , 5 $ 0 0 0 , 0 0 0 , 0 5 $ – 1 0 0 , 0 0 0 , 5 2 $ 0 0 0 , 0 0 0 , 0 5 $ r e v O 0 0 0 , 0 0 1 $ 0 0 0 , 0 5 $ – – 1 0 0 , 5 1 $ 1 0 0 , 0 5 $ 0 0 0 , 5 1 $ – 1 0 0 , 1 $ 0 0 0 , 0 5 2 $ 0 0 0 , 0 0 5 $ 0 0 0 , 0 0 0 , 1 $ – – – 1 0 0 , 0 0 1 $ 1 0 0 , 0 5 2 $ 1 0 0 , 0 0 5 $ 0 0 0 , 1 $ – 1 $ e n o N This page may be copied if more space is required.
78-995:78-995 3/1/13 4:11 AM Page 7 SCHEDULE III — LIABILITIES Name Page ___ of ___ Report liabilities of over $10,000 owed to any one creditor at any time during the reporting period by you, your spouse, or dependent child.

Mark the highest amount owed during the reporting period.
Exclude: Any mortgage on your personal residence (unless there is rental income); loans secured by automobiles, household furni- ture, or appliances; liabilities of a business in which you own an interest (unless you are personally liable); and liabilities owed to a spouse, or the child, parent, or sib- ling of you or your spouse.

Report revolving charge accounts (i.e., credit cards) only if the balance at the close of the previous calendar year exceeded $10,000.
SP, DC, JT Creditor Date Liability Incurred mo/year Type of Liability Example: First Bank of Wilmington, DE May 1998 Mortgage on 123 Main Street, Dover, DE Amount of Liability A B C D E F — 1 0 0 , 0 1 $ 0 0 0 , 5 1 $ — 1 0 0 , 5 1 $ 0 0 0 , 0 5 $ — 1 0 0 , 0 5 $ 0 0 0 , 0 0 1 $ — 1 0 0 , 0 5 2 $ 0 0 0 , 0 0 5 $ — 1 0 0 , 0 0 5 $ 0 0 0 , 0 0 0 , 1 $ — 1 0 0 , 0 0 1 $ 0 0 0 , 0 5 2 $ X G — 1 0 0 , 0 0 0 , 1 $ 0 0 0 , 0 0 0 , 5 $ H — 1 0 0 , 0 0 0 , 5 $ 0 0 0 , 0 0 0 , 5 2 $ I — 1 0 0 , 0 0 0 , 5 2 $ 0 0 0 , 0 0 0 , 0 5 $ J 0 0 0 , 0 0 0 , 0 5 $ r e v O C D / e s u o p S K r e v o y t i l i b a L i 0 0 0 , 0 0 0 , 1 $ SCHEDULE IV — POSITIONS Report all positions, compensated or uncompensated, held on or before the date of filing during the current calendar year and in the two prior years as an offi- cer, director, trustee, partner, proprietor, representative, employee, or consultant of any corporation, company, firm, partnership, or other business enterprise, any nonprofit organization, any labor organization, or any educational or other institution other than the United States.
Exclude: Positions listed on Schedule I; positions held in any religious, social, fraternal, or political entities (such as a political party or campaign organization); and positions solely of an honorary nature.

Position Name of Organization Use additional sheets if more space is required.
78-995:78-995 3/1/13 4:11 AM Page 8 SCHEDULE V — AGREEMENTS Name Page —— of —— Identify the date, parties to, and general terms of any agreement or arrangement with respect to: future employment; a leave of absence during the period of government service; continuation or deferral of payments by a former or current employer other than the U.S. Government; or continuing participation in an employee welfare or ben- efit plan maintained by a former employer.
Date Parties To Terms of Agreement SCHEDULE VI — COMPENSATION IN EXCESS OF $5,000 PAID BY ONE SOURCE Report sources of such compensation received by you or your business affiliation for services provided directly by you during the two prior years.

This includes the names of clients and customers of any corporation, firm, partnership, or other business enterprise, or any nonprofit organization if you directly provided the services generating a fee or payment of more than $5,000.
Exclude: Payments by the U.S. Government and any information considered confidential as a result of a privileged relationship recognized by law.

Do not repeat information listed on Schedule I.

Example: Doe Jones & Smith, Hometown, Homestate Accounting services Source (Name and Address) Brief Description of Duties GPO: 2013 78–995 (mac)