You need not disclose: If you or your household member does not own a business, or if your or your household business is not a member’s dependent business, you may leave this question blank. Name of Controlled or If the Land Was First Acquired or Completely Discharged Approximate Value of Dependent Business That Location and Approximate Size During This Reporting Period, Provide the Date Land Owns Land (MM/DD/YYYY) and Check the Appropriate Box $1,000 - $25,000 Date: $25,001 - $100,000 Acquired Divested $100,001 + $1,000 - $25,000 Date: $25,001 - $100,000 Acquired Divested $100,001 + $1,000 - $25,000 Date: $25,001 - $100,000 Acquired Divested $100,001 + 15. Controlled or Dependent Creditors Business’ What to disclose: The name and address of each creditor to which a controlled or dependent business owed more than $10,000, if that amount was also more than 30% of the total indebtedness at any time during the period covered by this Financial Disclosure Statement business’ business (“qualifying debt”). Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date and check whether it was incurred or discharged (double-click the box and change the default value to Otherwise, (for “checked”). write “N/A” “not the if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure applicable”) after word “Date” Statement. You need not disclose: If you or your household member does not own a business, or if your or your household business is not a member’s controlled or dependent business, you may leave this question blank. If the Debt Was First Incurred or Completely Discharged Name of Controlled or Dependent Business Name and Address of Creditor (or Person to During This Reporting Period, Provide the Date Owing the Qualifying Debt Whom Payments are Made) (MM/DD/YYYY) and Check the Appropriate Box Date: Incurred Discharged Date: Incurred Discharged Date:
You need not disclose: If you or your household member does not own a business, or if your or your household member’s business is not a dependent business, you may leave this question blank. Name of Controlled or Dependent Business That Owns Land Location and Approximate Size Approximate Value of Land If the Land Was First Acquired or Completely Discharged During This Reporting Period, Provide the Date (MM/DD/YYYY) and Check the Appropriate Box $1,000 - $25,000 $25,001 - $100,000 $100,001 + Date: Acquired Divested $1,000 - $25,000 $25,001 - $100,000 $100,001 + Date: Acquired Divested $1,000 - $25,000 $25,001 - $100,000 $100,001 + Date: Acquired Divested 15. Controlled or Dependent Business’ Creditors What to disclose: The name and address of each creditor to which a controlled or dependent business owed more than $10,000, if that amount was also more than 30% of the business’ total indebtedness at any time during the period covered by this Financial Disclosure Statement (“qualifying business debt”). Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date and check whether it was incurred or discharged (double-click the box and change the default value to “checked”). Otherwise, write “N/A” (for “not applicable”) after the word “Date” if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure Statement. You need not disclose: If you or your household member does not own a business, or if your or your household member’s business is not a controlled or dependent business, you may leave this question blank. Name of Controlled or Dependent Business Owing the Qualifying Debt Name and Address of Creditor (or Person to Whom Payments are Made) If the Debt Was First Incurred or Completely Discharged During This Reporting Period, Provide the Date (MM/DD/YYYY) and Check the Appropriate Box Date: Incurred Discharged Date: Incurred Discharged Date:
Financial%20Disclosure%20Statement%20'18.docx