Statement of Disclosure of Interests State and Local Office Holders, Candidates and Appointees to such Positions, Non-General Assembly Members **This form must be with the TBR General Counsel by Senior Staff; all others, file as appropriate with Institution Please see the attached instructions before completing this form. Attach additional pages as necessary. Note that this disclosure statement must be signed and the signature attested to by a witness in item 12. Please Print or Type 1. Staff Member Nam: 2. Number Work: Home: 3. Home Address 4. Senior Staff ________ Other ____________________________________________________________________________ 5. Sources of Income List major source(s) of private (non-governmental) income of more than $1,000 for yourself, your spouse or minor child residing with you. sources of private income” include, but are not limited to: offices, directorships and salaried “Major employments. No dollar amounts need to be stated. Select as many recipients as necessary. NONE Name of Source Recipients Spouse Minor Child Filer Spouse Minor Child Filer Spouse Minor Child 6. Investments List any investment by you, your spouse or child residing with you in any corporation or other – business organization in excess of ten thousand dollars ($10,000) or five percent (5%) of the total capital. The name of the corporation or organization must be listed but no dollar amounts or percentages of the investment need be stated. NONE Name of Corporation or Organization Held By Filer Spouse Minor Child Filer Spouse Minor Child Filer Spouse Minor Child
Statement of Disclosure of Interests State and Local Office Holders, Candidates and Appointees to such Positions, Non-General Assembly Members **This form must be with the TBR General Counsel by Senior Staff; all others, file as appropriate with Institution Please see the attached instructions before completing this form. Attach additional pages as necessary. Note that this disclosure statement must be signed and the signature attested to by a witness in item 12. Please Print or Type 1. Staff Member Nam: 2. Number Work: Home: 3. Home Address 4. Senior Staff ________ Other ____________________________________________________________________________ 5. Sources of Income List major source(s) of private (non-governmental) income of more than $1,000 for yourself, your spouse or minor child residing with you. “Major sources of private income” include, but are not limited to: offices, directorships and salaried employments. No dollar amounts need to be stated. Select as many recipients as necessary. NONE Name of Source Recipients Spouse Minor Child Filer Spouse Minor Child Filer Spouse Minor Child 6. Investments – List any investment by you, your spouse or child residing with you in any corporation or other business organization in excess of ten thousand dollars ($10,000) or five percent (5%) of the total capital. The name of the corporation or organization must be listed but no dollar amounts or percentages of the investment need be stated. NONE Name of Corporation or Organization Held By Filer Spouse Minor Child Filer Spouse Minor Child Filer Spouse Minor Child
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