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Part
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Report Information for the Following Period…
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Report Information for the Following Individuals…
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1. Filer’s Positions Held Outside United States Government
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Preceding Two Calendar Years to Filing Date
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You
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2. Filer’s Employment Assets & Income and Retirement Accounts
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Preceding Calendar Year to Filing Date*
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You
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3. Filer’s Employment Agreements and Arrangements
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As of Filing Date
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You
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4. Filer’s Sources of Compensation Exceeding $5,000 in a Year
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Preceding Two Calendar Years to Filing Date
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You
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5. Spouse’s Employment Assets & Income and Retirement Accounts
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Preceding Calendar Year to Filing Date*
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Your Spouse
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6. Other Assets and Income
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Preceding Calendar Year to Filing Date*
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You, Your Spouse, and Dependent Children
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7. Transactions
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N/A – Leave this Part blank
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N/A – Leave this Part blank
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8. Liabilities
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Preceding Calendar Year to Filing Date*
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You, Your Spouse, and Dependent Children
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9. Gifts and Travel Reimbursements
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N/A – Leave this Part blank
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N/A – Leave this Part blank
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