Annual Statement Of Financial Disclosure: Request For Delayed Filing Of Information Effected By An I.r.s. Individual Income Tax Return Extension Form - New York

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LEGISLATIVE ETHICS COMMISSION
Office Location: Alfred E. Smith Building, Suite 1431
Mailing Address: Box 75, Legislative Office Building Albany, New York 12247
Telephone: (518) 432-7837/7838
Fax: 518-426-6850
ANNUAL STATEMENT OF FINANCIAL DISCLOSURE: REQUEST FOR DELAYED
FILING OF INFORMATION EFFECTED BY AN I.R.S. INDIVIDUAL INCOME TAX
RETURN EXTENSION
(See instructions on reverse side.)
1. Name ______________________________________________________________________
2. Legislative Office ____________________________ Position _______________________
3. Preferred Mailing Address _____________________________________________________
City __________________________________
State ____________
Zip ___________
4. Daytime Telephone (_______)___________________________________________________
5. You are required to attach your Annual Financial Disclosure Statement, reporting all
information on the statement which is not affected by the extension of your federal income
tax return.
6. Attach a copy of your timely filed "Application for Automatic Extension of Time to File U.S.
Individual Income Tax Return" (Form 4868).
7. Identify the questions on the Annual Financial Disclosure Statement which cannot be
completed until your income tax return is filed, and describe the financial interest for which this
request is made.
QUESTION #
FINANCIAL INTEREST
HELD BY
___________
________________________
___________
___________
________________________
___________
___________
________________________
___________
I realize that the filing of this form does not automatically extend the due date of the May 15
statement.
_____________________________________
_____________________
Signature
Date

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