Financial Disclosure Report Form

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OMB Control No. 3095-0058 Expiration date: 6/30/2009
FINANCIAL DISCLOSURE REPORT
Please Note: Section 1.3 of E.O. 12968 requires that employees complete this form as a condition of access to specific types of classified information as
determined by the head of an agency. Before completing this form, read the Privacy Act Statement, the sections on Sensitive Personal Data and Public
Reporting Burden and the Instructions. Type or print clearly in black or blue ink.
Sensitive Personal Data: After this form is completed, it will contain sensitive personal information, which is to be safeguarded pursuant to the Privacy Act, 5
U.S.C. 552a. This information is to be released only to authorized personnel having a need to know for official uses. The completed form should be stored in a
locked file cabinet or secured room. When the completed form is no longer needed it should be destroyed by burning or shredding.
Public Reporting Burden for collection of information is estimated to average two hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the reported information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Office of Management and Budget, Paperwork
Reduction Project, Washington, DC 20503.
SECTION 1: EMPLOYEE IDENTIFICATION
1a. Name (Last, First, Middle Initial)
1b. Date of Birth
1c. Social Security Number 1d. Reserved for Agency
(MM/DD/YYYY)
Use
1e. Home Address (Number, Street, Apt. #, City, State, Country, Zip Code)
1f. Marital Status
1g. Employee Status
1h. Assigned Office and Contact Telephone Number
1i. Company or Home Agency
SECTION 2: ANNUAL INCOME, U.S. AND FOREIGN
2a. Codes
2b. US/Foreign
2c. Annual Salary
2d. Non-Taxable
2e. Interest
2f. Dividend
2g. Gross Rental
2h. Other
2i. Total Annual
Indicator
& Wages
Income
Income
Income
Receipts
Income
Income
Totals
SECTION 3: BANK ACCOUNTS, U.S. AND FOREIGN
3a. Codes
3b. Institution
3c. US/Foreign
3d. Total # of
3e. Address
3f. Year-End Balance
Indicator
Accounts
SECTION 4: INVESTMENT ACCOUNTS, U.S. AND FOREIGN
4a. Codes
4b. Institution
4c. US/Foreign
4d. Total # of
4e. Address
4f. Amount Invested 4g.Year-End Fair
Indicator
Accounts
(Cost Basis)
Market Value
SECTION 5: OWNED REAL ESTATE, U.S. AND FOREIGN
5a. Codes
5b. Address
5c. US/Foreign
5d. Year of
5e. Purchase Price 5f. Capital
Indicator
Purchase
Improvement Costs
SECTION 6: OWNED VEHICLES, BOATS, AIRPLANES, OTHER
6a. Codes
6b. Type
6c. Make
6d. Model/Year
6e. Plate or ID
6f. Year
6g. Purchase
Number
Purchased
Price
SF 714 (5-05) Page 1 of 17
Authorized for local reproduction

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