Financial Disclosure Report Form Page 3

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Name (Last, First, Middle Initial)
Social Security Number
ADDITIONAL ENTRIES
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
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
SECTION 7: REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S. AND FOREIGN
7a. Codes
7b. Address
7c. US/Foreign
7d. Year of Lease/Rental
7e. Monthly Lease/Rental
Indicator
Payment
SF 714 (5-05) Page 3 of 17

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