(for DLGS use only)
Last Name: ______________________________ First Name: ____________________________ Middle:_________
Municode:________________
State of New Jersey
Division of Local Government Services
Local Government Ethics Law
Department of Community Affairs
Local Finance Board
Financial Disclosure Statement
This Financial Disclosure Statement is required annually of all local government officers
Year of Service: ________
in accordance with N.J.S.A. 40A:9-22.1 et seq., the Local Government Ethics Law.
(Please Type or Print)
Section I. Personal Information- Local Government Officer
Local Government Served
Municipality:
____________________________________ County:____________________________________ Other:___________________________
First Name:
______________________________________ Middle:_________________ Last Name:________________________________________
*Spouse’s
First Name:
______________________________________ Middle:_________________ Last Name:________________________________________
Home Address: _____________________________________________
Telephone Numbers (optional)
(optional)
_____________________________________________
Home:
______________________
_____________________________________________
Business:
______________________
* Spouse includes a Civil Union partner.
Agency
Position Held
Term Expires (if applicable)
1. _________________________________________
________________________________________
________________
2. _________________________________________
________________________________________
________________
3. _________________________________________
________________________________________
________________
Section II. Financial Information
Provide the following information for yourself and members of your immediate family for the prior calendar year. If none, please indicate
NONE in the space provided. If additional space is needed, please use Extension Forms.
A.
List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the
source of income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization.
Name
Address
Self Spouse
Dependent Name
1.
2.
3.
4.
5.
B.
List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for
personal appearances, speeches, or writing.
Name
Address
Self Spouse
Dependent Name
1.
2.
3.
4.
5.
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