Fillable Local Government Ethics Law Financial Disclosure Statement Form (Page 2 of 2) in pdf

Local Government Ethics Law Financial Disclosure Statement Form Page 2

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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

Section lI. Financial Information- continued

List the name and address of each source of gifts, reimbursements or prepaid expenses having an aggregate value exceeding $400 from any single

source, excluding relatives.

Name

Address

Self Spouse

Dependent Name

D. List the name and address of all business organizations in which an interest was held.

Name

Address

Self Spouse

Dependent Name

E. List the address and a brief description of all real property in the State of New Jersey in which an interest was held.

% of

Municipality

County

Block

Lot

Qual.

Self Spouse

Dependent Name

Address (if applicable)

Ownership

F. Please add any other information you believe is necessary to complete this form.

Section Ill. Certification

I hereby certify that this Financial Disclosure Statement contains no willful misstatement of fact or omission of material fact and, together with any and all

statements previously submitted in writing to the clerk of my local government or the Local Finance Board, constitutes a full disclosure with respect to all matters

required by N.J.S.A. 40A:9-22.1 et seq., to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, I am

subject to fines and possible disciplinary action.

__________________________

_____________________________________________________

Date

Signature of Local Government Officer

(Original Signature)

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