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SFN 10172 (10-2015)
Page 2 of 4
Please Print
ITEM B
List the name of each business or trust that is NOT the principal source of income in which you and/or your spouse have a
financial interest.
[BUSINESS NAME OR TRUST NAME (list city and state where located)]
SELF
SPOUSE
X
X
EXAMPLE: Make Me A Lot of Money Investment Co. (Mutual Funds) Bismarck, ND
ITEM C
Place an "X" to
List below the associations or institutions with which you and/or your spouse are closely associated,
or serve as a director or officer, AND which may be affected by legislative action (for legislative
indicate the
interested party.
candidates), or action of the officeholder of the office to which you are a candidate or appointee.
ASSOCIATION OR INSTITUTION
CAPACITY
SELF
SPOUSE

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