Form A - Financial Disclosure Statement - 2016 (Page 3 of 12) in pdf

Page 1 of ___

Form A

UNITED STATES HOUSE OF REPRESENTATIVES

For Use by Members, Officers, and Employees

2016 FINANCIAL DISCLOSURE STATEMENT

(Office Use Only)

Name:____________________________________ Daytime Telephone:___________________

A $200 penalty shall be assessed against any

individual who files more than 30 days late.

Officer or

Employing Office:

Staff Filer Type: (If Applicable)

Member of the U.S.

State: _________________

FILER

Employee

__________________________ Shared

Principal Assistant

House of Representatives

District: _______________

STATUS

REPORT

2016 Annual (Due: May 15, 2017)

Amendment

Termination

TYPE

Date of Termination: _________________________________

PRELIMINARY INFORMATION – ANSWER EACH OF THESE QUESTIONS

A. Did you, your spouse, or your dependent child:

a. Own any reportable asset that was worth more than $1,000 at the

F. Did you have any reportable agreement or arrangement with an

Yes

end of the reporting period? or

outside entity during the reporting period or in the current calendar

b. Receive more than $200 in unearned income from any reportable

year up through the date of filing?

asset during the reporting period?

B. Did you, your spouse, or your dependent child purchase, sell, or

G. Did you, your spouse, or your dependent child receive any

exchange any securities or reportable real estate in a transaction

Yes

reportable gift(s) totaling more than $375 in value from a single

exceeding $1,000 during the reporting period?

source during the reporting period?

C. Did you or your spouse have “earned” income (e.g., salaries,

H. Did you, your spouse, or your dependent child receive any

honoraria, or pension/IRA distributions) of $200 or more during the

Yes

reportable travel or reimbursements for travel totaling more than

reporting period?

$375 in value from a single source during the reporting period?

I. Did any individual or organization make a donation to charity in

D. Did you, your spouse, or your dependent child have any reportable

Yes

lieu of paying you for a speech, appearance, or article during the

liability (more than $10,000) at any point during the reporting period?

reporting period?

E. Did you hold any reportable positions during the reporting period or

Yes

ATTACH THE CORRESPONDING SCHEDULE IF YOU ANSWER “YES”

in the current calendar year up through the date of filing?

IPO AND EXCLUSION OF SPOUSE, DEPENDENT, OR TRUST INFORMATION - ANSWER EACH OF THESE QUESTIONS

IPO – Did you purchase any shares that were allocated as a part of an Initial Public Offering during the reporting period? If you answered “yes” to this question, please

Yes

contact the Committee on Ethics for further guidance.

TRUSTS – Details regarding “Qualified Blind Trusts” approved by the Committee on Ethics and certain other “excepted trusts” need not be disclosed. Have you excluded

Yes

from this report details of such a trust that benefits you, your spouse, or dependent child?

EXEMPTION – Have you excluded from this report any other assets, “unearned” income, transactions, or liabilities of a spouse or your dependent child because they meet

Yes

all three tests for exemption? Do not answer “yes” unless you have first consulted with the Committee on Ethics.