Form A - Financial Disclosure Statement - 2016 (Page 4 of 12) in pdf

SCHEDULE A – ASSETS & “UNEARNED INCOME”

Name:

Page______ of _______

BLOCK A

BLOCK B

BLOCK C

BLOCK D

BLOCK E

Assets and/or Income Sources

Value of Asset

Type of Income

Amount of Income

Transaction

Identify (a) each asset held for investment or

Indicate value of asset at close of the reporting period. If you use a

Check all columns that apply.

For accounts that

For assets for which you checked “Tax-Deferred” in Block C, you

Indicate if the

production of income and with a fair market value

valuation method other than fair market value, please specify the method

generate tax-deferred income (such as 401(k), IRA, or

may check the “None” column. For all other assets indicate the

asset had

exceeding $1,000 at the end of the reporting period,

used.

529 accounts), you may check the “Tax-Deferred”

category of income by checking the appropriate box below.

purchases (P),

and (b) any other reportable asset or source of income

column. Dividends, interest, and capital gains, even

Dividends, interest, and capital gains, even if reinvested,

sales (S), or

If an asset was sold during the reporting period and is included only

that generated more than $200 in “unearned” income

if reinvested, must be disclosed as income for

must be disclosed as income for assets held in taxable

exchanges (E)

because it generated income, the value should be “None.”

assets held in taxable accounts. Check “None” if the

accounts. Check “None” if no income was earned or generated.

during the year.

exceeding $1,000

*Column M is for assets held by your spouse or dependent child in which

asset generated no income during the reporting period.

in the reporting

you have no interest.

Provide complete names of stocks and mutual funds

*Column XII is for assets held by your spouse or dependent child

period.

(do not use only ticker symbols).

in which you have no interest.

If only a portion of

an asset was sold,

For all IRAs and other retirement plans (such as

please indicate as

401(k) plans) provide the value for each asset held in

follows: (S (part)).

the account that exceeds the reporting thresholds.

III

VII

VIII

XII

Leave this column

For bank and other cash accounts, total the amount in

blank if there are

all interest-bearing accounts. If the total is over $5,000,

no transactions

list every financial institution where there is more than

that exceeded

$1,000 in interest-bearing accounts.

$1,000.

For rental and other real property held for investment,

provide a complete address or description, e.g., “rental

property,” and a city and state.

For an ownership interest in a privately-held business

that is not publicly traded, state the name of the

business, the nature of its activities, and its geographic

location in Block A.

Exclude: Your personal residence, including second

homes and vacation homes (unless there was rental

income during the reporting period); and any financial

interest in, or income derived from, a federal

retirement program, including the Thrift Savings Plan.

If you have a privately-traded fund that is an Excepted

Investment Fund, please check the “EIF” box.

If you so choose, you may indicate that an asset or

income source is that of your spouse (SP) or

dependent child (DC), or jointly held with anyone (JT),

in the optional column on the far left.

For a detailed discussion of Schedule A requirements,

please refer to the instruction booklet.

P, S, S(part), or E

SP,

EIF

S(part)

DC,

Mega Corp. Stock

Royalties

Simon & Schuster

Indefinite

Examples:

Partnership

ABC Hedge Fund

Income

Use additional sheets if more space is required.

Form A - Financial Disclosure Statement - 2016 Page 4

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