Form A - Financial Disclosure Statement - 2016 Page 5

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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
A
B
C
D
E
F
G
H
I
J
K
L
M
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
P, S, S(part), or E
SP,
EIF
DC,
ASSET NAME
JT
Use additional sheets if more space is required.

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