Form A - Financial Disclosure Statement - 2016 (Page 9 of 12) in pdf

Form A - Financial Disclosure Statement - 2016 Page 9

SCHEDULE F – AGREEMENTS

Name:

Page______ of _______

Identify the date, parties to, and general terms of any agreement or arrangement that you have with respect to: future employment; a leave of absence during the period of government service;

continuation or deferral of payments by a former or current employer other than the U.S. government; or continuing participation in an employee welfare or benefit plan maintained by a former

employer.

Date

Parties to Agreement

Terms of Agreement

SCHEDULE G – GIFTS

Report the source (by name), a brief description, and the value of all gifts totaling more than $375 received by you, your spouse, or your dependent child from any source during the year. Exclude:

Gifts from relatives, gifts of personal hospitality from an individual, local meals, and gifts to a spouse or dependent child that are totally independent of his or her relationship to you. Gifts with a value

of $150 or less need not be added towards the $375 disclosure threshold. Note: The gift rule (House Rule 25, clause 5) prohibits acceptance of gifts except as specifically provided in the rule.

Source

Description

Value

Example:

Mr. Joseph Smith, Arlington, VA

Silver Platter (determination of personal friendship received from the Ethics Committee)

$400

Use additional sheets if more space is required.