Form Rsa 15-A - New Hampshire Statement Of Financial Interests - 2018

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2018 NEW HAMPSHIRE STATEMENT OF FINANCIAL INTERESTS - RSA 15-A

Type or Print Clearly

Full Name

Work Address

Primary Occupation

e-mail*optional

Work Phone

Name the office, position, board or commission, board of

directors, etc. or employment with state or county

government held by you.

NO ACRONYMS

A. List below the name, address, and type of any profession, business, or other organization in which you or a family member was an officer, director, associate, partner,

proprietor, or employee, or served in any other professional or advisory capacity, and from which any income in excess of $10,000 was derived during the preceding

calendar year. Sources of retirement benefits other than federal retirement and/or disability benefits shall be included. ( Use additional sheets as necessary.)

If you have no qualifying income indicate by writing your initials next to the following statement.

My income does not qualify

B. Indicate below whether you or a family member has a special interest in any of the following businesses, professions, occupations, groups, or matters. A person has a

reportable special interest in an item on this list if a change in law, a change in administrative rule, a decision whether or not to award a contract, grant a license or permit,

discipline a licensee or permittee, or other decision by government affecting the listed business, profession, occupation, group, or matter would potentially have a greater

financial effect on you or a family member than it would on the general public:

1. Any profession, occupation, or business licensed or certified by the State of New Hampshire. List each such

profession, occupation, or category of business:

6. State of New Hampshire, county, or

Real Estate, including brokers,

Banking or financial

Health Care

3. Insurance

municipal employment

agent, developers, and landlords

services

Retirement