Personal Financial Disclosure Statement
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4Missouri Ethics Commission (MEC)
Office Use:
PO Box 1370, Jefferson City MO 65102, (800) 392‐8660,
Personal Financial Disclosure Statement
1.
Statement Information (select one)
Type: New Amended
2. (
Filing Status & Time Period Covered (select one & insert time period)
A. Filing Status
Annual Filer:
file from Jan 1 to Dec 31 of prior year (if no longer serving, enter the time period served), due by May 1
Newly Appointed/Employed:
file for calendar year before start date, due within 30 days
Incumbent Candidate:
file from Jan 1 of prior year to closing date for candidacy (may be longer than 12‐month period), due
within 14 days of closing date for candidacy
New Candidate:
file for the 12‐month period before the closing date for candidacy, due within 14 days of closing date for candidacy
B. Time Period Covered: From ____/____/_____ to ____/____/_____ (mm/dd/yyyy)
.
Filer’s Information
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_________________________________________
_________________________________________
Filer’s name (First, Middle, Last)
Spouse’s name (First, Middle, Last)
_________________________________________
_________________________________________
Mailing address
City/State/Zip
_________________________________________
_________________________________________
Dependent child(ren)’s name* (First, Middle, Last)
Dependent child(ren)’s name* (First, Middle, Last)
_________________________________________
_________________________________________
Political Subdivision or State Agency
Title (Position/Office Seeking)
Check if spouse is filing separate from yourself (if your spouse is not
required to file a PFD, this statement MUST disclose his/her information).
*Includes all children, stepchildren, foster children and wards under the age of eighteen residing in the person’s household and who receive in excess of 50% of their support from the person.
4.
Employment
List the name and address of every employer from whom you, your spouse or dependent child(ren) received income of $1,000
or more during the time period covered by this statement.
_____________________________
___________________________
_______________________
Employer Name
Employer Address/City/State/Zip
Person’s name who received income
_____________________________
___________________________
_______________________
Employer Name
Employer Address/City/State/Zip
Person’s name who received income
_____________________________
___________________________
_______________________
Employer Name
Employer Address/City/State/Zip
Person’s name who received income
_____________________________
___________________________
_______________________
Employer Name
Employer Address/City/State/Zip
Person’s name who received income
5.
Sole Proprietorships
List each sole proprietorship owned by you, your spouse or dependent child(ren) during the time period covered by this
statement.
________________________________________
_________________________________________
Sole Proprietorship Name
Sole Proprietorship Address/City/State/Zip
________________________________________
_________________________________________
Sole Proprietorship Name
Sole Proprietorship Address/City/State/Zip
General Partnerships, Joint Ventures
6.
List each general partnership and joint venture in which you, your spouse or dependent child(ren) were a partner or participant
during the time period covered by this statement, and the names of partners or co‐participants unless such names and addresses
are filed with the Secretary of State.
____________________ ________________ __________ ______________________ ___________
General Partnership or Joint Venture Name
Address/City/State/Zip
Nature of Business
Partner/Coparticipant’s Name & Address
Party Involved
____________________ ________________ __________ ______________________ ___________
General Partnership or Joint Venture Name
Address/City/State/Zip
Nature of Business
Partner/Coparticipant’s Name & Address
Party Involved
If additional space is needed, attach separate sheet.
Form must contain original signature, fax filings are not accepted.
MO 300‐0652 (08/2013)
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