Financial Disclosure Form - City Of Chicago (Page 3 of 3) in pdf

SECURITIES

Identify any securities (stocks, bonds, CODs, etc.) sold to fund Expenses, Part 2

Name of Security

Buy Date

Sell Date

# of shares

Price

Ticker

Amount Invested

Total dollar amount drawn from the sale of securities:

GIFTS FROM INDIVIDUALS

Identify any gifts from individuals used to fund Expenses, Part 2

Name of Giver

Date of Gift

Source of Funds for Gift

% Investment

Amount

Total financing from gifts:

GIFTS/GRANTS FROM INSTITUTIONS

Identify any gifts and/or grants from institutions used to fund Expenses, Part 2

Institution

Address (Street, City, State)

Contact Name & Phone

Grant Date

Amount Gifted

Total money received from institutional gifts and/or grants:

OTHER FINANCING

Identify any other financing (credit cards, etc.) used to fund Expenses, Part 2

Description of Financing

Amount Financed

Total money drawn from other financing:

FINANCING TOTALS

Sub-total all funds (sections a-h) used to fund Parts 2

Business Accounts

Gifts from Individuals

Personal Accounts

Gifts/Grants from Institutions

Loans from Financial Institutions

Other Financing

TOTAL BUSINESS FINANCING (a-h)*

Loans from Individuals

Securities

* should be equal to or greater than total amount of expenses listed in part 2

PART 4

ACKNOWLEDGEMENT

REVIEW THE FOLLOWING STATEMENT AND SIGN YOUR ACKNOWLEDGEMENT BELOW

I hereby certify, under penalty of perjury, that I am authorized to execute this form and that all information I have provided on this form is complete, true,

and, correct. I certify that I understand that all information provided on this Financial Disclosure Form will be corroborated. The City of Chicago reserves the

right to request any and all documentation it determines necessary to perform this verification. I and/or my Applicant will have three business days to meet

such requests, and failure to do so may result in a disapproved or suspended license application. I understand and accept that any falsification or purposely

holding back of this information is grounds for recalling the license(s) issued.

__________________________________________________________

_______________

Signature of Applicant

Date

Subscribed and sworn to before me this ___________Day of ____________________20____

______________________________________________________________________________

Notary Public in and for said County and State

(PLACE SEAL HERE)

Department of Business Affairs and Consumer Protection: Business Assistance Center

ITY OF

HICAGO