Tlc Base Financial Disclosure Statement Page 3
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4B. The personal interests of my immediate family are:
1. Real estate, address, or, if no address, location. …………………………………………………………………..
2. Name or principal business activity of each business in which stock, bond or equity interests is held ………….
…………………………………………………………………………………………………………………………
II. Offices, Directorships and Salaried Employments
The paid offices, paid directorships and salaried employments which I hold or which members of my immediate family
hold and the businesses from which I or members of my immediate family receive retirement benefits are as follows:
(You need not state any dollar amounts.)
A. My paid offices, paid directorships and salaried employments are:
………………………………………………………………………………………………………………………
Position held
Name of business
…………………………………………
……………………………………………….
…………………………………………
………………………………………………..
B. The paid offices, paid directorships and salaried employments of members my immediate family are:
………………………………………………………………………………………………………………………
Position held
Name of business
…………………………………………
……………………………………………….
…………………………………………
………………………………………………..
III. Businesses to Which Services Were Furnished
A. The businesses I have represented, excluding activity defined as lobbying in § 2.2-419, before any state
governmental agency, excluding any court or judge, for which I have received total compensation in excess of $1,000
during the preceding year, excluding compensation for other services to such businesses and representation consisting
solely of the filing of mandatory papers, are as follows:
Identify businesses by name and name the state governmental agencies before which you appeared on behalf of such
businesses.
Name of business
Name of governmental agency
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B. The businesses that, to my knowledge, have been represented, excluding activity defined as lobbying in § 2.2-419,
before any state governmental agency, excluding any court or judge, by persons with whom I have a close financial
association and who received total compensation in excess of $1,000 during the preceding year, excluding
compensation for other services to such businesses and representation consisting solely of the filing of mandatory
papers, are as follows:
Identify businesses by type and name the state governmental agencies before which such person appeared on behalf of
such businesses.
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