Tlc Base Financial Disclosure Statement Page 4
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Type of business
Name of state governmental agency
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C. All other businesses listed below that operate in Virginia to which services were furnished pursuant to an agreement
between you and such businesses and for which total compensation in excess of $1000 was received during the
preceding year:
Check each category of business to which services were furnished.
Electronic utilities
Banks
Retail companies
Beer, wine or liquor
Gas utilities
Savings institutions
companies or distributors
Telephone utilities
Loan or finance companies
Trade associations
Manufacturing companies
Water utilities
Professional associations
(state type of product, e.g.,
textile, furnitures, etc.)
Associations of public
Cable television companies
Mining companies
employees or officials
Intrastate transportation
Life insurance companies
Counties, cities or towns
companies
Interstate transportation
Casualty insurance
Labor organizations
companies
companies
Oil or gas retail companies
Other insurance companies
IV. COMPENSATION FOR EXPENSES
The persons, associations, or other sources other than my governmental agency from which I or a member of my
immediate family received remuneration in excess of $200 during the preceding year, in cash or otherwise, as
honorariums or payment of expenses in connection with my attendance at any meeting or other function to which I was
invited in my official capacity are as follows:
Description
Amount of remuneration
Name of Source
of occasion
for each occasion
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B. The provisions of Part III A and B of the disclosure form prescribed by this section shall not be applicable to
officers and employees of local governmental and local advisory agencies.
C. Except for real estate located within the county, city or town in which the officer or employee serves or a county,
city or town contiguous to the county, city or town in which the officer or employee serves, officers and employees of
local governmental or advisory agencies shall not be required to disclose under Part I of the form any other interests in
real estate.
I swear or affirm that the foregoing information is full, true and correct to the best of my
knowledge.
Signature ______________________________________________ Date __________________
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