Fillable State Elected Officials Financial Disclosure (Page 4 of 4) in pdf

State Elected Officials Financial Disclosure Page 4

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II. Sources of Income

(Please use additional sheets as necessary.)

Employment

Name of Employer

Address of Employer

_________________________________

Business Interests - list the names and addresses of all business entities in which you have a

business interest (W.S. 9-13-108 (c) states: “Name and address of all business entities but

excluding interests if less than ten percent (10%) of the entity is owned, or sole proprietorship

from which income is earned. . . .”)

Name of Business Entity

Address of Business Entity

_________________________________

Investments

Income Earned

Any security or interest earnings

_____ Yes

_____ No

Real estate, leases, royalties

_____ Yes

_____ No

Other (describe generally):

___________________________________________________

___________________________________________________________________________

On this _______________ day of _____________________, ________, I affirm that the preceding

information is accurate.

__________________________________________

Signature

State Elected Officials Financial Disclosure Page 4

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