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    Statement of Financial Interests

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    First Name
    Middle Initial
    Last Name
    Suffix

    Address Type
    Address 1
    Address 2
    City
    State
    Zipcode

    Telephone

    Filing Year

    Did you have any interest in real estate involved in transactions with the Commonwealth, its agencies, or political subdivisions?

    Did you have any creditors to whom you owed more than $6,500? Note: Do not include mortgages on your first or second property.

    Do you have additional sources of income of $1,300 or more that you have not already disclosed?

    Did you receive gifts of $250 or more from a single source?

    Did you receive transportation, lodging, or hospitality exceeding $650 from a single source?

    Did you hold any office, directorship, or employment in a business? Note: A non-profit organization or entity is considered a business. You must also disclose any office, directorship or employment that you hold in a non-profit organization or entity.

    Did you have any financial interests in a for-profit business entity?

    Did you transfer any business interests to an immediate family member?

    I hereby affirm that the foregoing information is true and correct to the best of my knowledge, information, and belief. This affirmation is being made subject to the penalties set forth in 18 Pa. C.S § 4904 (unsworn falsification to authorities) and the Public Official and Employee Ethics Act, 65 Pa.C.S § 1109(b). I confirm that I have read and understand the above statement.
    Full Name
    Submitted Date