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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

    Do you have any reportable real estate interests to report (i.e., real estate transactions involving the Commonwealth, its agencies, or any political subdivisions)?

    Do you have any creditors to whom you owed more than $6,500 at any point during the calendar year? (you do not need to list mortgage debt for a first or second property)

    Do you have any sources of income from which you received $1,300 or more?

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

    Did you receive any transportation, lodging, or hospitality (such as meals or tickets to events) in connection with your public position exceeding $650 from a single source?

    Did you hold any office, directorship, or employment in any business or non-profitable organization for the calendar year for which you are reporting?

    Do you have reportable financial interest in any legal entity in business for profit?

    Did you transfer any business interests to an immediate family memeber during the calendar year which you are reporting?

    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