A financial disclosure report must be in the following form:

    Basic Identifying Information

    1. Full name:_________________________________________________

    2. Mailing address:___________________________________________

    3. Telephone number:_____________________________________

    4. Email address:_____________________________________________

    5. Are you filing as a public officer or a candidate?__________

    (If you were both a public officer and a candidate during the reporting period, file as a public officer.)

    Spousal Information

    6. Were you married during the reporting period?

    (yes/no) ________________

    7. Spouse's name:_____________________________________________

    8. Was your spouse a registered lobbyist in the State of Michigan during the reporting period?

    _________________________

    9. For any employer that paid your spouse more than $1,000 in annual income during the reporting period, list the name of the employer(s) and the occupation(s) held:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Employment & Income

    10. List the name and address of each employer that paid you more than $1,000 and the positions held in the reporting period:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    11. Did you receive unearned income over $200 in the reporting period (e.g., financial prize, unemployment benefits, annuities, stock dividends, deferred compensation, pension, profit sharing, retirement income)? If yes, list the sources of unearned income, including the origins and addresses of the sources of unearned income:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Organizational Roles

    12. List all positions you held in any organization, corporation, firm, partnership, or other business enterprise, nonprofit organization, labor organization, or educational or other institution other than this state during the reporting period (e.g., officer, director, trustee, partner, proprietor, representative, employee, or consultant). If applicable, for each, please provide the name of the organization and the position held:

    (You do not need to include positions in any: religious, social, fraternal, or political entity, or any position solely honorary in nature.)

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Assets

    13. List any real property in which you held an ownership interest during the reporting period:

    (Include only real property valued over $1,000; you may choose to exclude the street number, if applicable.)

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    14. List any securities or investments (stocks, bonds, mutual funds, etc.) you held or held jointly with your spouse with a fair market value over $1,000 during the reporting period, including the origins and addresses of the securities or investments:

    (You are not required to disclose a stock within a widely held investment fund if neither you nor your spouse exercise control over the financial interests held by the fund and the fund is publicly traded or the assets of the fund are widely diversified.)

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    15. List any other assets, other than business assets, held for the production of income, or for investment purposes, exceeding $1,000 in value that you owned during the reporting period:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    16. Do you hold a beneficial interest in any blind trusts? (yes/no)

    ________________________

    Liabilities

    17. List any liabilities over $10,000 you (solely or jointly) owed at any point during the reporting period (e.g., mortgages, loans, credit lines):

    (You may exclude: any unsecured debt from a financial institution or the federal government, any revolving debt, or a business debt.)

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Employment Agreements

    18. List any agreements or arrangements made or in effect during the reporting period with respect to the following:

    (a) Any future employment that would commence after you leave office.

    (b) A leave of absence from any former or current employer taken while serving as a public officer.

    (c) A continuation or deferral of payments by a former or current employer other than this state to you, or your continuing participation in an employee welfare or benefit plan maintained by a former employer.

    (If a public officer is not reelected or is not seeking reelection to public office, MCL 15.708 requires the public officer to disclose any future employment agreement within 10 days of entering into the agreement.)

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Lobbyist Interactions

    19. Did you receive any gift required to be reported by a lobbyist or lobbyist agent during the reporting period? If yes, please list the lobbyist's name and the gift received:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    20. Did you receive any payments for travel required to be reported by a lobbyist or lobbyist agent during the reporting period? If yes, please list the lobbyist's name and the travel payment received:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    21. Did you receive any payments to a charity in lieu of honoraria required to be reported by a lobbyist or lobbyist agent during the reporting period? If yes, please list the lobbyist's name and the payment to charity received:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    State Contracts

    22. Do you or your spouse hold a majority financial interest in any current or prospective contracts with the State of Michigan? If yes, provide the name of the company and a description of all contracts:

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Additional disclosures

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    Certification

    "I certify that the statements I have made on this financial disclosure form are true, complete, and correct to the best of my knowledge and belief, and that I have not moved assets during the reporting period for purpose of avoiding disclosure under the public officers financial disclosure act."

    Signed: ______________________________________________________