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Your Name Was Submitted for Filing by an Entity that You Represent STATEMENT OF ECONOMIC INTERESTS TO BE FILED WITH THE COUNTY CLERK (Type or Hand Print) Name Each office or position of employment for which this statement is filed Full post office address to which notification of an examination of this statement should be sent HOME ADDRESS: GENERAL DIRECTIONS The interest (if constructively controlled by the person making the statement) of a spouse or any other party, shall be considered to be the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If additional space is needed, please attach supplemental listing. 1. List the name and instrument of ownership in any entity doing business with a unit of local government in relation to which the person is required to file, in which the ownership interest held by the person at the date of filing is in excess of $5,000 fair market value or from which dividends in excess of $1,200 were received during the preceding calendar year. (In the case of real estate, location thereof shall be listed by the street address, or if none, then by legal description.) No time or demand deposit in a financial institution, nor any debt instrument shall be listed. Business Entity Instrument of Ownership Position of Management 2. List the name, address and type of practice of any professional organization in which the person making the statement was an officer, director, associate, partner or proprietor or served in any advisory capacity, from which income in excess of $1,200 was derived during the preceding calendar year. Name Address Type of Practice 3. List the nature of professional services rendered (other than to the unit or units of local government in relation to which the person is required to file) to each entity from which income exceeding $5,000 was received for professional services rendered during the preceding calendar year by the person making the statement. Please check one of the following: Candidate OR Annual Filing ---PAGE BREAK--- 4. List the identity (including the address or legal description of real estate) of any capital asset from which a capital gain of $5,000 or more was realized during the preceding calendar year. 5. List the name of any entity and the nature of the governmental action requested by any entity which has applied to a unit of local government in relation to which the person must file for any license, franchise or permit for annexation, zoning of rezoning of real estate during the preceding calendar year if the ownership interest of the person filing is in excess of $5,000 fair market value at the time of filing or if income or dividends in excess of $1,200 were received by the person filing from the entity during the preceding calendar year. 6. List the name of any entity doing business with a unit of local government in relation to which the person is required to file from which income in excess of $1,200 was derived during the preceding calendar year other than for professional services and the title or description of any position held in that entity. No time or demand deposit in a financial institution nor any debt instrument need be listed. 7. List the name of any unit of government which employed the person making the statement during the preceding calendar year other than the unit or units of government in relation to which the person is required to file. 8. List the name of any entity from which a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in excess of $500, was received during the preceding calendar year. VERIFICATION “I declare that this statement of economic interests (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a fine not to exceed $1,000 or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment.” (signature of person making the statement) (date) 5. List the name of any entity and the nature of the governmental action requested by any entity which has applied to a unit of local government in relation to which the person must file for any license, franchise or permit for annexation, zoning or rezoning of real estate during the preceding calendar year if the ownership interest of the person filing is in excess of $5,000 fair market value at the time of filing or if income or dividends in excess of $1,200 were received by the person filing from the entity during the preceding calendar year. “I declare that this Statement of Economic Interests (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a fine not to exceed $1,000 or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment.” (Signature of Person Making the Statement) (Date) SIGN ---PAGE BREAK--- This will be returned to you when statement is filed in the office of the County Clerk . (COMPLETE BUT DO NOT DETACH) Receipt is hereby acknowledged of your Statement of Economic Interests, filed pursuant to the Illinois Governmental Ethics Act. The Statement was filed as of this date. (office or position of employment for which this statement is filed) TYPE OR HAND PRINT Name Address City State Zip Code All 3 pages must be returned to the Kane County Clerk for filing either in person or by mail. We will return this receipt to you. LOCATION: 719 S. Batavia Ave., Bldg. B Geneva MAILING ADDRESS: Kane County Clerk 719 S. Batavia Ave., Bldg. B Geneva, Illinois 60134 All three pages must be returned to the McLean County Clerk for filing either in person or by mail. We will return this receipt to you. LOCATION: 115 E Washington Street, Room 102, Bloomington, IL 61701 Kathy Michael, McLean County Clerk PO Box 2400 Bloomington, IL 61702-2400 (Office or Position of Employment for which this Statement is Filed) Complete and return to County Clerk's Office with Form . IL Return to County Clerk's Office with Form