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UNITEDSTATESSENATEFINANCIALDISCLOSUREREPORTFORANNUALANDTERMINATIONREPORTS
LastNameFirstNameandMiddleInitial
D
Amendment
I
KlobucharAmyJ.
SenateOfficeAddress(Number,Street,City,State,andZIPCode)
AnnualReport
SenateOffice/AgencyinWhichEmployed
UnitedStatesSenator/U.S.Senate
CalendarYearCoveredbyReport:
2011202-224-3244
SenateOfficeTelephoneNumber
(IncludeAreaCode)
302HartSenateOfficeBuildingWashington,D.C.20510
TerminationReport
PriorOffice/AgencyinWhichEmployed
AFTERREADINGTHEINSTRUCTIONS-ANSWEREACHOFTHESEQUESTIONSANDATTACHTHERELEVANTPART
IDidanyindividualororganizationmakeadonationtocharityinlieuofpayingyouforaspeech,appearance,orarticleinthereportingperiod?IfYes,CompleteandAttachPARTI.
TerminationDate(mm/dd/yy):
I
YES
I
Didyouoryourspousehaveearnedincome(e.g.,salariesorfees)ornon-iinvestmentincomeofmorethan$200fromanyreportablesourceinthereportingperiod?IfYes,CompleteandAttachPARTII.Didyou,yourspouse,ordependentchildholdanyreportableassetworthmorethan$1,000attheendoftheperiod,orreceiveunearnedorinvestmentincomeofmorethan$200inthereportingperiod?IfYes,Complete&AttachPARTIliAand/orIIIB.Didyou,yourspouse,ordependentchildpurchase,sell,orexchangeanyreportableassetworthmorethan$1,000inthereportingperiod?IfYes,CompleteandAttachPARTIV.Oldyou,yourspouse,ordependentchildreceiveanyreportablegiftinthereportingperiod(i.e.,aggregatingmorethan$350andnototherwiseexempt)?:fYes,CompleteandAttachPARTV.
YES
IfthisisyourFIRSTReport:Didyoureceivecompensationofmorethan$5,000fromasinglesourceinthetwoprioryears?IfYes,CompleteandAttachPARTX,
NO
Didyou,yourspouse,ordependentchildreceiveanyreportabletravelorreimbursementsfortravelinthereportingperiod(i.e.,worthmorethan$350fromonesource)?IfYes,CompleteandAttachPARTVI.Didyou,yourspouse,ordependentchildhaveanyreportableliability(morethan$10,000)duringthereportingperiod?IfYes,CompleteandAttachPARTVII.Didyouholdanyreportablepositionsonorbeforethedateoffilinginthecurrentcalendaryear?IfYes,CompleteandAttachPARTVIII.Doyouhaveanyreportableagreementorarrangementwithanoutsideentity?IfYes,CompleteandAttachPARTIX,
EachquestionmustbeansweredandtheappropriatePARTattachedforeach"YES"response.
,FilethisreportandanyamendmentswiththeSecretaryoftheSenate,OfficeofPublicRecords,Room232,HartSenateOfficeBuilding,U.S.Senate,Washington,DC20510.$200Penaltyforfilingmorethan30daysafterduedate.
FOROFFICIALUSEONLYDoNotWriteBelowthisLine
Date(Month,Day,Year)
ThisFinancialDisclosureStatementisrequiredbytheEthicsinGovernmentActof1978,asamended.ThestatementwillbemadeavailablebytheOfficeoftheSecretaryoftheSenatetoanyrequestingpersonuponwrittenapplicationandwillbereviewedbytheSelectCommitteeonEthics.Anyindividualwhoknowinglyandwillfullyfalsifies,orwhoknowinglyandwillfullyfailstofilethisreportmaybesubjecttocivilandcriminalsanctions.(See5USc.app.4,
§
104,and18U.S.C,
§
1001,)
SignatureofReportingIndividualertification
I
CERTIFYthatthestatements
I
havemadeonthisformandallattachedschedulesaretrue,completeandcorrecttothebest
of
myknowledgeandbelief~
ForOfficialUseOnly-DoNotWriteBelowThisLine
Date(Month,Day,Year)ignatureofReviewingOfficial
tistheopinionofthereviewerthatthestatementsmadeinthisformareincompliancewithTitle
I
oftheEthicsinGovernmentAct,
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PARTII.EARNEDANDNON-INVESTMENTINCOME
2
Reportthesource(nameandaddress),type,andamountofearnedincometoyoufromanysourceaggregating$200ormoreduringthereportingperiod.Foryourspouse,reportthesource(nameandaddress)andtypeofearnedincomewhichaggregate$1,000ormoreduringthereportingperiod.Noamountneedstobespecifiedforyourspouse.(Seep.3,CONTENTSOFREPORTSPartBofInstructions.)DonotreportincomefromemploymentbytheU.S.Governmentforyouoryourspouse.
IndividualsnotcoveredbytheHonorariaBan:
Foryouand
lor
yourspouse,reporthonorariaincomereceivedwhichaggregates$200ormorebyexactamount,givethedateof,anddescribetheactivity(speech,appearanceorarticle)generatingsuchhonorariapayment.DonotincludepaymentsinlieuofhonorariareportedonPart
I.
NameofIncomeSourceAddress(City,State)TypeofIncomeAmount
JPComputersWash.,DC
EXAMPLE
Salary$15,000
Example:
MCI(Spouse)Arlington,VA
EXAMPLE
SalaryOver$1,000
1
StateofMaryland(UniversityofBaltimore)(spouse)Baltimore,MDSalaryOver
$1,000
2
GeorgetownUniversity(spouse)Washington,DCSalaryOver
$1,000
3
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Amendment
eporting
Individual'sName
PageNumber
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PARTiliA.PUBLICLYTRADEDASSETSANDUNEARNEDINCOMESOURCES
3
BLOCKABLOCKBBLOCKC
IdentityofPubliclyTradedAssetsValuationofAssetsTypeandAmountofIncomeAndUnearnedIncomeSources
Atthecloseofreportingperiod.
Reportthecompletenameofeachpublicly
IfNone,orlessthan$1,001,Checkthefirstcolumn.
tradedassetheldbyyou,yourspouse,or
TypeofIncomeAmountofIncome
yourdependentchild,
(Seep.3,CONTENTSOFREPORTSPart
B
ofInstructions)
forproductionofincomeorinvestmentwhich:(1)hadavalueexceeding$1,000atthe
IActual
loseofthereportingperiod;and/or
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S,
IBMCorp.(stock)
XX
Example
X
Example
ExampleDC,orJ
(S)KeystoneFund
XX
Example
X
Example
1
(J)UnitedStatesSenateFederalCreditXXX
Union(savinos/checkmoaccounts)
2
(~C)(S)UnitedStatesSenateFederalXXXXCreditUnion(KidsClubaccountandCo)
3
(S)WellsFargo(checkingaccount)XXX
4
(J)TruStoneFinancial(IRAcertificatesXXXXandbankaccounts)
5
RydexSGIIntermediateBond-C(IRA)XXX
6
USBank(certificate)XXX
7
(S)VanguardSmCapGrowthIndxInstXXXI(MOSuppRetirementPlan-401(k))
8
(S)TIMCREF-CREFBondMarketXXXI(GWUSupplementalRetirementPlan)
9
(S)TIMCREF-T-CLifecycle2025-XXXPrm(MDUniv.Svs.RetirementPlan)
10
Waddell&ReedAdvisorsAssetStrategyXXXAliRABeneficiary)
EXEMPTIONTEST
(seeinstructionsbeforemarkingbox):
Ifyouomittedanyassetbecauseitmeetsthethree-parttestforexemptiondescribedintheinstructions,pleasecheckboxtotheright.
D
-
Thiscategoryappliesonlyiftheassetis/washeldindependentlybythespouseordependentchild.Iftheassetis/waseitherheldbythefilerorjointlyheld,usetheothercategoriesofvalue,asappropriate.
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