You are on page 1of 12
ecco sure in sateen ray Spofey gg Soy FMEA. suogsonb kee aaey nos 31 9¢59-522-207 W 204 an enonppe stn appr oy papuonzn 24 yates fe ey amon oi ued lous eg go A2eeo0g Sa on) 007305 Buy amsojmi roman sci Au Sun Aouy eo 2562. 3 Prom par Z9'¢ ‘Ajpueuaapeut :S00H a|quuoUEHY wad SIS0¢ 9 “worBuyse YOUGED OUL SIH 51910 aM Jo99IHFO seup “Tuam ojgesou0y ox, 9002 ‘91 OW HAND DELIVERED ees S1SOT DEE “HorbuntowraR saqunyuasandayg yo asnogy SEIS VID ahh Jo ssaahuoy UNITED STATES HOUSE OF REPRESENTATIVES oun rua oscLosie stareurn ron casnoan eanans | Teerinettnaeane| HAND DELIVERED UNT ee a AR * gognay 12. pm ses Crearor Exon Ea Oe Dente INFORMATION — ANSWER EACH OF THESE QUESTIONS ‘A $200 penalty shall We assessed ‘against anyone who 30 days late. T Ona or ake ee eae ap ma Snape Ee SET peeemermemey eamensemeaan” vel vol] MT OTN vel) nol ne Ba (| pee -O LBaymedesmesameesimneaee vain mums speeaanipaaeay See Som epSeet SEE” nol ]| SCN SAAN TS ver ‘yes, complete and attach Schedute i, | lies, Scmpets and wach Schedule Vit _ * dy er gen Da Femblealicamertateatwaeedatcpon YL vol] | ieee Mattie festaelee conta Z oO cob i Sash ee ott ya ats eae ieee vol oO EES oe =O “Ed spo. o cependencicihve ay rporiste x Each question in this part must be answered and the tyes! compat and eta Sonwaue Yes[}4 ol] _ appropriate schedule attached for each "Yes" response. EXCLUSION OF SPOUSE, DEPENDENT, OR TRUST INFORMATION — ANSWER EACH OF THESE QUESTIONS Waist eau anealacaraeesaaaoesoeeoeets vO «Bl Ee rycen eee ne ene nor een a domme wal no] CERTIFICATION — THIS DOCUMENT MUST BE SIGNED BY THE REPORTING INDIVIDUAL AND DATED "This Financial Dislosur Staton is required bythe Ethics in Government Act of 1978, ab amended. The Statement wil be avaiable o any requesting person upon writen application and vl be reviened by the Commitee on Standart of Oficial Conductor Hs designee. Ary mcivisa who knowingly and wily aie, ‘or ho knowingly and willy falls to fo this report may be subject o cl penaies and erminal sanctions (Soe 5 US.C. app. 4, §104 ena 18 USC. § 1001), aor a a Ra Sere TT St nae ea Sein Spee eel Mga H.200% SCHEDULE | — EARNED INCOME. Lstthe soute, type, and amount of earmed income from any sourc (other than the flere current employment by the U.S. Government totaling $200 or ‘more during he preceding calendar year, Fora spouse, st fhe source and amount of any honoraria list only the source for ater spouse earned income exceeding $1,000, LALTRIA Convoneng. Seeicer (Kener tos) |Spowe saraey | NA: For payments to charity In leu of honoraria, use Schedule