(5 ILCS 420/4A-104) (from Ch. 127, par. 604A-104)
Sec. 4A-104. The statement of economic interests required by this Article to be filed with the county clerk shall be filled in by typewriting or hand printing, shall be verified, dated, and signed by the person making the statement and shall contain substantially the following: STATEMENT OF ECONOMIC INTERESTS (TYPE OR HAND PRINT) ..............................................................(Name).............................................................. (each office or position of employment for which this statement is filed) . (full mailing 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 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 Instrument of Position of Entity Ownership 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. .............................................................. ..............................................................
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 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 $1200 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." ................
..........................................(date
of
filing)
(signature
of
person
making
the
statement)
(Source: P.A. 95-173, eff. 1-1-08.)
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Last modified: February 18, 2015