Sample Annual Statement of Financial Disclosure Form

ANNUAL STATEMENT OF FINANCIAL DISCLOSURE FORM

__________ FIRE DISTRICT, COUNTY OF __________

FOR 20__

1. Name and Address:

______________________________________________________________________

Last Name Middle Initial First Name

______________________________________________________________________

Residence Address Telephone No.

______________________________________________________________________

Title or Position

______________________________________________________________________

Fire District Town

2. Family:

   Provide the name of your spouse (if married) and the names of any dependent children.

   _______________________________ _________________________

   Spouse Child/Age

   _______________________________ _________________________

   Child/Age Child/Age

   _______________________________ _________________________

   Child/Age Child/Age

   Note: For questions 3 to 6, do not report exact dollar amounts. Instead, report categories of amounts, using the following:

   Category A: under $5,000 Category D: $25,001 to $50,000

   Category B: $5,001 to $10,000 Category E: $50,001 to $100,000

   Category C: $10,001 to $25,000 Category F: Over $100,000

   THE CATEGORIES OF AMOUNTS ON AN OFFICIAL’S DISCLOSURE STATEMENT MAY NOT BE REVEALED TO THE PUBLIC OR TO ANY OTHER OFFICIAL, EXCEPT TO THE MEMBERS AND STAFF OF THE FIRE DISTRICT’S ETHICS BOARD.

3. Financial Interests:

   1. Business Positions. List any office, trusteeship, directorship, partnership, or other position in any business, association, proprietary, or not-for-profit organization held by you and your spouse and dependent children, if any, and indicate whether these businesses are involved with the _________ Fire District in any manner.

      Name of

      Family Member Position Organization Nature of Involvement

      _______________ ___________ __________ _________________

      _______________ ___________ __________ _________________

      _______________ ___________ __________ _________________

      _______________ ___________ __________ _________________

   2. Outside Employment. Describe any outside occupation, employment, trade, business, or profession providing more than $1,000/year for you and your spouse and dependent children, if any, and indicate whether such activities are regulated by the ____________ Fire District.

      Name, Address,

      Name of Description of

      Family Member Position Organization Activity Regulated

      _______________ ___________ __________ _________________

      _______________ ___________ __________...