N00007248_2002 by chrstphr

VIEWS: 64 PAGES: 9

									   Fiier
  star{as                             U,S
                        House of Representatives    State:
                                                    District:          _ }                   El      Officer
                                                                                                          o_
                                                                                                     Em@oyee           Employing       office:
                                                                                                                        ............................                               A $200 pena#y shah be assessed
                ,                                               "....................                                                                                              against anyonewho flies morethan
  Repo_t                                                   i                                                                                Termination Date;
   Type                         (May 15)                                Amendment                                                                                                    30
                                                                                                                                l%rmination .............................................. days   iste_


PRELIMINARYINFORMATION_ ANSWER BACH OF THESEQUESTIONS
                                                                                Yes
                                                                                                                   # yes, complete and attach Schedule Vt,

II. Did any individuat or organization make a donation to charity in                                               VII. Did )you 'your spouse or a dependent child receive any

            retied?
            [ng you for a speech_ appearance_ or artie,e in the                 YesE3             No               pddod (worth more than $285 from for source)?
                                                                                                                   _eoo_ab,e trave, or reimbursements one trave, in the report,ng                            Yes Eli
              _ete and attach 8chedute IL                                                                          If          stets a_d attach Schedule V&
IlL Did you. your spouse or a dependent child receive 'kmeamed"                                                    VHI. Did you hold any reportable positions on or before the
           '                                                                                                       date of fiting in the currant calendar 'year?
                                                                                                                                                                                                                            ,o[;]


V_ Did you. your spouse, or a dependent child have any reportable                                    _                  Bach question in this part must be answered and the
_fyes, {more than $10_000) Schedule V,
liability 6omplete and attach during the repo_{ng period?                                         He _                 appropriate schedule attached for each "Yes" response°

                            OR               _
EXCLUSIONOF SPOUSE,DEPENDEN% TRUST#,aFORMATtON ANSWER EACHOF THESEQUESTIONS

                                                                                                                                                                                                              YesE3 .o@
                                                                                                                                                                                                                            No

CERTiFICATiON               _ THIS DOCUMENT                          MUST BE SIGNED                           BY THE REPORTING                                [NOIVIDUAL                  AND DATED



                                                                              Signature of Re_'_'SHflgtndividua_                                                                                            h,     _
                                                                                                                                                                                                   Date (Mona, De%l, f%ad

  CERTIFY that the statemmitc          t have made on this form
 and ail attached     schedules  a_e true, comp,ete                  and                                                                                                                                      i'_,/    0
 correct to the best of my know!edge and beiie£

  Brought to you by OpenSecrets.org
                                                                       H.
                  For paymentsto charity in Heuof henoreda,use Sched[_te
Brought to you by OpenSecrets.org
SCHEDULE I! -- PAYMENTS _NL_EU OF HONORARIA MADE TO CHARITY

 List the source, actMty (i.e, speech, appearance, oFarticle), date, and amount of any payment made by the sponsor of an event to a cr_antab}e organizatlon
in lieu of an honorarium. A separate confidential list of charities receiving such payments must be fi_ed directly with the Committee on Standards of Official
Conduct. An envelope for transmitting the list is included in each Member's filing package.

                                          Source                                                                            Date                 Amount
Exam_/es:   Assoc}ation of American Assoc;ations,   Wash., D_C.                     Speech                                Feb_ 2, 2002              s2_ 300
            XYZ Magazine                                                            Article                              A_g, 13, 2002               Sh00




                 This page may be copied _fmore space {s r_uired_

Brought to you by OpenSecrets.org
SCHEDULE               HI -- ASSETS                 AND "UNEARNED"                             _NCOME

                       BLOCK A                                                      BLOCK       B                        BLOCK   C                   BLOCK   D                    BLOCK       E

    Asset anger income Source                                                  Va_ueof Asset                              Type              Amount of income                    Transaction
Identify    (a) each    asset   held    for investment            at dose      of reposing     year,                    of Income     For retirement  plane or accounts that    _nd4eate if
                                                                                                                                     de not allow you to choose specific
or production of Hncome with a fair market va_ue                  If yOU    use     a valuation             method                                                              asset was
exceeding $1,O00 at the end of the reporting                                                                                         investments,    you may write "NA g' for
period, and (b) any other asset or source of                      other than fair market                      value,                 income. For all other assets, Indicate     purchased
income which generated     more than $200 in                      ptease specify the method                 use&                     the category     of income by checking     (P), sold IS)
_unearned" income durlng the year. Forrenta_                                                                                         the    appropriate        box    betow_
property or _and, provide an address: Provide                     If an asset    was    sold    and    is                            Dividends,   even if reinvested,  shouid   of
            of any one where you have the
full names_RA (Le. mutua_ funds. For a se_f-
dlrected                                                          included oRJy because   it generated                               be Hated as income°                        exchanged
power      to select   the specific     investments),             income,      the value     should       be °'None."                                                           (E) in
provide   information    on each asset in the
account that exceeds the report!ng threshold,
                                                                                                                                                                                reporting
end the Income earned for the account. For an                                                                                                                                   year.
}RA or retirement plan that is not se{f_directed_
name the institution ho_din9 the account and
provide _te va_ue at the end of the reporting                                                                      K
period, For an active business       that is not
publicly traded, in Block A state the nature
of the business and Its geographic location. For
additJena_ information,    see the instruction
booklet for the reporting year


       ¥          _es_dar_ce{_)
 E×o_de: o,_pereo_a        (unless
there is rental income); any debt owed to you                I                                  .......            o
 by your spouse, or by your ot your spouse's
 child, parent, or sibling; any deposits toteJin9            I                                                     ©
 $5,000 or _ess n personat savings accounts;                                                                       d
 any finenciat ir_terest in or income derived from                                                                 _e
 U,S Govemrqent retirement programs.                                                                                I

                                                             I                                                     O
                                                                                                                   O
 _f you so choose, you may indicate that an                   I                                                    ©-
 asset or income source is that of yo{_r spouse            ¢ I                                                     ©
 (SP) or dependent chitd (DC) or is jointly he!d
                       "                                 0 c: _                                                    _)
                                                                                                                   _a
 (JT), in the optional column on the far !eft             Z:



                                                                  Indefinite




                       FOr additional      assets   and unearned         income,      usa _e×t            page,
  Brought to you by OpenSecrets.org
Brought to you by OpenSecrets.org
SCHEDULE _V-_TRANSACTIONS

 Report any purchase, sate, or exchange by you, your spouse, or          Type
 dependent chitd during the reporting year of any real property     Of Transaction     Date       Amount of Transaot_on
 stocks_bonds_commodities futures, or other securities when the
 amount d the transaction exceeded $1,000. Include transactions
 that resulted in a ioss Do not report a transaction between you,
 your spouse, or your dependent child_or the purchase or sale of                     (MO/DAWYR)
 your personal residence, unbss it is rented out.


                                Asset
 SP     E_amp/e:   Mega Corporation Common S_ock                                      I0-!2_@2




Brought to you by OpenSecrets.org
SCHEDULE V '_ LiABILiTiES                                                                                 L_m°

 Report liabilities of over $10,000 owed to any one creditor a_ any dine during the reporting period by you, },our spouse, or dependent child Mark tile highest amount owed
 during the year. Exctude_ Any mortgage on your personal resideece (unless it is rented out); toans secured by automobiles, household furniture, or appliances; and Iiabifities
 owed to a spouse, or the chHd_   parent, or sibling of you or your spouse. Repo£ revoh,,Jng charge accounts only if the baiance at the ctose of the preceding calendar year
 exceeded $10,000
                                                                                                                                                                                           ,J
                                                                                                                                                 Amount of Liability

sP_
DO,                                C_edito_                                               Type of Uability
j1 °



                                        D
       Exampie: i FirstBankof Wilmington_ elaware                                         on                Del.
                                                                                  Mortgage !23 MainSt, Dover_




SCHEDULE W _ GIFTS

Report the source, a brief description, and the va_ueof alt gifts totalling more than $285 received by you, your spouse, or a dependent chi!d from any source during the year.
E×o_ude:Giftsfrom relatives, gifts of personal hospitality'of an individual, ioeat meals, and gifts to a spouse or dependentchild that are totally independentof his or her relationship
to you°Gifts with a vatue of $! 14 or less need not be added towards the $285 disclosurethreshotd.
                                        5)
Note: The gift ru_e(House Rule25, c_ause prohibits acceptance of gifts except as speeifieatlyprovided in the rule.


                      Source                                                                        Description                                                          Va_ue
                                                                                           o
                                                                 SilverPtatter(determination n personalfriendshipreceived            on
                                                                                                                         fromCommittee Standards)                         $29




                   Use additional sheets If mo_e spaae i8 requi_ed,
Brought to you by OpenSecrets.org
 SCHEDULE Vii --TRAVEL                         PAYMENTS AND REIMBURSEMENTS

  Identify the source and list trave_ itinerary, dates, and nature of expenses provided for traveI and traveFretated expenses totalling more than $285 received by
  you_ your spouse, or a dependent child during the reporting perio& Indicate whether a fatuity member accompanied the traveter at the sponsor's expense, and
  the amount of time, if any, that was not at the sponsor's expense° Disclosure is required regardless of whether the expenses were reimbursed or paid directly
  by the sponsor
  Exclude: TraveFrelated expenses provided by federal, state, and local governments, or by a foreign government required to be separately reported under the
  Foreign Gifts and Decorations Act (5 U°SoC. § 7842); political travel that is required to be reported under the Federal Election Campaign Act; travel provided to
  a spouse or dependent child that is totalfy independent of !sis or her relationship to you_

                         Source                            Date{a)       Point of Depa_ture---oDest_nat_on_ !Lodging?             Food?          Was Family
                                                                                                                                               _ember a_nc_uded?              not
                                                                                                                                                                     Any time ---- at
                                                                                   Point of Return             (WN)                {Y/N}            (WN)           aponsor's expense
                Chicago Chamber of Commerce                 Mar. 2       Wash., D.C,---Chicago-_Wash. D.C.          N.....
                                                                                                              .............         N ......                                            [:

                                  .....................
  Sxamp!aa/'-:q°ycroddgrP °i_ti_ori                           _&-li_-
                                                          -A-ug                              d
                                                                        _Wash:,5:c:--zLosA_-ng es£C[eve!and   "    Y          .     v                 v                 2Days




Brought to youTh_s page may be copied _fmore apace is required,
               by OpenSecrets.org
SCHEDULE Viii-                     POSITIONS
 Report all positions, compensated or uncompensated, held during the current calendar year as an officer, director, t_ustee of an organization, partner
 proprietor_ representative, employee, or consultant of any corporation, firm, partnership, or other' business enterprise, any nonprofit orgar_ization, any labor
 organization, or any educational or other institution other than the United States.

 BxcJude: Positions held in any religious, social       fraternal, or political entitiesl positions solely of an honorary nature; and positions !isted on Schedule !.

                        Position                                                               Name of Organization




SCHEDULE JX                        AGREEMENTS
 _dentify the date, parties to, and genera_ terms of any agreement or arrangement with respect to: future em@oyment; a teave of absence during the period of
 government service; continuation or deferral of payments by a former or current employer other than the U.S. Govemmentl or continuing participation in an
 emptoyee welfare or benefit plan mainta;ned by a former em@oyer.

          Date                                     Parties To                                                          Terms of Agreement




 _D:   2003   85137   (mac
                                       Use additional sheets Hmore space is required,
Brought to you by OpenSecrets.org

								
To top