COMMONWEALTH OF KENTUCKY
Commonwealth of Kentucky
Executive Branch Ethics Commission
When you have answered every question, PRINT , SIGN it, and SUBMIT by:
ELECTRONIC MAIL: EthicsFiler@ OR FAX: (502) 696-5091 OR By MESSENGER or U.S. MAIL:
Executive Branch Ethics Commission
Capital Complex East
1025 Capital Center Drive, Suite 104
Frankfort, KY 40601
REQUEST FOR EXTENSION OF FILING DATE
STATEMENT OF FINANCIAL DISCLOSURE
For Calendar Year 20___
KRS 11A.990 (2) provides:
The commission may grant a reasonable extension of time for filing a statement of financial disclosure.
Name: Last First Middle or Maiden
Home Street Address:
City: State: Zip:
Home Phone: ( ) - Home E-mail address:
CURRENT STATE AGENCY:
Cabinet:
Department or Office:
Division:
Work Street Address:
City: State: Zip:
Work Phone: ( ) - Work E-mail address: :
PLEASE STATE YOUR REASON FOR THIS EXTENSION REQUEST:
Requested extension date:
Signature: ________________________________________ Date: ____________________
Printed name: _________________________________________
For EBEC Use
Date of Commission approval: ______________________________________
Extension granted for 20___ Statement of Financial Disclosure until : ______________________
Signature of Executive Director: ____________________________________________________
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