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: ____________________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download