Local Government Ethics Law Financial Disclosure Statement

State of New Jersey Department of Community Affairs Division of Local Government Services Local Finance Board

Local Government Ethics Law Financial Disclosure Statement

This Financial Disclosure Statement is required annually of all local government officers

in accordance with N.J.S.A. 40A:9-22.1 et seq., the Local Government Ethics Law.

Year of Service:

* The Year that you are filing the statement

Enter the Local Government Served: Select Your Local Government Agency

Section I. Personal Information - Local Government Officer

First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________

Home Address: _____________________________________________

Telephone Numbers (optional*)

(Optional*)

_____________________________________________

Home:

______________________

_____________________________________________

Business: ______________________

**Spouse's

First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________

* Optional information, if supplied, is subject to public disclosure as part of the Financial Disclosure Statement.

** Spouse includes a Civil Union partner.

Agency

Position Held

1. _________________________________________ ________________________________________

2. _________________________________________ ________________________________________

3. _________________________________________ ________________________________________

4. _________________________________________ ________________________________________

5. _________________________________________ ________________________________________

Term Expires (if applicable) ________________ ________________ ________________ ________________ ________________

Section II. Financial Information

Provide the following information for yourself and members of your immediate family for the prior calendar year. If none, please indicate NONE in the space provided. If additional space is needed, please scroll down and use the Extension Forms that have been provided.

A. List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the source of income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization.

Name

1. 2. 3. 4. 5.

Address

Self Spouse

Dependent Name

B. List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for personal appearances, speeches, or writing.

Name

1. 2. 3. 4. 5.

Address Page 1

Self Spouse

Dependent Name

C. List the name and address of each source of gifts, reimbursements or prepaid expenses having an aggregate value exceeding $400 from any single source,

excluding relatives.

Name

Address

Self Spouse

Dependent Name

1.

2. 3. 4. 5.

D. List the name and address of all business organizations in which an interest was held.

Name

Address

1.

2. 3. 4. 5.

Self Spouse

Dependent Name

E. List the address and a brief description of all real property in the State of New Jersey in which an interest was held.

Municipality/County

1. 2. 3. 4. 5.

Block Lot Qual.

Address (if applicable)

% of Ownership

Self

Spouse

Dependent Name

F. Please add any other information you believe is necessary to complete this form.

Section III. Certification I hereby certify that this Financial Disclosure Statement contains no willful misstatement of fact or omission of material fact and, together with any and all statements

previously submitted in writing to the clerk of my local government or the Local Finance Board, constitutes a full disclosure with respect to all matters required by N.J.S.A.

40A:9-22.1 et seq., to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to fines and possible

disciplinary action.

Date:_5_/1_4_/2_0_1_3______________

Type your name _____________________________________

To complete the online filing process: Enter the e-mail address that was provided to you by the municipal clerk, county clerk, or other representative for the local government that you serve. LGA Email: ___________________________________________________________

Enter the Email address that you use as a local government officer (optional*). LGO Email: _______________________________________________________

E-Filing Statement ? (a.) I have personally reviewed and approved the foregoing financial disclosure statement and any Extention forms attached hereto; (b.) I have

personally filed or somebody has been authorized by me to file this form electronically with my consent. Accept

Denied

After you click the "Submit" button below the system will populate the receipt form indicating the date and time that you electronically submitted your financial disclosure

statement and assigning a receipt number. You must print the receipt and deliver a signed original copy of the receipt to your local government agency representative.

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Page 2

Section I Personal Information - Extension Forms.

Agency 6. _________________________________________ 7. _________________________________________ 8. _________________________________________ 9. _________________________________________ 10. _________________________________________ 11. _________________________________________ 12. _________________________________________ 13. _________________________________________ 14. _________________________________________ 15. _________________________________________ 16. _________________________________________ 17. _________________________________________ 18. _________________________________________ 19. _________________________________________ 20. _________________________________________ 21. _________________________________________ 22. _________________________________________ 23. _________________________________________ 24. _________________________________________ 25. _________________________________________ 26. _________________________________________ 27. _________________________________________ 28. _________________________________________ 29. _________________________________________ 30. _________________________________________ 31. _________________________________________ 32. _________________________________________ 33. _________________________________________ 34. _________________________________________ 35. _________________________________________ 36. _________________________________________ 37. _________________________________________ 38. _________________________________________ 39. _________________________________________ 40. _________________________________________ 41. _________________________________________ 42. _________________________________________ 43. _________________________________________ 44. _________________________________________ 45. _________________________________________ 46. _________________________________________ 47. _________________________________________ 48. _________________________________________ 49. _________________________________________ 50. _________________________________________

Position Held ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

Term Expires (if applicable) ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________

Page 3

Section II financial Information - Extension Forms.

List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the source of income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization.

Name

6.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

28.

29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Address

Self Spouse

Dependent Name

Page 4

Section II financial Information - Extension Forms.

List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for personal appearances, speeches, or writing.

Name

6.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Address

Self Spouse

Dependent Name

Page 5

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