SF 714 Financial Disclosure Report

Financial Disclosure Report

Form 714_9_07

Financial Disclosure Report

OMB: 3095-0058

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3095-0058 can be found here:

2009-05-15 - Revision of a currently approved collection

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OMB Control No. 3095-0058

Expiration date: 6/30/2009

FINANCIAL DISCLOSURE REPORT
Please Note: Section 1.3 of E.O. 12968 requires that employees complete this form as a condition of access to specific types of classified information as
determined by the head of an agency. Before completing this form, read the Privacy Act Statement, the sections on Sensitive Personal Data and Public
Reporting Burden and the Instructions. Type or print clearly in black or blue ink.
Sensitive Personal Data: After this form is completed, it will contain sensitive personal information, which is to be safeguarded pursuant to the Privacy Act, 5
U.S.C. 552a. This information is to be released only to authorized personnel having a need to know for official uses. The completed form should be stored in a
locked file cabinet or secured room. When the completed form is no longer needed it should be destroyed by burning or shredding.
Public Reporting Burden for collection of information is estimated to average two hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the reported information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Office of Management and Budget, Paperwork
Reduction Project, Washington, DC 20503.

SECTION 1: EMPLOYEE IDENTIFICATION
1a. Name (Last, First, Middle Initial)

1b. Date of Birth
(MM/DD/YYYY)

1c. Social Security Number 1d. Reserved for Agency
Use

1e. Home Address (Number, Street, Apt. #, City, State, Country, Zip Code)

1g. Employee Status

1f. Marital Status

1h. Assigned Office and Contact Telephone Number

1i. Company or Home Agency

SECTION 2: ANNUAL INCOME, U.S. AND FOREIGN
2a. Codes

2b. US/Foreign
Indicator

2c. Annual Salary
& Wages

2d. Non-Taxable
Income

2e. Interest
Income

2f. Dividend
Income

2g. Gross Rental
Receipts

2h. Other
Income

2i. Total Annual
Income

Totals

SECTION 3: BANK ACCOUNTS, U.S. AND FOREIGN
3a. Codes

3b. Institution

3c. US/Foreign
Indicator

3d. Total # of
Accounts

3e. Address

3f. Year-End Balance

SECTION 4: INVESTMENT ACCOUNTS, U.S. AND FOREIGN
4a. Codes

4b. Institution

4c. US/Foreign
Indicator

4d. Total # of
Accounts

4e. Address

4f. Amount Invested 4g.Year-End Fair
(Cost Basis)
Market Value

SECTION 5: OWNED REAL ESTATE, U.S. AND FOREIGN
5a. Codes

5b. Address

5c. US/Foreign
Indicator

5d. Year of
Purchase

5e. Purchase Price 5f. Capital
Improvement Costs

SECTION 6: OWNED VEHICLES, BOATS, AIRPLANES, OTHER
6a. Codes

6b. Type

6c. Make

6d. Model/Year

6e. Plate or ID
Number

6f. Year
Purchased

6g. Purchase
Price

SF 714 (9-07) Page 1 of 18
Authorized for local reproduction

SECTION 7: REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S. AND FOREIGN
7a. Codes

7b. Address

7c. US/Foreign
Indicator

7d. Year of Lease/Rental

7e. Monthly Lease/Rental
Payment

SECTION 8: LEASED VEHICLES, BOATS, AIRPLANES, OTHER
8a. Codes

8b. Type

8c. Make

8d. Model/Year

8e. Plate or ID
Number

8f. Year Leased 8g. Monthly Lease/
Rental Payment

SECTION 9: OTHER ASSETS, U.S. AND FOREIGN
9a. Codes

9b. Description

9c. US/Foreign
Indicator

9d. Year of
Purchase

9e. Purchase Price
or Other Cost Basis

9f. Year-End Fair
Market Value

SECTION 10: MORTGAGES, LOANS (including installment and personal loans), U.S. AND FOREIGN
10a. Codes

10b. Type
of Loan

10c. Name of
Creditor

10d. US/Foreign 10e. Address of Creditor
Indicator

10f. Original
Balance

10g. Year-End
Balance

10h. Monthly
Payment

11f. Original
Balance

11g. Year-End
Balance

11h. Monthly
Payment

SECTION 11: OTHER LIABILITIES, U.S. AND FOREIGN
11a. Codes

11b. Type
of Liability

11c. Name of
Creditor

11d. US/Foreign 11e. Address of Creditor
Indicator

SECTION 12: ADDITIONAL INCOME/BANKRUPTCY
12a. Item Type

12b. $ Amount

12c. Explanation

SECTION 13: SAFE DEPOSIT BOX/COMMENTS
13a. Name of Institution

13b. Address of Institution

13c. Explanation (Optional)

SECTION 14: CERTIFICATION BY PERSON COMPLETING THE FORM: I certify that the entries made by me are true, complete and
accurate to the best of my knowledge and belief and are made in good faith. I understand that knowing and willful false statement on this form can be
punished by fine or imprisonment or both. (See U.S. Code Title 18, Section 1001.)
14a. Type Name (Last, First, Middle Initial)

14b. Signature

14c. Date Signed (MM/DD/YYYY)

SF 714 (9-07) Page 2 of 18

Name (Last, First, Middle Initial)

Social Security Number

ADDITIONAL ENTRIES
SECTION 2: ANNUAL INCOME, U.S. AND FOREIGN
2a. Codes