Form SF 714 SF 714 Financial Disclosure Report

Financial Disclosure Report

SF714_1_09final

Financial Disclosure Report

OMB: 3095-0058

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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 instructions, which include the Privacy Act Statement located in the instructions for completion of this form and the sections below on Sensitive Personal Data and Public Reporting Burden. 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 required, 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 date 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 suggestion 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, Suffix)

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

1c. Social Security Number

1d. Reserved for Agency Use

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

1f. Marital Status

1g. Employee Status

1h. Daytime Telephone Number and Office e-mail Address

1i. Company or Home Agency

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

2a. Codes

2b. Name of Country

2c. Annual Salary & Wages

2d.Interest Income

2e. Dividend Income

2f. Gross Rental Receipts

2g. Other Income

2h. Total Annual Income

Totals

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

3a. Codes

3b. Institution

3c. Name of Country

3d. Total # of Accounts

3e. Address

3f. Year-End Balance

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

4a. Codes

4b. Institution

4c. Name of Country

4d. Total # of Accounts

4e. Address

4f. Year-End Fair Market Value

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

5a. Codes

5b. Address (include Country)

5c. Year Acquired

5d. How Acquired

5e. Purchase Price or Acquisition Value

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 Acquired

6g. How Acquired

6h. Purchase Price or Acquisition Value

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

7a. Codes

7b. Address (include Country)

7c. Month and Year of Initial Lease/Rental (MM/YYYY)

7d. 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. Month and Year of Initial Lease (MM/YYYY)

8g. Monthly Lease/Rental Payment

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

9a. Codes

9b. Description

9c. Name of Country

9d. Year/Period Acquired

9e. Purchase Price or Other Cost Basis

9f. Year-End Fair Market Value

SECTION 10: MORTGAGES, LOANS, AND OTHER LIABILITIES (except credit cards), U.S. AND FOREIGN

10a. Codes

10b. Type of Loan/Liability

10c. Name of Creditor

10d. Address of Creditor (include Country)

10e. Original Balance

10f. Year-End Balance

10g. Monthly Payment

SECTION 11: CREDIT CARDS, U.S. AND FOREIGN

11a. Codes

11b. Name of Creditor

11c. Address of Creditor (include Country)

11d. Year-End Balance

11e. Last Payment Amount

11f. Last Payment Date (MM/YYYY)

SECTION 12: ADDITIONAL INCOME/BANKRUPTCY

12a. Item Type

12b. $ Amount

12c. Explanation

SECTION 13: SAFE DEPOSIT BOX

13a. Name of Institution

13b. Address of Institution

SECTION 14: COMMENTS

SECTION 15: 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.)

15a. Type Name (Last, First, Middle Initial, Suffix)

15b. Signature

15c. Date Signed (MM/DD/YYYY)

Name (Last, First, Middle Initial, Suffix)

Social Security Number

ADDITIONAL ENTRIES