Form SF 714 SF 714 Financial Disclosure Form

OMB Control Number: 3440-0001
Expiration date: 11/30/2021

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

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

1i. Company or Home Agency

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

S - Staff/Civilian

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

F

0

F

0

F

0

F

0

F

0

F

0

Totals

0

0

0

0

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

3b. Institution

3c. Name of Country

3d. Total # of
Accounts

3e. Address

0

0

3f. Year-End
Balance

F

F
F

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

F

F
F

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

P

F

F

P

F

P

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

5f. Capital
Improvement Costs

6b. Type

6c. Make

6d.
Model/Year

6e. Plate or ID
Number

6f. Year
Acquired

6g. How Acquired

F

V

P

F

V

P

F

V

P

Authorized for local reproduction

6h. Purchase Price or
Acquisition Value

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Page 1 of 18

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

F
F
F
F

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

8b. Type

8c. Make

8d. Model/Year

8e. Plate or ID
Number

8g. Monthly Lease/Rental
Payment

V

F

V

F

V

F

V

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

8f. Month and Year of Initial
Lease (MM/YYYY)

9b. Description

9c. Name of
Country

9d. Year/Period
Acquired

9e. Purchase Price or
Other Cost Basis

9f. Year-End Fair
Market Value

F
F
F

F

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

10b. Type of
Loan/Liability

F

2

F

2

F

2

F

2

10c. Name of Creditor

10d. Address of Creditor (include Country)

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

11b. Name of Creditor

11c. Address of Creditor (include Country)

10e. Original
Balance

11d. Year-End
Balance

10f. Year-End
Balance

11e. Last Payment
Amount

10g. Monthly
Payment

11f. Last Payment
Date (MM/YYYY)

F

F
F

F

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

12b. $ Amount

12c. Explanation

B
B

B

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)
STANDARD FORM 714 (REV. 2/2015)
PAGE 2 of 18

Name (Last, First, Middle Initial, Suffix)

Social Security Number

ADDITIONAL ENTRIES
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

F

0

F

0

F

0

F

0

F

0

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

F
F

F
F

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

F

F
F

F

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

5b. Address (include Country)

5c. Year Acquired

5d. How Acquired

F

P

F

P

F

P

F

P

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

6b. Type

6c. Make

6d. Model/Year

6e. Plate or ID
Number

6f. Year Acquired

5e. Purchase Price or
Acquisition Value

5f. Capital
Improvement Costs

6g. How Acquired

6h. Purchase Price or
Acquisition Value

F

V

P

F

V

P

F

V

P

F

V

P

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

F

F
F
F

F
F

STANDARD FORM 714 (REV. 2/2015)
PAGE 3 of 18

Name (Last, First, Middle Initial, Suffix)

Social Security Number

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

8b. Type

F

V

F

V

F

V

F

V

F

V

8c. Make

8d. Model/Year

8e. Plate or ID
Number

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

9b. Description

9c. Name of
Country

8f. Month and Year of Initial
Lease (MM/YYYY)

9d. Year/Period
Acquired

8g. Monthly Lease/Rental
Payment

9e. Purchase Price or
Other Cost Basis

9f. Year-End Fair
Market Value

F
F

F
F
F

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

10b. Type of
Loan/Liability

F

2

F

2

F

2

F

2

F

2

10c. Name of Creditor

10d. Address of Creditor (include Country)

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

11b. Name of Creditor

11c. Address of Creditor (include Country)

10e. Original
Balance

11d. Year-End
Balance

10f. Year-End
Balance

11e. Last Payment
Amount

10g. Monthly
Payment

11f. Last Payment
Date (MM/YYYY)

F

F
F
F

F

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

12b. $ Amount

12c. Explanation

B

B
B

B

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

13b. Address of Institution

SECTION 14: COMMENTS

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PAGE 4 of 18

PRIVACY ACT STATEMENT
AUTHORITY:

Collection of the information requested by this form is authorized under: Executive Order
(E.O.) 12968, Access to Classified Information; National Security Act of 1947, as
amended; E.O. 12333, United States Intelligence Activities; and E.O. 13467, as
amended, Reforming Processes Related to Suitability for Government Employment,
Fitness for Contractor Employees, and Eligibility for Access to Classified National
Security Information.
CONSEQUENCES:

Failure to furnish the requested information could result in your being considered
unfavorably for new or continued access to particularly sensitive classified information as
defined by E.O. 12968.
PRINCIPAL PURPOSE:

The information will be used to help make personnel security determinations, including
whether to grant a security clearance; to allow access to classified information, sensitive
areas, and equipment; or to permit assignment to sensitive national security positions.
The data may later be used as part of a review process to evaluate continued eligibility
for access to classified information or as evidence in legal proceedings. (See Routine
Uses.)
ROUTINE USES:

Information may be disclosed to individuals, entities, or agencies in order to assist the
U.S. Government in connection with investigating or resolving security,
counterintelligence, or federal employment suitability matters.
Information may be disclosed to local, state, or federal agencies or entities for security or
counterintelligence purposes or when the information alone, or in conjunction with other
information, indicates a violation or potential violation of law, whether civil, criminal, or
regulatory in nature.
Information may be disclosed to cooperating foreign government officials for security or
counterintelligence purposes.
Information may be disclosed when required by federal statute.

STANDARD FORM 714 (REV. 2/2015)
PAGE 5 of 18

FINANCIAL DISCLOSURE REPORT INSTRUCTIONS
SCOPE OF DISCLOSURE:
Disclose the requested information concerning income, assets and liabilities generated, held or incurred
by you, your spouse (your legal wife or husband) and any of your dependent children* including any legal
or beneficial interest. Do not include spousal information where there is a legal separation. Do not report
financial information for any person living with you other than your spouse and your dependent children.
On those accounts where you maintain signature access only in the event of an emergency you are not
required to list the account balances.
*The term “dependent child” means your son, daughter, stepson, or stepdaughter who qualifies as a
dependent under Section 152 of the Internal Revenue Code of 1986.
The reporting period for the Financial Disclosure REPORT is the preceding calendar year. All amounts
should be listed in United States Dollars. Do not report cents. If you cannot locate the exact amount for a
particular disclosure, please list your best honest estimate.
ADDITIONAL ENTRIES for Sections 2 through 14 are available on pages 3 and 4 of the SF 714.
Section 1 - EMPLOYEE IDENTIFICATION
1a. Name
Enter your full name (Last, First, Middle Initial, Suffix).
1b. Date of Birth
Enter your date of birth using the following format (MM/DD/YYYY).
1c. Social Security Number (SSN)
Enter your SSN using the following format (###-##-####).
The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals at the time information is
solicited from them, whether the disclosure is mandatory or voluntary, by the authority such number is
solicited and what uses will be made of the information. You are hereby advised that the authority for
soliciting your SSN is Public Law 104-134 (April 26, 1996), as amended in Title 31, Section 7701. The
disclosure of your SSN is voluntary. It will be used to confirm your identity.
1d. Reserved for Agency Use
1e. Home Address
Enter your home street address, apartment number, city, state, zip/postal code, and country.
1f. Marital Status
Enter one of the following letters to describe your marital status:
Si = Single
M = Married
D = Divorced
W = Widowed
Se = Separated
1g. Employee Status
Enter the appropriate letter(s) to describe your employee status:
S = Staff/Civilian
M = Military
C = Contractor
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PAGE 6 of 18

D = Detailee
For example, enter M D if you are a Military member and have been detailed to another agency.
1h. Daytime Telephone Number and Office e-mail Address
Enter your daytime telephone number and office e-mail address.
1i. Company or Home Agency
If contractor, enter the name of your company.
If independent contractor, type the word ‘Self’.
If detailee, enter the name of your home agency.
Section 2 - ANNUAL INCOME, U.S. AND FOREIGN
This section is intended to capture total annual income received in payment for you, your spouse and
your dependent children during the preceding calendar year. Add a separate entry line for each unique
combination of Income Recipient Code and Country that income was received (See Section 2 Example).
Report annual salaries and wages less than $500 as the number zero (0). Report salary and wages
earned even if you, your spouse or your dependent children did not file a tax return. All real estate profit
or loss from property sold during the preceding year should be included in this section even if some or all
of it is not taxable. Profits or losses on investments sold during the preceding year should be included in
this section. Losses should be reported using a negative sign (-) before the amount (e.g., -400 for a loss
of $400). Provide your spouse’s salary and wages in a separate entry line that only includes income
earned solely by that spouse, even if you filed a joint tax return. Enter the number zero (0) if your spouse
did not have salary and wages.
For Salary & Wages, Other Income, and Gross Rental Receipts columns, enter the number zero (0) if
values are less than $500.
For Interest Income and Dividend Income columns, enter the number zero (0) if these values are less
than $25.
Describe non-recurring cash income over $10,000 in Section 12, plus list it under the appropriate
column(s) in this section.

Section 2 – Example
Code

Name of
Country

F
F
F
S
F&S
F&S

US
Germany
France
US
US
France
Total

Annual
Salary &
Wages
10573
123
20000
0
0
0
30696

Interest
Income

Dividend
Income

12
0
0
0
172
0
184

9
0
0
0
112
0
121

Gross
Rental
Receipts
0
0
0
0
0
30000
30000

Other
Income
12
0
0
0
-24
0
-12

Total
Annual
Income
10606
123
20000
0
260
30000
60989

2a. Codes
Enter one of the following, per row, to describe the person(s) who earned the income:
F = Filer
S = Spouse
D = Dependent child
O = Other Individual(s)
 F&S = Filer & Spouse
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PAGE 7 of 18

Example: A joint income producing account held by husband and wife would be listed as “F&S.” A joint
account held by the Filer’s spouse and dependent child would be listed as “S&D.”
2b. Name of Country
Enter the name of the country where the income was earned. Enter U.S. if United States.
2c. Annual Salary & Wages
Enter the total applicable Annual Salary and Wages received in payment for personal services during the
preceding calendar year. Report annual salaries of less than $500 as the number zero (0). Report salary
and wages earned even if you, your spouse or your dependent children did not file a tax return. If you are
married, your spouse’s salary and wages should be reported on a separate line that reflects only income
applicable to that spouse (i.e., no joint income should be reported on that line). Total salary and wages for
dependent children also should be reported on a separate line.
2d. Interest Income
Enter the total applicable amount of Taxable Interest Income reported for the preceding calendar year.
Report Taxable Interest Income less than $25 as the number zero (0). Report interest income received
even if you, your spouse or your dependent children did not file a tax return.
2e. Dividend Income
Enter the total applicable amount of Dividend Income reported for the preceding calendar year. Report
Taxable Dividend Income less than $25 as the number zero (0). Report Dividend Income received even if
you, your spouse or your dependent children did not file a tax return.
2f. Gross Rental Receipts
Enter the total applicable amount of Gross Rental Receipts received for the previous year. Report Gross
Rental Receipts less than $500 as the number zero (0).
2g. Other Income
Enter the total applicable amount of Other Income or loss received during the preceding calendar year.
Report Other Income less than $500 as the number zero (0). Report Other Income received, even if you,
your spouse or your dependent children did not file a tax return. Other Income includes Alimony; Awards;
Business Profit or Loss; Gambling Winnings or losses; Lottery Winnings; Prizes; Taxable Capital Gains or
losses from sales of investments, property, or other assets; Taxable Scholarships; Gifts; Inheritances; Life
Insurance Proceeds; Child Support; Veteran’s Benefits; Welfare Payments; Court Awards or Settlements
for personal injury; Worker’s Compensation; Foster Care Payments; Non-Taxable Gains from real estate
sales. A loss should be reported using a negative sign in front of the amount (e.g., a loss of $400 would
be reported as -400).
If the total of this column is equal to or exceeds $10,000, provide description identifying the source(s) of
the income in Section 12.
2h. Total Annual Income
Compute the total for each row and column.
Section 3 - BANK ACCOUNTS, U.S. AND FOREIGN
This section is intended for you to provide information for any savings or checking accounts which are in
the name, or signature authority of you, your spouse, or any of your dependent children during the
preceding calendar year. Use one line to report all accounts held by one or more individuals at the same
bank, savings bank, savings and loan association, or credit union.
3a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the account:
F = Filer
S = Spouse
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PAGE 8 of 18

D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: A joint bank account held by husband and wife would be listed as “F&S.” A joint account held
by the filer and someone other than their spouse or dependent child would be listed as “F&O.”
3b. Institution
Enter the name of the financial institution.
3c. Name of Country
Enter the name of country where the financial institution account(s) is/are held. Enter U.S. if United States.
3d. Total # of Accounts
Enter the total number of accounts (not account numbers) held at the same financial institution and
address as indicated in columns 3b and 3e.
3e. Address
Enter the address of the financial institution where the account(s) is maintained (Number, Street, City,
State, and Zip/Postal Code. If foreign, specify country).
3f. Year-End Balance
Enter the grand total of all the account balances as of December 31 of the preceding calendar year.
Section 4 - INVESTMENT ACCOUNTS, U.S. AND FOREIGN
This section is intended for you to provide the following information on any investment accounts which are
in the name, or signature authority of you, your spouse, or any of your dependent children during the
preceding calendar year. Investment accounts are defined as accounts maintained by stockbrokers,
brokerage houses, investment firms, securities dealers, holding companies, limited partnerships, and
financial institutions who invest your money in stocks, bonds, mutual funds, certificates of deposit, real
estate investment trusts, money market funds, commodities, futures, options, and any other types of
investments. Thrift Savings Plan (TSP), IRA’s, Keogh accounts, 401 (k) accounts, 403 (b) accounts, thrift
savings, college savings funds, and all other forms of retirement and investment accounts should be
included in this section. Use one line to report all accounts held by one or more individuals at the same
financial institution.
4a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the account:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: A joint investment account held by husband and wife would be listed as “F&S.” A joint account
held by a dependent child and someone other than the filer or spouse would be listed as “D&O.”
4b. Institution
Enter the name of the financial institution that maintains the investment account(s).
4c. Name of Country
Enter the name of country where the financial institution account(s) is/are held. Enter U.S. if United States.
4d. Total # of Accounts
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PAGE 9 of 18

Enter the number of accounts (not account numbers) held at the financial institution and address
indicated in items 4b and 4e.
4e. Address
Enter the address of the financial institution that maintains the investment account (Number, Street, City,
State, and Zip/Postal Code. If foreign, specify country).
4f. Year-End Fair Market Value
Enter the total year-end balance (fair market value) for all investments at each institution. You may use
the year-end market value as reported on your year-end statement or as provided by the financial
institution. The market value may also be determined by multiplying the number of shares you own by the
December 31st price per share as posted on the New York Stock Exchange, American Stock Exchange,
or other market reference. The market value includes the amount you invested plus any subsequent
appreciation or depreciation.
Section 5 - OWNED REAL ESTATE, U.S. AND FOREIGN
This section is intended for you to list any foreign and domestic real estate owned totally or in part by you,
your spouse, or any of your dependent children on December 31 of the preceding calendar year.
5a. Codes
Enter one or more of the following letters to describe the person(s) who own(s) the real estate:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: Real estate held jointly by husband and wife would be listed as “F&S.”
5b. Address (include Country)
Enter the address of property owned (Number, Street, City, State, Zip/Postal code, and Country). Enter
U.S. if United States.
5c. Year Acquired
Enter the year in which the property was acquired by purchase, gift/inheritance or through other means.
5d. How Acquired
Enter one of the following letters to indicate how the real estate was acquired.
P = Purchase
G = Gift
I = Inheritance
O = Other: Describe

5e. Purchase Price or Acquisition Value
If you purchased the property, enter the amount you paid. If you are part owner of a property, enter the
amount you contributed to the purchase. If you inherited or were given property, the acquisition value is
the fair market value at the time you acquired the property.
Remember, whenever a property is acquired by gift or inheritance during the preceding year, the fair
market value of that item at the time ownership was transferred must be provided in Section 2g Other
Income, and the details explained in Section 12.

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PAGE 10 of 18

5f. Capital Improvement Costs
Enter the total cost of any capital improvements to the property since it was purchased. Capital
improvements are alterations that add to the value of the property, such as remodeling of kitchens or
adding a bathroom. Repair and replacement of worn out items does not constitute capital improvements.
You do not have to include capital improvement costs that totaled less than $5,000 in the total amount
you report.
Section 6 - OWNED VEHICLES, BOATS, AIRPLANES, OTHER
This section is intended for you to list any vehicles, boats, and airplanes owned by you, your spouse, or
any of your dependent children on 31 December of the preceding calendar year. Vehicles include RV’s,
motorcycles, trailers, tractors, etc. Use “Other” for items not defined as Vehicle, Boat, or Airplane.
Report nothing if ‘Purchase Price or Acquisition Value’ is less than $1,000.
6a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) ownership:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: Joint ownership of a vehicle by husband and wife would be listed as “F&S.”
6b. Type
Enter one of the following letters to describe the type:
V = Vehicle (e.g., car, truck, motorcycle, RV, snowmobile, tractors, etc.)
B = Boat (e.g., power/row boat, canoe, sail boat, jet ski, etc.)
A = Airplane (fixed wing, glider, helicopter, ultra light, etc.)
O = Other: Describe
6c. Make
Enter the manufacturer of the vehicle, boat, airplane, or other.
6d. Model/Year
Enter the model and year manufactured of the vehicle, boat, airplane, or other.
6e. Plate or ID Number
Enter either the license plate number (beginning with the two letter state abbreviation, followed by a colon
(:), then the plate number e.g. VA:123XYZ or DC:7831HV) or the Vehicle Identification Number of the
vehicle, boat, airplane, or other.
6f. Year Acquired
Enter the year the vehicle, boat, airplane, or other was purchased or received as a gift/inheritance or
through other means.
6g. How Acquired
Enter one of the following letters to indicate how the vehicle, boat, airplane or other was acquired.
P = Purchase
G = Gift
I = Inheritance
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O = Other: Describe

6h. Purchase Price or Acquisition Value
Enter the amount you paid for the vehicle, boat, airplane or other. Do not list current fair market value or
current assessed value. If you are part owner of a vehicle, boat, airplane or other or assisted another in
purchasing such items, enter the amount you contributed to the purchase. If you inherited or were given a
vehicle, boat, airplane or other, the acquisition value is the fair market value at the time you acquired the
item.
Remember, whenever a vehicle, boat, airplane or other is acquired by gift or inheritance during the
preceding year, the fair market value of that item at the time ownership was transferred must be provided
in Section 2g Other Income and explained in Section 12.
Section 7 - REAL ESTATE YOU LEASE OR RENT FROM ANOTHER, U.S. AND FOREIGN
This section is provided for you to list any foreign and domestic real estate leased or rented totally or in
part by you, your spouse, or any of your dependent children at any time during the preceding calendar
year. Include vacation rentals leased or rented for 30 days or more.

 Report monthly lease or rental payment less than $50 as the number zero (0).
7a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) responsibility for the
lease or rental:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: Property leased or rented by husband and wife would be listed as “F&S.”
7b. Address (include Country)
Enter the address of the property you lease or rent (Number, Street, City, State, Zip/Postal code, and
country). Enter U.S. if United States.
7c. Month and Year of Initial Lease/Rental (MM/YYYY)
Enter the month and year the property was initially leased or rented.
7d. Monthly Lease/Rental Payment
Enter the lease or rental monthly payment.
Report monthly lease or rental payment less than $50 as the number zero (0).
Section 8 - LEASED VEHICLES, BOATS, AIRPLANES, OTHER
This section is provided for you to list any vehicles, boats, and airplanes leased for 30 days or more by
you, your spouse, or any of your dependent children during the preceding calendar year. Vehicles include
RV’s, trailers, tractors, etc. Use “Other” for items not defined as Vehicle, Boat, or Airplane.
Report nothing if lease payment is less than $50.
8a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the lease:

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F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: Joint lease of a vehicle by husband and wife would be listed as “F&S.”
8b. Type
Enter one of the following letters to describe the lease type:
V = Vehicle (e.g., car, truck, motorcycle, RV, snowmobile, tractors, etc.)
B = Boat (e.g., power/row boat, canoe, sail boat, jet ski, etc.)
A = Airplane (fixed wing, glider, helicopter, ultra light, etc.)
O = Other: Describe
8c. Make
Enter the manufacturer of the vehicle, boat, airplane, or other.
8d. Model/Year
Enter the model and year manufactured of the vehicle, boat, airplane, or other.
8e. Plate or ID Number
Enter either the license plate number (beginning with the two letter state abbreviation, followed by a colon
(:), then the plate number e.g. VA:123XYZ or DC:7831HV) or the Vehicle Identification Number of the
vehicle, boat, airplane, or other.
8f. Month and Year of Initial Lease (MM/YYYY)
Enter the month and year the vehicle, boat, airplane, or other was initially leased.
8g. Monthly Lease/Rental Payment
Enter the monthly lease payment.
Report nothing if lease payment is less than $50.
Section 9 - OTHER ASSETS, U.S. AND FOREIGN
This section is intended for you to list any other assets with an estimated value of $5,000 or more owned
totally or in part by you, your spouse, or any of your dependent children on December 31 of the preceding
calendar year. This includes but is not limited to, antiques, art, and other collectibles*; jewelry; livestock;
cash on hand or other monetary instruments (money orders, savings bonds, traveler’s checks, etc.); trusts,
cash value of whole life insurance policies, self-held securities, net worth of personal business(s) or any
other assets that are not listed elsewhere on this form.
The $5,000 threshold applies to the category of the asset. For example, if you personally hold the
certificates for $8,000 worth of stock in Company A and your spouse holds certificates for $4,000 worth of
stock in Company B, you would report $12,000 worth of stock in this section.
Report nothing for a particular asset category if the total year-end fair market value of assets in that
category is less than $5,000.
*A collectible can be defined as a rare object collected by investors with the expectation of appreciation.
Examples are stamps, coins, oriental rugs, antiques, baseball cards, and photographs. While it is
important to have a reliable baseline figure, it is not necessary to have an appraisal. Please provide the
year-end market value to the best of your ability. If you do not have records, provide your best honest
estimate of the value.
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9a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the asset:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: If you share ownership of an asset, such as a racehorse, through a limited partnership, you
would enter “F&O.”
9b. Description
Provide a description of the asset. If the asset is owned in part, include the percentage of the asset
owned by you. If the asset(s) is a trust, indicate the name of the trust, the trustee and the type of assets
held by the trust.
9c. Name of Country
Enter the name of the country where the asset is held. Enter U.S. if United States.
9d. Year/Period Acquired
Enter the year the asset was purchased/acquired. If you have purchased more than one asset of the
same type (e.g. $10,000 worth of jewelry purchased over a period of years), list the period of purchase
(e.g. 1980 - 1985).
9e. Purchase Price or Other Cost Basis
If you purchased the asset, enter the amount you paid for it. If you inherited or were given the asset, enter
the fair market value at the time ownership of the asset was transferred. If you are part owner of the asset
or assisted another in purchasing the asset, enter the amount you contributed to the purchase.
Remember, whenever an asset is acquired by gift or inheritance during the preceding year, the fair
market value of that item at the time ownership was transferred must also be provided in Section 2g
Other Income and explained in Section 12.
9f. Year-End Fair Market Value
Enter the total year-end fair market value for the asset or item. The market value includes the amount you
invested plus any subsequent appreciation or depreciation. If the asset is a self-held stock, security, or
bond, you may use the year-end market value as determined by multiplying the number of shares you
own by the December 31st price per share as posted on the New York Stock Exchange, American Stock
Exchange, or other market reference. If the asset or item is jewelry, antiques, art, coins, or other
collectibles, enter the fair market value as best determined from publications or other reference materials.
If the item is insured, you may use the insured value.
Section 10 - MORTGAGE, LOANS and OTHER LIABILITIES (except credit cards), U.S. AND
FOREIGN
This section is intended for you to list any mortgages, loans, or other liabilities (except credit cards) under
the name or signature authority of you, your spouse, or any of your dependent children during the
preceding calendar year. Do not report personal loans made between you, your spouse or your
dependent children. List all liabilities you owe to other people and organizations, such as judgments owed
to others, bankruptcy payments, amount you owe others paid by garnishments, alimony you owe former
spouses, tuition you owe to others, settlements owed to others, child support owed to others, etc.
Report nothing if the ‘Year-End Balance’ is less than $500.

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10a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the mortgage or loan:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: If you and your spouse have a mortgage on a house, you would enter “F&S.”
10b. Type of Loan/Liability
Enter one of the following characters (number or letters) to describe the loan type:
2 = 2nd Mortgage
A = Auto
AL= Alimony
BP = Bankruptcy Payment
CS = Child Support
E = Equity
G = Garnishment
J = Judgment
L = Line of Credit
M = Mortgage
O = Other Loan
P = Personal Loan
S = Student Loan
SE = Settlement
T = Tuition

10c. Name of Creditor
Enter the name of the creditor or lender.
10d. Address of Creditor (include Country)
Enter the address of the creditor or lender (Number, Street, City, State, Zip/Postal code, and Country).
Enter U.S. if United States.
10e. Original Balance
Enter the original balance of the liability.
Do not report if ‘Year End-Balance’ is less than $500.
10f. Year-End Balance
Enter the year-end balance of the liability as of December 31 of the preceding calendar year (if
unavailable provide your best honest estimate).
Do not report if year-end balance is less than $500.
10g. Monthly Payment
Enter the monthly payment made.
Section 11 - CREDIT CARDS, U.S. AND FOREIGN

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This section is provided for you to list all unpaid credit card balances as of December 31 of the preceding
calendar year.
Report nothing if the credit card balance is less than $500.
11a. Codes
Enter one or more of the following letters to describe the person(s) who maintain(s) the credit card
account:
F = Filer
S = Spouse
D = Dependent child
O = Other individual(s)
 F&S = Filer & Spouse
Example: If you share a credit card account with your spouse, you would enter “F&S”
11b. Name of Creditor
Enter the name of the creditor.
11c. Address of Creditor (include Country)
Enter the address of the creditor who receives payment (Number, Street, City, State, Zip/Postal code, and
country). Enter U.S. if United States.
11d. Year-End Balance
Enter the year-end balance of the credit card liability as of December 31 of the preceding calendar year (if
unavailable provide your best honest estimate).
Do not report if the year-end balance is less than $500.
11e. Last Payment Amount
Enter the last monthly payment amount made on the credit card balance. Report the number zero (0) if no
payment was made in December (e.g., there was a zero balance or if no payment was made that month).
Report nothing if the ‘Year-End Balance’ is less than $500.
11f. Last Payment Date (MM/YYYY)
Enter the month and year (MM/YYYY) of the last payment amount reflected in 11e. Normally this will be
December of the preceding calendar year.

Section 12 - ADDITIONAL INCOME/BANKRUPTCY
This section is intended for you to provide additional information about inheritances, gifts, and other types
of “Additional Income” you received and about bankruptcies. Only describe “Additional Income” (e.g., gifts,
inheritances, winnings, etc.) received during the preceding year. Only report bankruptcies filed during the
preceding year.
You must describe additional income in this Section if you, your spouse, and/or dependent children
received one or more of the following categories of income during the preceding year:






Any U.S. or foreign investments acquired by gift or inheritance
Any U.S. or foreign real estate/property valued at $5,000 or more acquired by gift or inheritance
One or more vehicles worth $1,000 or more acquired by gift or inheritance
Any other assets valued at $5,000 or more acquired by gift or inheritance
Section 2 ‘Other Income’ totaling $10,000 or more.
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 Any non-recurring cash income over $10,000.
Make certain each amount of Additional Income in this section has also been reported appropriately in
Section 2. For example, Gifts; Inheritance; Settlements; Trust Distributions; Winnings; Business Profit or
loss; Taxable Capital Gains or losses from sales of investments, property, or other assets; Non-Taxable
Gaines from real estate sale; Alimony; Prizes; Taxable Scholarships; Life Insurance Proceeds; Child
Support; Veteran’s Benefits; Welfare Payments; Worker’s Compensation; Foster Care Payments; and
other types of similar income should be listed in Section 2g Other Income.
12a. Item Type
Enter one of the following letters to describe the item:
B = Bankruptcy
G = Gift
I = Inheritance
S = Settlements Received
T = Trust Distributions
W = Winnings
 P = Profit from the sale of a house or other asset(s)
 O = Other
12b. $ Amount
Enter the dollar amount. Provide the total amount applicable for the item type addressed. For amounts
applicable to gifts and inheritances provide the estimated fair market value at the time ownership was
transferred.
For bankruptcies provide the amount of court approved discharge of debts. If that amount is not known,
leave the amount blank.
12c. Explanation
Provide an explanation regarding income from settlements, winnings, gifts, or inheritances that you
received. Note the date and source of that income. Note the location of probate records for inheritances, if
applicable. Also note any amounts received in cash as opposed to paid by check or direct deposit. If
bankruptcy, provide the type (e.g., Chapter 7, 11, 13, etc.), date and place filed, and current status.
Section 13 – SAFE DEPOSIT BOX
List the names and addresses of all institutions where you have a safe deposit box. Make certain you also
report the value of cash or other valuables kept in your safety deposit box in Section 9 “Other Assets”.
13a. Name of Institution
Enter the name of the financial institution.
13b. Address of Institution (include Country)
Enter the address of the financial institution where the account(s) is maintained (Number, Street, City,
State, Zip/Postal Code, and country). Enter U.S. if United States.
Section 14 - COMMENTS
Provide any comments which you believe clarify previous entries on this form.
Section 15 - CERTIFICATION BY THE PERSON COMPLETING THE FORM
15a. Type Name
Enter your full name (Last, First, Middle Initial, Suffix).
15b. Signature
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Before mailing, sign the Financial Disclosure REPORT.
15c. Date Signed (MM/DD/YYYY)
Enter the date the Financial Disclosure REPORT was signed.

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