Statements of Economic Interests

Question 1:
If you have any single asset that was worth more than $10,000 as of the end of the preceding calendar year and is held in, or payable to, your name, held jointly by, or payable to, you with your spouse, or held jointly by, or payable to, you with your minor child, list such assets below. In the case of investment real estate, list the city and state where the investment real estate is located. If you do not have any such assets, list "none" below.

Question 2:
Excluding the position for which you are required to file this form, list the source of any income in excess of $7,500 required to be reported during the preceding calendar year. If you sold an asset that produced more than $7,500 in capital gains in the preceding calendar year, list the name of the asset and the transaction date on which the sale or transfer took place. If you had no such sources of income or assets, list "none" below.

Question 3:
Excluding debts incurred on terms available to the general public, such as mortgages, student loans, and credit card debts, if you owed any single debt in the preceding calendar year exceeding $10,000, list the creditor of the debt below. If you had no such debts, list "none" below. List the creditor for all applicable debts owed by you, owed jointly by you with your spouse, or owed jointly by you with your minor child. In addition to the types of debts listed above, you do not need to report any debts to or from financial institutions or government agencies, such as debts secured by automobiles, household furniture or appliances, as long as the debt was made on terms available to the general public, debts to members of your family, or debts to or from a political committee registered with the Illinois State Board of Elections or any political committee, principal campaign committee, or authorized committee registered with the Federal Election Commission.

Question 4:
List the name of each unit of government of which you or your spouse were an employee, contractor, or office holder during the preceding calendar year other than the unit or units of government in relation to which the person is required to file and the title of the position or nature of the contractual services.

Question 5:
If you maintain an economic relationship with a lobbyist or if a member of your family is known to you to be a lobbyist registered with any unit of government in the State of Illinois, list the name of the lobbyist below and identify the nature of your relationship with the lobbyist. If you do not have an economic relationship with a lobbyist or a family member known to you to be a lobbyist registered with any unit of government in the State of Illinois, list "none" below.

Question 6:
List the name of each person, organization, or entity that was the source of a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in excess of $500 received during the preceding calendar year and the type of gift or gifts, or honorarium or honoraria, excluding any gift or gifts from a member of your family that was not known to be a lobbyist registered with any unit of government in the State of Illinois. If you had no such gifts, list "none" below.

Question 7: Madison County Only
Other than your principal residence, do you or any members of your immediate family own any interest in real property located within the County?

Question 8: Madison County Only
Do you or members of your immediate family own an interest in any business or professional entity doing business with the County or any other public/local government agency within Madison County? ___ Are you or any members of your immediate family an officer or director of any business or professional entity doing business with the County or any other local, public government agency within Madison County? ____

Question 9: Madison County Only
Other than a debt to secure a mortgage upon your principal residence or business loan are you or members of your immediate family indebted to any person or business or professional entity doing business with the County or any other local, public government within Madison County?

Question 10: Madison County Only
If you or members of your immediate family have been released from any indebtedness from any person, business or professional entity doing business with the County or any other local, public government within Madison County exceeding in its principal amount of $1,200.00 within the last year without repaying the total balance due on such indebtedness, list the name of the creditor providing the release, the nature and the amount of the indebtedness, and describe the circumstances surrounding the release. EXCLUDE: Any liability of $1,200.00 or less; student loans; installment loans (cars, household effects, etc...); medical and dental debts; credit card purchases; support or alimony obligations; debts owed to spouse or close relative; and debts incurred in the maintenance of your household.