Statement of Economic Interests to be Filed with the County Clerk Statement of Economic Interests to be Filed with the County Clerk Your Name Was Submitted For Filing by an Entity That You Represent Your Name Was Submitted For Filing by an Entity That You Represent (Type or Print) (Type or Print) ______________________________________________________________________________________________________________ Name: ______________________________________________________________________________________________________________ Name: ______________________________________________________________________________________________________________ Each Office or Position of Employment for which this Statement is Filed: ______________________________________________________________________________________________________________ Each Office or Position of Employment for which this Statement is Filed: ______________________________________________________________________________________________________________ Full Post Office Address: ______________________________________________________________________________________________________________ Full Post Office Address: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ GENERAL DIRECTIONS GENERAL DIRECTIONS The interest (if constructively controlled by the person making the statement) of a spouse or any other party shall be considered to be the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If more space is needed, please attach supplemental listing. The interest (if constructively controlled by the person making the statement) of a spouse or any other party shall be considered to be the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If more space is needed, please attach supplemental listing. 1. List the name and instrument of ownership in any entity doing business with a unit of local government in relation to which the person is required to file, in which the ownership interest held by the person at the date of filing is in excess of $5,000 fair mar­ ket value, or from which dividends in excess of $1,200 were received during the preceding calendar year: (In the case of real estate, location thereof shall be listed by the street address, or if none, then by legal description.) No time or demand deposit in a finan­ cial institution, nor any debt instrument shall be listed. 1. List the name and instrument of ownership in any entity doing business with a unit of local government in relation to which the person is required to file, in which the ownership interest held by the person at the date of filing is in excess of $5,000 fair market value, or from which dividends in excess of $1,200 were received during the preceding calendar year: (In the case of real estate, location thereof shall be listed by the street address, or if none, then by legal description.) No time or demand deposit in a financial institution, nor any debt instrument shall be listed. Business Entity Instrument of Ownership Position of Management __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Instrument of Ownership Position of Management __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ 2. List the name, address and type of practice of any professional organization in which the person making the statement was an offi­ cer, director, associate, partner or proprietor, or served in any advisory capacity, from which income in excess of $1,200 was derived during the preceding calendar year: Name Address __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ 2. List the name, address and type of practice of any professional organization in which the person making the statement was an officer, director, associate, partner or proprietor, or served in any advisory capacity, from which income in excess of $1,200 was derived during the preceding calendar year: Type of Practice __________________________________ Business Entity Name Address Type of Practice __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ 3. List the nature of professional services rendered (other than to the unit or units of local government in relation to which the per­ son is required to file) to each entity from which income exceeding $5,000 was received for professional services rendered during the preceding calendar year by the person making the statement: 3. List the nature of professional services rendered (other than to the unit or units of local government in relation to which the person is required to file) to each entity from which income exceeding $5,000 was received for professional services rendered during the preceding calendar year by the person making the statement: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ COMPLETE BUT DO NOT DETACH COMPLETE BUT DO NOT DETACH This section will be returned to you when the Statement is filed with the County Clerk. ______________________________________________________ Office or Position of Employment for which this statement is filed Receipt is hereby acknowledged of your Statement of Economic Interests, filed pursuant to the Illinois Governmental Ethics Act. The Statement was filed on this date: This section will be returned to you when the Statement is filed with the County Clerk. ______________________________________________________ Office or Position of Employment for which this statement is filed (Type or Print) (Type or Print) Name ________________________________________________ Name ________________________________________________ Address ______________________________________________ Address ______________________________________________ City/State/ZIP Code ____________________________________ Receipt is hereby acknowledged of your Statement of Economic Interests, filed pursuant to the Illinois Governmental Ethics Act. The Statement was filed on this date: City/State/ZIP Code ____________________________________ Printed by authority of the State of Illinois. August 2007 — 80M — I-107.8 Printed by authority of the State of Illinois. August 2007 — 80M — I-107.8 American LegalNet, Inc. www.FormsWorkflow.com 4. List the identity (including address or legal description of real estate) of any capital asset from which a capital gain of $5,000 or more was realized during the preceding calendar year: 4. List the identity (including address or legal description of real estate) of any capital asset from which a capital gain of $5,000 or more was realized during the preceding calendar year: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 5. List the name of any entity and the nature of the governmental action requested by any entity that has applied to a unit of local government in relation to which the person must file for any license, franchise or permit for annexation, zoning or rezoning of real estate during the preceding calendar year, if the ownership interest of the person filing is in excess of $5,000 fair market value at the time of filing, or if income or dividends in excess of $1,200 were received by the person filing from the entity during the pre­ ceding calendar year: 5. List the name of any entity and the nature of the governmental action requested by any entity that has applied to a unit of local government in relation to which the person must file for any license, franchise or permit for annexation, zoning or rezoning of real estate during the preceding calendar year, if the ownership interest of the person filing is in excess of $5,000 fair market value at the time of filing, or if income or dividends in excess of $1,200 were received by the person filing from the entity during the preceding calendar year: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 6. List the name of any entity doing business with a unit of local government in relation to which the person is required to file, from which income in excess of $1,200 was derived during the preceding calendar year other than for professional services and the title or description of any position held in that entity: (No time or demand deposit in a financial institution nor any debt instrument need be listed.) 6. List the name of any entity doing business with a unit of local government in relation to which the person is required to file, from which income in excess of $1,200 was derived during the preceding calendar year other than for professional services and the title or description of any position held in that entity: (No time or demand deposit in a financial institution nor any debt instrument need be listed.) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 7. List the name of any unit of government that employed the person making the statement during the preceding calendar year, other than the unit or units of government in relation to which the person is required to file: 7. List the name of any unit of government that employed the person making the statement during the preceding calendar year, other than the unit or units of government in relation to which the person is required to file: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 8. List the name of any entity from which a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in excess of $500, was received during the preceding calendar year: 8. List the name of any entity from which a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in excess of $500, was received during the preceding calendar year: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ VERIFICATION VERIFICATION I declare that this Statement of Economic Interests (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a fine not to exceed $1,000, or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and impris­ onment. ______________________________________________________ I declare that this Statement of Economic Interests (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a fine not to exceed $1,000, or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment. ______________________________________________________ Signature of Person Making Statement Date Signature of Person Making Statement Printed by authority of the State of Illinois. August 2007 — 80M — I-107.8 Printed by authority of the State of Illinois. August 2007 — 80M — I-107.8 DO NOT DETACH (WILL BE RETURNED AS YOUR RECEIPT) DO NOT DETACH (WILL BE RETURNED AS YOUR RECEIPT) American LegalNet, Inc. www.FormsWorkflow.com Date