STATE FINANCIAL DISCLOSURE STATEMENT
(For use by all Public Officers and Candidates in the State of Arizona)
Name of Public Officer or Candidate:

Kelly J. Townsend

Address:

7103 E. Indigo St

(please note: this address is public
information and not subject to redaction)

Mesa, AZ 85207

Public Office Held or Sought:

State Representative

District / Division # (if applicable):

16

Please select the appropriate box that reflects your service for this filing year (double-click the box and change the default value to “checked”):
I am a public officer filing this Financial Disclosure Statement covering the 12 months of calendar year 2016.
I have been appointed to fill a vacancy in a public office within the last 60 days and am filing this Financial Disclosure Statement covering
the 12 month period ending with the last full month prior to the date I took office.
I am a public officer who has served in the last full year of my final term, which expires less than thirty-one days into calendar year
2017. This is my final Financial Disclosure Statement covering the last 12 months plus the final days of my term for the current year.
I am a candidate for a public office, and am filing this Financial Disclosure Statement covering the 12 months preceding the date of this
statement, from the month of
20
, to the month of
20
.

VERIFICATION
I verify under penalty of perjury that the information provided in this Financial Disclosure Statement is true and correct.

Kelly Townsend
Signature of Public Officer or Candidate
(Typewritten signatures accepted)
Secretary of State Revision January 2017

1

 A. PERSONAL FINANCIAL INTERESTS
This section requires disclosure of your financial interests and/or the financial interests of the member(s) of your household. 1

1. Identification of Household Members and Business Interests
What to disclose: If you are married, is your spouse a member of your household?
Are any minor children 2 members of your household?

Yes

Yes (if yes, disclose how many

No
1

)

N/A (If not married/widowed, select N/A)
No

N/A (If no children, select N/A)

For the remaining questions in this Financial Disclosure Statement, the term “member of your household” or “household member” will be defined as
the person(s) who correspond to your “yes” answers above.
You are not required to disclose the names of your spouse or minor children when answering the questions below. Thus, you may identify your
household members as “spouse,” “minor child 1”, “minor child 2,” etc. Please note that if you choose to identify your spouse or minor children
by name, the Secretary of State’s office or other local filing officer are not expected to redact that information when posting this Financial
Disclosure Statement on the internet or providing it in response to a public records request.

2. Sources of Personal Compensation
What to disclose: In subsection (2)(a), provide the name and address of each employer who paid you or any member of your household more
than $1,000 in salary, wages, commissions, tips or other forms of compensation (other than “gifts”) during the period covered by this report.
Describe the nature of each employer’s business and the type of services for which you or a member of your household were compensated.
In subsection (2)(b), if applicable, list anything of value that any other person (outside your household) received for your or a member of your
household’s use or benefit. For example, if a person was paid by a third-party to be your personal housekeeper, identify that person, describe the
nature of that person’s services that benefited you, and provide information about the third-party who paid for the services on your behalf.
You need not disclose income of a business, including money you or any member of your household received that constitutes income paid to a
business that you or your household member owns or does business as. This type of business income will be disclosed in Question 11 below.
1

If additional space is needed to report information on this Financial Disclosure Statement, select the appropriate reporting area and add additional rows to the form. For example,
to report an additional employer’s name in Section 2, right-click in any row, click “Insert,” and click “Insert Rows Above” or “Insert Rows Below” as needed.
2
Minor children include children 18 years old and younger whom you have joint or sole legal custody over.
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Secretary of State Revision January 2017

 Subsection (2)(a):
PUBLIC OFFICER OR HOUSEHOLD
3
MEMBER BENEFITTED
Kelly Townsend

NAME AND ADDRESS OF EMPLOYER W HO
PROVIDED COMPENSATION > $1,000
State of Arizona

NATURE OF EMPLOYER’S
BUSINESS
Government

NATURE OF SERVICES PROVIDED BY PUBLIC
OFFICER OR HOUSEHOLD MEMBER FOR EMPLOYER
Legislative

Subsection (2)(b) (if applicable):

PUBLIC OFFICER OR HOUSEHOLD
3
MEMBER BENEFITTED

NAME AND ADDRESS OF PERSON W HO
PROVIDED SERVICES VALUED OVER
$1,000 FOR YOUR OR YOUR HOUSEHOLD
MEMBER’S USE OR BENEFIT

NATURE OF SERVICES
PROVIDED BY PERSON FOR
YOUR OR YOUR HOUSEHOLD
MEMBER’S USE OR BENEFIT

NAME AND ADDRESS OF THIRD PARTY W HO PAID
FOR PERSON’S SERVICES ON YOUR OR YOUR
HOUSEHOLD MEMBER’S BEHALF

3. Professional, Occupational and Business Licenses
What to disclose: List all professional, occupational or business licenses held by you or any member of your household at any time during the
period covered by this Financial Disclosure Statement.
This includes licenses in which you or a member of your household had an “interest,” which includes (but is not limited to) any business license held
by a “controlled” or “dependent” business as defined in Question 11 below.

3

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 PUBLIC OFFICER OR
4
HOUSEHOLD MEMBER
AFFECTED

TYPE OF LICENSE

PERSON OR ENTITY HOLDING THE
LICENSE

JURISDICTION OR ENTITY THAT ISSUED
LICENSE

4. Personal Creditors
What to disclose: The name and address of each creditor to whom you or a member of your household owed a qualifying personal debt 5 over
$1,000 during any point during the period covered by this Financial Disclosure Statement.
Additionally, if the qualifying personal debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check the applicable box to indicate whether it was incurred or discharged (double-click the box and change the default value to “checked”).
Otherwise, write “N/A” (for “not applicable”) after the word “Date” if the debt was not first incurred or fully discharged during the period covered by
this Financial Disclosure Statement.
You need not disclose the following, which do not qualify as “personal debt”:
•
•
•
•
•
•

Debts resulting from the ordinary conduct of a business (these will be disclosed in Section B below);
Debts on any personal residence or recreational property;
Debts on motor vehicles used primarily for personal purposes (not commercial purposes);
Debts secured by cash values on life insurance;
Debts owed to relatives;
Personal credit card transactions or the value of any retail installment contracts you or your household member entered into.
4

PUBLIC OFFICER OR HOUSEHOLD MEMBER
OWING THE DEBT
Kelly Townsend

Kelly Townsend

NAME AND ADDRESS OF CREDITOR (OR PERSON
TO W HOM PAYMENTS ARE MADE)

IF THE DEBT W AS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

Capital One Auto
PO Box 60511 Industry, CA 91716

Date:

Chase Bank
270 Park Ave. New York, NY 10017

Date:

Incurred

Incurred

Discharged

Discharged

Date:
Incurred
4

Discharged

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
A “qualifying” debt is a personal debt other than the types of debts in the bullet point list above.
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Secretary of State Revision January 2017
5

 5. Personal Debtors
What to disclose: The name of each debtor who owed you or a member of your household a debt over $1,000 at any time during the period
covered by this Financial Disclosure Statement, along with the approximate value of the debt by financial category (double-click the applicable box
and change the default value to “checked”).
Additionally, if the debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date and check whether
it was incurred or discharged (double-click the appropriate box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the debt was not first incurred or fully discharged during the period covered by this Financial Disclosure
Statement.
PUBLIC OFFICER OR
6
HOUSEHOLD MEMBER OWED
THE DEBT

NAME OF DEBTOR

APPROXIMATE VALUE OF
DEBT

IF THE DEBT W AS FIRST INCURRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

Incurred

Incurred

Incurred

Discharged

Discharged

Discharged

6. Gifts
What to disclose: The name of the donor who gave you or a member of your household a single gift or an accumulation of gifts during the
preceding calendar year with a cumulative value over $500, subject to the exceptions listed in the below “You need not disclose” paragraph. A “gift”
means a gratuity (tip), special discount, favor, hospitality, service, economic opportunity, loan or other benefit received without adequate
consideration (reciprocal value) and not provided to members of the public at large (in other words, a personal benefit you or your household
member received without providing an equivalent benefit in return).
Please note: the concept of a “gift” for purposes of this Financial Disclosure Statement is separate and distinct from the gift restrictions outlined in
Arizona’s lobbying statutes. Thus, disclosure in a lobbying report does not relieve you or a member of your household’s duty to disclose gifts in this
Financial Disclosure Statement.
You need not disclose the following, which do not qualify as “gifts”:
•
•
•
6

Gifts received by will;
Gift received by intestate succession (in other words, gifts distributed to you or a household member according to Arizona’s intestate
succession laws, not by will);
Gift distributed from an inter vivos (living) or testamentary (by will) trust established by a spouse or family member;

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 •
•
•

Gifts received from any other member of the household;
Gifts received by parents, grandparents, siblings, children and grandchildren; or
Political campaign contributions reported on campaign finance reports.
7

PUBLIC OFFICER OR HOUSEHOLD MEMBER W HO RECEIVED
GIFT(S) OVER $500

NAME OF GIFT DONOR

Kelly Townsend

American Legislative Exchange Council

Kelly Townsend

National Conference of State Legislatures

Kelly Townsend

Citizens for Self Governance

7. Office, Position or Fiduciary Relationship in Businesses, Nonprofit Organizations or Trusts
What to disclose: The name and address of each business, organization, trust or nonprofit organization or association in which you or any member
of your household held any office, position, or fiduciary relationship during the period covered by this Financial Disclosure Statement, including a
description of the office, position or relationship.
7

PUBLIC OFFICER OR HOUSEHOLD MEMBER
HAVING THE REPORTABLE RELATIONSHIP
Kelly Townsend

7

NAME AND ADDRESS OF BUSINESS,
ORGANIZATION, TRUST, OR NONPROFIT
ORGANIZATION OR ASSOCIATION
Monarch Maternity Project
1616 E. Main Mesa, AZ 85203

DESCRIPTION OF OFFICE, POSITION OR FIDUCIARY
RELATIONSHIP HELD BY THE PUBLIC OFFICER OR HOUSEHOLD
MEMBER
Director

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 8. Ownership or Financial Interests in Businesses, Trusts or Investment Funds
What to disclose: The name and address of each business, trust, or investment fund in which you or any member of your household had an
ownership or beneficial interest of over $1,000 during the period covered by this Financial Disclosure Statement. This includes stocks, annuities,
mutual funds, or retirement funds. It also includes any financial interest in a limited liability company, partnership, joint venture, or sole
proprietorship. Also, put a check mark to indicate the value of the debt (double-click the applicable box and change the default value to “checked”).
PUBLIC OFFICER OR HOUSEHOLD MEMBER
HAVING THE INTEREST

8

NAME AND ADDRESS OF BUSINESS, TRUST
OR INVESTMENT FUND

DESCRIPTION OF THE BUSINESS, TRUST
OR INVESTMENT FUND

N/A

APPROXIMATE EQUITY
VALUE OF THE INTEREST
$1,000 - $25,000
$25,001 - $100,000
$100,001 +

N/A

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

N/A

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

9. Ownership of Bonds
What to disclose: Bonds issued by a state or local government agency worth more than $1,000 that you or a member of your household held
during the period covered by this Financial Disclosure Statement. Also, put a check mark to indicate the value of the bonds (double-click the
applicable box and change the default value to “checked”).
Additionally, if the bonds were either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether
the bonds were acquired or divested (double-click the appropriate box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the bonds were not first acquired or fully divested during the period covered by this Financial Disclosure
Statement.
PUBLIC OFFICER OR
8
HOUSEHOLD MEMBER
ISSUED BONDS
N/A

N/A

N/A

8

ISSUING STATE OR LOCAL
GOVERNMENT AGENCY

APPROXIMATE VALUE OF
BONDS

IF THE BONDS W ERE FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

Acquired

Acquired

Acquired

Divested

Divested

Divested

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 10. Real Property Ownership
What to disclose: Arizona real property (land) and improvements which was owned by you or a member of your household during the period
covered by this Financial Disclosure Statement, other than your primary residence or property you use for personal recreation. Also describe the
property’s location (city and state) and approximate size (acreage or square footage), and put a check mark to indicate the approximate value of the
land (double-click the applicable box and change the default value to “checked”).
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether
the land was acquired or divested (double-click the appropriate box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the land was not first acquired or fully divested during the period covered by this Financial Disclosure Statement.
You need not disclose: Your primary residence or property you use for personal recreation.
PUBLIC OFFICER OR
9
HOUSEHOLD MEMBER THAT
OWNS LAND
N/A

N/A

N/A

LOCATION AND APPROXIMATE
SIZE

APPROXIMATE VALUE OF
LAND

IF THE LAND W AS FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

Acquired

Acquired

Acquired

Divested

Divested

Divested

B. BUSINESS FINANCIAL INTERESTS
This section requires disclosure of any financial interests of a business owned by you or a member of your household.

11.

Business Names

What to disclose: The name of any business under which you or any member of your household owns or did business under (in other words, if
you or your household member were self-employed) during the period covered by this Financial Disclosure Statement, which include any
corporations, limited liability companies, partnerships, sole proprietorships or any other type of business conducted under a trade name.
Also disclose if the named business is controlled or dependent. A business is “controlled” if you or any member of your household (individually or
combined) had an ownership interest that amounts to more than 50%. A business is classified as “dependent,” on the other hand, if: (1) you or any
household member (individually or combined) had an ownership interest that amounts more than 10%; and (2) the business received more than
$10,000 from a single source during the period covered by this Financial Disclosure Statement, which amounted to more than 50% of the business’
gross income for the period.
9

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 Please note: If the business was either controlled or dependent, check whether it was controlled or dependent (double-click the appropriate box
and change the default value to “checked”) in the last column below. If the business was both controlled and dependent during the period covered
by this Financial Disclosure Statement, check both boxes. Otherwise, leave the boxes in the last column below blank.
PUBLIC OFFICER OR HOUSEHOLD MEMBER
OWNING THE BUSINESS

10

NAME AND ADDRESS OF BUSINESS

CHECK THE APPROPRIATE BOX IF THE BUSINESS IS “CONTROLLED”
BY OR “DEPENDENT” ON YOU OR A HOUSEHOLD MEMBER

N/A

Controlled

Dependent

N/A

Controlled

Dependent

N/A

Controlled

Dependent

Please note: If a business listed in the foregoing Question 11 was neither “controlled” nor “dependent” during the period covered by this Financial
Disclosure Statement, you need not complete the remainder of this Financial Disclosure Statement with respect to that business. If none of the
businesses listed in Question 11 were “controlled” or “dependent,” you need not complete the remainder of this Financial Disclosure Statement.

12. Controlled Business Information
What to disclose: The name of each controlled business listed in Question 11 above, and the goods or services provided by the business.
If a single client or customer (whether a person or business) accounts for more than $10,000 and 25% of the business’ gross income during the
period covered by this Financial Disclosure Statement, the client or customer is deemed a “major client” and therefore you must describe what your
business provided to this major client in the third column below. Also, if the major client is a business, please describe the client’s type of business
activities in the final column below (but if the major client is an individual, write “N/A” for “not applicable” in the final column below).
If the business does not have a major client, write “N/A” for “not applicable” in the last two columns below.
You need not disclose: The name of any major client, or the activities of any major client that is an individual.
If you or your household member does not own a business, or if your or your household member’s business is not a controlled business, you may
leave this question blank.

10

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017

 NAME OF YOUR OR YOUR HOUSEHOLD
MEMBER’S CONTROLLED BUSINESS

GOODS OR SERVICES PROVIDED BY
THE CONTROLLED BUSINESS

DESCRIBE W HAT YOUR BUSINESS
PROVIDES TO ITS MAJOR CLIENT

TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CLIENT (IF A BUSINESS)

N/A
N/A
N/A
N/A

13. Dependent Business Information
What to disclose: The name of each dependent business listed in Question 11 above, and the goods or services provided by the business.
If a single client or customer (whether a person or business) accounts for more than $10,000 and 25% of the business’ gross income during the
period covered by this Financial Disclosure Statement, the client or customer is deemed a “major client” and therefore you must describe what your
business provided to this major client in the third column below. Also, if the major client is a business, please describe the client’s type of business
activities in the final column below (but if the major client is an individual, write “N/A” for “not applicable” in the final column below).
If the business does not have a major client, write “N/A” for “not applicable” in the last two columns below. Likewise, if the dependent business is
also a controlled business, disclose the business only in Question 12 above and leave this question blank.
You need not disclose: The name of any major client, or the activities of any major client that is an individual.
If you or your household member does not own a business, or if your or your household member’s business is not a dependent business, you may
leave this question blank.

NAME OF YOUR OR YOUR HOUSEHOLD
MEMBER’S DEPENDENT BUSINESS

GOODS OR SERVICES PROVIDED BY
THE DEPENDENT BUSINESS

DESCRIBE W HAT YOUR BUSINESS
PROVIDES TO ITS MAJOR CUSTOMER

N/A
N/A
N/A
N/A

Secretary of State Revision January 2017

10

TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CUSTOMER (IF A BUSINESS)

 14. Real Property Owned by a Controlled or Dependent Business
What to disclose: Arizona real property (land) and improvements which was owned by a controlled or dependent business during the period
covered by this Financial Disclosure Statement. Also describe the property’s location (city and state) and approximate size (acreage or square
footage), and put a check mark to indicate the approximate value of the land (double-click the applicable box and change the default value to
“checked”). If the business is one that deals in real property and improvements, check the box that corresponds to the aggregate value of all
parcels held by the business during the period covered by this Financial Disclosure Statement.
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether
the land was acquired or divested (double-click the appropriate box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the land was not first acquired or fully divested during the period covered by this Financial Disclosure Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member’s business is not a
dependent business, you may leave this question blank.
NAME OF CONTROLLED OR
DEPENDENT BUSINESS THAT
OWNS LAND

LOCATION AND APPROXIMATE
SIZE

N/A

N/A

N/A

APPROXIMATE VALUE OF
LAND

IF THE LAND W AS FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

Acquired

Acquired

Acquired

Divested

Divested

Divested

15. Controlled or Dependent Business’ Creditors
What to disclose: The name and address of each creditor to which a controlled or dependent business owed more than $10,000, if that amount
was also more than 30% of the business’ total indebtedness at any time during the period covered by this Financial Disclosure Statement
(“qualifying business debt”).
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check whether it was incurred or discharged (double-click the box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure
Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member’s business is not a
controlled or dependent business, you may leave this question blank.

Secretary of State Revision January 2017

11

 NAME OF CONTROLLED OR DEPENDENT
BUSINESS OWING THE QUALIFYING DEBT

NAME AND ADDRESS OF CREDITOR (OR PERSON
TO W HOM PAYMENTS ARE MADE)

IF THE DEBT W AS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
Date:

N/A
Incurred

Discharged

Date:
N/A
Incurred

Discharged

Date:

N/A

Incurred

Discharged

16. Controlled or Dependent Business’ Debtors
What to disclose: The name of each debtor who owed more than $10,000 to a controlled or dependent business, if that amount was also more
than 30% of the total indebtedness owed to the controlled or dependent business at any time during the period covered by this Financial Disclosure
Statement (“qualifying business debt”). Also disclose the approximate value of the debt by financial category (double-click the applicable box and
change the default value to “checked”).
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check whether it was incurred or discharged (double-click the box and change the default value to “checked”). Otherwise, write “N/A” (for “not
applicable”) after the word “Date” if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure
Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member’s business is not a
controlled or dependent business, you may leave this question blank.
PUBLIC OFFICER OR
HOUSEHOLD
11
MEMBER OWED THE DEBT
N/A

N/A

N/A

11

NAME OF DEBTOR

APPROXIMATE VALUE OF
DEBT

IF THE DEBT W AS FIRST INCURRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

$1,000 - $25,000
$25,001 - $100,000
$100,001 +

Date:

Incurred

Incurred

Incurred

Discharged

Discharged

Discharged

You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as “spouse,” “minor child 1”, “minor child 2,” etc.
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Secretary of State Revision January 2017