L150 9A HOUSE OF REPRESENTATIVES sons Mavens pee. str FoncALoanveR es |e nel IND DELIVERED tcaarversone cence FY }—__Heatrer Dison 20 Tint Placa Sole ode rs TO6HAY 15 PH 5: 26 - Adsesuy 8 ) me Wane —~ CrHice OF The coeRK Re Bio aoe a ee ese usneise ages — AYE Menberche US Sra | rests atcenitee ee PRELIMINARY INFORMATION — ANSWER EACH OF THESE QUESTIONS ‘A $200 penalty shall be assessed ‘against anyone who files more than 30days tate, mera Yeap SE ne cee) aa a S29" WO] Oa] Sec eer, —— —— fies Sl se — a wl eetey openness oaaacas ar cde traeareess ey vee] No ela cee enone iReoieae asda este en DR] [| Bugis perme WSepeuar ase on a | ae aly ota epeonan o wpa 20 oataiecoaaina raascion eae ven Bt og volar cowegpa ves] vo | Free corpie nt atacn Senet. cori Sa ao | =] eels YO YO st, a Each question in this part must be answered. si yn Soni an ey Sty YB vol] acon duestion in ts part mast cach "Yes" response. EXCLUSION OF SPOUSE, DEPENDENT, OR TRUST INFORMATION ~ ANSWER EACH OF THESE QUESTIONS eR erannrem piesa Dena ie RA aah uae noeecoene an =H «ol EXEMPTION. Have you ec tom Peo ony te anew Lneanes none, raretons abi a pce oF pada dena Fay ves] ree a hoe este exertion (CERTIFICATION — THIS DOCUMENT MUST BE SIGNED BY THE TOERTIFY that tne Satornta | Sane ante ae and ll attached schedules’ are tue socmts oT tothe est of my known etSCHEDULE | — EARNED INCOME ame Hecther Uso [row ‘more during the preceding calendar year. Fer a epousa, tthe souree and amount of List the source, ype, and amount of earned income from any source (other than the fe’ exceeding $1,000. ‘ary honoraria ist only the souree fer aher spouse eamed income 's current employment by tho U.S. Goverrment) totaling $200 or Sra Cry Boas sas Air Fore Reserie Seley, Aibuoeargue WH Hee Lew Fira Atboe vers A _ For payments to charty in eu of honoraria, use Schedule ISCHEDULE Ill — ASSETS AND “UNEARNED” INCOME ‘eL00Kn mocks ocKe ‘tocK | Asset andor Income Source ‘Value of Asset ‘Amount of Income na sts naldioriasimant | at cose of rearing yer of income ‘otftrapant er cr cc at Hf you uso a valuation method other than fair market value, Check at cokenes tat apei. | ossimon, You Sug ones eae Leave vant esa cd at | Sr thar ts se generate ary income curing | ne “aproprice eer helene ‘he calendar yr, Betsente (som Fo tans, Paes rene aman i i Biel g I s Age ae 7 fal ; geste re rea men Rigg) ge [leer ; ERS aR eer eral isels) 3] Bi lalg 2 os eee ee SECEeL psa EEE | [itera esas | Cheers, Accs Self NH, + [Bets Base | REET as KITT Corde oe re Cont, al | i t ana CLM ee - | Seuselo S49 \RA a we abet a 0 [eon 3b Lo Natoncine, ly For adational assets and unearned income, use next pegs.