INSTRUCTIONS
Financial Institution |
[] Check box if none.
Name of Issuer or Mutual Fund or ETF Family | Nature of Security (i.e., stock, bond, mutual fund, ETF) |
[] Check box if none.
Address (other than for a personal residence) | Type of Property (e.g., single-family residence,. condominium, farmland, etc.) | Income Received? (Yes/No) |
[] Check box if none.
Plan Sponsor/ Administrator | Income Received? (Yes/No) |
[] Check box if none.
Description of Intangible Property | Nature of Interest | Income Received? (Yes/No) |
[] Check box if none.
Name of Employer |
[] Check box if none.
Source of Noninvestment Income | Nature of Noninvestment Income (Commission, Royalty, etc.) |
[] Check box if none.
Name of Creditor | Valuation Category on Record Date | Identity of any Surety or Guarantor of the Indebtedness |
[] Check box if none.
Name of Lawyer | Nature of Economic Interest, Indebtedness, or Income, Payments, or Benefits | Ongoing or Terminated |
[] Check box if none.
Name of Lawyer or Law Firm | Address |
[] Check box if none.
Name of Organization | Position Held | Compensation Received? (Yes/No) |
[] Check box if none.
Case Name, Tribunal, and Case Number |
[] Check box if none.
Case Name, Court Where Pending, and Case Number | Identity of Lawyer or Law Pending Firm to Which the Case Was Referred | Pending Case? (Yes/No) |
[] Check box if none.
Fiduciary Position | Name of Person for Whom the Filing Judge Is Serving as Fiduciary |
[] Check box if none.
The value of each Benefit shall be reported by reference to a letter category, as follows: Category A- $500-$2,500; Category B - $2,500.01- $5,000; Category C -greater than $5,000.
Identity of Provider of the Gift | Description of the Gift | Type of Redpient of the Gift | Value of the Gift |
[] Check box if none.
The value of each gift shall be reported by reference to a letter category, as follows: Category A $500-$2,500; Category B- $2,500.01- $5,000; Category C-greater than $5,000.
Identity of Provider of the Gift | Description of the Gift | Type of Redpient of the Gift | Value of the Gift |
[] Check box if none.
Type of Covered Person or Identity of Other Person with an Economic Interest That Could Create a Basis for Disqualification | Nature of Economic Interest |
[] Check box if none.
VERIFICATION
Pursuant to Supreme Court Rule 3.15, 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 true, correct, and complete.
_____________________ ___________
(Signature of Filing Judge) (Date)
________________________________
(Printed Name of Filing Judge)