# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS

Last Name: <empty>
First Name and Middle Initial: <empty>
Annual Report
Calendar Year Covered by Report: <empty>
Senate Office / Agency in Which Employed: <empty>
Senate Office Address (Number, Street, City, State, and ZIP Code): <empty>
Senate Office Telephone Number (Include Area Code): <empty>
Termination Report
Termination Date (mm/dd/yy): <empty>
Prior Office / Agency in Which Employed: <empty>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## AFTER READING THE INSTRUCTIONS - ANSWER EACH OF THESE QUESTIONS AND ATTACH THE RELEVANT PART

Did any individual or organization make a donation to charity in lieu of paying you for a speech, appearance, or article in the reporting period? If Yes, Complete and Attach PART I.:
 YES
 NO

Did you, your spouse, or dependent child receive any reportable travel or reimbursements for travel in the reporting period (i.e., worth more than $335 from one source)? If Yes, Complete and Attach PART VI.:
 YES
 NO

Did you or your spouse have earned income (e.g., salaries or fees) or non-investment income of more than $200 from any reportable source in the reporting period? If Yes, Complete and Attach PART II.:
 YES
 NO

Did you, your spouse, or dependent child have any reportable liability (more than $10,000) during the reporting period? If Yes, Complete and Attach PART VII.:
 YES
 NO

Did you, your spouse, or dependent child hold any reportable asset worth more than $1,000 at the end of the period, or receive unearned or investment income of more than $200 in the reporting period? If Yes, Complete & Attach PART IIIA and/or IIIB.:
 YES
 NO

Did you hold any reportable positions on or before the date of filing in the current calendar year? If Yes, Complete and Attach PART VIII.:
 YES
 NO

Did you, your spouse, or dependent child purchase, sell, or exchange any reportable asset worth more than $1,000 in the reporting period? If Yes, Complete and Attach PART IV.:
 YES
 NO

Do you have any reportable agreement or arrangement with an outside entity? If Yes, Complete and Attach PART IX.:
 YES
 NO

Did you, your spouse, or dependent child receive any reportable gift in the reporting period (i.e., aggregating more than $335 and not otherwise exempt)? If Yes, Complete and Attach PART V.:
 YES
 NO

If this is your FIRST Report: Did you receive compensation of more than $5,000 from a single source in the two prior years? If Yes, Complete and Attach PART X:
 YES
 NO

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## <u>Each</u> question must be answered and the appropriate PART attached for each "YES" response.

File this report and any amendments with the Secretary of the Senate, Office of Public Records, Room 232, Hart Senate Office Building, U.S. Senate, Washington, DC 20510. $200 Penalty for filing more than 30 days after due date.

This Financial Disclosure Statement is required by the Ethics in Government Act of 1978, as amended. The statement will be made available

by the Office of the Secretary of the Senate to any requesting person upon written application and will be reviewed by the Select Committee

on Ethics. Any individual who knowingly and willfully falsifies, or who knowingly and willfully fails to file this report may be subject to civil and

criminal sanctions. (See 5 U.S.C. app. 6, 104, and 18 U.S.C. 1001.)

Certification: I CERTIFY that the statements I have made on this form and all attached schedules are true, complete and correct to the best of my knowledge and belief.
Signature of Reporting Individual: ████████████████████████████████████████
Date (Month, Day, Year): <empty>

For Official Use Only - Do Not Write Below This Line

It is the Opinion of the reviewer that the statements made in this form are in compliance with Title I of the Ethics in Government Act.
Signature of Reviewing Official: <empty>
Date (Month, Day, Year): <empty>

FOR OFFICIAL USE ONLY
Do Not Write Below this Line

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## <u>Each</u> question must be answered and the appropriate PART attached for each "YES" response. (cont.)

Reporting Individual's Name

Page Number

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART I. PAYMENTS TO PAY CHARITABLE ORGANIZATIONS IN LIEU OF HONORARIA

Report the source (name and address), date, and amount of any payment from each source to a charitable organization made in lieu of honoraria to you during the reporting period. Identify the activity (speech, article, or appearance), which generated the payment. For further information, see Instructions.

Note: Travel expenses in excess of $335 related to activities giving rise to these payments must be reported in Part VI, Reimbursements.

<table><tr><th colspan="2">Date of Payment</th><th>Name of Source</th><th>Address (City, State)</th><th>Speech, Article,
or Appearance</th><th>Amount</th></tr><tr><td rowspan="2">Example:</td><td>3/26/0X</td><td>Association of American Associations</td><td>Wash., DC EXAMPLE</td><td>Speech EXAMPLE</td><td>$1,000</td></tr><tr><td>7/23/0X</td><td>XYZ Magazine</td><td>NY, NY EXAMPLE</td><td>Article EXAMPLE</td><td>$500</td></tr><tr><td>1</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>14</td><td></td><td></td><td></td><td></td><td></td></tr></table>

A separate, confidential report which names the charitable organization receiving such payments must be filed directly with the Select Committee on Ethics.

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART I. PAYMENTS TO PAY CHARITABLE ORGANIZATIONS IN LIEU OF HONORARIA (cont.)

Reporting Individual's Name

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART II. EARNED AND NON-INVESTMENT INCOME

Page Number

Report the source (name and address), type, and amount of earned income to you from any source aggregating $200 or more during the reporting period. For your spouse, report the source (name and address) and type of earned income which aggregate $1,000 or more during the reporting period. No amount needs to be specified for your spouse. (See p.3, CONTENTS OF REPORTS Part B of Instructions.) Do not report income from employment by the U.S. Government for you or your spouse.

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban:

For you and for your spouse, report honoraria income received which aggregates $200 or more by exact amount, give the date of, and describe the activity (speech, appearance or article) generating such honoraria payment. Do not include payments in lieu of honoraria reported on Part I.

<table><tr><th colspan="2">Name of Income Source</th><th>Address (City, State)</th><th>Type of Income</th><th>Amount</th></tr><tr><td rowspan="2">Example:</td><td>JP Computers</td><td>Wash., DC Example</td><td>Salary Example</td><td>$15,000</td></tr><tr><td>MCI (Spouse)</td><td>Arlington, VA Example</td><td>Salary Example</td><td>Over $1,000</td></tr><tr><td>1</td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban: (cont.)

Reporting Individual's Name
<empty>

Page Number
<empty>

<table><tr><th rowspan="4" colspan="3">BLOCK A
Identity of Publicly Traded Assets
And Unearned Income Sources
Report the complete name of each publicly
traded asset held by you, your spouse, or
your dependent child, (See p.3,
CONTENTS OF REPORTS Pert B of
Instructions) for production of income or
investment which:
(1) had a value exceeding $1,000 at the
close of the reporting period; and/or
(2) generated over $200 in "uneamed"
income during the reporting period.
Include on this PART IIIA a complete
identification of each public bond, mutual
fund, publicly traded partnership interest,
excepted investment funds, bank
accounts, excepted and qualified blind
trusts, and publicly traded assets of a
retirement plan.</th><th rowspan="3" colspan="12">BLOCK B
Valuation of Assets
At the close of reporting period.
If None, or less than $1,001,
Check the first column. </th><th rowspan="2" colspan="21">BLOCK C
Type and Amount of Income
If 'None (or less than $201). is Checked, no other entry is needed in Block C for that item. This
includes income received or accrued to the benefit of the individual.</th></tr><tr></tr><tr><td colspan="9">Type of Income</td><td colspan="12">Amount of Income</td></tr><tr><td>$1,001)
than
less
(or
None</td><td>$15,000
$1,001 -</td><td>$50,000
$15,001 -</td><td>$100,000
$50,001 -</td><td>$250,000
$100,001 -</td><td>$500,000
$250,001 -</td><td>$500,001-$1,000,000</td><td>$1,000,000***
Over</td><td>$1,000,001-$5,000,000</td><td>$25,000,000
$5,000,001 -</td><td>$50,000,000
$25,000,001 -</td><td>$50,000,000
Over</td><td>None</td><td>xDividends</td><td>Rent</td><td>Interest</td><td>Gains
Capital</td><td>Fund
Investment
Excepted</td><td>Trust
Excepted</td><td>Trust
Blind
Qualified</td><td>Other

(Specify
Type)</td><td>$201)
than
less
(or
None</td><td>$201-$1,000</td><td>$2,500
$1,001 -</td><td>$5,000
$2,501 -</td><td>$5,001-$15,000</td><td>$15,001-$50,000</td><td>$50,001-$100,000</td><td>$1,000,000
$100,001 -</td><td>$1,000,000***
Over</td><td>$5,000,000
$1,000,001 -</td><td>$5,000,000
Over</td><td>Actual
Amount

Required
if
"Other"
Specified</td></tr><tr><td colspan="2">S₁
Example: DC,
or J</td><td>IBM Corp. (stock)
(S) Keystone Fund</td><td>[ ]</td><td>[ ]</td><td></td><td>[x]</td><td>[x]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>[x] X</td><td></td><td>[ ]
[ ]</td><td>Example
Example</td><td>[x] X</td><td>[x] X</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Example

Example</td></tr><tr><td>1</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>2</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td></td></tr><tr><td>3</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>4</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>5</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>6</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>7</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>8</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>9</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>10</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban: (cont.)

Reporting Individual's Name

Page Number

PART IIIB. NON-PUBLICLY TRADED ASSETS AND UNEARNED INCOME SOURCES

<table><tr><th rowspan="3" colspan="3">BLOCK A
Identity of Non-Publicly Traded
Assets and Unearned Income Sources
Report the name, address (city, state and
description)  of each interest held by you,
your spouse, or your dependent child (See
p.3. CONTENTS OF REPORTS Part B of 
Instructions)  for the production of income
or investment in a <u>Eton-oublic</u> trade or
business which:
(1)  had a value exceeding $1,000 at the
close of the reporting period; and/or
(2) generated over $200 in "unearned"
income during the reporting period.
Include the above report for each
underlying asset, which is not incidental to 
the trade or business. Publicly traded
assets held by non-public entity may be
listed on Part IIIA. 
JP</th><th rowspan="2" colspan="12">BLOCK B
Valuation of Assets

At the close of reporting period.
If None, or less than $1,001,
Check the first column.</th><th colspan="21">BLOCK C
Type and Amount of Income
If 'None (or less than $201)' is Checked. no other entry is needed in Block C for that item. This
includes Income received or accrued to the benefit of the individual.</th></tr><tr><td colspan="9">Type of Income</td><td colspan="12">Amount of Income</td></tr><tr><td>$1,001)
than
less
(or
None</td><td>$15,000
$1,001 -</td><td>$50,000
$15,001 -</td><td>$50,001-$100,000</td><td>$250,000
$100,001 -</td><td>$250,001-$500,000</td><td>$1,000,000
$500,001 -</td><td>$1,000,000***
Over</td><td>$1,000,001-$5,000,000</td><td>$5,000,001-$25,000,000</td><td>$50,000,000
$25,000,001 -</td><td>$50,000,000
Over</td><td>= None</td><td>Dividends</td><td>Rent</td><td>Interest</td><td>Gains
Capital</td><td>Fund
Investment
Excepted</td><td>Trust
Excepted</td><td>Trust
Blind
Qualified</td><td>Other

(Specify
Type)</td><td>$201)
than
less
(or
None</td><td>$201-$1,000</td><td>$1,001-$2,500</td><td>$5,000
$2,501 -</td><td>$5,001-$15,000</td><td>$15,001-$50,000</td><td>$100,000
$50,001 -</td><td>$1,000,000
$100,001 -</td><td>$1,000,000***
Over</td><td>$5,000,000
$1,000,001 -</td><td>$5,000,000
Over</td><td>Actual
Amount

Required
if
"Other"
Specified</td></tr><tr><td rowspan="2" colspan="2">S₁
Example: DC,
or J</td><td>Computer. Software Design.
Wash DC</td><td></td><td></td><td></td><td>[x]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>[x] x</td><td></td><td></td><td></td><td></td><td></td><td></td><td>Example</td><td></td><td>[x]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Example</td></tr><tr><td>Undeveloped land, Dubuque, Iowa</td><td></td><td></td><td></td><td></td><td>[x] x</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Example</td><td>[x] X</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>Example</td></tr><tr><td>1</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td></td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td></td></tr><tr><td>2</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>3</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>4</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>5</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>6</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>7</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>8</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>9</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr><tr><td>10</td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr></table>

EXEMPTION TEST (see insinfictions before marking box): If you omitted any asset because it meets the three-part test for exemption described in the instructions. please check box to the right ❑ •" Th s category applies only if the asset is/was held independently by the spouse or dependent child. If the asset is/was either held by the ler or jointly held, use the other ca egoiles of value, as appropiaW.

[ ]

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban: (cont.)

Reporting Individual's Name
PART IV. TRANSACTIONS
Page Number

<table><tr><th rowspan="3" colspan="2">Report any purchase, sale, or exchange by you, your spouse, or dependent
child (See p.3 CONTENTS OF REPORTS Part B of Instructions) during the
reporting period of any real property, stocks, bonds, commodity futures, and
other securities when the amount of the transaction exceeded $1,000.
Include transactions that resulted in a loss. Do not report a transaction
involving property used solely as your personal residence, or a transaction
between you, your spouse, or dependent child. Please clarify which two
properties are involved in any reportable exchange.

Identification of Assets</th><th></th><th></th><th></th><th></th><th colspan="11">Amount of Transaction (x)</th></tr><tr><td colspan="3">Transaction
Type (x)</td><td rowspan="2">Transaction
Date
(Mo., Day, Yr.)</td><td rowspan="2">$15,000
-
$1,001
[ ]</td><td rowspan="2">$15,001-$50,000
[x]</td><td rowspan="2">$100,000
-
$50,001
[ ]</td><td rowspan="2">$250,000
$100,001 -</td><td rowspan="2">$500,000
$250,001 -</td><td rowspan="2">$1,000,000
$500,001 -</td><td rowspan="2">$1,000,000***
Over</td><td rowspan="2">$5,000,000
$1,000,001 -</td><td rowspan="2">$25,000,000
$5,000,001 -</td><td rowspan="2">$25,000,001-$50,000,000</td><td rowspan="2">$50,000,000
Over</td></tr><tr><td>Purchase</td><td>Sale</td><td>Exchange</td></tr><tr><td rowspan="2">S.
Example: DC,
or J</td><td>IBM Corp. (stock) NYSE</td><td>[x] X</td><td>[ ]</td><td>[ ]</td><td>2/1/0X</td><td></td><td></td><td></td><td>[ ]</td><td>E</td><td>[x]</td><td>&gt; A</td><td>M</td><td>P</td><td>L</td><td>E</td></tr><tr><td>(DC) Microsoft (stock) NASDAQ/OTC</td><td>[ ]</td><td>[x]</td><td>[ ]</td><td>1/27/0X</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[x]</td><td>E</td><td>[x] X</td><td>A</td><td>33 M</td><td>P</td><td>L</td><td>E</td></tr><tr><td>1</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>2</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>3</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>4</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>5</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>6</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>7</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>8</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>9</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>10</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>11</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>12</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr></table>

EXEMPTION TEST (see instructions before marking box): If youomitted any asset because it meets the three-part est for exemption described in the instructions. please chec box to the right. •" This category applies only if the asset is/was held independently by the spouse or dependent chid If the asset isiwas ether held by the filer or jointly held. use the other categories of v lue. as appropnato.

[ ]

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban: (cont.)

<table><tr><th>PART V. GIFTS</th><th>Page Number</th></tr></table>

Report the source, brief description and value of all gifts aggregating more than $335 in value received by you, your spouse, or your dependent child, (See p.3 CONTENTS OF REPORTS Part B of Instructions), from each source. Gifts with a value of $134 or less need not be aggregated towards the disclosure threshold. "Gift" is defined in the Instructions.

Exclude: (1) Bequests and other forms of inheritance; (2) Political campaign contributions; (3) Communications to your offices including subscriptions to newspapers and periodicals; (4) Consumable products provided by home state businesses to your offices, if those products are intended for consumption by persons other than yourself; (5) Gifts received prior to your Federal employment; (6) Gifts to your spouse or dependent child totally independent of his or her relationship to you; (7) Gifts from relatives; (8) Personal hospitality of any individual (see instructions); (9) meals and beverages <u>unless</u> consumed in connection with a gift of overnight lodging; and (10) Food, lodging, transportation, and entertainment provided by a foreign government within a foreign country, or by federal, state, D.C., or local governments.

<table><tr><th colspan="2">Name of Income Source</th><th>Address of Source</th><th>Dates and Brief Description</th><th>Gift Value</th></tr><tr><td>Example:</td><td>Mr. John Q. Smith</td><td>Anytown, VA Example</td><td>August 12, 200X, Silver platter - Ethics Committee waiver granted</td><td>$400</td></tr><tr><td>1</td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="4">Note: The Senate Gift Rule prohibits most gifts in excess of $49.99.</td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## Individuals not covered by the Honoraria Ban: (cont.)

Page Number

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART VI. REIMBURSEMENTS

Report necessary travel related expenses from each source aggregating more than $335 in value during the reporting period received by you, your spouse and/or dependent child in connection with your provision of services at a speaking engagement, fact-finding event, or other event (personal campaign, or otherwise). Disclosure is required regardless of whether those expenses were reimbursed to the individual or paid directly by the sponsoring organization. A description of the itinerary, including date(s) and the nature of expenses is required. If you are reimbursed for more than one trip from the same sponsor (and the trips added together are worth more than $335), then you must report each trip individually, even if the reimbursement for each separate trip does not equal more than $335. Report Gifts of travel in Part V.

Exclude: Travel related expenses provided by federal, state, D.C., and local governments; or by a foreign government; reimbursements from campaign funds which are reported to the FEC; reimbursements to a spouse or dependent child totally independent of his or her relationship to you; and reimbursements reported to the Office of Public Records pursuant to Senate Rule 35. For further information, see Instructions.

<table><tr><th colspan="2">Name of Income Source</th><th>Address of Source</th><th>Dates and Brief Description</th></tr><tr><td>Example:</td><td>All States Company</td><td>Maintown, TX EXAMPLE</td><td>Roundtrip air travel from Washington, D.C. to Maintown, TX and lunch for self and spouse
for speaking engagement: May 1-3, 200X EXAMPLE</td></tr><tr><td>1</td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART VI. REIMBURSEMENTS (cont.)

Reporting Individual's Name: <empty>
PART VII. LIABILITIES
Page Number: <empty>

Report liabilities over $10,000 owed by you, your spouse, or dependent child (See p.3 CONTENTS OF REPORTS Part B of Instructions), to any one creditor at any time during the reporting period. Check the highest amount owed during the reporting period. Exclude: (1) Mortgages on your personal residences unless rented; (2) loans secured by automobiles, household furniture or appliances; and (3) liabilities owed to certain relatives listed in Instructions. See Instructions for reporting revolving charge accounts.

<table><tr><th colspan="2">Name of Creditor</th><th>Address</th><th>Type of Liability</th><th></th><th></th><th></th><th>$10,001</th><th>$15,001</th><th>$50,001</th><th>$100,001</th><th></th><th>$250,001</th><th></th><th>$500,001</th><th></th><th>Over</th><th></th><th>$1,000,001</th><th></th><th>$5,000,001</th><th></th><th></th><th>Over</th></tr><tr><td rowspan="2">S,
Example: DC,
or J</td><td>First District Bank</td><td>Wash., DC</td><td>Mortgage on undeveloped land</td><td>1991</td><td>13%</td><td>25yrs</td><td>[ ]</td><td>[ ]</td><td>× X</td><td>[ ]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>EXAMPLE</td><td></td></tr><tr><td>(J) John Jones</td><td>Wash., DC</td><td>Promissory Note</td><td>1999</td><td>10%</td><td>On
dmd</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[x] ×</td><td></td><td></td><td></td><td>XX</td><td></td><td>&gt;&gt;</td><td></td><td>EXAMP 33</td><td></td><td>PP</td><td></td><td>L</td><td>E</td></tr><tr><td>1</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>2</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>3</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>4</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>5</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>6</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>7</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>8</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>9</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>10</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>11</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td>[ ]</td></tr><tr><td>12</td><td></td><td></td><td></td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td><td>[ ]</td><td></td></tr></table>

<table><tr><th></th><th rowspan="2">Rate
Interest</th><th></th><th colspan="11">Category of Amount of Value (x)</th></tr><tr><td>Incurred
Date</td><td>Applicable
if
Term</td><td>$15,000
$10,001 -</td><td colspan="2">$50,000 $100,000
$15,001 - $50,001 -</td><td>$250,000
$100,001 -</td><td>$500,000
$250,001 -</td><td>$1,000,000
$500,001 -</td><td>$1,000,000***
Over</td><td>$5,000,000
$1,000,001 -</td><td>$25,000,000
$5,000,001 -</td><td>000'000'09$
100'000'97$</td><td>$50,000,000
Over</td></tr><tr><td>1991</td><td>13%</td><td>25yrs</td><td>[ ]</td><td>[ ]</td><td>× X</td><td>[ ]</td><td></td><td></td><td></td><td></td><td></td><td></td><td>EXAMPLE</td></tr><tr><td>1999</td><td>10%</td><td>On
dmd</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[x] ×</td><td></td><td>XX</td><td>EXAMP &gt;&gt;</td><td>33</td><td>PP</td><td>L</td><td>E</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td></tr><tr><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td>[ ]</td><td></td></tr></table>

EXEMPTION TEST (see instructions before marking box): If you omitted any asset because it meets the three-part test for exemption described in the instructions, please check box to the right. — This category applies only if the asset is/yeas held independently by the spouse or dependent child. If the asset is/was either held by the filer or jointly held. use the other categories of value. as appropriate.

[ ]

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART VI. REIMBURSEMENTS (cont.)

Reporting Individual's Name

Page Number

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART VIII. POSITIONS HELD OUTSIDE U.S. GOVERNMENT

Report any positions held by you during the applicable reporting period whether compensated or not. Positions include, but are not limited to those of an officer, director, trustee, general partner, proprietor, representative, employee, or consultant of any corporation, firm, partnership, or other business enterprise or any non-profit organization or educational institution. Both the year and month must be reported for the period of time that the position was held.

Exclude: Positions with federal government, religious, social, fraternal, or political entities, and those solely of an honorary nature.

<table><tr><th colspan="2">Name of Organization</th><th>Address (City, State)</th><th>Type of Organization</th><th>Position Held</th><th>From
(Mo/Yr)</th><th>To
(Mo/Yr)</th></tr><tr><td rowspan="2">Example:</td><td>National Assn. of Rock Collectors</td><td>NY, NY EXAMPLE</td><td>Non-profit education</td><td>President</td><td>6/90</td><td>Present</td></tr><tr><td>Jones &amp; Smith</td><td>Hometown, USA EXAMPLE</td><td>Law Firm</td><td>Partner</td><td>7/95</td><td>11/0X</td></tr><tr><td>1</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table>

Compensation in excess of $200 from any position must be reported in Part II.

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART VIII. POSITIONS HELD OUTSIDE U.S. GOVERNMENT (cont.)

Reporting Individual's Name

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART IX. AGREEMENTS OR ARRANGEMENTS

Page Number

Report your agreements or arrangements for future employment (including agreements with a publisher for writing a book or sale of other intellectual property), leaves of absence, continuation of payment by a former employer (including severance payments), or continuing participation in an employee benefit plan. See Instructions regarding the reporting of negotiations for any of these arrangements or benefits.

<table><tr><th colspan="2">Status and Terms of any Agreement or Arrangement</th><th>Parties</th><th>Date</th></tr><tr><td rowspan="2">Example:</td><td>Pursuant to partnership agreement, will receive lump sum payment of capital account &amp; partnership
share calculated on services performed through 11/0X and retained pension benefits (diversified,
<u>independently managed, fully funded, defined contribution plan)</u></td><td>Jones &amp; Smith, Hometown, USA Example</td><td>1/93</td></tr><tr><td>Employment agreement with XYZ Co. to become Vice President of Government Relations. Terms of
agreement include salary between $50,001-$100,000, signing bonus between $2,501-$5,000 and stock
options</td><td>XYZ Co., Bethesda, MD Example</td><td>1/0X</td></tr><tr><td>1</td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td></tr><tr><td>14</td><td></td><td></td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART IX. AGREEMENTS OR ARRANGEMENTS (cont.)

Reporting Individual's Name: <empty>
PART X. COMPENSATION IN EXCESS OF $5,000 PAID BY ONE SOURCE
Page Number: <empty>

FIRST TIME FILERS ONLY:

Report sources of compensation received by you or your business affiliation for services provided directly by you during the reporting period. This includes the names of clients and customers of any corporation, firm, partnership, or other business enterprise, or any non-profit organization when you directly provided the services to the clients and/or customers of the firm that generated a fee or payment of more than $5,000. You need not report the U.S. Government as a source.

<table><tr><th colspan="2">Name of Source</th><th>Address of Source</th><th colspan="2">Brief Description of Duties</th></tr><tr><td rowspan="2">Example:</td><td>Jones &amp; Smith</td><td>Hometown, TX</td><td>Legal Services</td><td>EXAMPLE</td></tr><tr><td>Metro University (client of Jones &amp; Smith</td><td>Moneytown, USA</td><td>Legal Services in connection with university construction</td><td>EXAMPLE</td></tr><tr><td>1</td><td></td><td></td><td></td><td></td></tr><tr><td>2</td><td></td><td></td><td></td><td></td></tr><tr><td>3</td><td></td><td></td><td></td><td></td></tr><tr><td>4</td><td></td><td></td><td></td><td></td></tr><tr><td>5</td><td></td><td></td><td></td><td></td></tr><tr><td>6</td><td></td><td></td><td></td><td></td></tr><tr><td>7</td><td></td><td></td><td></td><td></td></tr><tr><td>8</td><td></td><td></td><td></td><td></td></tr><tr><td>9</td><td></td><td></td><td></td><td></td></tr><tr><td>10</td><td></td><td></td><td></td><td></td></tr><tr><td>11</td><td></td><td></td><td></td><td></td></tr><tr><td>12</td><td></td><td></td><td></td><td></td></tr><tr><td>13</td><td></td><td></td><td></td><td></td></tr><tr><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td>15</td><td></td><td></td><td></td><td></td></tr></table>

# UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS (cont.)

## PART IX. AGREEMENTS OR ARRANGEMENTS (cont.)

# CONFIDENTIAL DISCLOSURE OF PAYMENTS TO CHARITABLE ORGANIZATIONS IN LIEU HONORARIA

Last Name
<empty>
First Name and Middle Initial
<empty>
Telephone Number (Include Area Code)
<empty>
[ ] ANNUAL FILER
Calendar Year Covered by Annual Report
<empty>
Office / Agency in which Employed (or formerly employed)
<empty>
[ ] TERMINATION FILER
Dates Covered by Termination Report:
<empty>
Office / Agency in which Formerly Employed
<empty>
Termination Date (mm/dd/yy):
<empty>

Who Must File: Any reporting Individual who files an annual or termination public financial disclosure report with the Senate Select Committee on Ethics must also file this confidential report if that individual writes, gives a speech, or makes an appearance (or a series of articles, speeches, or appearances which are directly related to official duties or the status of the individual within the government) for which the sponsoring organization makes a payment directly to a charitable organization in lieu of honoraria. To determine whether you are a reporting individual for purposes of this report, please refer to the instructions for the Senate Public Financial Disclosure Report or contact the U.S. Senate Select Committee on Ethics.

Where to File: File this report with the Select Committee on Ethics, Room 220. Hart Senate Office Building. U.S. Senate. Washington. DC 20510. (Ptease note: This is rsj the filing location for the public reports.)

When to File: Reporting individuals should file this report no later than May 15th, annually. In the event that May 15 or other filing date falls on a weekend, or other holiday, the filing deadline shall be on the next business day. If an individual terminates employment, the report must be filed no later than the 30th day after termination. Reasonable extensions may be granted if requested in writing, but the total of all such extensions may not exceed 90 days. These tiling deadlines correspond with the filing dates of the Senate Public Financial Disclosure Report.

Contents of Reports: List the date of the payment (or, if unascertainable. the date of the activity giving rise to the payment). the name and address (city, state) of the source of the payment, the name and address (city, state) of the recipient charitable organization. and the amount of the payment. Include all payments which correspond to the reporting period of the annual or termination public financial disclosure form filed in conjunction with this report. Please sign your report certifying that your report is complete and correct, and that no payments were made to charitable organizations from which you or Your parent. sibling. spouse. child. or dependent

relative receives any financial benefit. If you attach additional pages. please number them.

Penalty Provisions: My individual who is required to file this report and does so more than 30 days alter the date the report is required to be filed, or, if an extension is granted, more than 30 days after the last day of the filing extension period, shall be subject to a 5200 penalty fee. Waivers of this fee may be granted by the Committee in extraordinary circumstances, if requested in writing. Falsifying or failing to file this report may result in the imposition of a civil and criminal sanctions. (See 2 U.S.C. 701 at seq. and 18 U.S.C. 1001.)

Review of Reports: These reports will be reviewed by the Committee along with the corresponding public reports within 60 days of the filing date. These reports will be kept confidential by the Committee in accordance with the Ethics in Government Act of 1978, as amended.

Date: <empty>
Source of Payment (Name, Address): <empty>
Recipient Charitable Organization (Name, Address): <empty>
Amount: <empty>

Date: <empty>
Source of Payment (Name, Address): <empty>
Recipient Charitable Organization (Name, Address): <empty>
Amount: <empty>

Date: <empty>
Source of Payment (Name, Address): <empty>
Recipient Charitable Organization (Name, Address): <empty>
Amount: <empty>

Date: <empty>
Source of Payment (Name, Address): <empty>
Recipient Charitable Organization (Name, Address): <empty>
Amount: <empty>

Date: <empty>
Source of Payment (Name, Address): <empty>
Recipient Charitable Organization (Name, Address): <empty>
Amount: <empty>

<table><tr><th>Certification </th><th>Signature of Reporting Individual</th><th>Date (Month, Day, Year)</th></tr><tr><td>I CERTIFY that the statements 1 have made on
this loan are true, complete end correct fo the
best of my knowledge and belief. No financial
benefit is derived from any charitable
organization listed by me, or a parent, sibling.
spouse, child or dependent relative of mine.</td><td></td><td></td></tr></table>

<empty>
EFTA_R1_01522044
EFTA02444847