Form A - Financial Disclosure Statement - 2016 printable pdf download

United States House of Representatives

ETHICS IN GOVERNMENT ACT FINANCIAL DISCLOSURE STATEMENT

For Use by Annual and Termination Filers

____________________

WHO MUST FILE AND WHEN: Annual Filers: Each Member, officer, and employee of the Legislative Branch compensated at or above the

“senior staff” rate ($123,175) for at least 60 days in calendar year 2016, and any employee designated by a Member as a principal assistant must

file a Financial Disclosure Statement on or before May 15, 2017. Termination Filers: A termination report must be filed within 30 days of leaving

a covered position. For all filers, a clear postmark is accepted as the filing date.

LATE REPORTS AND PENALTIES FOR FALSE REPORTS: A $200 late filing fee shall be assessed against any individual who files more than

30 days after the due date of a report or amendment (or the due date of any extension). Any individual who knowingly and willfully falsifies or who

knowingly or willingly fails to file the required report may be subject to civil penalties and criminal sanctions. See section 104 of the Ethics in

Government Act (5 U.S.C. app. §§ 101-111) and 18 U.S.C. § 1001.

REPORTING PERIOD: Annual Filers: The period covered by this report is calendar year 2016, unless otherwise indicated on the Schedule.

Termination Filers: If you leave before May 15, 2017, the period covered is January 1, 2016, through the date of your termination. If you leave

after May 15, 2017, the period covered is January 1, 2017, through the date of your termination.

EXTENSIONS: Requests for extension must be made using the extension request form either in the electronic filing system, available at

https://fd.house.gov, or in hard copy form on the Committee’s website, The extension request must be e-mailed or faxed

to the Committee and received by the due date of the report.

WHERE TO OBTAIN ASSISTANCE: Counsel from the Committee on Ethics are available to answer questions and offer assistance at (202) 225-

7103. Additional forms and instructions are available on the Committee’s website, , under the “Financial Disclosure” tab.

BEFORE FILING: Answer each question on the “Preliminary Information” page, and attach the appropriate schedule for each “Yes” response.

Please type or print using blue or black ink. Do not use pencil. Attach additional sheets if necessary, indicating the section that is being continued.

Type or print your name at the top of each page filed. Redact any confidential information from any attachments.

RETURN COMPLETED STATEMENT TO:

Filing Instructions for Members: File a signed original and two photocopies of your

The Clerk, U.S. House of Representatives

report, including all attachments. Filers who use the online system only need to submit

Legislative Resource Center

once.

135 Cannon House Office Building

Washington, DC 20515-6612

Filing Instructions for Officers and Employees: File a signed original and one

photocopy of your report, including all attachments. Filers who use the online system only

need to submit once.

Form A - Financial Disclosure Statement - 2016

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