Form A - Financial Disclosure Statement - 2016 Page 2
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12UNITED STATES HOUSE OF REPRESENTATIVES
ETHICS IN GOVERNMENT ACT
2016 FINANCIAL DISCLOSURE STATEMENT – FORM A
Please provide the following information. Your address and signature WILL NOT be made available to the public.
____________________________________________
___________________________
(Print Full Name)
(Daytime Telephone)
___________________________________________________________________________
(Complete Address – Office or Home)
Filer Status:
Member
Officer or Employee
CERTIFICATION – THIS DOCUMENT MUST BE SIGNED BY THE REPORTING INDIVIDUAL AND DATED
The attached Financial Disclosure Statement is required by the Ethics in Government Act of 1978, as amended. The Statement will be available
to any requesting person upon written application and will be reviewed by the Committee on Ethics or its designee. Any individual who knowingly
and willfully falsifies, or who knowingly and willfully fails to file, the attached 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.
Certification
Signature of Reporting Individual
Date
I CERTIFY that the statements I have made on the attached
financial disclosure statement and all attached schedules are true,
complete, and correct to the best of my knowledge and belief.
Members must file a signed original and two photocopies thereof.
Officers and Employees must file a signed original and one photocopy thereof.
***FOR OFFICIAL USE ONLY – DO NOT WRITE BELOW***
Certification
Signature of Certifying Official
Date
It is my opinion, based on the information contained in this
Financial Disclosure Statement, that the reporting individual is in
compliance with title I of the Ethics in Government Act
(5 U.S.C.
app. §§ 101-111).
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