Employment information for your spouse and any other adult residing
9.
in your household that is not related to you by blood or marriage -
include current employer and employer(s) during the preceding year.
[2014 Gen. Session, HB 394, pgs. 20 and 22]
SPOUSE's current employer(s):
Address of spouse's current employer(s)
SPOUSES's employer(s) in the preceding year:
Address of spouse's preceding year employer(s)
Information for other adults not related by blood or
marriage who are living in the same home as officeholder:
Brief description of employment & occupation
NAME OF INDIVIDUAL:
NAME OF INDIVIDUAL:
Brief description of employment & occupation
Any other matter or interest you believe may constitute a conflict of
10.
interest. (
optional)
(2014 Gen. Session, HB 394, pg. 22)
I certify that I believe the information provided on this form
is true and accurate to the best of my knowledge.
___________________________________
_______________________________
(Signature of House member)
(Date)
Received by the Chief Clerk of the House:
___________________________________
_______________________________
(Signature)
(Date)
Page 4 of 4
revised May 30, 2014