Conflict Of Interest & Financial Disclosure - Utah House Of Representatives

Conflict Of Interest & Financial Disclosure - Utah House Of Representatives - 2017 Page 4

Employment information for your spouse and any other adult residing

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:

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

Conflict Of Interest & Financial Disclosure - Utah House Of Representatives - 2017 Page 4