Professional Documents
Culture Documents
A0-10 (WP)
Rev. 1/2004
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DISCLOSURE REPORT
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Annual
Final
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6. Reporting Period
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NAME OF ORGANIZATION/ENTITY
POSITION
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NONE
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Ill. NON-INVESTMENT INCOME. (Reporting individual and spouse; see pp. I 7-24 of Instructions.)
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GROSS INCOME
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Spouse's Non-Investment Income - If you were married during any portion of the reporting year, please complete this
section .(dollar amount not required except for honoraria)
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DESCRIPTION
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V. GIFTS. (Includes those to spouse and dependent children. See pp. 28-31 ofInstructions.)
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SOURCE
VALUE
DESCRIPTION
VI. LIABILITIES. (Includes those of spouse and dependent children See pp. 32-33 ofInstructions.)
CREDITOR
NONE (No reportable liabilities.)
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DESCRIPTION
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VALUE CODE*
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Date of Report
34-57 ofInstructions.)
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Date of Report
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IX. CERTIFICATION.
I certify that all information given above (including information pertaining to my spouse and minor or dependent children, if any) is
accurate, true, and complete to the best of my knowledge and belief, and that any information not reported was withheld because it met applicable
statutory provisions permitting non-disclosure.
earned income from outside employment and honoraria and the acceptance of gifts which have been reported are in
et. seq., 5 U.S.C. 7353 and Judicial Conference regulations.