Professional Documents
Culture Documents
S/~010
~pon Requiredby the glhics in Government Act of 1978 (s U,s.c. app. 101-111)
3. Date of Repot~
4- Title (~cl~ ]]I judges in~cale ac~vo or senior s~am~; ma~s~t~ judges in~t~ ~I- or
6. Repo~g
8. O~ t~e b~ 0[ lh~ ~formation coala~ed ~ this Repo~ modificafio~ p~ain~g therelo~ it ~. ~ my op~ion, ~ compliance
IMPORTANT NO TES: ~e instructions accompanying this form must be followed. Complete all parts, checkb~g the NONE box for each part where you have no reportable h~formz~ion. Sign on lastpage.
N~ME OF ORGA~ATION/ENTITY
3.
:-"-
Date of Repor~
III. N O N-I~STMENT INC OME. cn,vo,n,~ ~,a~,,~ ,.d ~o,~; ~,. ,~. 17-24 of filing ins~octio~.)
A. Filers Non-Investment Income ~NON~ ~o reportable non-invesonent income.) DA~,
1,
SOkNCE A~ ~E
~CO~
{yours, not
2. 3,
4.
B, Spouses Non-Investment Income - Jf~,ou ,w,e married during any portion of the reporting year, complete this section.
(Dollar amato~t not required except for honoraria.)
3, 4.
LOCATION
PU~OSE
4.
5.
Date
V.
~/NO2~E (No reportable ~J~s.) SOURCE I. 2. 3. 4. DESCRIPTION V _ALUE.
DISCLOSURE REPORT
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~+,~0 ~ ~.
Q =A~I
a~ o~,~o~
[ Name of P ....
Reporting
J Date of Repor~
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. I further certify that earned income from outside employment and honoraria and the acceptance of gifts which have been reported are in compliance with the provisions of 5 U.S.C. app. 501 et. seq., 5 U.S.C. 7353, and Judicial Conference regulations.
NOTE: ANY INDIVIDUAL WHO KNOWINGLY AND WILFULLY FALSIFIES OR FALLS TO b~LE THIS REPORT bLAY BE SUBJECI" TO CIVIL AND CKIMINAL SANC~IIONS (5 U.S.C. app. 104)