HomeMy WebLinkAboutFinancial Disclosure Statements - Annual - - 1/26/2022PUBLIC OFFICER AND CANDIDATE FINANCIAL DISCLOSURE STATEMENT
Name of Public Officer or Candidate:
!Joyce V. Clark
Address: Please note: this address is ublic information and not sub·ect to redaction
8628 W. Cavalier Drive, Glendale, AZ 85305
Public Office Held or Sought:
jcouncilmember
District I Division Number if a licable :
Yucca District, Glendale, AZ
Please check the appropriate box that reflects your service for this filing year:
~ I am a public officer filing this Financial Disclosure Statement covering the 12 months of calendar year 2021.
• I have been appointed to fill a vacancy in a public office within the last 60 days and am filing this Financial Disclosure Statement covering the
12-month period ending with the last full month prior to the date I took office.
• I am a public officer who has served in the last full year of my final term, which expires less than thirty-one days into calendar year
2022. This is my final Financial Disclosure Statement covering the last 12 months plus the final days of my term for the current year.
• I am a candidate for a public office and am filing this Financial Disclosure Statement covering the 12 months preceding the date of this
statement, from the month of ______ ~ to the month of _______ .
YEBIEICATION
By signing, I verify under penalty of perjury that the information provided in this Financial Disclosure Statement is true and correct.
ISi Joyce V. Clark
Signature of Public Officer or Candidate
(Electronic Signatures Accepted)
1/26/2022
Date
Secretary of State Revision August 12, 2021
A. PERSONAL FINANCIAL INTERESTS
This section requires disclosure of your financial interests and/or the financial interests of the member(s) of your household.1
1· Identification of Household Members and Business Interests
What to disclose: If you are married, is your spouse a member of your household? liiYes •No DN/A (If not married/widowed, select N/A)
Are any minor children 2 members of your household? •Yes (If yes, disclose how many__J iii No •NIA (If no children, select NIA)
For the remaining questions in this Financial Disclosure Statement, the term "member of your household" or "household member'' will be defined as
the person(s) who correspond to your "yes" answers above.
You are not required to disclose the names of your spouse or minor children when answering the questions below. Thus, you may identify your
household members as "spouse," "minor child 1 ", "minor child 2," etc. Please note that if you choose to identify your spouse or minor children
by name, the Secretary of State's Office or other local filing officer are not expected to redact that information when posting this Financial
Disclosure Statement on the internet or providing it in response to a public records request.
1 If additional space is needed to report information on this Financial Disclosure Statement, please attach additional information as numbered exhibits.
2 Minor children include children 18 years old and younger over whom you have joint or sole legal custody.
2
Secretary of State Revision August 12, 2021
2. Sources of Personal Compensation
What to disclose: In subsection (2)(a), provide the name and address of any employer and/or any other source of compensation who provided you
or any member of your household more than $1,000 (other than "Gifts") during the period covered by this report. 3 Describe the nature of each and
the type of services for which you or a member of your household were compensated.
Subsection 2 a:
PUBLIC OFFICER OR HOUSEHOLD
MEMBER4 BENEFITTED
NAME AND ADDRESS OF SOURCE WHO
PROVIDED COMPENSATION> $1,000
NATURE OF SOURCE OR
EMPLOYER'S BUSINESS
NATURE OF SERVICES PROVIDED BY PUBLIC OFFICER
OR HOUSEHOLD MEMBER
In subsection (2)(b), if applicable, list anything of value that any other person (outside your household) received for your, or a member of your
household's, use or benefit. For example, if a person was paid by a third-party to be your personal housekeeper, identify that person, describe the
nature of that person's services that benefited you, and provide information about the third-party who paid for the services on your behalf. You need
not disclose income of a business, including money you or any member of your household received that constitutes income paid to a business
that you or your household member owns or does business as. This type of business income will be disclosed in Question 12.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER5
BENEFITTED
NAME AND ADDRESS OF PERSON WHO
PROVIDED SERVICES VALUED OVER $1,000
FOR YOUR OR YOUR HOUSEHOLD MEMBER'S
USE OR BENEFIT
NATURE OF SERVICES
PROVIDED BY PERSON FOR
YOUR OR YOUR HOUSEHOLD
MEMBER'S USE OR BENEFIT
NAME AND ADDRESS OF THIRD PARTY WHO PAID
FOR PERSON'S SERVICES ON YOUR OR YOUR
HOUSEHOLD MEMBER'S BEHALF
3 Compensation is defined as "anything of value or advantage, present or prospective, including the forgiveness of debt." A.R.S. § 38-541 (2).
4 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
5 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1 ."
"minor child 2," etc.
3
Secretary of State Revision August 12, 2021
3. Professional, Occupational, and Business Licenses
What to disclose: List all professional, occupational or business licenses held by you or any member of your household at any time during
the period covered by this Financial Disclosure Statement. This includes licenses in which you or a member of your household had an
"interest," which includes (but is not limited to) any business license held by a "controlled" or "dependent" business as defined in Question
12 below.
PUBLIC OFFICER OR HOUSEHOLD
TYPE OF LICENSE PERSON OR ENTITY HOLDING THE JURISDICTION OR ENTITY THAT ISSUED
MEMBER6 LICENSE LICENSE
1'1o I~( -
-
6 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
4
Secretary of State Revision August 12, 2021
4. Personal Creditors
What to disclose: The name and address of each creditor to whom you or a member of your household owed a qualifying personal debt over
$1,000 during any point during the period covered by this Financial Disclosure Statement.
Additionally, if the qualifying personal debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check the applicable box to indicate whether it was incurred or discharged. Otherwise, check the box for "NIA" if the debt was not first incurred
or fully discharged during the period covered by this Financial Disclosure Statement.
You need run disclose the following, which W2.W2t qualify as "personal debt":
• Debts resulting from the ordinary conduct of a business (these will be disclosed in Section B below);
• Debts on any personal residence or recreational property;
• Debts on motor vehicles used primarily for personal purposes (not commercial purposes);
• Debts secured by cash values on life insurance;
• Debts owed to relatives;
Personal credit card transactions or the value of any retail installment contracts you or your household member entered into.
PUBLIC OFFICER OR HOUSEHOLD MEMBER 7
OWING THE DEBT
NAME AND ADDRESS OF CREDITOR (OR PERSON TO
WHOM PAYMENTS ARE MADE)
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE MM/DD/YYYY AND CHECK THE APPROPRIATE Box
Date: •Discharged ON/A
•Incurred •Discharged ON/A
7 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
5
Secretary of State Revision August 12, 2021
5. Personal Debtors
What to disclose: The name of each debtor who owed you or a member of your household a debt over $1,000 at any time during the period
covered by this Financial Disclosure Statement, along with the approximate value of the debt by financial category.
Additionally, if the debt was either incurred for the first time or completely discharged {paid in full) during this period, list the date and check the box
to indicate whether ii was incurred or discharged. Otherwise, check "N/A" (for "not applicable") after the word "Date" if the debt was not first incurred
or fully discharged during the period covered by this Financial Disclosure Statement.
PUBLIC OFFICER OR HOUSEHOLD
MEMBER8 OWED THE DEBT
No
NAME OF DEBTOR APPROXIMATE VALUE OF
DEBT
0$1000 -$25,00
0$25,001 -$100,000
0$100,001 +
0$1000-$25,000
0$25,001 -$100,000
0$100,001 +
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE MM/DD/YYYY AND CHECK THE APPROPRIATE Box
Date:
•Incurred
•Discharged ON/A
•Discharged ON/A
8 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
6
Secretary of State Revision August 12, 2021
6. Gifts
What to disclose: The name of the donor who gave you or a member of your household a single gift or an accumulation of gifts during the preceding
calendar year with a cumulative value over $500, subject to the exceptions listed in the below "You need .DQLdisclose" paragraph. A "gift" means a
gratuity (tip), special discount, favor, hospitality, service, economic opportunity, loan or other benefit received without adequate consideration (reciprocal
value) and not provided to members of the public at large (in other words, a personal benefit you or your household member received without providing
an equivalent benefit in return).
Please note: the concept of a "gift" for purposes of this Financial Disclosure Statement is separate and distinct from the gift restrictions outlined in
Arizona's lobbying statutes. Thus, disclosure in a lobbying report does not relieve you or a member of your household's duty to disclose gifts in this
Financial Disclosure Statement.
You need not disclose the following, which do not qualify as "gifts":
• Gifts received by will;
• Gift received by intestate succession (in other words, gifts distributed to you or a household member according to Arizona's intestate
succession laws, not by will);
• Gift distributed from an inter vivas (living) or testamentary (by will) trust established by a spouse or family member;
• Gifts received from any other member of the household;
• Gifts received by parents, grandparents, siblings, children and grandchildren; or
Political campaign contributions reported on campaign finance reports.
PUBLIC OFFICER OR HOUSEHOLD MEMBER9 WHO RECEIVED GIFTS OVER $500 NAME OF GIFT DONOR
9 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
7
Secretary of State Revision August 12, 2021
7. Office, Position or Fiduciary Relationship in Businesses, Nonprofit Organizations or Trusts
What to disclose: The name and address of each business, organization, trust or nonprofit organization or association in which you or any member
of your household held any office, position, or fiduciary relationship during the period covered by this Financial Disclosure Statement, including a
description of the office, position or relationship.
PUBLIC OFFICER OR HOUSEHOLD MEMBER 10 HAVING
THE REPORTABLE RELATIONSHIP
NAME AND ADDRESS OF BUSINESS, ORGANIZATION,
TRUST, OR NONPROFIT ORGANIZATION OR ASSOCIATION
DESCRIPTION OF OFFICE, POSITION OR
FIDUCIARY RELATIONSHIP HELD BY THE PUBLIC
OFFICER OR HOUSEHOLD MEMBER
10 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
8
Secretary of State Revision August 12, 2021
8. Ownership or Financial Interests in Businesses, Trusts or Investment Funds
What to disclose: The name and address of each business, trust, or investment fund in which you or any member of your household had an
ownership or beneficial interest of over $1,000 during the period covered by this Financial Disclosure Statement. This includes stocks, annuities,
mutual funds, or retirement funds. It also includes any financial interest in a limited liability company, partnership, joint venture, or sole proprietorship.
Also, check the box to indicate the value of the interest.
PUBLIC OFFICER OR HOUSEHOLD MEMBER 11 NAME AND ADDRESS OF BUSINESS, TRUST DESCRIPTION OF THE BUSINESS, TRUST OR APPROXIMATE EQUITY
HAVING INTEREST OR INVESTMENT FUND INVESTMENT FUND VALUE OF THE INTEREST
Joye.£ I{_ LLA1UL W ze-tJ U><<.. 1 Ho~\/A-T}---f'.e,u'?, j+ ec-o oi5T
JJ$1000 -$25,000
t..f 5 ex:::, ~ l--lt/Le ? ~(l___e ] ;,e,Je-0$25,001 -$100,000
Jlt,$100,001 +
:5ut-t'"'i:? c-oo 0$1000 -$25,000
'1e-M. l1e 1 It v fsZ,.'l2.-0$25,001 -$100,000
0$100,001 +
0$1000 -$25,000
0$25,001 -$100,000
0$100,001 +
11 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1 ,"
"minor child 2," etc.
9
Secretary of State Revision August 12, 2021
9. Ownership of Bonds
What to disclose: Bonds issued by a state or local government agency worth more than $1,000 that you or a member of your household held
during the period covered by this Financial Disclosure Statement. Also, check the box to indicate the approximate value of the bonds.
Additionally, if the bonds were either acquired for the first time or completely divested (sold in full) during this period, list the date and check the
box whether the bonds were acquired or divested. Otherwise, check "N/A" (for "not applicable") after the word "Date" if the bonds were not first
acquired or fully divested during the period covered by this Financial Disclosure Statement.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER 12 ISSUED
BONDS
ISSUING STATE OR LOCAL
GOVERNMENT AGENCY
APPROXIMATE VALUE OF
BONDS
0$1000 -$25,000
001 -$100,000
0$100,0
0$1000 -$25,000
0$25,001 -$100,000
0$100,001 +
0$1000 -$25,000
0$25,001 -$100,000
0$100,001 +
IF THE BONDS WERE FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDETHE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE Box
Date: •Divested ON/A
Date: •Acquired •Divested ON/A
12 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
10
Secretary of State Revision August 12, 2021
10.Real Property Ownership
What to disclose: Arizona real property (land and improvements), which was owned by you or a member of your household during the period
covered by this Financial Disclosure Statement, other than your primary residence or property you use for personal recreation. Also describe the
property's location (city and state) and approximate size (acreage or square footage) and check the box to indicate the approximate value of the
land.
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check the
box to indicate whether the land was acquired or divested. Otherwise, check "N/A" (for "not applicable") if the land was not first acquired or fully
divested during the period covered by this Financial Disclosure Statement.
You need not disclose: Your primary residence or property you use for personal recreation.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER 13 THAT
OWNS LAND
LOCATION AND APPROXIMATE
SIZE
APPROXIMATE VALUE
OF LAND
0$1000 -$25,000
0$25,001 -$100,000
-'-=,~• 001 +
IF THE LAND WAS FIRST ACQUIRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE Box
•Divested ON/A
0$1000 -$2 ,vv".---..J.-'"'~•~
0$25,001 -$100,000
0$100,001 +
0$1000 -$25,000
0$25,001 -$100,000
0$100,001 +
Date: •Acquired •Divested ON/A
13 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1 ,"
"minor child 2," etc.
11
Secretary of State Revision August 12, 2021
11.TravelExpenses
What to disclose: Each meeting, conference or other event during the period covered in this Financial Disclosure Statement where you
participated in your official capacity and travel-related expenses of $1,000 or more were paid on your behalf (or for which you were reimbursed)
for that meeting, conference, or other event. "Travel-related expenses" include, but are not limited to, the value of transportation, meals, and
lodging to attend the meeting, conference, or other event.
You need not disclose: Any meeting, conference, or other event where paid or reimbursed travel-related expenses were less than $1,000 or
your personal monies were expended related to the travel.
NAME OF MEETING, CONFERENCE, OR EVENT ATTENDED
IN OFFICIAL PACITY AS PUBLIC OFFICER LOCATION
12
AMOUNT OR VALUE OF
TRAVEL COSTS
0$1000 -$25,000
0$25,001 -$100,000
0$100,001 +
0$1000 -$25,000
0$25,001 -$100,000
1 +
0$1000 -$2 ,vvv---
O$25,001 -$100,000
0$100,001 +
Secretary of State Revision August 12, 2021
A. BUSINESS FINANCIAL INTERESTS
This section requires disclosure of any financial interests of a business owned by you or a member of your household.
12. Business Names
What to disclose: The name of any business under which you or any member of your household owns or did business under (in other words, if
you or your household member were self-employed) during the period covered by this Financial Disclosure Statement, which include any
corporations, limited liability companies, partnerships, sole proprietorships or any other type of business conducted under a trade name.
Also disclose if the named business is controlled or dependent. A business is "controlled" if you or any member of your household (individually or
combined) had an ownership interest that amounts to more than 50%. A business is classified as "dependent," on the other hand, if: (1) you or any
household member (individually or combined) had an ownership interest that amounts more than 10%; and (2) the business received more than
$10,000 from a single source during the period covered by this Financial Disclosure Statement, which amounted to more than 50% of the business'
gross income for the period.
Please note· If the business was either controlled or dependent, check the box to indicate whether it was controlled or dependent in the last column
below. If the business was both controlled and dependent during the period covered by this Financial Disclosure Statement, check both boxes.
Otherwise, leave the boxes in the last column below blank.
PUBLIC OFFICER OR HOUSEHOLD MEMBER 14
NAME AND ADDRESS OF BUSINESS CHECK THE APPROPRIATE Box IF THE BUSINESS IS "CONTROLLED"
;:lWNING THE BUSINESS BY OR "DEPENDENT" ON You OR A HOUSEHOLD MEMBER
f) ~\? -~ •Controlled •Dependent
' V I --•Controlled uue,.._ -•
•Controlled •Dependent
Please note: If a business listed in the foregoing Question 12 was neither "controlled" nor "dependent" during the period covered by this Financial
Disclosure Statement, you need not complete the remainder of this Financial Disclosure Statement with respect to that business. If none of the
businesses listed in Question 12 were "controlled" or "dependent," you need not complete the remainder of this Financial Disclosure Statement.
14 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1 ,"
"minor child 2," etc.
13
Secretary of State Revision August 12, 2021
13. Controlled Business Information
What to disclose: The name of each controlled business listed in Question 12 above, and the goods or services provided by the business. If a
single client or customer (whether a person or business) accounts for more than $10,000 and 25% of the business' gross income during the period
covered by this Financial Disclosure Statement, the client or customer is deemed a "major client" and therefore you must describe what your
business provided to this major client in the third column below. Also, if the major client is a business, please describe the client's type of business
activities in the final column below (but if the major client is an individual, write "N/A" for "not applicable" in the final column below). If the business
does not have a major client, write "N/A" for "not applicable" in the last two columns below.
You need not disclose: The name of any major client, or the activities of any major client that is an individual. If you or your household member
does not own a business, or if your or your household member's business is not a controlled business, you may leave this question blank.
GOODS OR SERVICES PROVIDED
BY THE CONTROLLED BUSINESS
DESCRIBE WHAT YOUR BUSINESS
PROVIDES TO ITS MAJOR CLIENT
14
TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CLIENT IF A BUSINESS
Secretary of State Revision August 12. 2021
14.Dependent Business Information
What to disclose: The name of each dependent business listed in Question 12 above, and the goods or services provided by the business. You
must describe what your business provided to its major "source of compensation"* in the third column below. Also, if the "source of compensation" is
a business, please describe the type of business activities it performs in the final column below (but if the "source of compensation" is an individual,
write "N/A" for "not applicable" in the final column below).
If the dependent business is also a controlled business, disclose the business only in Question 13 above and leave this question blank.
You need not disclose: The name of any "source of compensation," or the activities of any "source of compensation" that is an individual. If you or
your household member does not own a business, or if your or your household member's business is not a dependent business, you may leave this
question blank.
NAME OF YOUR OR YOUR
HOUSEHOLO MEMBER'S DEPENDENT
USINESS
GOODS OR SERVICES PROVIDED
BY THE DEPENDENT BUSINESS
DESCRIBE WHAT YOUR BUSINESS
PROVIDES TO SOURCE OF
COMPENSATION
TYPE OF BUSINESS ACTIVITIES OF
THE SOURCE OF COMPENSATION (IF A
BUSINESS
* For this section, "source of compensation" is defined as a person or a business that accounts for more than $10,000 and 50% of the dependent
business' gross income during the reporting period.
15
Secretary of State Revision August 12, 2021
15. Real Property Owned by a Controlled or Dependent Business
What to disclose: Arizona real property (land and improvements), which was owned by a controlled or dependent business during the
period covered by this Financial Disclosure Statement. Also describe the property's location (city and state) and approximate size (acreage
or square footage) and check the box to indicate the approximate value of the land. If the business is one that deals in real property and
improvements, check the box that corresponds to the aggregate value of all parcels held by the business during the period covered by this
Financial Disclosure Statement.
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check
whether the land was acquired or divested. Otherwise, check "N/A" (for "not applicable") if the land was not first acquired or fully divested during
the period covered by this Financial Disclosure Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is
not a dependent business, you may leave this question blank.
NAME OF CONTROLLED OR
DEPENDENT BUSINESS THAT OWNS
LAND
LOCATION AND APPROXIMATE
SIZE
APPROXIMATE VALUE OF
LAND
D$1000 -$25,
D$25,001 -$100,000
D$100,001 +
D$1000 -$25,000
D$25,001 -$100,000
D$100,001 +
16
IF THE LAND WAS FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE MM/DD/YYYY AND CHECK THE APPROPRIATE Box
Date: •Acquired •Divested ON/A
Date: •Acquired •Divested ON/A
Secretary of State Revision August 12, 2021
16. Controlled or Dependent Business' Creditors
What to disclose: The name and address of each creditor to which a controlled or dependent business owed more than $10,000, if that amount
was also more than 30% of the business' total indebtedness at any time during the period covered by this Financial Disclosure Statement
("qualifying business debt").
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the
date and check the box to indicate whether it was incurred or discharged. Otherwise, check "NIA" (for "not applicable") after the word "Date" if
the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is
not a controlled or dependent business, you may leave this question blank.
NAME AND ADDRESS OF CREDITOR (OR
PERSON TO WHOM PAYMENTS ARE MADE)
17
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
MM/DD/YYYY AND CHECK THE APPROPRIATE Box
Date:
•Incurred
•Incurred
•Discharged ON/A
ON/A
•Discharged ON/A
Secretary of State Revision August 12, 2021
17.Controlled or Dependent Business' Debtors
What to disclose: The name of each debtor who owed more than $10,000 to a controlled or dependent business, if that amount was also more
than 30% of the total indebtedness owed to the controlled or dependent business at any time during the period covered by this Financial Disclosure
Statement ("qualifying business debt"). Also check the box to indicate the approximate value of the debt by financial category.
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the
date and check the box to indicate whether it was incurred or discharged. Otherwise, check "N/A" (for "not applicable") if the business debt was
not first incurred or fully discharged during the period covered by this Financial Disclosure Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is
not a controlled or dependent business, you may leave this question blank.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER 15 OWED THE
DEBT
NAME OF DEBTOR APPROXIMATE VALUE
OF DEBT
D$1000 -$2 ,
D$25,001 -$100,000
D$100,001 +
D$1000 -$25,000
D$25,001 -$100,000
D$100,001 +
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE Box
Date:
•Incurred
Date:
•Incurred
•Discharged DN/A
•Discharged DN/A
15 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1,"
"minor child 2," etc.
18
Secretary of State Revision August 12, 2021