III. Family Members: Please list all Dependent Children, Adult Children, Parents, Brothers and Sisters. (Attach Additional Sheets If Necessary) IV. Real Estate Holdings: (FOR CANDIDATES AND OFFICIALS ONLY) EXCLUDE YOUR HOMESTEAD. IF YOU OWN NO OTHER REAL ESTATE, CHECK NO FOR QUESTIONS A AND B. A. Do you or a business with which you are associated receive rent or lease income from any governmental agency in Alabama? B. NO If yes, you must attach specific details of the lease and submit them with this report. Do you, your spouse or dependents own real estate for investment or revenue purposes? NO YES. If yes, list each piece of real estate separately and provide the requested information. (Attach Additional Sheets If Necessary) V. Professional or Consulting Services: To be completed by those individuals who have received income in return for professional activities. State the number of clients and check the appropriate blocks. 90-971 O 77 - 35 VI. Statement of Indebtedness A. 1. Exclude indebtedness for the mortgage on the home in which you live. 2. Report debts owed to all businesses operating in Alabama on December 31. Include debts of your spouse and dependent children. (Name of Reporting Person) Statement of Economic Interests, Form ASEC-1 (Revised), and do swear (or affirm) that the information contained in said Statement of Economic Interests is true and correct. I fully understand that anyone who violates any provision of Alabama Act No. 130 of the Regular Session of the Alabama Legislature, 1975, shall be subject to a fine of not more than $10,000 or to im prisonment for not more than 10 years or both. FOR OFFICE USE ONLY Date Received: Preliminary Check By: Date: Signed: |