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SCHEDULE IEARNED INCOME (INCLUDING HONORARIA)Name [})\)U$lti
Page iL*k_
List the source, type, and amount of earned income, including
honoraria, from any source (other than your current employment by
the U.S. Government) totalling
$200 or more during the current year to the filing date and,
separately, the preceding calendar year. For a spouse, list the
source and amount of any honorana;
list only the source for other spouse earned income exceeding
$1,000.
Sourc e (include date of receipt lor honoraria) Type^ O C Amount
i ^ c j
Sourc e (include date of receipt lor honoraria) Type Current
Year to Filing Preceding Year
Examples:
XYZ Corporation, Houston, Texas Salary $8,300 $28,450
Examples: First Bank & Trust. Houston, TexasDirector's Fee
$400 $3,200
Examples:XYZ Trade Association, Chicago. IL. (Rec'd Dec. 2)
Honorarium 0 $1,000
Examples:
Harris Countv. Texas. Public Schools Spouse Salary NA NA
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SCHEDULE II ASSETS AND "UNEARNED" INCOMENams VOuuSf/tf Page
M
BLOCKA
Asset and/or Income SourceIdentify (a) each asset held tor
investment orproduction of Income with a fair marks! valueexceeding
$1,000 at the end of the reportingperiod, and (b) any other asset
or source of
income which generated mora than $200 In"unearned" income during
the year. For rentalproperty or land, provide an address.
Providefull names of any mutual funds. For a self-directed IRA
(i.e., one where you have thepower to select ihe specific
Investments),provide information on each asset in theaccount that
exceeds the reporting threshold,and the income earned for ihe
account. For anIRA or retirement pla n that Is not
self-directed,name tha institution holding the account andprovide
its value at the end of the reportingperiod. For an active business
that Is notpublicly traded. In Block A state Ihe nature oltha
business and its geographic locailon. Foradditiona l Informa tion,
sse the Instructionbooklet for the reporting year.
Exclude ; Your personal residence(t) (unlessthere la rental
Income); any debt owed to youby your spouse, or by your or your
spouse'schild, parent, or sibling; any deposits totaling$5,000 or
less in personal savings accounts;any linancial interests in or
Income derivedfro m U.S. Gove rnme nt retirement programs .
If you no choose, you may Indicate that anasset or Income source
Is that *>'uttT$
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indefinite!
8
BLOCK C
T y p e o f I n c o m e
Check all that apply.
Leave blank if asset did not
generate any Income dur ing
the reporting period.
*
Y
m
B L O C K D
Amount of IncomeFor retirement plans or accounts (hut du
not allow you to choose specific
investments, you may write "NA" for
income. For an other assets, indicate th e
category of Income by checking the
appropriate box below. Dividends, even
If reinvested, should be listed as Income.
Check "None" i f an asset did nut
generate any income tor a reporting year.
Current Year
Royal las
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Preceding Year
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