(5 ILCS 420/4A-103) (from Ch. 127, par. 604A-103)

Sec. 4A-103. The statement of economic interests required by this Article to be filed with the Secretary of State or county clerk shall be verified, dated, and signed by the person making the statement and shall contain substantially the following:

STATEMENT OF ECONOMIC INTERESTS

INSTRUCTIONS:

You may find the following documents helpful to you in completing this form:

(1) federal income tax returns, including any related schedules, attachments, and forms; and

(2) investment and brokerage statements.

To complete this form, you do not need to disclose specific amounts or values or report interests relating either to political committees registered with the Illinois State Board of Elections or to political committees, principal campaign committees, or authorized committees registered with the Federal Election Commission.

The information you disclose will be available to the public.

You must answer all 6 questions. Certain questions will ask you to report any applicable assets or debts held in, or payable to, your name; held jointly by, or payable to, you with your spouse; or held jointly by, or payable to, you with your minor child. If you have any concerns about whether an interest should be reported, please consult your department's ethics officer, if applicable.

Please ensure that the information you provide is complete and accurate. If you need more space than the form allows, please attach additional pages for your response. If you are subject to the State Officials and Employees Ethics Act, your ethics officer must review your statement of economic interests before you file it. Failure to complete the statement in good faith and within the prescribed deadline may subject you to fines, imprisonment, or both.

BASIC INFORMATION:

Name:..........................................................................................................................................

Job title:...................................................................................................................................

Office, department, or agency that requires you to file this form:...............................................

Other offices, departments, or agencies that require you to file a Statement of Economic Interests form: .

Full mailing address:..................................................................................................................

Preferred e-mail address (optional):............................................................................................

QUESTIONS:

1. If you have any single asset that was worth more than $10,000 as of the end of the preceding calendar year and is held in, or payable to, your name, held jointly by, or payable to, you with your spouse, or held jointly by, or payable to, you with your minor child, list such assets below. In the case of investment real estate, list the city and state where the investment real estate is located. If you do not have any such assets, list "none" below.

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2. Excluding the position for which you are required to file this form, list the source of any income in excess of $7,500 required to be reported during the preceding calendar year. If you sold an asset that produced more than $7,500 in capital gains in the preceding calendar year, list the name of the asset and the transaction date on which the sale or transfer took place. If you had no such sources of income or assets, list "none" below.

3. Excluding debts incurred on terms available to the general public, such as mortgages, student loans, and credit card debts, if you owed any single debt in the preceding calendar year exceeding $10,000, list the creditor of the debt below. If you had no such debts, list "none" below.

List the creditor for all applicable debts owed by you, owed jointly by you with your spouse, or owed jointly by you with your minor child. In addition to the types of debts listed above, you do not need to report any debts to or from financial institutions or government agencies, such as debts secured by automobiles, household furniture or appliances, as long as the debt was made on terms available to the general public, debts to members of your family, or debts to or from a political committee registered with the Illinois State Board of Elections or any political committee, principal campaign committee, or authorized committee registered with the Federal Election Commission.

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4. List the name of each unit of government of which you or your spouse were an employee, contractor, or office holder during the preceding calendar year other than the unit or units of government in relation to which the person is required to file and the title of the position or nature of the contractual services.

5. If you maintain an economic relationship with a lobbyist or if a member of your family is known to you to be a lobbyist registered with any unit of government in the State of Illinois, list the name of the lobbyist below and identify the nature of your relationship with the lobbyist. If you do not have an economic relationship with a lobbyist or a family member known to you to be a lobbyist registered with any unit of government in the State of Illinois, list "none" below.

6. List the name of each person, organization, or entity that was the source of a gift or gifts, or honorarium or honoraria, valued singly or in the aggregate in excess of $500 received during the preceding calendar year and the type of gift or gifts, or honorarium or honoraria, excluding any gift or gifts from a member of your family that was not known to be a lobbyist registered with any unit of government in the State of Illinois. If you had no such gifts, list "none" below.

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7. List the name of any spouse or immediate family member living with the person making this statement employed by a public utility in this State and the name of the public utility that employs the relative.

VERIFICATION:

"I declare that this statement of economic interests (including any attachments) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement is a fine not to exceed $2,500 or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment."

Printed Name of Filer:.................................................................................................................

Date:..........................................................................................................................................

Signature:...................................................................................................................................

If this statement of economic interests requires ethics officer review prior to filing, the applicable ethics officer must complete the following:

CERTIFICATION OF ETHICS OFFICER REVIEW:

"In accordance with law, as Ethics Officer, I reviewed this statement of economic interests prior to its filing."

Printed Name of Ethics Officer:...................................................................................................

Date:..........................................................................................................................................

Signature:...................................................................................................................................

Preferred e-mail address (optional):............................................................................................

(Source: P.A. 102-662, eff. 9-15-21; 102-664, eff. 1-1-22.)