IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

IG > Financial Disclosure Statements > Financial Disclosure Statement Financial Disclosure Statement

State Form 40876 (R10 / 7-06)

For the Calendar Year  
(You are filing for the 2012 calendar year if you are filing to comply with the Feb. 1, 2013 deadline.)

 

Check if this is an amendment to your current statement.


Name (Last) Name (First) Name (Middle)
Spouse's Name (Last) Name (First) Name (Middle)
Office Address City Zip Code
Office Telephone Number Email Address (required)
( )

I am filing this statement as a (please select one):
candidate for office incumbent officeholder state employee

Office or Agency
Job Title

Each part must be answered. Words in bold italics are included in the definitions.

PART 1 - GIFTS

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the name and address of any person known to have a business relationship with the agency of the state officer or employee or the office sought by the candidate, and from whom the state officer, candidate, or the employee, or that individuals spouse or unemancipated children received a gift or gifts having a total fair market value in excess of one hundred dollars ($100).
Name (Last)
Address (City) Address (Zip)
Name (Last)
Address (City) Address (Zip)
Name (Last)
Address (City) Address (Zip)

PART - 2 REAL PROPERTY INTERESTS

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the location of all real property in which you, your spouse, or your unemancipated children have equitable or legal interest either amounting to five thousand dollars ($5,000) or more or comprising ten percent (10%) of your net worth or the net worth of your spouse or your unemancipated children. You need not include your residence unless it also serves as income property.
Property and its location
Property and its location
Property and its location

PART - 3 Non-State Employers

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the name of your employer(s) and the employer(s) of your spouse and the nature of each employer's business.

Your employer

Nature of business

Spouse's employer

Nature of business

PART 4 - SOLE PROPRIETORSHIP OR PROFESSIONAL PRACTICE

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List any sole proprietorship owned or professional practice operated by you or your spouse and the nature of the business.
Name of Your Business
Nature of Business
Name of Spouse's Business
Nature of Spouse's Business
Do any clients for these businesses listed above have a business relationship with your agency (or in the case of a candidate, with the office sought)?
Yes No
List the name of any client or customer from whom you or your spouse received more than thirty-three percent (33%) of your (or your spouses) non-state income in a year.

PART 5 - PARTNERSHIPS

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List any partnership in which you or your spouse is a member and the nature of the partnership business.
Name of Your partnership
Nature of partnership
Name of Spouse's partnership
Nature of Spouse's partnership

PART 6 - OFFICER OR DIRECTOR OF CORPORATION

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the name of any corporation in which you or your spouse is a officer or director and the nature of the corporation's business. Churches need not be listed.
Name of Corporation
Nature of Business
Name of Spouse's Corporation
Nature of Spouse's Business

PART 7 - STOCKHOLDER OF CORPORATION

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the name of any corporation in which you, your spouse, or your unemancipated children own stock or stock options having a fair market value in excess of ten thousand dollars ($10,000). A time or demand deposit in a financial institution or insurance policy need not be listed.
Name of corporation
 yours
 spouse's
 children
Name of corporation
Name of corporation

PART 8 - MOST RECENT EMPLOYER

(If you have information to report below, select YES. If no information, select NO.)

Yes
No

List the name and address of your most recent former employer.
Name of your most recent former employer
Address
Street:
City:
State:
Zip Code:

COMMENTS

Please place any comments in the fields below


AFFIRMATION

I swear or affirm, under the penalty of perjury, that the facts as presented on this Financial Disclosure Statement are true, complete, and correct to the best of my knowledge and belief.

I understand that I may file an amended statement upon discovery of additional information required to be reported.

I acknowledge awareness of Indiana Code 4-2-6-8(d) under which a failure to file in a timely manner or filing a deficient statement is subject to a civil penalty at the rate of not more than ten dollars ($10) for each day the statement remains delinquent or deficient. The maximum penalty under this subsection is one thousand dollars ($1,000). I also acknowledge awareness of Indiana Code 4-2-6-8(e) under which a person who intentionally or knowingly files a false statement commits a class A infraction.



INSTRUCTIONS

Each part must be answered. Incomplete statements will be returned. Please note that the statement must be affirmed and signed. Complete the form by printing legibly or typing. Bold italicized words in the form are defined below. Financial Disclosure Statements filed with the Office of the Inspector General are available for public inspection, photocopying, and possible access on the agency Web site [www.in.gov/ig].

WHO MUST FILE THIS FORM, AND WHEN

1) The Governor, Lieutenant Governor, Secretary of State, Auditor of State, Treasurer of State, Attorney General, and State Superintendent of Public Instruction, any person who is the appointing authority of an agency, the director of each division of the Department of Administration, any purchasing agent within the Procurement Division of the Department of Administration, any agency employee, special state appointee, former agency employee, or former special state appointee with final purchasing authority or an employee required to do so by rule adopted by the Inspector General must file this financial disclosure form no later than February 1 of every year.

2) Candidates for Governor, Lieutenant Governor, Secretary of State, Auditor of State, Treasurer of State, Attorney General, and Superintendent of Public Instruction must file this disclosure before filing a declaration of candidacy under IC 3-8-2, petition of nomination under IC 3-8-6, or declaration of intent to be a write-in candidate under IC 3-8-2-2.5, or before a certificate of nomination is filed under IC 3-8-7-8.

3) The persons listed in (1) above, must file not later than sixty (60) days after employment or taking office, unless the previous employment or office required the filing of a statement under this section.

4) The same persons required to file in (1) above must file not later than thirty (30) days after leaving employment or office, unless the subsequent employment or office requires the filing of a statement under this section.


DEFINITIONS OF TERMS USED IN THIS FORM

1) "Business relationship" includes the following:
(A) Dealings of a person with an agency seeking, obtaining, establishing, maintaining, or implementing:
(i) a pecuniary interest in a contract or purchase with the agency; or
(ii) a license or permit requiring the exercise of judgment or discretion by the agency.
(B) The relationship a lobbyist has with an agency.
(C) The relationship an unregistered lobbyist has with an agency.

2) "Employer" means any person from whom a state officer or employee or the officer's or employee's spouse received compensation (a customer or client of a self-employed individual in a sole proprietorship or a professional practice is not considered to be an employer).

3) "Gift" means the transfer or promise of a transfer of something of value regardless of the form without adequate and lawful consideration or consideration less than that required of others who are not state officers or employees, including the full or partial forgiveness of indebtedness, which is not extended to others who are not state employees on the same terms and conditions. However, "gift" does not include gifts from relatives of less than two hundred fifty dollars ($250) or campaign contributions subject to IC 3-9-2.

4) "Person" means any individual, proprietorship, partnership, unincorporated association, trust, business trust, group, limited liability company, or corporation, whether or not operated for profit, or a governmental agency or political subdivision.