Income from Employment by Another *

Complete this section if you were a full or part time employee of any public or private organization and received compensation of $2,000 or more during the reporting period. Do not include information regarding self-employment, or the practice of law in this section.

• Job Title *

  Employer Name *

  Employer Mailing Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Business Activity Category of Employer *

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other
  Remove

Income from Self Employment *

Complete this section if you sold goods or provided services to others during the reporting year. If the amount you received from any client or customer was more than $2,000 or more than 10% of your gross income from self-employment during the year, whichever is greater, enter the name address, and principal type of economic business activity of the client or customer. If this type of disclosure is prohibited by law, rule, or an established code of professional ethics, specify only the principal type of economic or business activity of the client or customer.

• Business/Trade Name *

  Business Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Business Activity Category *

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other

  Client or Customer Name Optional

  Client or Customer Address

  Address Optional

  City Optional

  State Optional

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP Optional

  Client or Customer Business Activity Category Optional

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other
  Remove

Business Entities *

Complete this section by listing if you and/or members of your immediate family, directly or indirectly, own or control more than 5% of the outstanding equity of any corporation, partnership, limited liability company, or other business entity that had revenue of $2,000 or more in the reporting year.

• Business Name *

  Business Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Business Activity Category *

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other
  Remove

Income from Practice of Law *

Complete this section if you received income of $2,000 or more from the practice of law.

• Practice or Firm Name *

  Practice or Firm Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Major Practice Area *

  Select Administrative Law Banking and Securities Law Bankruptcy and Creditors' Rights Civil Legal Aid Civil Litigation Civil Rights Law Education Law Energy and Utilities Law Environmental and Land Use Law Family Law Government Relations Health Care Law Immigration Law Insurance Law Intellectual Property and Patent Law Labor and Employment Law Personal Injury Trusts and Estates and Tax Law Workers' Compensation and SSDI Other

  Position in Firm *

  Select Sole Practitioner Partner Shareholder Of Counsel Associate Other
  Remove

Compensation Income of Immediate Family Members *

Complete this section if you had immediate family members who received $2,000 or more in compensation income from employment during the reporting year. Include all sources of income received through employment by another, self-employment, the practice of law, or other forms of employment.

• Name of Family Member *

  For dependent children receiving income, do not include the dependent child’s name. Instead write “dependent” in this section.

  Job Title *

  Employer Name *

  Employer Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Business Activity of Employer *

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other
  Remove

Income from Any Other Source *

Complete this section by listing all other source of gross income of $2,000 or more that you or a family member received during the reporting year such as investments, sales of property, inheritance, or retirement benefits (e.g., Social Security, public or private pensions). Income does not include alimony, child support or similar support payments, campaign contributions, gifts, or honoraria. Income also does not include funds or other property held in trust for another such as fees that are paid in advance or money to be spent on behalf of a client for a licensing or filing fee.

• Source Name *

  Source Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Type of Income *

  Select Business Income Capital Gains Court Award or Settlement Payment Debt Discharge and Loan Forgiveness Inheritance Investment and Interest Income Real Estate Sales or Transfer Rental Income Retirement Plan or Pension and Annuity Scholarships including Fellowships or other Grants Social Security Benefits Trust Distribution Unemployment Compensation Other
  Remove

• Name of Family Member *

  For dependent children receiving income, do not include the dependent child’s name. Instead write “dependent” in this section.

  Source of Income Name *

  Source of Income Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Type of Income *

  Select Business Income Capital Gains Court Award or Settlement Payment Debt Discharge and Loan Forgiveness Inheritance Investment and Interest Income Real Estate Sales or Transfer Rental Income Retirement Plan or Pension and Annuity Scholarships including Fellowships or other Grants Social Security Benefits Trust Distribution Unemployment Compensation Other
  Remove

Unsecured Loans *

Complete this section by listing all loans of $3,000 or more that you recieved during the reporting year that was not secured by collateral. Do not enter mortgages, student loans or credit card debt in this section.

• Lender Name *

  Lender Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Business Activity Category of Lender *

  Select Advertising and Marketing Alcoholic Beverage Production and Sales Aquaculture Arts and Entertainment Cannabis Related Production and Sales Church and Other Religious Organizations Commercial Fishing and Lobstering Construction Education Farming and Agriculture Financial Services and Insurance Food Services and Hospitality Gambling Industry Government Relations Health Care Information Technology Legal Services Logging and Forestry Manufacturing Military Nursing and Residential Care Facilities Paper and Pulp Industry Professional and Business Services Property Development and Management Property Rental Real Estate Sales Retail Business Social Services State and Local Government Telecommunications Transportation Other
  Remove

Gifts, including Travel and Accommodations *

Complete this section by listing all gifts with a total value of more than $300 the you recieved from a single source during the reporting year. If a person or organization has spent more than $300 in the year to finance your travel, meals, or accommodations, those payments are considered gifts which must be reported.

• Source *

  Type of Gift *

  Select Conference (meals, lodging and travel) Travel and Lodging (other than conference) Meals (other than conference) Tangible Goods Monetary Other

  Description of Gift *
  Remove

Honoraria *

Complete this section by listing all sources of honoraria of $2,000 or more you received during the reporting year. “Honoraria” means a payment of money or anything with resale value received for an appearance or speech by you in your official capacity.

• Source of Honoraria *
  Remove

Positions in Political Action Committees, Ballot Question Committees, or Party Committees *

Complete this section by listing all political action committee, ballot question committee, or political party committee for which you or a member of your immediate family were the treasurer, a principal officer, fundraiser or decision-maker during the reporting year.

• Committee Name *

  Title in Committee *

  Select Advisory Board Member Chair Chief Executive Officer Chief Financial Officer Member - Board of Directors Member - LLC Partner President Secretary Treasurer Trustee Vice President Other
  Remove

• Committee Name *

  Title in Committee *

  Select Advisory Board Member Chair Chief Executive Officer Chief Financial Officer Member - Board of Directors Member - LLC Partner President Secretary Treasurer Trustee Vice President Other
  Remove

Business Conducted with State Agencies *

Complete this section by entering each State agency, board or commission to which you or an immediate family member or an associated organization rented, leased or sold goods or services for more than $10,000 during the reporting period.

• Name of Agency *

  Select Administrative and Financial Services Agriculture Conservation & Forestry Attorney General Commission on Indigent Legal Services Corrections Defense, Veterans and Emergency Management Economic & Community Development Education Environmental Protection Finance Authority of Maine Health and Human Services Inland Fisheries & Wildlife Labor Maine Human Rights Commission Maine Lottery Commission Maine State Housing Authority Marine Resources Office of the Public Advocate Professional & Financial Regulation Public Safety Public Utilities Commission Secretary of State Transportation Unemployment Insurance Commission Workers' Compensation Board Other

  Name of Individual or Organization Selling Goods or Services *

  Description of Goods or Services *
  Remove

Representing Others Before State Agencies *

• Name of Agency *

  Select Administrative and Financial Services Agriculture Conservation & Forestry Attorney General Commission on Indigent Legal Services Corrections Defense, Veterans and Emergency Management Economic & Community Development Education Environmental Protection Finance Authority of Maine Health and Human Services Inland Fisheries & Wildlife Labor Maine Human Rights Commission Maine Lottery Commission Maine State Housing Authority Marine Resources Office of the Public Advocate Professional & Financial Regulation Public Safety Public Utilities Commission Secretary of State Transportation Unemployment Insurance Commission Workers' Compensation Board Other

  Name of Individual Receiving Compensation *
  Remove

Positions in Organizations *

Complete this section by enter all for-profit or non-profit corporation, firm, association, limited liability company, partnership or business in which you and/or your family members held any office, trusteeship, directorship, or position of any nature in the reporting year. A clerk of a corporation or a registered agent authorized to receive service of any process, notice or other demand for a business entity is not considered a position with the corporation or business entity.

• Organization Name *

  Organization Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Position Title *

  Select

  Position received compensation?

  *

  Yes

  No
  Remove

• Organization Name *

  Organization Address

  Address *

  City *

  State *

  Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  ZIP *

  Name of Position Holder *

  Position Title *

  Select

  Relationship to Official *

  Select

  Position received compensation?

  *

  Yes

  No
  Remove