SUPPLEMENTAL STATEMENT OF FINANCIAL INTEREST

SUPPLEMENTAL STATEMENT OF FINANCIAL INTEREST

INSTRUCTIONS: Please type or print legibly. This form supplements the Statement of Financial Interest form issued by the State Ethics Commission and is required by the Reading Board of Ethics.

First Name*

Initial

Last Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Position with the City*

Phone Number*

Email Address*

Real Estate Interest: List addresses of any property in the City of Reading in which you, your souse, or any member of your immediate family have any ownership interest.

Do you use a City vehicle?*

YESNO

If yes, do you report mileage as required?*

YESNO

Do you own or manage a business that does business with the City?*

YESNO

On a separate sheet, please list the names and addresses of the businesses, the goods or services provided, and the amount of the revenue received annually. Then upload that sheet here (we except Word and/or PDF format.)

Do you use a City credit card?*

YESNO

If yes, do you follow the City’s credit card policies?*

YESNO

Have you made any donations to a City election campaign?*

YESNO

On a separate sheet, please list the candidates and the amounts contributed. Then upload that sheet here (we except Word and/or PDF format.)

The undersigned hereby affirms that the foregoing information is true and correct to the best of said persons knowledge, information and belief, said affirmation being made subject to the penalties prescribed by 18 Pa. C.S.A. s4904 (unsworn falsifications to authorities).

Signature*

Date*

Date

ALL statements of Financial Interest are available for public inspection and copying during regular office
hours.