If the answer is yes, please describe the nature of the business transaction:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Were you or any of your family members indebted to pay money to ______________________________________
At any time in the past year?
___ Yes ___ No
If the answer is yes, please describe the nature of the indebtedness:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
In the past year have you or any member of your family become entitled to receive any personal benefits from _________________________________ or as a
result of your relationship with ____________________________
that an aggregate amount of more than $1,000 that was not a result of compensation was given to you by _________________________________ that was not
directly related to your duties?
___ Yes ___ No
If the answer is yes, please describe the nature of the benefit:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you or any of your family members involved with any legal proceeding involving _________________________
___ Yes ___ No
If the answer is yes, please describe the nature of the services or property that was provided:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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