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19 subdivision, state the name of the purchasing 20 political subdivision. The amount of commission 21 earned is not required to be listed. 22 1_____________________________________________________ 23 2_____________________________________________________ 24 3_____________________________________________________ 25 4_____________________________________________________ 26 5_____________________________________________________ 27 6_____________________________________________________ 28 Division III. Sources of Gross Income. 29 In each one of the following categories list each 30 source which produces more than $1,000 in annual gross Page 19 1 income, if the revenue produced by the source was 2 subject to federal or state income taxes last year. 3 List the nature or type of each company, business, 4 financial institution, corporation, partnership, or 5 other entity which produces more than $1,000 of annual 6 gross income. Neither the amount of income produced 7 nor value of the holding is required to be listed in 8 any of the items. 9 A. Securities: State the nature of the business of 10 any company in which you hold stock, bonds, or other 11 pecuniary interests that generate more than $1,000 in 12 annual gross income. Income generated by multiple 13 holdings in a single company are deemed received from 14 a single source. 15 ______________________________________________________ 16 ______________________________________________________ 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 B. Instruments of Financial Institutions: State the 22 types of institutions in which you hold financial 23 instruments, such as certificates of deposit, savings 24 accounts, etc., that produce annual gross income in 25 excess of $1,000, e.g., banks, savings and loans, or 26 credit unions. 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 ______________________________________________________ Page 20 1 ______________________________________________________ 2 ______________________________________________________ 3 C. Trusts: State the nature or type of any trust 4 from which you receive more than $1,000 of gross 5 income annually.
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