House Resolution 7 - Introduced HOUSE RESOLUTION NO. 7 BY COMMITTEE ON ETHICS (SUCCESSOR TO HSB 15) A Resolution relating to the House code of ethics. 1 BE IT RESOLVED BY THE HOUSE OF REPRESENTATIVES, That 2 the House Code of Ethics shall be as follows: 3 HOUSE CODE OF ETHICS 4 PREAMBLE. Every legislator and legislative employee 5 has a duty to uphold the integrity and honor of the 6 general assembly, to encourage respect for the law and 7 for the general assembly, and to observe the house code 8 of ethics. The members and employees of the house 9 have a responsibility to conduct themselves so as to 10 reflect credit on the general assembly, and to inspire 11 the confidence, respect, and trust of the public. The 12 following rules are adopted pursuant to chapter 68B of 13 the Code, to assist the members and employees in the 14 conduct of their activities: 15 1. DEFINITIONS. The definitions of terms provided 16 in chapter 68B of the Code apply to the use of those 17 terms in these rules. 18 2. ECONOMIC INTEREST OF MEMBER OR EMPLOYEE OF 19 HOUSE. 20 a. Economic or investment opportunity. A member 21 or employee of the house shall not solicit or accept 22 economic or investment opportunity under circumstances 23 where the member or employee knows, or should know, 24 that the opportunity is being afforded with the intent 25 to influence the member’s or employee’s conduct in 26 the performance of official duties. If a member 27 -1- LSB 1353HV (2) 84 tm/rj 1/ 22

H.R. 7 or employee of the house learns that an economic 1 or investment opportunity previously accepted was 2 offered with the intent of influencing the member’s or 3 employee’s conduct in the performance of the official 4 duties, the member or employee shall take steps to 5 divest that member or employee of that investment or 6 economic opportunity, and shall report the matter 7 in writing to the chairperson of the house ethics 8 committee. 9 b. Excessive charges for services, goods, or 10 property interests. A member or employee of the 11 house shall not charge to or accept from a person 12 known to have a legislative interest, a price, fee, 13 compensation, or other consideration for the sale or 14 lease of any property or the furnishing of services 15 which is in excess of that which the member or employee 16 would ordinarily charge another person. 17 c. Use of confidential information. A member or 18 employee of the house, in order to further the member’s 19 or employee’s own economic interests, or those of any 20 other person, shall not disclose or use confidential 21 information acquired in the course of the member’s or 22 employee’s official duties. For the purpose of this 23 rule, information disclosed in open session at a public 24 meeting and information that is a public record is not 25 confidential information. 26 d. Employment. A member or employee of the 27 house shall not accept employment, either directly 28 or indirectly, from a political action committee. A 29 member of the house shall not act as a paid lobbyist 30 -2- LSB 1353HV (2) 84 tm/rj 2/ 22

H.R. 7 for any organization. However, this paragraph shall 1 not prohibit a member or employee of the house from 2 working for a candidate’s committee, a political 3 party’s action committee, or a political action 4 committee which does not expressly advocate the 5 nomination, election, or defeat of a candidate for 6 public office in this state or expressly advocate the 7 passage or defeat of a ballot issue in this state and 8 which is not interested in issues before the general 9 assembly. 10 For the purpose of this rule, a political action 11 committee means a committee, but not a candidate’s 12 committee, which accepts contributions, makes 13 expenditures, or incurs indebtedness in the aggregate 14 of more than seven hundred fifty dollars in any one 15 calendar year to expressly advocate the nomination, 16 election, or defeat of a candidate for public office or 17 to expressly advocate the passage or defeat of a ballot 18 issue or for the purpose of influencing legislative 19 action. 20 e. A member or employee of the house shall not 21 solicit employment on behalf of the member or employee, 22 or on behalf of another legislator or employee, as a 23 lobbyist while the general assembly is in session. 24 f. Certain goods or services. A member or employee 25 of the house shall not solicit or obtain goods or 26 services from another person under circumstances where 27 the member or employee knows or should know that the 28 goods or services are being offered or sold with the 29 intent to influence the member’s or employee’s conduct 30 -3- LSB 1353HV (2) 84 tm/rj 3/ 22

H.R. 7 in the performance of official duties. If a member or 1 employee of the house is afforded goods or services 2 by another person at a price that is not available to 3 other members or classes of members of the general 4 public or is afforded goods or services that are 5 not available to other members or classes of members 6 of the general public by another person where the 7 member or employee knows or should know that the other 8 person intends to influence the member’s or employee’s 9 official conduct, the member or employee shall not take 10 or purchase the goods or services. 11 3. APPEARANCE BEFORE STATE AGENCY. A member or 12 employee of the house may appear before a state agency 13 in any representation case but shall not act as a 14 lobbyist with respect to the passage, defeat, approval, 15 veto, or modification of any legislation, rule, or 16 executive order. Whenever a member or employee of 17 the house appears before a state agency, the member 18 or employee shall carefully avoid all conduct which 19 might in any way lead members of the general public 20 to conclude that the member or employee is using the 21 member’s or employee’s official position to further the 22 member’s or employee’s professional success or personal 23 financial interest. 24 4. CONFLICTS OF INTEREST. In order for the general 25 assembly to function effectively, members of the house 26 may be required to vote on bills and participate in 27 committee work which will affect their employment and 28 other areas in which they may have a monetary interest. 29 Action on bills and committee work which furthers a 30 -4- LSB 1353HV (2) 84 tm/rj 4/ 22

H.R. 7 member’s specific employment, specific investment, or 1 other specific interest, as opposed to the interests of 2 the public in general or the interests of a profession, 3 trade, business, or other class of persons, shall be 4 avoided. In making a decision relative to a member’s 5 activity on particular bills or in committee work, the 6 following factors should be considered: 7 a. Whether a substantial threat to the member’s 8 independence of judgment has been created by the 9 conflict situation. 10 b. The effect of the member’s participation on 11 public confidence in the integrity of the general 12 assembly. 13 c. Whether the member’s participation is likely to 14 have any significant effect on the disposition of the 15 matter. 16 d. The need for the member’s particular 17 contribution, such as special knowledge of the subject 18 matter, to the effective functioning of the general 19 assembly. 20 If a member decides not to participate in committee 21 work or to abstain from voting because of a possible 22 conflict of interest, the member should disclose 23 this fact to the legislative body. The member shall 24 not vote on any question in which the member has an 25 economic interest that is distinguishable from the 26 interests of the general public or a substantial class 27 of persons. 28 5. STATUTORY REQUIREMENTS. Members and employees 29 of the house shall comply with the requirements 30 -5- LSB 1353HV (2) 84 tm/rj 5/ 22

H.R. 7 contained in chapters 68B ( Conflicts of Interest of 1 Public Officers and Employees Government Ethics and 2 Lobbying ), 721 (Official Misconduct), and 722 (Bribery 3 and Corruption), and sections 2.18 (Contempt) and 711.4 4 (Extortion) of the Code. 5 6. CHARGE ACCOUNTS. Members and employees of the 6 house shall not charge any amount or item to a charge 7 account to be paid for by a lobbyist or any client of 8 a lobbyist. 9 7. TRAVEL EXPENSES. A member or employee of the 10 house shall not charge to the state of Iowa amounts 11 for travel and expenses unless the member or employee 12 actually has incurred those mileage and expense costs. 13 Members or employees shall not file the vouchers for 14 weekly mileage reimbursement required by section 2.10, 15 subsection 1 of the Code, unless the travel expense was 16 actually incurred. 17 A member or employee of the house shall not file 18 a claim for per diem compensation for a meeting of 19 an interim study committee or a visitation committee 20 unless the member or employee attended the meeting. 21 However, the speaker may waive this provision and allow 22 a claim to be filed if the member or employee attempted 23 to attend the meeting but was unable to do so because 24 of circumstances beyond the member’s or employee’s 25 control. 26 8. GIFTS ACCEPTED OR RECEIVED. Members and 27 employees of the house shall comply with the 28 restrictions relating to the receipt or acceptance of 29 gifts contained in section 68B.22 of the Code. 30 -6- LSB 1353HV (2) 84 tm/rj 6/ 22

H.R. 7 9. HONORARIA RESTRICTIONS. Members and employees 1 of the house shall comply with the restrictions 2 relating to the receipt of honoraria contained in 3 section 68B.23 of the Code. 4 10. DISCLOSURE REQUIRED. Each member of the 5 house and the chief clerk of the house shall file the 6 personal financial disclosure statements required under 7 section 68B.35 of the Code by February 15 of each year 8 for the prior calendar year. 9 11. SEXUAL HARASSMENT. Members and employees of 10 the house shall not engage in conduct which constitutes 11 sexual harassment as defined in section 19B.12 of 12 the Code or pursuant to the sexual harassment policy 13 adopted by the house committee on administration and 14 rules. 15 12. COMPLAINTS. 16 a. Filing of complaint. Complaints may be filed by 17 any person believing that a member or employee of the 18 house, a lobbyist, or a client of a lobbyist is guilty 19 of a violation of the house code of ethics, the house 20 rules governing lobbyists, or chapter 68B of the Code. 21 b. Complaints by committee. The ethics committee 22 may initiate a complaint on its own motion. Committee 23 complaints may be initiated by the committee as a 24 result of a committee investigation or as a result of 25 receipt of any complaint or other information that does 26 not meet the requirements of these rules regarding the 27 form of a complaint but that contains allegations that 28 would form the basis for a valid complaint. 29 c. Form and contents of complaint. A complaint 30 -7- LSB 1353HV (2) 84 tm/rj 7/ 22

H.R. 7 shall be in writing. 1 Complaint forms shall be available from the chief 2 clerk of the house, but a complaint shall not be 3 rejected for failure to use the approved form if it 4 complies with the requirements of these rules. The 5 complaint shall contain a certification made by the 6 complainant, under penalty of perjury, that the facts 7 stated in the complaint are true to the best of the 8 complainant’s knowledge. 9 To be valid, a complaint shall allege all of the 10 following: 11 (1) Facts, that if true, establish a violation of a 12 provision of chapter 68B of the Code, the house code of 13 ethics, or house rules governing lobbyists for which 14 penalties or other remedies are provided. 15 (2) That the conduct providing the basis for the 16 complaint occurred within three years of the filing of 17 the complaint. 18 (3) That the party charged with a violation is 19 a party subject to the jurisdiction of the ethics 20 committee. 21 d. Confidentiality of complaint. The filing of the 22 complaint identity of the parties and the contents of 23 the complaint shall be confidential until the time that 24 the committee meets to determine whether the complaint 25 is valid, unless either the complainant or the party 26 charged in the complaint makes the existence identity 27 of the parties , or the information contained in, the 28 complaint public. However, if either the complainant 29 or party alleged to have committed the violation 30 -8- LSB 1353HV (2) 84 tm/rj 8/ 22

H.R. 7 requests that the meeting to determine whether the 1 complaint is valid be a closed meeting and the filing 2 identity of the complaint parties or the contents of 3 the complaint have not been disclosed, the meeting 4 shall be closed. 5 e. Notice of complaint. Upon receipt of the 6 complaint, the chief clerk of the house shall promptly 7 notify the chairperson and ranking member of the 8 ethics committee that a complaint has been filed and 9 provide both the chairperson and the ranking member 10 with copies of the complaint and any supporting 11 information. Within two working days, the chief clerk 12 shall send notice, either by personal delivery or by 13 certified mail, return receipt requested, to the person 14 or persons alleged to have committed the violation, 15 along with a copy of the complaint and any supporting 16 information. The notice to the accused person shall 17 contain a request that the person submit a written 18 response to the complaint within ten working days of 19 the date that the notice was sent by the chief clerk. 20 At the request of the accused person, the committee may 21 extend the time for the response, not to exceed ten 22 additional calendar days. 23 f. Hearing regarding validity of complaint. The 24 committee chairperson and the ranking member shall 25 review the complaint and supporting information to 26 determine whether the complaint meets the requirements 27 as to form. If the complaint is deficient as to form, 28 the complaint shall be returned to the complainant 29 with instructions indicating the deficiency unless the 30 -9- LSB 1353HV (2) 84 tm/rj 9/ 22

H.R. 7 committee decides to proceed on its own motion. If the 1 complaint is in writing and contains the appropriate 2 certification, as soon as practicable, the chairperson 3 shall call a meeting of the committee to review the 4 complaint to determine whether the complaint meets the 5 requirements for validity and whether the committee 6 should take action on the complaint pursuant to 7 paragraph “g” or whether the committee should request 8 that the chief justice of the supreme court appoint an 9 independent special counsel to conduct an investigation 10 to determine whether probable cause exists to believe 11 that a violation of the house code of ethics, house 12 rules governing lobbyists, or chapter 68B of the Code, 13 has occurred. 14 If the committee finds that a complaint does not 15 meet the content requirements for a valid complaint, 16 the committee shall dismiss the complaint and notify 17 both the complainant and the party alleged to have 18 committed the violation of the dismissal and the 19 reasons for dismissal. A dismissal for failure to meet 20 the formal requirements for the filing of a complaint 21 shall be without prejudice and the complainant may 22 refile the complaint at any time within three years of 23 the date that the alleged violation took place. If 24 the dismissal is based upon a failure to allege facts 25 and circumstances necessary for a valid complaint, the 26 dismissal shall be with prejudice and the party shall 27 not be permitted to file a complaint based upon the 28 same facts and circumstances. 29 g. If the committee determines a complaint is 30 -10- LSB 1353HV (2) 84 tm/rj 10/ 22

H.R. 7 valid and determines no dispute exists between the 1 parties regarding the material facts that establish 2 a violation, the committee may take action on the 3 complaint under this paragraph without requesting the 4 appointment of an independent special counsel. 5 The committee may do any of the following: 6 (1) Issue an admonishment to advise against the 7 conduct that formed the basis for the complaint and to 8 exercise care in the future. 9 (2) Issue an order to cease and desist the conduct 10 that formed the basis for the complaint. 11 (3) Make a recommendation to the house that 12 the person subject to the complaint be censured or 13 reprimanded. 14 h. Request for appointment of independent special 15 counsel. If, after review of the complaint and any 16 response made by the party alleged to have committed 17 the violation, the committee determines that the 18 complaint meets the requirements for form and content 19 and the committee has not taken action under paragraph 20 “g”, the committee shall request that the chief justice 21 of the supreme court appoint independent special 22 counsel to investigate the matter and determine whether 23 probable cause exists to believe that a violation of 24 chapter 68B of the Code, the house code of ethics, or 25 the house rules governing lobbyists has occurred. 26 i. Receipt of report of independent special 27 counsel. The report from the independent special 28 counsel regarding probable cause to proceed on a 29 complaint shall be filed with the chief clerk of the 30 -11- LSB 1353HV (2) 84 tm/rj 11/ 22

H.R. 7 house. Upon receipt of the report of the independent 1 special counsel, the chief clerk shall notify the 2 chairperson of the filing of the report and shall send 3 copies of the report to the members of the ethics 4 committee. As soon as practicable after the filing of 5 the report, the chairperson shall schedule a public 6 meeting for review of the report. The purpose of 7 the public meeting shall be to determine whether the 8 complaint should be dismissed, whether a formal hearing 9 should be held on the complaint, or whether other 10 committee action is appropriate. The complainant and 11 the person alleged to have committed the violation 12 shall be given notice of the public meeting, shall have 13 the right to be present at the public meeting, and may, 14 at the discretion of the committee, present testimony 15 in support of or against the recommendations contained 16 in the report. 17 If the committee determines that the matter should 18 be dismissed, the committee shall cause an order to 19 be entered dismissing the matter and notice of the 20 dismissal shall be given to the complainant and the 21 party alleged to have committed the violation. If 22 the committee determines that the complaint should be 23 scheduled for formal hearing, the committee shall issue 24 a charging statement which contains the charges and 25 supporting facts that are to be set for formal hearing 26 and notice shall be sent to the complainant and the 27 accused person. 28 The notice shall include a statement of the nature 29 of the charge or charges, a statement of the time and 30 -12- LSB 1353HV (2) 84 tm/rj 12/ 22

H.R. 7 place of hearing, a short and plain statement of the 1 facts asserted, and a statement of the rights of the 2 accused person at the hearing. 3 j. Formal hearing. Formal hearings shall be public 4 and conducted in the manner provided in section 68B.31, 5 subsection 8 of the Code. At a formal hearing the 6 accused shall have the right to be present and to 7 be heard in person and by counsel, to cross-examine 8 witnesses, and to present evidence. Members of 9 the committee shall also have the right to question 10 witnesses. 11 The committee may require, by subpoena or otherwise, 12 the attendance and testimony of witnesses and the 13 production of such books, records, correspondence, 14 memoranda, papers, documents, and any other things it 15 deems necessary to the conduct of the inquiry. 16 Evidence at the formal hearing shall be received 17 in accordance with rules and procedures applicable to 18 contested cases under chapter 17A of the Code. 19 The committee chairperson, or the vice chairperson 20 or ranking member in the absence of the chairperson, 21 shall preside at the formal hearing and shall rule on 22 the admissibility of any evidence received. The ruling 23 of the chairperson may be overturned by a majority 24 vote of the committee. Independent special counsel 25 shall present the evidence in support of the charge 26 or charges. The burden shall be on the independent 27 special counsel to prove the charge or charges by 28 a preponderance of clear and convincing evidence. 29 Upon completion of the formal hearing, the committee 30 -13- LSB 1353HV (2) 84 tm/rj 13/ 22

H.R. 7 shall adopt written findings of fact and conclusions 1 concerning the merits of the charges and make its 2 report and recommendation to the house. 3 k. Disqualification of member. Members of the 4 committee may disqualify themselves from participating 5 in any investigation of the conduct of another person 6 upon submission of a written statement that the member 7 cannot render an impartial and unbiased decision 8 in a case. A member may also be disqualified by a 9 unanimous vote of the remaining eligible members of the 10 committee. 11 A member of the committee is ineligible to 12 participate in committee meetings, as a member of the 13 committee, in any proceeding relating to the member’s 14 own official conduct. 15 If a member of the committee is disqualified or 16 ineligible to act, the majority or minority leader who 17 appointed the member shall appoint a replacement member 18 to serve as a member of the committee during the period 19 of disqualification or ineligibility. 20 k. l. Recommendations by the committee. The 21 committee shall recommend to the house that the 22 complaint be dismissed, or that one or more of the 23 following be imposed: 24 (1) That the member or employee of the house 25 or lobbyist or client of a lobbyist be censured or 26 reprimanded, and the recommended appropriate form of 27 censure or reprimand be used. 28 (2) That the member of the house be suspended or 29 expelled from membership in the house and required 30 -14- LSB 1353HV (2) 84 tm/rj 14/ 22

H.R. 7 to forfeit the member’s salary for that period, the 1 employee of the house be suspended or dismissed from 2 employment, or that the lobbyist’s or lobbyist’s 3 client’s lobbying privileges be suspended. 4 13. COMMUNICATIONS WITH ETHICS COMMITTEE. After a 5 complaint has been filed or an investigation has been 6 initiated, a party to the complaint or investigation 7 shall not communicate, or cause another to communicate, 8 as to the merits of the complaint or investigation with 9 a member of the committee, except under the following 10 circumstances: 11 a. During the course of any meetings or other 12 official proceedings of the committee regarding the 13 complaint or investigation. 14 b. In writing, if a copy of the writing is 15 delivered to the adverse party or the designated 16 representative for the adverse party. 17 c. Orally, if adequate prior notice of the 18 communication is given to the adverse party or the 19 designated representative for the adverse party. 20 d. As otherwise authorized by statute, the house 21 code of ethics, house rules governing lobbyists, or 22 vote of the committee. 23 14. PERMANENT RECORD. The chief clerk of the house 24 shall maintain a permanent record of all complaints 25 filed and any corresponding committee action. The 26 permanent record shall be prepared by the ethics 27 committee and shall contain the date the complaint was 28 filed, name and address of the complainant, name and 29 address of the accused person, a brief statement of the 30 -15- LSB 1353HV (2) 84 tm/rj 15/ 22

H.R. 7 charges made, any evidence received by the committee, 1 any transcripts or recordings of committee action, and 2 ultimate disposition of the complaint. The chief clerk 3 shall keep each complaint confidential until public 4 disclosure is made by the ethics committee. 5 15. MEETING AUTHORIZATION. The house ethics 6 committee is authorized to meet at the discretion of 7 the committee chairperson in order to conduct hearings 8 and other business that properly may come before it. 9 If the committee submits a report seeking house action 10 against a member or employee of the house or lobbyist 11 after the second regular session of a general assembly 12 has adjourned sine die, the report shall be submitted 13 to and considered by the subsequent general assembly. 14 16. ADVISORY OPINIONS. 15 a. Requests for formal opinions. A request for a 16 formal advisory opinion may be filed by any person who 17 is subject to the authority of the ethics committee. 18 The ethics committee may also issue a formal advisory 19 opinion on its own motion, without having previously 20 received a formal request for an opinion, on any issue 21 that is within the jurisdiction of the committee. 22 Requests shall be filed with either the chief clerk of 23 the house or the chairperson of the ethics committee. 24 b. Form and contents of requests. A request for 25 a formal advisory opinion shall be in writing and 26 may pertain to any subject matter that is related to 27 application of the house code of ethics, the house 28 rules governing lobbyists, or chapter 68B of the Code 29 to any person who is subject to the authority of 30 -16- LSB 1353HV (2) 84 tm/rj 16/ 22

H.R. 7 the ethics committee. Requests shall contain one or 1 more specific questions and shall relate either to 2 future conduct or be stated in the hypothetical. A 3 request for an advisory opinion shall not specifically 4 name any individual or contain any other specific 5 identifying information, unless the request relates 6 to the requester’s own conduct. However, any request 7 may contain information which identifies the kind of 8 individual who may be affected by the subject matter 9 of the request. Examples of this latter kind of 10 identifying information may include references to 11 conduct of a category of individuals, such as but not 12 limited to conduct of legislators, legislative staff, 13 or lobbyists. 14 c. Confidentiality of formal requests and opinions. 15 Requests for formal opinions are not confidential and 16 any deliberations of the committee regarding a request 17 for a formal opinion shall be public. Opinions issued 18 in response to requests for formal opinions are not 19 confidential, shall be in writing, and shall be placed 20 on file in the office of the chief clerk of the house. 21 Persons requesting formal opinions shall personally 22 receive a copy of the written formal opinion that is 23 issued in response to the request. 24 17. PERSONAL FINANCIAL DISCLOSURE FORM. The 25 following form shall be used for disclosure of economic 26 interests under these rules and section 68B.35 of the 27 Code: 28 STATEMENT OF ECONOMIC INTERESTS 29 Name:_________________________________________________ 30 -17- LSB 1353HV (2) 84 tm/rj 17/ 22

H.R. 7 (Last) (First) (Middle Initial) 1 Address:______________________________________________ 2 (Street Address, Apt.#/P.O. Box) 3 ______________________________________________ 4 (City)(State)(Zip) 5 Phone:(Home)_____/____-_____(Business)_____/____-_____ 6 ****************************************************** 7 This form is due each year on or before February 15. 8 The reporting period is the most recently completed 9 calendar year. 10 In completing Division III of this form, if your 11 percentage of ownership of an asset is less than 100 12 percent, multiply your percentage of ownership by the 13 total revenue produced to determine if you have reached 14 the $1,000 threshold. 15 Do not report income received by your spouse or 16 other family members. 17 In completing this form, if insufficient space is 18 provided for your answer, you may attach additional 19 information/answers on full-size sheets of paper. 20 Division I. Business, Occupation, Profession. 21 List each business, occupation, or profession in 22 which you are engaged, the nature of the business if 23 not evident, and your position or job title. No income 24 threshold or time requirement applies. 25 Examples: 26 If you are employed by an individual, state the name 27 of the individual employer, the nature of the business, 28 and your position. 29 If you are self-employed and are not incorporated 30 -18- LSB 1353HV (2) 84 tm/rj 18/ 22

H.R. 7 or are not doing business under a particular business 1 name, state that you are self-employed, the nature of 2 the business, and your position. 3 If you own your own corporation, are employed by a 4 corporation, or are doing business under a particular 5 business name, state the name and nature of the 6 business or corporation and your position. 7 1_____________________________________________________ 8 2_____________________________________________________ 9 3_____________________________________________________ 10 4_____________________________________________________ 11 5_____________________________________________________ 12 6_____________________________________________________ 13 Division II. Commissions from Sales of Goods or 14 Services to Political Subdivisions. 15 This part is to be completed only by Legislators. 16 If you received income in the form of a commission 17 from the sale of goods or services to a political 18 subdivision, state the name of the purchasing political 19 subdivision. The amount of commission earned is not 20 required to be listed. 21 1_____________________________________________________ 22 2_____________________________________________________ 23 3_____________________________________________________ 24 4_____________________________________________________ 25 5_____________________________________________________ 26 6_____________________________________________________ 27 Division III. Sources of Gross Income. 28 In each one of the following categories list each 29 source which produces more than $1,000 in annual gross 30 -19- LSB 1353HV (2) 84 tm/rj 19/ 22

H.R. 7 income, if the revenue produced by the source was 1 subject to federal or state income taxes last year. 2 List the nature or type of each company, business, 3 financial institution, corporation, partnership, or 4 other entity which produces more than $1,000 of annual 5 gross income. Neither the amount of income produced 6 nor value of the holding is required to be listed in 7 any of the items. 8 A. Securities: State the nature of the business of 9 any company in which you hold stock, bonds, or other 10 pecuniary interests that generate more than $1,000 in 11 annual gross income. Income generated by multiple 12 holdings in a single company are deemed received from 13 a single source. 14 ______________________________________________________ 15 ______________________________________________________ 16 ______________________________________________________ 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 B. Instruments of Financial Institutions: State 21 the types of institutions in which you hold financial 22 instruments, such as certificates of deposit, savings 23 accounts, etc., that produce annual gross income in 24 excess of $1,000, e.g., banks, savings and loans, or 25 credit unions. 26 ______________________________________________________ 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 -20- LSB 1353HV (2) 84 tm/rj 20/ 22

H.R. 7 ______________________________________________________ 1 ______________________________________________________ 2 C. Trusts: State the nature or type of any trust 3 from which you receive more than $1,000 of gross income 4 annually. 5 ______________________________________________________ 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 ______________________________________________________ 10 ______________________________________________________ 11 D. Real Estate: State the general nature of real 12 estate interests that generate more than $1,000 of 13 gross income annually, e.g., residential leasehold 14 interest or farm leasehold interest. The size or 15 location of the property interest is not required to 16 be listed. 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 ______________________________________________________ 22 ______________________________________________________ 23 E. Retirement Systems: State the name of each 24 pension plan or other corporation or company that pays 25 you more than $1,000 annually in retirement benefits. 26 ______________________________________________________ 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 -21- LSB 1353HV (2) 84 tm/rj 21/ 22

H.R. 7 ______________________________________________________ 1 ______________________________________________________ 2 F. Other Income Categories Specified in State and 3 Federal Income Tax Regulations. 4 ______________________________________________________ 5 ______________________________________________________ 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 _______________________________________ ___________ 10 (Signature of Filer) (Date) 11 -22- LSB 1353HV (2) 84 tm/rj 22/ 22