House Study Bill 15 - Introduced HOUSE RESOLUTION NO. _____ BY (PROPOSED COMMITTEE ON ETHICS RESOLUTION BY CHAIRPERSON KOESTER) 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 1353HC (15) 84 tm/rj 1/ 22

H.R. _____ 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 1353HC (15) 84 tm/rj 2/ 22

H.R. _____ 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 1353HC (15) 84 tm/rj 3/ 22

H.R. _____ 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 1353HC (15) 84 tm/rj 4/ 22

H.R. _____ 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 1353HC (15) 84 tm/rj 5/ 22

H.R. _____ 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 29 of gifts contained in section 68B.22 of the Code. 30 -6- LSB 1353HC (15) 84 tm/rj 6/ 22

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

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

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

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

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

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

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

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

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

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

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

H.R. _____ interests under these rules and section 68B.35 of the 1 Code: 2 STATEMENT OF ECONOMIC INTERESTS 3 Name:_________________________________________________ 4 (Last) (First) (Middle Initial) 5 Address:______________________________________________ 6 (Street Address, Apt.#/P.O. Box) 7 ______________________________________________ 8 (City)(State)(Zip) 9 Phone:(Home)_____/____-_____(Business)_____/____-_____ 10 ****************************************************** 11 This form is due each year on or before February 15. 12 The reporting period is the most recently completed 13 calendar year. 14 In completing Division III of this form, if your 15 percentage of ownership of an asset is less than 100 16 percent, multiply your percentage of ownership by the 17 total revenue produced to determine if you have reached 18 the $1,000 threshold. 19 Do not report income received by your spouse or 20 other family members. 21 In completing this form, if insufficient space is 22 provided for your answer, you may attach additional 23 information/answers on full-size sheets of paper. 24 Division I. Business, Occupation, Profession. 25 List each business, occupation, or profession in 26 which you are engaged, the nature of the business if 27 not evident, and your position or job title. No income 28 threshold or time requirement applies. 29 Examples: 30 -18- LSB 1353HC (15) 84 tm/rj 18/ 22

H.R. _____ If you are employed by an individual, state the name 1 of the individual employer, the nature of the business, 2 and your position. 3 If you are self-employed and are not incorporated 4 or are not doing business under a particular business 5 name, state that you are self-employed, the nature of 6 the business, and your position. 7 If you own your own corporation, are employed by a 8 corporation, or are doing business under a particular 9 business name, state the name and nature of the 10 business or corporation and your position. 11 1_____________________________________________________ 12 2_____________________________________________________ 13 3_____________________________________________________ 14 4_____________________________________________________ 15 5_____________________________________________________ 16 6_____________________________________________________ 17 Division II. Commissions from Sales of Goods or 18 Services to Political Subdivisions. 19 This part is to be completed only by Legislators. 20 If you received income in the form of a commission 21 from the sale of goods or services to a political 22 subdivision, state the name of the purchasing political 23 subdivision. The amount of commission earned is not 24 required to be listed. 25 1_____________________________________________________ 26 2_____________________________________________________ 27 3_____________________________________________________ 28 4_____________________________________________________ 29 5_____________________________________________________ 30 -19- LSB 1353HC (15) 84 tm/rj 19/ 22

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

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