House Study Bill 27 - Introduced HOUSE RESOLUTION NO. _____ BY (PROPOSED COMMITTEE ON ETHICS RESOLUTION BY CHAIRPERSON SMITH) A Resolution relating to the code of ethics of the 1 House of Representatives for the Eighty-fifth 2 General Assembly. 3 BE IT RESOLVED BY THE HOUSE OF REPRESENTATIVES, That 4 the House Code of Ethics shall be as follows: 5 HOUSE CODE OF ETHICS 6 PREAMBLE. Every legislator and legislative employee 7 has a duty to uphold the integrity and honor of the 8 general assembly, to encourage respect for the law 9 and for the general assembly, and to observe the house 10 code of ethics. The members and employees of the house 11 have a responsibility to conduct themselves so as to 12 reflect credit on the general assembly, and to inspire 13 the confidence, respect, and trust of the public. The 14 following rules are adopted pursuant to chapter 68B of 15 the Code, to assist the members and employees in the 16 conduct of their activities: 17 1. DEFINITIONS. The definitions of terms provided 18 in chapter 68B of the Code apply to the use of those 19 terms in these rules. 20 2. ECONOMIC INTEREST OF MEMBER OR EMPLOYEE OF 21 HOUSE. 22 a. Economic or investment opportunity. A member 23 or employee of the house shall not solicit or accept 24 economic or investment opportunity under circumstances 25 where the member or employee knows, or should know, 26 that the opportunity is being afforded with the intent 27 -1- LSB 1565HC (5) 85 tm/rj 1/ 22

H.R. _____ to influence the member’s or employee’s conduct in 1 the performance of official duties. If a member 2 or employee of the house learns that an economic 3 or investment opportunity previously accepted was 4 offered with the intent of influencing the member’s or 5 employee’s conduct in the performance of the official 6 duties, the member or employee shall take steps to 7 divest that member or employee of that investment or 8 economic opportunity, and shall report the matter 9 in writing to the chairperson of the house ethics 10 committee. 11 b. Excessive charges for services, goods, or 12 property interests. A member or employee of the 13 house shall not charge to or accept from a person 14 known to have a legislative interest, a price, fee, 15 compensation, or other consideration for the sale or 16 lease of any property or the furnishing of services 17 which is in excess of that which the member or employee 18 would ordinarily charge another person. 19 c. Use of confidential information. A member or 20 employee of the house, in order to further the member’s 21 or employee’s own economic interests, or those of any 22 other person, shall not disclose or use confidential 23 information acquired in the course of the member’s or 24 employee’s official duties. For the purpose of this 25 rule, information disclosed in open session at a public 26 meeting and information that is a public record is not 27 confidential information. 28 d. Employment. A member or employee of the house 29 shall not accept employment, either directly or 30 -2- LSB 1565HC (5) 85 tm/rj 2/ 22

H.R. _____ indirectly, from a political action committee. A 1 member of the house shall not act as a paid lobbyist 2 for any organization. However, this paragraph shall 3 not prohibit a member or employee of the house from 4 working for a candidate’s committee, a political 5 party’s action committee, or a political action 6 committee which does not expressly advocate the 7 nomination, election, or defeat of a candidate for 8 public office in this state or expressly advocate the 9 passage or defeat of a ballot issue in this state and 10 which is not interested in issues before the general 11 assembly. 12 For the purpose of this rule, a political action 13 committee means a committee, but not a candidate’s 14 committee, which accepts contributions, makes 15 expenditures, or incurs indebtedness in the aggregate 16 of more than seven hundred fifty dollars in any one 17 calendar year to expressly advocate the nomination, 18 election, or defeat of a candidate for public office or 19 to expressly advocate the passage or defeat of a ballot 20 issue or for the purpose of influencing legislative 21 action. 22 e. Solicitation of employment as lobbyist. A 23 member or employee of the house shall not solicit 24 employment on behalf of the member or employee, or on 25 behalf of another legislator or employee, as a lobbyist 26 while the general assembly is in session. 27 f. Certain goods or services. A member or employee 28 of the house shall not solicit or obtain goods or 29 services from another person under circumstances where 30 -3- LSB 1565HC (5) 85 tm/rj 3/ 22

H.R. _____ the member or employee knows or should know that the 1 goods or services are being offered or sold with the 2 intent to influence the member’s or employee’s conduct 3 in the performance of official duties. If a member 4 or employee of the house is afforded goods or services 5 by another person at a price that is not available to 6 other members or classes of members of the general 7 public or is afforded goods or services that are not 8 available to other members or classes of members 9 of the general public by another person where the 10 member or employee knows or should know that the other 11 person intends to influence the member’s or employee’s 12 official conduct, the member or employee shall not take 13 or purchase the goods or services. 14 3. APPEARANCE BEFORE STATE AGENCY. A member or 15 employee of the house may appear before a state agency 16 in any representation case but shall not act as a 17 lobbyist with respect to the passage, defeat, approval, 18 veto, or modification of any legislation, rule, or 19 executive order. Whenever a member or employee of 20 the house appears before a state agency, the member 21 or employee shall carefully avoid all conduct which 22 might in any way lead members of the general public 23 to conclude that the member or employee is using the 24 member’s or employee’s official position to further the 25 member’s or employee’s professional success or personal 26 financial interest. 27 4. CONFLICTS OF INTEREST. In order for the general 28 assembly to function effectively, members of the house 29 may be required to vote on bills and participate in 30 -4- LSB 1565HC (5) 85 tm/rj 4/ 22

H.R. _____ committee work which will affect their employment and 1 other areas in which they may have a monetary interest. 2 Action on bills and committee work which furthers a 3 member’s specific employment, specific investment, or 4 other specific interest, as opposed to the interests of 5 the public in general or the interests of a profession, 6 trade, business, or other class of persons, shall be 7 avoided. In making a decision relative to a member’s 8 activity on particular bills or in committee work, the 9 following factors should be considered: 10 a. Whether a substantial threat to the member’s 11 independence of judgment has been created by the 12 conflict situation. 13 b. The effect of the member’s participation on 14 public confidence in the integrity of the general 15 assembly. 16 c. Whether the member’s participation is likely to 17 have any significant effect on the disposition of the 18 matter. 19 d. The need for the member’s particular 20 contribution, such as special knowledge of the subject 21 matter, to the effective functioning of the general 22 assembly. 23 If a member decides not to participate in committee 24 work or to abstain from voting because of a possible 25 conflict of interest, the member should disclose 26 this fact to the legislative body. The member shall 27 not vote on any question in which the member has an 28 economic interest that is distinguishable from the 29 interests of the general public or a substantial class 30 -5- LSB 1565HC (5) 85 tm/rj 5/ 22

H.R. _____ of persons. 1 5. STATUTORY REQUIREMENTS. Members and employees 2 of the house shall comply with the requirements 3 contained in chapters 68B (Government Ethics and 4 Lobbying), 721 (Official Misconduct), and 722 (Bribery 5 and Corruption), and sections 2.18 (Contempt) and 711.4 6 (Extortion) of the Code. 7 6. CHARGE ACCOUNTS. Members and employees of the 8 house shall not charge any amount or item to a charge 9 account to be paid for by a lobbyist or any client of a 10 lobbyist. 11 7. TRAVEL EXPENSES. A member or employee of the 12 house shall not charge to the state of Iowa amounts 13 for travel and expenses unless the member or employee 14 actually has incurred those mileage and expense costs. 15 Members or employees shall not file the vouchers for 16 weekly mileage reimbursement required by section 2.10, 17 subsection 1 of the Code, unless the travel expense was 18 actually incurred. 19 A member or employee of the house shall not file 20 a claim for per diem compensation for a meeting of 21 an interim study committee or a visitation committee 22 unless the member or employee attended the meeting. 23 However, the speaker may waive this provision and allow 24 a claim to be filed if the member or employee attempted 25 to attend the meeting but was unable to do so because 26 of circumstances beyond the member’s or employee’s 27 control. 28 8. GIFTS ACCEPTED OR RECEIVED. Members and 29 employees of the house shall comply with the 30 -6- LSB 1565HC (5) 85 tm/rj 6/ 22

H.R. _____ restrictions relating to the receipt or acceptance 1 of gifts contained in section 68B.22 of the Code. 2 The sponsor of a function under section 68B.22, 3 subsection 4, paragraph “s”, shall electronically 4 file a registration with the chief clerk of the house 5 five days prior to the function disclosing the name of 6 the sponsor, and the date, time, and location of the 7 function. The sponsor shall also electronically file a 8 report of expenditures as required pursuant to section 9 68B.22, subsection 4, paragraph “s”. 10 9. HONORARIA RESTRICTIONS. Members and employees 11 of the house shall comply with the restrictions 12 relating to the receipt of honoraria contained in 13 section 68B.23 of the Code. 14 10. DISCLOSURE REQUIRED. Each member of the 15 house and the chief clerk of the house shall file the 16 personal financial disclosure statements required under 17 section 68B.35 of the Code by February 15 of each year 18 for the prior calendar year. 19 11. SEXUAL HARASSMENT. Members and employees of 20 the house shall not engage in conduct which constitutes 21 sexual harassment as defined in section 19B.12 of 22 the Code or pursuant to the sexual harassment policy 23 adopted by the house committee on administration and 24 rules. 25 12. COMPLAINTS. 26 a. Filing of complaint. Complaints may be filed by 27 any person believing that a member or employee of the 28 house, a lobbyist, or a client of a lobbyist is guilty 29 of a violation of the house code of ethics, the house 30 -7- LSB 1565HC (5) 85 tm/rj 7/ 22

H.R. _____ joint rules governing lobbyists, or chapter 68B of the 1 Code. 2 b. Complaints by committee. The ethics committee 3 may initiate a complaint on its own motion. Committee 4 complaints may be initiated by the committee as a 5 result of a committee investigation or as a result of 6 receipt of any complaint or other information that does 7 not meet the requirements of these rules regarding the 8 form of a complaint but that contains allegations that 9 would form the basis for a valid complaint. 10 c. Form and contents of complaint. A complaint 11 shall be in writing. 12 Complaint forms shall be available from the chief 13 clerk of the house, but a complaint shall not be 14 rejected for failure to use the approved form if it 15 complies with the requirements of these rules. The 16 complaint shall contain a certification made by the 17 complainant, under penalty of perjury, that the facts 18 stated in the complaint are true to the best of the 19 complainant’s knowledge. 20 To be valid, a complaint shall allege all of the 21 following: 22 (1) Facts, that if true, establish a violation of 23 a provision of chapter 68B of the Code, the house code 24 of ethics, or house joint rules governing lobbyists for 25 which penalties or other remedies are provided. 26 (2) That the conduct providing the basis for the 27 complaint occurred within three years of the filing of 28 the complaint. 29 (3) That the party charged with a violation is 30 -8- LSB 1565HC (5) 85 tm/rj 8/ 22

H.R. _____ a party subject to the jurisdiction of the ethics 1 committee. 2 d. Confidentiality of complaint. The identity of 3 the parties and the contents of the complaint shall 4 be confidential until the time that the committee 5 chairperson and ranking member determine under 6 paragraph “f” that the complaint is sufficient as 7 to form, unless either the complainant or the party 8 charged in the complaint makes the identity of the 9 parties, or the information contained in the complaint, 10 public. The chief clerk of the house and the committee 11 chairperson and ranking member may communicate 12 confidentially with appropriate legislative staff 13 during any stage of the complaint process. 14 e. Notice of complaint. Upon receipt of the 15 complaint, the chief clerk of the house shall promptly 16 notify the chairperson and ranking member of the 17 ethics committee that a complaint has been filed and 18 provide both the chairperson and the ranking member 19 with copies of the complaint and any supporting 20 information. Within two working days, the chief clerk 21 shall send notice, either by personal delivery or by 22 certified mail, return receipt requested, to the person 23 or persons alleged to have committed the violation, 24 along with a copy of the complaint and any supporting 25 information. The notice to the accused person shall 26 contain a request that the person submit a written 27 response to the complaint within ten working days of 28 the date that the notice was sent by the chief clerk. 29 At the request of the accused person, the committee may 30 -9- LSB 1565HC (5) 85 tm/rj 9/ 22

H.R. _____ extend the time for the response, not to exceed ten 1 additional calendar days. A response to a complaint 2 shall not be confidential. 3 f. Hearing regarding validity of complaint. The 4 committee chairperson and the ranking member shall 5 review the complaint and supporting information to 6 determine whether the complaint meets the requirements 7 as to form. If the complaint is deficient as to form, 8 the complaint shall be returned to the complainant 9 with instructions indicating the deficiency. If the 10 complaint is in writing, is sufficient as to form, 11 and contains the appropriate certification, as soon 12 as practicable, the chairperson shall call a meeting 13 of the committee to review the complaint to determine 14 whether the complaint meets the requirements for 15 validity and whether the committee should take action 16 on the complaint pursuant to paragraph “g” or whether 17 the committee should request that the chief justice 18 of the supreme court appoint an independent special 19 counsel to conduct an investigation to determine 20 whether probable cause exists to believe that a 21 violation of the house code of ethics, house joint 22 rules governing lobbyists, or chapter 68B of the Code, 23 has occurred. The sufficiency as to form determination 24 and the valid complaint requirements determination 25 shall be based solely upon the original complaint and 26 the response to the complaint. Additional documents 27 or responses shall not be filed by the parties or 28 otherwise considered by the committee prior to a 29 validity determination. The committee shall not 30 -10- LSB 1565HC (5) 85 tm/rj 10/ 22

H.R. _____ receive or consider oral testimony in support of or 1 against a validity determination. 2 If the committee finds that a complaint does not 3 meet the content requirements for a valid complaint, 4 the committee shall dismiss the complaint and notify 5 both the complainant and the party alleged to have 6 committed the violation of the dismissal and the 7 reasons for dismissal. A dismissal for failure to meet 8 the formal requirements for the filing of a complaint 9 shall be without prejudice and the complainant may 10 refile the complaint at any time within three years 11 of the date that the alleged violation took place. If 12 the dismissal is based upon a failure to allege facts 13 and circumstances necessary for a valid complaint, the 14 dismissal shall be with prejudice and the party shall 15 not be permitted to file a complaint based upon the 16 same facts and circumstances. 17 g. Action on undisputed complaint. If the committee 18 determines a complaint is valid and determines no 19 dispute exists between the parties regarding the 20 material facts that establish a violation, the 21 committee may take action on the complaint under this 22 paragraph without requesting the appointment of an 23 independent special counsel. 24 The committee may do any of the following: 25 (1) Issue an admonishment to advise against the 26 conduct that formed the basis for the complaint and to 27 exercise care in the future. 28 (2) Issue an order to cease and desist the conduct 29 that formed the basis for the complaint. 30 -11- LSB 1565HC (5) 85 tm/rj 11/ 22

H.R. _____ (3) Make a recommendation to the house that 1 the person subject to the complaint be censured or 2 reprimanded. 3 h. Request for appointment of independent special 4 counsel. If, after review of the complaint and any 5 response made by the party alleged to have committed 6 the violation, the committee determines that the 7 complaint meets the requirements for form and content 8 and the committee has not taken action under paragraph 9 “g”, the committee shall request that the chief justice 10 of the supreme court appoint independent special 11 counsel to investigate the matter and determine whether 12 probable cause exists to believe that a violation of 13 chapter 68B of the Code, the house code of ethics, or 14 the house joint rules governing lobbyists has occurred. 15 i. Receipt of report of independent special counsel. 16 The report from the independent special counsel 17 regarding probable cause to proceed on a complaint 18 shall be filed with the chief clerk of the house. 19 Upon receipt of the report of the independent special 20 counsel, the chief clerk shall notify the chairperson 21 of the filing of the report and shall send copies of 22 the report to the members of the ethics committee. As 23 soon as practicable after the filing of the report, the 24 chairperson shall schedule a public meeting for review 25 of the report. The purpose of the public meeting 26 shall be to determine whether the complaint should be 27 dismissed, whether a formal hearing should be held on 28 the complaint, or whether other committee action is 29 appropriate. The complainant and the person alleged to 30 -12- LSB 1565HC (5) 85 tm/rj 12/ 22

H.R. _____ have committed the violation shall be given notice of 1 the public meeting, shall have the right to be present 2 at the public meeting, and may, at the discretion 3 of the committee, present testimony in support of or 4 against the recommendations contained in the report. 5 If the committee determines that the matter should 6 be dismissed, the committee shall cause an order to 7 be entered dismissing the matter and notice of the 8 dismissal shall be given to the complainant and the 9 party alleged to have committed the violation. If 10 the committee determines that the complaint should be 11 scheduled for formal hearing, the committee shall issue 12 a charging statement which contains the charges and 13 supporting facts that are to be set for formal hearing 14 and notice shall be sent to the complainant and the 15 accused person. 16 The notice shall include a statement of the nature 17 of the charge or charges, a statement of the time and 18 place of hearing, a short and plain statement of the 19 facts asserted, and a statement of the rights of the 20 accused person at the hearing. 21 j. Formal hearing. Formal hearings shall be public 22 and conducted in the manner provided in section 68B.31, 23 subsection 8 of the Code. At a formal hearing the 24 accused shall have the right to be present and to 25 be heard in person and by counsel, to cross-examine 26 witnesses, and to present evidence. Members of 27 the committee shall also have the right to question 28 witnesses. 29 The committee may require, by subpoena or otherwise, 30 -13- LSB 1565HC (5) 85 tm/rj 13/ 22

H.R. _____ the attendance and testimony of witnesses and the 1 production of such books, records, correspondence, 2 memoranda, papers, documents, and any other things it 3 deems necessary to the conduct of the inquiry. 4 Evidence at the formal hearing shall be received 5 in accordance with rules and procedures applicable to 6 contested cases under chapter 17A of the Code. 7 The committee chairperson, or the vice chairperson 8 or ranking member in the absence of the chairperson, 9 shall preside at the formal hearing and shall rule on 10 the admissibility of any evidence received. The ruling 11 of the chairperson may be overturned by a majority 12 vote of the committee. Independent special counsel 13 shall present the evidence in support of the charge 14 or charges. The burden shall be on the independent 15 special counsel to prove the charge or charges by 16 a preponderance of clear and convincing evidence. 17 Upon completion of the formal hearing, the committee 18 shall adopt written findings of fact and conclusions 19 concerning the merits of the charges and make its 20 report and recommendation to the house. 21 k. Disqualification of member. Members of the 22 committee may disqualify themselves from participating 23 in any investigation of the conduct of another person 24 upon submission of a written statement that the member 25 cannot render an impartial and unbiased decision 26 in a case. A member may also be disqualified by a 27 unanimous vote of the remaining eligible members of the 28 committee. 29 A member of the committee is ineligible to 30 -14- LSB 1565HC (5) 85 tm/rj 14/ 22

H.R. _____ participate in committee meetings, as a member of the 1 committee, in any proceeding relating to the member’s 2 own official conduct. 3 If a member of the committee is disqualified or 4 ineligible to act, the majority or minority leader who 5 appointed the member shall appoint a replacement member 6 to serve as a member of the committee during the period 7 of disqualification or ineligibility. 8 l. Recommendations by the committee. The committee 9 shall recommend to the house that the complaint be 10 dismissed, or that one or more of the following be 11 imposed: 12 (1) That the member or employee of the house 13 or lobbyist or client of a lobbyist be censured or 14 reprimanded, and the recommended appropriate form of 15 censure or reprimand be used. 16 (2) That the member of the house be suspended or 17 expelled from membership in the house and required 18 to forfeit the member’s salary for that period, the 19 employee of the house be suspended or dismissed from 20 employment, or that the lobbyist’s or lobbyist’s 21 client’s lobbying privileges be suspended. 22 13. COMMUNICATIONS WITH ETHICS COMMITTEE. After a 23 complaint has been filed or an investigation has been 24 initiated, a party to the complaint or investigation 25 shall not communicate, or cause another to communicate, 26 as to the merits of the complaint or investigation with 27 a member of the committee, except under the following 28 circumstances: 29 a. During the course of any meetings or other 30 -15- LSB 1565HC (5) 85 tm/rj 15/ 22

H.R. _____ official proceedings of the committee regarding the 1 complaint or investigation. 2 b. In writing, if a copy of the writing is 3 delivered to the adverse party or the designated 4 representative for the adverse party. 5 c. Orally, if adequate prior notice of the 6 communication is given to the adverse party or the 7 designated representative for the adverse party. 8 d. As otherwise authorized by statute, the house 9 code of ethics, house joint rules governing lobbyists, 10 or vote of the committee. 11 14. PERMANENT RECORD. The chief clerk of the house 12 shall maintain a permanent record of all complaints 13 filed and any corresponding committee action. The 14 permanent record shall be prepared by the ethics 15 committee and shall contain the date the complaint was 16 filed, name and address of the complainant, name and 17 address of the accused person, a brief statement of the 18 charges made, any evidence received by the committee, 19 any transcripts or recordings of committee action, and 20 ultimate disposition of the complaint. The Except as 21 provided in rule 12, paragraph “d”, the chief clerk 22 shall keep each complaint confidential until public 23 disclosure is made by the ethics committee. 24 15. MEETING AUTHORIZATION. The house ethics 25 committee is authorized to meet at the discretion of 26 the committee chairperson in order to conduct hearings 27 and other business that properly may come before it. 28 If the committee submits a report seeking house action 29 against a member or employee of the house or lobbyist 30 -16- LSB 1565HC (5) 85 tm/rj 16/ 22

H.R. _____ after the second regular session of a general assembly 1 has adjourned sine die, the report shall be submitted 2 to and considered by the subsequent general assembly. 3 16. ADVISORY OPINIONS. 4 a. Requests for formal opinions. A request for a 5 formal advisory opinion may be filed by any person who 6 is subject to the authority of the ethics committee. 7 The ethics committee may also issue a formal advisory 8 opinion on its own motion, without having previously 9 received a formal request for an opinion, on any issue 10 that is within the jurisdiction of the committee. 11 Requests shall be filed with either the chief clerk of 12 the house or the chairperson of the ethics committee. 13 b. Form and contents of requests. A request for 14 a formal advisory opinion shall be in writing and 15 may pertain to any subject matter that is related to 16 application of the house code of ethics, the house 17 joint rules governing lobbyists, or chapter 68B of the 18 Code to any person who is subject to the authority of 19 the ethics committee. Requests shall contain one or 20 more specific questions and shall relate either to 21 future conduct or be stated in the hypothetical. A 22 request for an advisory opinion shall not specifically 23 name any individual or contain any other specific 24 identifying information, unless the request relates 25 to the requester’s own conduct. However, any request 26 may contain information which identifies the kind 27 of individual who may be affected by the subject 28 matter of the request. Examples of this latter kind 29 of identifying information may include references to 30 -17- LSB 1565HC (5) 85 tm/rj 17/ 22

H.R. _____ conduct of a category of individuals, such as but not 1 limited to conduct of legislators, legislative staff, 2 or lobbyists. 3 c. Confidentiality of formal requests and opinions. 4 Requests for formal opinions are not confidential and 5 any deliberations of the committee regarding a request 6 for a formal opinion shall be public. Opinions issued 7 in response to requests for formal opinions are not 8 confidential, shall be in writing, and shall be placed 9 on file in the office of the chief clerk of the house. 10 Persons requesting formal opinions shall personally 11 receive a copy of the written formal opinion that is 12 issued in response to the request. 13 17. PERSONAL FINANCIAL DISCLOSURE FORM. The 14 following form shall be used for disclosure of economic 15 interests under these rules and section 68B.35 of the 16 Code: 17 STATEMENT OF ECONOMIC INTERESTS 18 Name:_________________________________________________ 19 (Last) (First) (Middle Initial) 20 Address:______________________________________________ 21 (Street Address, Apt.#/P.O. Box) 22 ______________________________________________ 23 (City)(State)(Zip) 24 Phone:(Home)_____/____-_____(Business)_____/____-_____ 25 ****************************************************** 26 This form is due each year on or before February 15. 27 The reporting period is the most recently completed 28 calendar year. 29 In completing Division III of this form, if your 30 -18- LSB 1565HC (5) 85 tm/rj 18/ 22

H.R. _____ percentage of ownership of an asset is less than 100 1 percent, multiply your percentage of ownership by the 2 total revenue produced to determine if you have reached 3 the $1,000 threshold. 4 Do not report income received by your spouse or 5 other family members. 6 In completing this form, if insufficient space is 7 provided for your answer, you may attach additional 8 information/answers on full-size sheets of paper. 9 Division I. Business, Occupation, or Profession. 10 List each business, occupation, or profession in 11 which you are engaged, the nature of the business if 12 not evident, and your position or job title. No income 13 threshold or time requirement applies. 14 Examples: 15 If you are employed by an individual, state the name 16 of the individual employer, the nature of the business, 17 and your position. 18 If you are self-employed and are not incorporated 19 or are not doing business under a particular business 20 name, state that you are self-employed, the nature of 21 the business, and your position. 22 If you own your own corporation, are employed by a 23 corporation, or are doing business under a particular 24 business name, state the name and nature of the 25 business or corporation and your position. 26 1_____________________________________________________ 27 2_____________________________________________________ 28 3_____________________________________________________ 29 4_____________________________________________________ 30 -19- LSB 1565HC (5) 85 tm/rj 19/ 22

H.R. _____ 5_____________________________________________________ 1 6_____________________________________________________ 2 Division II. Commissions from Sales of Goods or 3 Services to Political Subdivisions. 4 This part is to be completed only by Legislators. 5 If you received income in the form of a commission 6 from the sale of goods or services to a political 7 subdivision, state the name of the purchasing political 8 subdivision. The amount of commission earned is not 9 required to be listed. 10 1_____________________________________________________ 11 2_____________________________________________________ 12 3_____________________________________________________ 13 4_____________________________________________________ 14 5_____________________________________________________ 15 6_____________________________________________________ 16 Division III. Sources of Gross Income. 17 In each one of the following categories list each 18 source which produces more than $1,000 in annual gross 19 income, if the revenue produced by the source was 20 subject to federal or state income taxes last year. 21 List the nature or type of each company, business, 22 financial institution, corporation, partnership, or 23 other entity which produces more than $1,000 of annual 24 gross income. Neither the amount of income produced 25 nor value of the holding is required to be listed in 26 any of the items. 27 A. Securities: State the nature of the business of 28 any company in which you hold stock, bonds, or other 29 pecuniary interests that generate more than $1,000 30 -20- LSB 1565HC (5) 85 tm/rj 20/ 22

H.R. _____ in annual gross income. Income generated by multiple 1 holdings in a single company are deemed received from a 2 single source. 3 ______________________________________________________ 4 ______________________________________________________ 5 ______________________________________________________ 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 B. Instruments of Financial Institutions: State 10 the types of institutions in which you hold financial 11 instruments, such as certificates of deposit, savings 12 accounts, etc., that produce annual gross income in 13 excess of $1,000, e.g., banks, savings and loans, or 14 credit unions. 15 ______________________________________________________ 16 ______________________________________________________ 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 C. Trusts: State the nature or type of any trust 22 from which you receive more than $1,000 of gross income 23 annually. 24 ______________________________________________________ 25 ______________________________________________________ 26 ______________________________________________________ 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 -21- LSB 1565HC (5) 85 tm/rj 21/ 22

H.R. _____ D. Real Estate: State the general nature of real 1 estate interests that generate more than $1,000 of 2 gross income annually, e.g., residential leasehold 3 interest or farm leasehold interest. The size or 4 location of the property interest is not required to be 5 listed. 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 ______________________________________________________ 10 ______________________________________________________ 11 ______________________________________________________ 12 E. Retirement Systems: State the name of each 13 pension plan or other corporation or company that pays 14 you more than $1,000 annually in retirement benefits. 15 ______________________________________________________ 16 ______________________________________________________ 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 F. Other Income Categories Specified in State and 22 Federal Income Tax Regulations. 23 ______________________________________________________ 24 ______________________________________________________ 25 ______________________________________________________ 26 ______________________________________________________ 27 ______________________________________________________ 28 _______________________________________ ___________ 29 (Signature of Filer) (Date) 30 -22- LSB 1565HC (5) 85 tm/rj 22/ 22