House Study Bill 97 - Introduced HOUSE RESOLUTION NO. _____ BY (PROPOSED COMMITTEE ON ETHICS RESOLUTION BY CHAIRPERSON McKEAN) A Resolution relating to the code of ethics of the 1 House of Representatives for the Eighty-eighth 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 1483YC (3) 88 jh/tm 1/ 23

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 1483YC (3) 88 jh/tm 2/ 23

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 one thousand dollars in any one calendar 17 year to expressly advocate the nomination, election, or 18 defeat of a candidate for public office or to expressly 19 advocate the passage or defeat of a ballot issue or for 20 the purpose of influencing legislative action. 21 e. Solicitation of employment as lobbyist. A member 22 or employee of the house shall not solicit employment 23 on behalf of the member or employee, or on behalf of 24 another legislator or employee, as a lobbyist while the 25 general assembly is in session. 26 f. Certain goods or services. A member or employee 27 of the house shall not solicit or obtain goods or 28 services from another person under circumstances where 29 the member or employee knows or should know that the 30 -3- LSB 1483YC (3) 88 jh/tm 3/ 23

H.R. _____ goods or services are being offered or sold with the 1 intent to influence the member’s or employee’s conduct 2 in the performance of official duties. If a member 3 or employee of the house is afforded goods or services 4 by another person at a price that is not available to 5 other members or classes of members of the general 6 public or is afforded goods or services that are not 7 available to other members or classes of members 8 of the general public by another person where the 9 member or employee knows or should know that the other 10 person intends to influence the member’s or employee’s 11 official conduct, the member or employee shall not take 12 or purchase the goods or services. 13 3. APPEARANCE BEFORE STATE AGENCY. A member or 14 employee of the house may appear before a state agency 15 in any representation case but shall not act as a 16 lobbyist with respect to the passage, defeat, approval, 17 veto, or modification of any legislation, rule, or 18 executive order. Whenever a member or employee of 19 the house appears before a state agency, the member 20 or employee shall carefully avoid all conduct which 21 might in any way lead members of the general public 22 to conclude that the member or employee is using the 23 member’s or employee’s official position to further the 24 member’s or employee’s professional success or personal 25 financial interest. 26 4. CONFLICTS OF INTEREST. In order for the general 27 assembly to function effectively, members of the house 28 may be required to vote on bills and participate in 29 committee work which will affect their employment and 30 -4- LSB 1483YC (3) 88 jh/tm 4/ 23

H.R. _____ other areas in which they may have a monetary interest. 1 Action on bills and committee work which furthers a 2 member’s specific employment, specific investment, or 3 other specific interest, as opposed to the interests of 4 the public in general or the interests of a profession, 5 trade, business, or other class of persons, shall be 6 avoided. In making a decision relative to a member’s 7 activity on particular bills or in committee work, the 8 following factors should be considered: 9 a. Whether a substantial threat to the member’s 10 independence of judgment has been created by the 11 conflict situation. 12 b. The effect of the member’s participation on 13 public confidence in the integrity of the general 14 assembly. 15 c. Whether the member’s participation is likely to 16 have any significant effect on the disposition of the 17 matter. 18 d. The need for the member’s particular 19 contribution, such as special knowledge of the subject 20 matter, to the effective functioning of the general 21 assembly. 22 If a member decides not to participate in committee 23 work or to abstain from voting because of a possible 24 conflict of interest, the member should disclose 25 this fact to the legislative body. The member shall 26 not vote on any question in which the member has an 27 economic interest that is distinguishable from the 28 interests of the general public or a substantial class 29 of persons. 30 -5- LSB 1483YC (3) 88 jh/tm 5/ 23

H.R. _____ 5. STATUTORY REQUIREMENTS. Members and employees 1 of the house shall comply with the requirements 2 contained in chapters 68B (Government Ethics and 3 Lobbying), 721 (Official Misconduct), and 722 (Bribery 4 and Corruption), and sections 2.18 (Contempt) and 711.4 5 (Extortion) of the Code. 6 6. CHARGE ACCOUNTS. Members and employees of the 7 house shall not charge any amount or item to a charge 8 account to be paid for by a lobbyist or any client of a 9 lobbyist. 10 7. TRAVEL EXPENSES. A member or employee of the 11 house shall not charge to the state of Iowa amounts 12 for travel and expenses unless the member or employee 13 actually has incurred those mileage and expense costs. 14 Members or employees shall not file the vouchers for 15 weekly mileage reimbursement required by section 2.10, 16 subsection 1 of the Code, unless the travel expense was 17 actually incurred. 18 A member or employee of the house shall not file 19 a claim for per diem compensation for a meeting of 20 an interim study committee or a visitation committee 21 unless the member or employee attended the meeting. 22 However, the speaker may waive this provision and allow 23 a claim to be filed if the member or employee attempted 24 to attend the meeting but was unable to do so because 25 of circumstances beyond the member’s or employee’s 26 control. 27 8. GIFTS ACCEPTED OR RECEIVED. Members and 28 employees of the house shall comply with the 29 restrictions relating to the receipt or acceptance 30 -6- LSB 1483YC (3) 88 jh/tm 6/ 23

H.R. _____ of gifts contained in section 68B.22 of the Code. 1 The sponsor of a function under section 68B.22, 2 subsection 4, paragraph “s”, shall electronically 3 file a registration with the chief clerk of the house 4 five days prior to the function disclosing the name of 5 the sponsor, and the date, time, and location of the 6 function. The sponsor shall also electronically file a 7 report of expenditures as required pursuant to section 8 68B.22, subsection 4, paragraph “s”. 9 9. HONORARIA RESTRICTIONS. Members and employees 10 of the house shall comply with the restrictions 11 relating to the receipt of honoraria contained in 12 section 68B.23 of the Code. 13 10. DISCLOSURE REQUIRED. Each member of the 14 house and the chief clerk of the house shall file the 15 personal financial disclosure statements required under 16 section 68B.35 of the Code by February 15 of each year 17 for the prior calendar year. 18 11. SEXUAL HARASSMENT. Members and employees of 19 the house shall not engage in conduct which constitutes 20 sexual harassment as defined in section 19B.12 of 21 the Code or pursuant to the sexual harassment policy 22 adopted by the house committee on administration and 23 rules. 24 12. COMPLAINTS. 25 a. Filing of complaint. Complaints may be filed by 26 any person believing that a member or employee of the 27 house, a lobbyist, or a client of a lobbyist is guilty 28 of a violation of the house code of ethics, the joint 29 rules governing lobbyists, or chapter 68B of the Code. 30 -7- LSB 1483YC (3) 88 jh/tm 7/ 23

H.R. _____ b. Complaints by committee. The ethics committee 1 may initiate a complaint on its own motion. Committee 2 complaints may be initiated by the committee as a 3 result of a committee investigation or as a result of 4 receipt of any complaint or other information that does 5 not meet the requirements of these rules regarding the 6 form of a complaint but that contains allegations that 7 would form the basis for a valid complaint. 8 c. Form and contents of complaint. A complaint 9 shall be in writing. 10 Complaint forms shall be available from the chief 11 clerk of the house, but a complaint shall not be 12 rejected for failure to use the approved form if it 13 complies with the requirements of these rules. The 14 complaint shall contain a certification made by the 15 complainant, under penalty of perjury, that the facts 16 stated in the complaint are true to the best of the 17 complainant’s knowledge. 18 To be valid, a complaint shall allege all of the 19 following: 20 (1) Facts, that if true, establish a violation of 21 a provision of chapter 68B of the Code, the house code 22 of ethics, or joint rules governing lobbyists for which 23 penalties or other remedies are provided. 24 (2) That the conduct providing the basis for the 25 complaint occurred within three years of the filing of 26 the complaint. 27 (3) That the party charged with a violation is 28 a party subject to the jurisdiction of the ethics 29 committee. 30 -8- LSB 1483YC (3) 88 jh/tm 8/ 23

H.R. _____ d. Confidentiality of complaint. The identity of 1 the parties and the contents of the complaint shall 2 be confidential until the time that the committee 3 chairperson and ranking member determine under 4 paragraph “f” that the complaint is sufficient as 5 to form, unless either the complainant or the party 6 charged in the complaint makes the identity of the 7 parties, or the information contained in the complaint, 8 public. The chief clerk of the house and the committee 9 chairperson and ranking member may communicate 10 confidentially with appropriate legislative staff 11 during any stage of the complaint process. 12 e. Notice of complaint. Upon receipt of the 13 complaint, the chief clerk of the house shall promptly 14 notify the chairperson and ranking member of the 15 ethics committee that a complaint has been filed and 16 provide both the chairperson and the ranking member 17 with copies of the complaint and any supporting 18 information. Within two working days, the chief clerk 19 shall send notice, either by personal delivery or by 20 certified mail, return receipt requested, to the person 21 or persons alleged to have committed the violation, 22 along with a copy of the complaint and any supporting 23 information. The notice to the accused person shall 24 contain a request that the person submit a written 25 response to the complaint within ten working days of 26 the date that the notice was sent by the chief clerk. 27 At the request of the accused person, the committee may 28 extend the time for the response, not to exceed ten 29 additional calendar days. A response to a complaint 30 -9- LSB 1483YC (3) 88 jh/tm 9/ 23

H.R. _____ shall not be confidential. 1 f. Hearing regarding validity of complaint. The 2 committee chairperson and the ranking member shall 3 review the complaint and supporting information to 4 determine whether the complaint meets the requirements 5 as to form. If the complaint is deficient as to form, 6 the complaint shall be returned to the complainant 7 with instructions indicating the deficiency. If the 8 complaint is in writing, is sufficient as to form, 9 and contains the appropriate certification, as soon 10 as practicable, the chairperson shall call a meeting 11 of the committee to review the complaint to determine 12 whether the complaint meets the requirements for 13 validity and whether the committee should take action 14 on the complaint pursuant to paragraph “g” or whether 15 the committee should request that the chief justice 16 of the supreme court appoint an independent special 17 counsel to conduct an investigation to determine 18 whether probable cause exists to believe that a 19 violation of the house code of ethics, joint rules 20 governing lobbyists, or chapter 68B of the Code, has 21 occurred. The sufficiency as to form determination 22 and the valid complaint requirements determination 23 shall be based solely upon the original complaint and 24 the response to the complaint. Additional documents 25 or responses shall not be filed by the parties or 26 otherwise considered by the committee prior to a 27 validity determination. The committee shall not 28 receive or consider oral testimony in support of or 29 against a validity determination. 30 -10- LSB 1483YC (3) 88 jh/tm 10/ 23

H.R. _____ If the committee finds that a complaint does not 1 meet the content requirements for a valid complaint, 2 the committee shall dismiss the complaint and notify 3 both the complainant and the party alleged to have 4 committed the violation of the dismissal and the 5 reasons for dismissal. A dismissal for failure to meet 6 the formal requirements for the filing of a complaint 7 shall be without prejudice and the complainant may 8 refile the complaint at any time within three years 9 of the date that the alleged violation took place. If 10 the dismissal is based upon a failure to allege facts 11 and circumstances necessary for a valid complaint, the 12 dismissal shall be with prejudice and the party shall 13 not be permitted to file a complaint based upon the 14 same facts and circumstances. 15 g. Action on undisputed complaint. If the committee 16 determines a complaint is valid and determines no 17 dispute exists between the parties regarding the 18 material facts that establish a violation, the 19 committee may take action on the complaint under this 20 paragraph without requesting the appointment of an 21 independent special counsel. 22 The committee may do any of the following: 23 (1) Issue an admonishment to advise against the 24 conduct that formed the basis for the complaint and to 25 exercise care in the future. 26 (2) Issue an order to cease and desist the conduct 27 that formed the basis for the complaint. 28 (3) Make a recommendation to the house that 29 the person subject to the complaint be censured or 30 -11- LSB 1483YC (3) 88 jh/tm 11/ 23

H.R. _____ reprimanded. 1 h. Request for appointment of independent special 2 counsel. If, after review of the complaint and any 3 response made by the party alleged to have committed 4 the violation, the committee determines that the 5 complaint meets the requirements for form and content 6 and the committee has not taken action under paragraph 7 “g”, the committee shall request that the chief justice 8 of the supreme court appoint independent special 9 counsel to investigate the matter and determine whether 10 probable cause exists to believe that a violation of 11 chapter 68B of the Code, the house code of ethics, or 12 the joint rules governing lobbyists has occurred. 13 i. Receipt of report of independent special counsel. 14 The report from the independent special counsel 15 regarding probable cause to proceed on a complaint 16 shall be filed with the chief clerk of the house. 17 Upon receipt of the report of the independent special 18 counsel, the chief clerk shall notify the chairperson 19 of the filing of the report and shall send copies of 20 the report to the members of the ethics committee. As 21 soon as practicable after the filing of the report, the 22 chairperson shall schedule a public meeting for review 23 of the report. The purpose of the public meeting 24 shall be to determine whether the complaint should be 25 dismissed, whether a formal hearing should be held on 26 the complaint, or whether other committee action is 27 appropriate. The complainant and the person alleged to 28 have committed the violation shall be given notice of 29 the public meeting, shall have the right to be present 30 -12- LSB 1483YC (3) 88 jh/tm 12/ 23

H.R. _____ at the public meeting, and may, at the discretion 1 of the committee, present testimony in support of or 2 against the recommendations contained in the report. 3 If the committee determines that the matter should 4 be dismissed, the committee shall cause an order to 5 be entered dismissing the matter and notice of the 6 dismissal shall be given to the complainant and the 7 party alleged to have committed the violation. If 8 the committee determines that the complaint should be 9 scheduled for formal hearing, the committee shall issue 10 a charging statement which contains the charges and 11 supporting facts that are to be set for formal hearing 12 and notice shall be sent to the complainant and the 13 accused person. 14 The notice shall include a statement of the nature 15 of the charge or charges, a statement of the time and 16 place of hearing, a short and plain statement of the 17 facts asserted, and a statement of the rights of the 18 accused person at the hearing. 19 j. Formal hearing. Formal hearings shall be public 20 and conducted in the manner provided in section 68B.31, 21 subsection 8 of the Code. At a formal hearing the 22 accused shall have the right to be present and to 23 be heard in person and by counsel, to cross-examine 24 witnesses, and to present evidence. Members of 25 the committee shall also have the right to question 26 witnesses. 27 The committee may require, by subpoena or otherwise, 28 the attendance and testimony of witnesses and the 29 production of such books, records, correspondence, 30 -13- LSB 1483YC (3) 88 jh/tm 13/ 23

H.R. _____ memoranda, papers, documents, and any other things it 1 deems necessary to the conduct of the inquiry. 2 Evidence at the formal hearing shall be received 3 in accordance with rules and procedures applicable to 4 contested cases under chapter 17A of the Code. 5 The committee chairperson, or the vice chairperson 6 or ranking member in the absence of the chairperson, 7 shall preside at the formal hearing and shall rule on 8 the admissibility of any evidence received. The ruling 9 of the chairperson may be overturned by a majority 10 vote of the committee. Independent special counsel 11 shall present the evidence in support of the charge 12 or charges. The burden shall be on the independent 13 special counsel to prove the charge or charges by 14 a preponderance of clear and convincing evidence. 15 Upon completion of the formal hearing, the committee 16 shall adopt written findings of fact and conclusions 17 concerning the merits of the charges and make its 18 report and recommendation to the house. 19 k. Disqualification of member. Members of the 20 committee may disqualify themselves from participating 21 in any investigation of the conduct of another person 22 upon submission of a written statement that the member 23 cannot render an impartial and unbiased decision 24 in a case. A member may also be disqualified by a 25 unanimous vote of the remaining eligible members of the 26 committee. 27 A member of the committee is ineligible to 28 participate in committee meetings, as a member of the 29 committee, in any proceeding relating to the member’s 30 -14- LSB 1483YC (3) 88 jh/tm 14/ 23

H.R. _____ own official conduct. 1 If a member of the committee is disqualified or 2 ineligible to act, the majority or minority leader who 3 appointed the member shall appoint a replacement member 4 to serve as a member of the committee during the period 5 of disqualification or ineligibility. 6 l. Recommendations by the committee. The committee 7 shall recommend to the house that the complaint be 8 dismissed, or that one or more of the following be 9 imposed: 10 (1) That the member or employee of the house 11 or lobbyist or client of a lobbyist be censured or 12 reprimanded, and the recommended appropriate form of 13 censure or reprimand be used. 14 (2) That the member of the house be suspended or 15 expelled from membership in the house and required 16 to forfeit the member’s salary for that period, the 17 employee of the house be suspended or dismissed from 18 employment, or that the lobbyist’s or lobbyist’s 19 client’s lobbying privileges be suspended. 20 13. COMMUNICATIONS WITH ETHICS COMMITTEE. After a 21 complaint has been filed or an investigation has been 22 initiated, a party to the complaint or investigation 23 shall not communicate, or cause another to communicate, 24 as to the merits of the complaint or investigation with 25 a member of the committee, except under the following 26 circumstances: 27 a. During the course of any meetings or other 28 official proceedings of the committee regarding the 29 complaint or investigation. 30 -15- LSB 1483YC (3) 88 jh/tm 15/ 23

H.R. _____ b. In writing, if a copy of the writing is 1 delivered to the adverse party or the designated 2 representative for the adverse party. 3 c. Orally, if adequate prior notice of the 4 communication is given to the adverse party or the 5 designated representative for the adverse party. 6 d. As otherwise authorized by statute, the house 7 code of ethics, joint rules governing lobbyists, or 8 vote of the committee. 9 14. PERMANENT RECORD. The chief clerk of the house 10 shall maintain a permanent record of all complaints 11 filed and any corresponding committee action. The 12 permanent record shall be prepared by the ethics 13 committee and shall contain the date the complaint was 14 filed, name and address of the complainant, name and 15 address of the accused person, a brief statement of the 16 charges made, any evidence received by the committee, 17 any transcripts or recordings of committee action, and 18 ultimate disposition of the complaint. Beginning with 19 the 2017 Regular Session of the General Assembly, in In 20 recording the ultimate disposition of a complaint that 21 is dismissed, the information shall include whether 22 the complaint was dismissed due to formal insufficiency 23 or due to a failure to meet the content requirements 24 of a valid complaint. Except as provided in rule 25 12, paragraph “d”, the chief clerk shall keep each 26 complaint confidential until public disclosure is made 27 by the ethics committee. 28 15. MEETING AUTHORIZATION. The house ethics 29 committee is authorized to meet at the discretion of 30 -16- LSB 1483YC (3) 88 jh/tm 16/ 23

H.R. _____ the committee chairperson in order to conduct hearings 1 and other business that properly may come before it. 2 If the committee submits a report seeking house action 3 against a member or employee of the house or lobbyist 4 after the second regular session of a general assembly 5 has adjourned sine die, the report shall be submitted 6 to and considered by the subsequent general assembly. 7 16. ADVISORY OPINIONS. 8 a. Requests for formal opinions. A request for a 9 formal advisory opinion may be filed by any person who 10 is subject to the authority of the ethics committee. 11 The ethics committee may also issue a formal advisory 12 opinion on its own motion, without having previously 13 received a formal request for an opinion, on any issue 14 that is within the jurisdiction of the committee. 15 Requests shall be filed with either the chief clerk of 16 the house or the chairperson of the ethics committee. 17 b. Form and contents of requests. A request for 18 a formal advisory opinion shall be in writing and 19 may pertain to any subject matter that is related to 20 application of the house code of ethics, the joint 21 rules governing lobbyists, or chapter 68B of the 22 Code to any person who is subject to the authority of 23 the ethics committee. Requests shall contain one or 24 more specific questions and shall relate either to 25 future conduct or be stated in the hypothetical. A 26 request for an advisory opinion shall not specifically 27 name any individual or contain any other specific 28 identifying information, unless the request relates 29 to the requester’s own conduct. However, any request 30 -17- LSB 1483YC (3) 88 jh/tm 17/ 23

H.R. _____ may contain information which identifies the kind 1 of individual who may be affected by the subject 2 matter of the request. Examples of this latter kind 3 of identifying information may include references to 4 conduct of a category of individuals, such as but not 5 limited to conduct of legislators, legislative staff, 6 or lobbyists. 7 c. Confidentiality of formal requests and opinions. 8 Requests for formal opinions are not confidential and 9 any deliberations of the committee regarding a request 10 for a formal opinion shall be public. Opinions issued 11 in response to requests for formal opinions are not 12 confidential, shall be in writing, and shall be placed 13 on file in the office of the chief clerk of the house. 14 Persons requesting formal opinions shall personally 15 receive a copy of the written formal opinion that is 16 issued in response to the request. 17 17. PERSONAL FINANCIAL DISCLOSURE FORM. The 18 following form shall be used for disclosure of economic 19 interests under these rules and section 68B.35 of the 20 Code: 21 STATEMENT OF ECONOMIC INTERESTS 22 Name:_________________________________________________ 23 (Last) (First) (Middle Initial) 24 Address:______________________________________________ 25 (Street Address, Apt.#/P.O. Box) 26 ______________________________________________ 27 (City)(State)(Zip) 28 Phone:(Home)_____/____-_____(Business)_____/____-_____ 29 ****************************************************** 30 -18- LSB 1483YC (3) 88 jh/tm 18/ 23

H.R. _____ This form is due each year on or before February 15. 1 The reporting period is the most recently completed 2 calendar year. An amended form shall be filed if a 3 change in business, occupation, or profession reported 4 in Division I of the form has occurred. The amended 5 form shall include the date the change took effect and 6 must be filed within thirty days of the first day of 7 the change in employment or engagement necessitating 8 the amended form. If the date of the change occurs 9 between January 1 and February 15, the change shall be 10 included in the filing due February 15. 11 In completing Division III of this form, if your 12 percentage of ownership of an asset is less than 100 13 percent, multiply your percentage of ownership by the 14 total revenue produced to determine if you have reached 15 the $1,000 threshold. 16 Do not report income received by your spouse or 17 other family members. 18 In completing this form, if insufficient space is 19 provided for your answer, you may attach additional 20 information/answers on full-size sheets of paper. 21 Division I. Business, Occupation, or Profession. 22 List each business, occupation, or profession in 23 which you are engaged, the nature of the business if 24 not evident, and your position or job title. No income 25 threshold or time requirement applies. 26 Examples: 27 If you are employed by an individual, state the name 28 of the individual employer, the nature of the business, 29 and your position. 30 -19- LSB 1483YC (3) 88 jh/tm 19/ 23

H.R. _____ If you are self-employed and are not incorporated 1 or are not doing business under a particular business 2 name, state that you are self-employed, the nature of 3 the business, and your position. 4 If you own your own corporation, are employed by a 5 corporation, or are doing business under a particular 6 business name, state the name and nature of the 7 business or corporation and your position. 8 1_____________________________________________________ 9 2_____________________________________________________ 10 3_____________________________________________________ 11 4_____________________________________________________ 12 5_____________________________________________________ 13 6_____________________________________________________ 14 Division II. Commissions from Sales of Goods or 15 Services to Political Subdivisions. 16 This part is to be completed only by Legislators. 17 If you received income in the form of a commission 18 from the sale of goods or services to a political 19 subdivision, state the name of the purchasing political 20 subdivision. The amount of commission earned is not 21 required to be listed. 22 1_____________________________________________________ 23 2_____________________________________________________ 24 3_____________________________________________________ 25 4_____________________________________________________ 26 5_____________________________________________________ 27 6_____________________________________________________ 28 Division III. Sources of Gross Income. 29 In each one of the following categories list each 30 -20- LSB 1483YC (3) 88 jh/tm 20/ 23

H.R. _____ source which produces more than $1,000 in annual gross 1 income, if the revenue produced by the source was 2 subject to federal or state income taxes last year. 3 List the nature or type of each company, business, 4 financial institution, corporation, partnership, or 5 other entity which produces more than $1,000 of annual 6 gross income. Neither the amount of income produced 7 nor value of the holding is required to be listed in 8 any of the items. 9 A. Securities: State the nature of the business of 10 any company in which you hold stock, bonds, or other 11 pecuniary interests that generate more than $1,000 12 in annual gross income. Income generated by multiple 13 holdings in a single company are deemed received from a 14 single source. 15 ______________________________________________________ 16 ______________________________________________________ 17 ______________________________________________________ 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 B. Instruments of Financial Institutions: State 22 the types of institutions in which you hold financial 23 instruments, such as certificates of deposit, savings 24 accounts, etc., that produce annual gross income in 25 excess of $1,000, e.g., banks, savings and loans, or 26 credit unions. 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 -21- LSB 1483YC (3) 88 jh/tm 21/ 23

H.R. _____ ______________________________________________________ 1 ______________________________________________________ 2 ______________________________________________________ 3 C. Trusts: State the nature or type of any trust 4 from which you receive more than $1,000 of gross income 5 annually. 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 ______________________________________________________ 10 ______________________________________________________ 11 ______________________________________________________ 12 D. Real Estate: State the general nature of real 13 estate interests that generate more than $1,000 of 14 gross income annually, e.g., residential leasehold 15 interest or farm leasehold interest. The size or 16 location of the property interest is not required to be 17 listed. 18 ______________________________________________________ 19 ______________________________________________________ 20 ______________________________________________________ 21 ______________________________________________________ 22 ______________________________________________________ 23 ______________________________________________________ 24 E. Retirement Systems: State the name of each 25 pension plan or other corporation or company that pays 26 you more than $1,000 annually in retirement benefits. 27 ______________________________________________________ 28 ______________________________________________________ 29 ______________________________________________________ 30 -22- LSB 1483YC (3) 88 jh/tm 22/ 23

H.R. _____ ______________________________________________________ 1 ______________________________________________________ 2 ______________________________________________________ 3 F. Other Income Categories Specified in State and 4 Federal Income Tax Regulations. 5 ______________________________________________________ 6 ______________________________________________________ 7 ______________________________________________________ 8 ______________________________________________________ 9 ______________________________________________________ 10 _______________________________________ ___________ 11 (Signature of Filer) (Date) 12 -23- LSB 1483YC (3) 88 jh/tm 23/ 23