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-10- [[preprinted]] IV. PROPERTY INTERESTS and ASSETS (employee, spouse, and dependent child) Report any interests in property held in a trade or business, for the production of income, or for investment, which had a fair market value in excess of $1,000 at the close of the preceding calendar year. Report debts owed to you by corporations, partnerships, and other entities, include property of a trust of which you, hyour spouse, or dependent child is a beneficiary. Exclude: Property, or that portion thereof, used as residence(s) by you, your spouse or dependent child, tangible property (objects) not held for investment and used by you or a spouse or dependent child for personal purposes such as furnishing for your residence, or for personal transportation; securities issued by a govermental entity; dpeosits in banks, credit unions and savings institutions, or certificates of deposit debts owed you by a spouse, dependent child, or a relative. [[table of 4 columns]] | Description and Location of Property [when identifying securities give name of issuing company; if not listed on stock exchanges, give address and nature of business.) | Category of Amount or Value: $1,000 to $10,000 | Category of Amount or Value: $10,000 to $50,000 | Category of Amount or Value: Over $50,000 | [[4 rows, none completed]] [[check box [blank] ]] 'None' | | | | V. LIABILITIES (employee, spouse, and dependent chiled) Report debts to individuals, businesses, or non-profit organizations where indebted to any single creditor exceeded $10,000 at any time during the preceding year. Exlude: Alimony, child support or other obligations arising from the dissolution of a marriage or permanent separation from a spouse: mortgage loans secured by the residence of employee or spouse; loans secured by personal automobile, funiture or appliances, if the loan did not exceed the purchase price of item; and mortgages or debts payable to relatives. [[table of 4 columns]] | Name and Address of Creditor | Type of liability (e.g., mortgage, promissory note, margin account, or loan from business partners or corporation) | Category of Value: $10,000 to $50,000 | Category of Value: Over $50,000 | [[2 rows not filled in]] | [[blank check box]] 'None' [[whole row not completed]] VI. TRANSACTIONAL IN REAL AND PERSONAL PROPERTY (employee, spouse, and dependent child) Report purchase, sale, or exchange of real or personal property, including stocks, bonds, other forms of securities, or any other property held for invvestment (including objects), where the value of the property involved exceeded $1,000. Report the approximate date of any transaction, and designate if purchase, sale, or exchange. Exclude: Transactions between you, your spouse, or dependent children, or that involve the personal residence(s) of these persons; transactions involving securities issued by a governmental entity; and other transactions in property not required to be reported under Section IV. [[table of 8 columns]] | Description of Property [To identify securities give name of issuing company if not listed on stock exchange, give address and nature of business; to identify real and personal property, describe its general nature and where located.)| Approximate Date | P - Purchase | S - Sale | E - Exchange | Category of Value: $1,000 to $10,000 | Category of Value: $10,000 to $50,000 | Category of Value: Over $50,000 | [[4 rows, none completed]] [[check box [blank] ]] 'None' | | | | 3 [[/preprinted]]