Financial Disclosure Entry - Form PODA-1

NAME OF FILER:

REPORTING PERIOD:

OFFICE SOUGHT / HELD:

DATE OF FILING:

PART I: STATEMENT OF ASSETS AND LIABILITIES

ASSETS	COST BASIS	ESTIMATED VALUE
Cash on Hand and in Banks
Notes and Accounts Receivable
Marketable Securities (Stocks/Bonds)
Real Estate Investments
Other Assets (Personal Property, etc.)
TOTAL ASSETS

LIABILITIES	COST BASIS	ESTIMATED VALUE
Notes Payable (Secured)
Notes Payable (Unsecured)
Accounts Payable / Other Liabilities
TOTAL LIABILITIES
NET WORTH (Total Assets - Total Liabilities)

PART II: SOURCES OF INCOME

SOURCE (Name and Address of Employer/Payer)	AMOUNT



TOTAL INCOME