Annual Benefit Reporting Statement

Submitted for the year ending December 31:

Employee name:

First name

Last name

List Anything of Value you have received as defined in Section 2.222.010 of the Metropolitan Code of Laws other than donations in connection with political campaigns made and reported in compliance with Tennessee election laws.

Benefit type may be described by reference to the following abbreviations:

M = Meals, food, and beverage items
A = Admissions, tickets to events, or other access (including parking)
T = Travel expense
O = Other (describe)

I have benefits to report.

Yes

No

List of benefits received:

Re-order	Source:	Date;	Benefit type:	Value:	Weight	Operations
	Source:	Date;	Benefit type:	Value:	Item weight

more items

Email address:

Please provide a valid email address if you would like to receive a copy of your submission.

Attestation

Under penalty of perjury, the information contained herein is true to the best of my information and belief.

Electronic Signature:

Date: