Annual Disclosure Statement

This Annual Disclosure Statement is submitted in compliance with Section 2.222.030 of the Metropolitan Code.

Submitted for the year ending December 31:

Name:

Position/Office:

List all sources of your income for the preceding calendar year:

Gifts from family members and relatives by blood or marriage need not be disclosed.

To the best of your knowledge, list all sources of income for your spouse for the preceding year:

Gifts from family members and relatives by blood or marriage need not be disclosed.

Do you or your spouse presently have a financial interest of at least 5% (five percent) of any business with operations, offices, or interests in the Metropolitan Nashville area?

Yes

Please provide information for each business:

Re-order	Yourself or Spouse	Business Name	Business Address	Percent of interest (if known)	Weight	Operations
	Yourself or Spouse	Business Name	Business Address	Percent of interest (if known)	Item weight

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Do you or your spouse have a direct or indirect financial interest in any real property located in Davidson County, excluding your primary residence?

Yes

Indirect interests indicate interests of greater than 5% in Real Estate Investment Trusts, other trusts in which you hold a beneficial interest in excess of 5% and other legal entities whose primary business is real estate related.

Please provide information for each property:

Re-order	Yourself or Spouse	Property Name	Property Address	Weight	Operations
	Yourself or Spouse	Property Name	Property Address	Item weight

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Do you or your spouse hold any paid or unpaid position with any for-profit entity, non-profit entity, labor group, or educational or other institution which you have not already listed on this form?

Yes

Please provide information for each position:

Re-order	Yourself or Spouse	Position	Entity	Weight	Operations
	Yourself or Spouse	Position	Entity	Item weight

more items

Do you or your spouse have a financial interest in, or are you or a family member a party to, any litigation involving the Metropolitan Government?

Yes

Describe each:

Do you or your spouse have any* debts, guarantees, or endorsements of debts aggregating over $5,000 owed to any one creditor?

Yes

*Excluding liabilities owed to a family member or relative by blood or marriage, and excluding loans from established financial institutions made in the ordinary course of business on usual and customary terms.

Describe each:

Do you or your spouse have any debts in excess of $5,000 which are secured by a guarantee or collateral of any individual other than a family member or a relative by blood or marriage?

Yes

Describe each:

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: