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Election System of the Virgin Islands
Sunny Isle Shopping Center, Christiansted, St. Croix, V.I. (340) 773-1021
Lockhart Gardens, St. Thomas, V.I. (340) 774-3107
Market Place, St. John (340) 776-6535
P.O. Box 1499, Kingshill, St. Croix, U.S. Virgin Islands 00851 / P.O. Box 6038, St. Thomas, U.S. Virgin Islands 00801
FINANCIAL DISCLOSURE REPORT
PART ONE
Please type or print legibly in ink.
Please complete all entries.
Please sign completed form.
List the name, instrument of ownership, and any position of management held in any business entity held by you, your spouse or any other party constructively controlled by you in which the ownership is in excess of $5,000 fair market value as of the date of filing or from which income of $1,000 or more was derived during the preceding calendar year. No time or demand deposit in a financial institution, or any debt instrument having a fixed yield need be listed unless it is convertible to any equity instrument. Do not list the amounts involved on PART ONE.
(Please attach additional numbered pages, if required).
Election System of the Virgin Islands
FINANCIAL DISCLOSURE REPORT – PART ONE
Page 2
List name, address, and type of practice of any professional organization in which you or your spouse is an officer, director, or partner, or serves in any advisory capacity, from which income of $l,000 or more was derived during the preceding calendar year. Do not list the amounts involved on PART ONE.
(Please attach additional numbered pages, if required).
List the source of income of each of the following items received during the preceding calendar year, excluding any political campaign contributions. Do not list the amounts involved on PART ONE.
Any income for services rendered exceeding $5,000:
Any capital gain from a single source exceeding $5,000, other than from the sale of a residence occupied by you:
Reimbursement for expenditures exceeding $1,000 in each instance:
Honorariums from a single source aggregating $300 or more:
Election System of the Virgin Islands
FINANCIAL DISCLOSURE REPORT – PART ONE
Page 3
List each creditor to whom you were indebted for a period of ninety (90) consecutive days or more during the preceding calendar year in an aggregate amount in excess of $10,000, excluding any indebtedness specifically secured by a pledge of your assets of appropriate value. Do not list the amounts involved in PART ONE.
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Election System of the Virgin Islands
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Election System of the Virgin Islands
Bookman Old Style
Sunny Isle Shopping Center
, Christiansted, St. Croix, V.I. (340) 773
1021
Lockhart Gardens
, St. Thomas, V.I. (340) 774
3107
Market Place, St. John (340)
6535
P.O. Box 1499
Kingshill
St. Croix
U.S. Virgin Islan
00851
P.O. Box 6038
St. Thoma
U.S. Virgin Islands
00801
"Arial Black
FINANCIAL DISCLOSURE REPORT
PART ONE
Please type or print legibly in ink.
Please complete all entries.
Please sign completed form.
Bookman Old Style
"Gautami
1Courier New
Name of Person Filing:
Bookman Old Style
Home Addr
ess:
Telephone:
"Gautami
Mailing Address
1Courier New
Position Held:
Department or Agency:
Spouse’s Name, if Married:
Children’s Names, if Any:
Filing Date
"Arial
List the name, instrument of ownership, and any position of management held in
any business entity held by you, your spouse or any other party
constructively
controlled by you
in which the ownership is in excess o
f $5,000 fair market value
as of the date of filing or from which income of $1,000 or more was derived during
the preceding calendar year. No time or demand deposit in a financial institution,
or any debt instrument h
aving a fixed yield need be listed unl
ess it is convertible to
any equity instrument. Do not
list the amounts involved on
PART ONE
Bookman Old Style
Bookman Old Style
"Arial
(Please attach additional numbered pages, if required).
"Arial
VI BOE
Election System of the Virgin Islands
Title