Jersey County Clerk and Recorder of Deeds
200 N. Lafayette | P. O. Box 216 | Jerseyville, IL 62052            (618) 498-5571 Option 6

STATEMENT OF ECONOMIC INTERESTS

TO BE FILED WITH
JERSEY COUNTY CLERK PAM WARFORD
200 N. LAFAYETTE ST, JERSEYVILLE, IL 62052

GENERAL DIRECTIONS

The interest (if constructively controlled by the person making the statement) of a spouse or any other party shall be considered to be the same as the interest of the person making the statement. Campaign receipts shall not be included in this statement. If more space is needed, please attach supplemental listing.

1. List the name and instrument of ownership in any entity doing business with a unit of local government in relation to which the person is required to file, in which the ownership interest held by the person at the date of filing is in excess of $5,000 fair market value, or from which dividends in excess of $1,200 were received during the preceding calendar year: (In the case of real estate, location thereof shall be listed by three street address, or if none, then by legal description.) No time or demand deposit in a financial institution, nor any debt instrument shall be listed.

2. List the name, address, and type of practice or any professional organization in which the person making the statement was an officer, director, associate, partner or proprietor, or served in any advisory capacity, from which income in excess of $1,200 was derived during the preceding calendar year:

VERIFICATION

I declare that this Statement of Economic Interests (including any accompanying scheduled and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of my economic interests as required by the Illinois Governmental Ethics Act. I understand that the penalty for willfully filing a false or incomplete statement shall be a fine not to exceed $1,000 or imprisonment in a penal institution other than the penitentiary not to exceed one year, or both fine and imprisonment.