RHODE ISLAND ETHICS COMMISSION
40 Fountain Street
Providence, RI 02903
(401) 222-3790 (Voice/TT)
(800) 752-8088
Fax: 222-3382
|
GIFTS DISCLOSURE STATEMENT |
|
(This report covers the period from January 1 through December 31 of the preceding year and is due on January 31 of the current year) |
|
NAME: |
STATE POSITION: |
|
POSITION: |
STATE TEL NO: |
|
STATE MAILING ADDRESS: |
|
1. DONOR NAME AND ORGANIZATION |
2. DESCRIPTION OF GIFT |
3. DATE REC’D |
4. GIFT VALUE |
5. AGGREGATE VALUE |
|
|
|
|
||
|
|
|
|
||
|
|
|
|
||
|
|
|
|
||
|
|
|
|
||
|
|
|
|
||
|
|
|
CERTIFICATION: I hereby certify that the above is a true, correct and complete statement.
SIGNATURE:_________________________________________ DATE:___________________