The Commission has provided an electronic form that can be completed on your computer, printed, signed and mailed to the Commission. If you cannot complete the Statement in this manner, please type or print responses carefully with blue or black ink. Remember to sign and date the Statement at the end of the form.

You must respond to each and every part of every question. If a question does not pertain to you, or if you do not have any information to provide in response to a question check the box "None". DO NOT LEAVE ANY ITEMS ON THE FORM BLANK, UNLESS TOLD TO SKIP A QUESTION.

IF YOU FAIL TO ANSWER EVERY QUESTION,
YOUR FORM WILL BE RETURNED TO YOU AS INCOMPLETE.

Do NOT abbreviate words, even your agency name. You may attach extra sheets to the Statement if necessary.

You do not have to disclose specific dollar amounts or privileged information. If you do not respond to a question because you believe it to be privileged, you must affirmatively state that fact and indicate the privilege upon which you rely. There is no attorney-client privilege as to the identity of a client.

Any officer or public servant who fails to file a required Statement shall be subject to salary withholding in accordance with the provisions of KRS11A.990(2).