AG 2012 12 17 - Laserfiche WebLink

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This entire document and any attachments are public record. Page 4 of 9 Attachment number 4 F -2 Page 80 6(c). If you know that any company or business entity listed in 6(a) or (b) above has any material business dealings or business contracts with the State, or is regulated by the State, provide a brief description of that business activity. Name of Company or Business Entity Description of Business Activity with the State None or Not Known 7. Are you, your spouse, or members of your immediate family the beneficiaries of a vested trust with a value of $10,000 or more that is created, established, or controlled by you? ❑ Yes ❑ No ► Do not list blind trusts Name and Address of Trustee Description of the Trust Your Relationship to the Trust 8. Do you, your spouse, or members of your immediate family have a liability (debt) of $10,000 or more, excluding indebtedness (mortgage) on your primary personal residence? Examples include credit card debts, auto loans, and student loans. ❑ Yes ❑ No Name of Debtor (You, Spouse, Immediate Family Member) Type of Creditor (Commercial Bank, Credit Union, Individual, etc.) II. OTHER DISCLOSURES 9(a). During the preceding calendar year, were you, your spouse or members of your immediate family a director, officer, governing board member, employee, independent contractor, or registered lobbyist of a nonprofit corporation or organization operating in the State primarily for religious, charitable, scientific, literary, public health and safety, or educational purposes? ❑ Yes ❑ No - If "No ", proceed to question 10. ► Do not list State boards or entities, or entities created by a political subdivision of the State. ► Do not list organizations of which you are a mere member or subscriber. Name of Person His /Her Position Name of Nonprofit Corporation or Organization Nature of Business or Purpose of Organization This entire document and any attachments are public record. Page 4 of 9 Attachment number 4 F -2 Page 80