Schedule C, Income, Loans and Business Positions (Other than Gifts and Travel Payments)

1. Income Received

Name of Source of Income:

Address (Business Address Acceptable):

Business Activity, If Any, Of Source:

Your Business Position:

Gross Income Received:

No Income - Business Position Only

$500-$1,000

$1,001-$10,000

$10,001-$100,000

Over $100,000

Consideration For Which Income Was Received

Salary

Spouse’s or registered domestic partner’s income (For self-employed use Schedule A-2.)

Partnership (Less than 10% ownership. For 10% or greater use Schedule A-2.)

Sale of (Real property, car, boat, etc.) , Describe:

Loan repayment

Commission   or  Rental Income,  list each source of $10,000 or more

Other , Describe:

1. Income Received

Name of Source of Income:

Address (Business Address Acceptable):

Business Activity, If Any, Of Source:

Your Business Position:

Gross Income Received:

No Income - Business Position Only

$500-$1,000

$1,001-$10,000

$10,001-$100,000

Over $100,000

Consideration For Which Income Was Received

Salary

Spouse’s or registered domestic partner’s income (For self-employed use Schedule A-2.)

Partnership (Less than 10% ownership. For 10% or greater use Schedule A-2.)

Sale of (Real property, car, boat, etc.) , Describe:

Loan repayment

Commission   or  Rental Income,  list each source of $10,000 or more

Other, Describe:

2. Loans Received or Outstanding During the Reporting Period

* You are not required to report loans from a commercial lending institution, or any indebtedness created as part of a retail installment or credit card transaction, made in the lender’s regular course of business on terms available to members of the public without regard to your official status. Personal loans and loans received not in a lender’s regular course of business must be disclosed as follows:

Name of Lender*:

Address of Lender (Business Address Acceptable):

Business Activity, if any, of Lender:

Highest Balance During Reporting Period

$500-$1,000 $1,001-$10,000 $10,001-$100,000 Over $100,000

Interest Rate of Loan (Percent):

None (Interest Rate)

Term (Months/Years):

Security for Loan

None

Personal residence

Real Property

Street Address of Real Property:

City of Real Property:

Guarantor, Name of Guarantor:

Other, Describe: Other: