ANNUAL INCOME DISCLOSURE REPORT

Employee Individual Income Above $1,000

Please disclose the name and address of the income sources of $1,000 or greater for the employee: (excluding income received from DeKalb County)

Spousal Income Disclosure
Please disclose the name and address of Spousal Income Sources of $1,000 or greater:
Example of How to Disclose Income
Please disclose the name and address of Interest or Dividends of $1,000 or greater of Employee and/or Spouse:
Example of How to Disclose Income
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Under penalty of perjury, by signing this electronic document; you certify that the information provided in this Disclosure of Income Report is correct, complete and truthful, to the best of my knowledge. In signing this Disclosure Report, I understand that the failure to file this report and the failure to provide truthful, complete and accurate information may result in disciplinary action against me and/or a referral of such violation to the DeKalb County Board of Ethics for punitive action.