Please identify any source of income of the filer and the filer’s immediate family members that exceeds $5,000 during the preceding calendar year, and the nature of the income (e.g., salary, commission, dividends, retirement fund distribution and the like) (Item 4).
Income Recipient | Source of Income | Type of Income | |
Check here if the filer or any member of filer’s immediate family had income of over $5,000 as dividends and interest on stocks and bonds listed and customarily sold on national or regional stock exchanges and do not list elsewhere on this form. | |||
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