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FINANCIAL DISCLOSURE For help completing this application, please call 336/627-6195. Mail date PATIENT INFORMATION Name: Address: City, State, ZIP: County: Home phone: Time at current address: SSN:
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How to fill out a financial disclosure form:

01
Start by gathering all the necessary financial documents, including bank statements, tax returns, investment statements, and any other documents that provide an overview of your financial situation.
02
Read through the form carefully, paying close attention to any instructions or guidelines provided. Make sure you understand what information is required and how it should be presented.
03
Begin by providing your personal information, such as your name, address, and social security number. Some forms may also require information about your spouse or dependents.
04
List all your sources of income, including salaries, bonuses, investments, rental income, and any other sources of income you receive. Be as detailed and accurate as possible.
05
Declare all your assets, such as properties, vehicles, stocks, bonds, and other investments. Again, provide specific details including the value of each asset and any liabilities associated with it.
06
Disclose any debts or liabilities you may have, including mortgages, car loans, credit card debts, student loans, and any other outstanding debts.
07
Indicate any financial interests or ownership you have in businesses or other entities. This may include partnerships, corporations, or trusts.
08
If applicable, report any gifts or payments you have received or made that meet the criteria for disclosure as defined by the form's guidelines. This could include gifts from individuals or organizations.
09
Review the completed form carefully, ensuring that all the information provided is accurate and up to date. Take the time to double-check all figures and calculations.
10
Sign and date the form, certifying that the information you have provided is true and complete to the best of your knowledge.

Who needs a financial disclosure form:

01
Individuals in government positions or public office may be required to complete a financial disclosure form. This is to ensure transparency and prevent conflicts of interest.
02
Employees of certain industries or organizations, such as those in the financial sector or government contractors, may also be required to fill out financial disclosure forms.
03
Individuals going through divorce or separation proceedings may need to complete a financial disclosure form as part of the legal process.
04
Some financial institutions or lenders may request a financial disclosure form as part of their loan application or credit evaluation process.
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A financial disclosure form is a document that individuals are required to fill out in order to provide information about their financial activities, assets, and liabilities.
Certain individuals, such as government officials, public servants, and employees in positions of authority, are typically required to file a financial disclosure form.
To fill out a financial disclosure form, individuals usually need to provide details about their income, investments, real estate holdings, business interests, and any potential conflicts of interest.
The purpose of a financial disclosure form is to promote transparency and prevent conflicts of interest by making financial information of individuals in positions of power or authority available to the public.
Typically, individuals are required to report their sources of income, assets, liabilities, investments, real estate holdings, and any potential conflicts of interest on a financial disclosure form.
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