Escolar Documentos
Profissional Documentos
Cultura Documentos
Report Required by the Ethics in Government Act of 1978 (5 U.S.C. app. 101-111)
[] Initial
8. On the basis of the information contained in this Report and any modifications pertaining thereto, it is, in my opinion, in compliance with applicable laws and regulations. Reviewing Officer Date
IMPORTANT NOTES: The instructions accompanying this form must be followed. Complete all parts,
checking the NONE box for each part where you have no reportable information. Sign on last page.
NAME OF ORGANIZATION/ENTITY
2. 3. 4. 5.
II. AGREEMENTS. m~po.lng inaZvlauut only; see pp. 14-16 of filing instruction&) ~] NONE (No reportable agreements.)
DATE PARTIES AND TERMS
Coffman, Jennifer B.
Ill. NON-INVESTMENT INCOME. (Repo.ing i.dlvidu.l a.d sponse; see pp. I 7-Z4 of filing instructions.)
A. Filers Non-lnvestment Income
~ NONE (No reportable non-investment income.) DATE SOURCE AND TYPE INCOME (yours, not spouses)
2. 3. 4.
B. Spouses Non-Investment Income - if you were married during anyportion of the reporting year, complete this section.
(Dollar amount not required except for honoraria.)
~]
1.2010 2.2010 3. 4.
DATES
LOCATION
PURPOSE
V. GIFTS. anduaes those to s, ouse and dependent children; see pp. 28-31 of filing instructions.)
NONE (No reportable gifts.)
SOURCE
1. 2. 3. 4. 5.
DESCRIPTION
VALUE
VI. LIABILITIES. andudes those oyspouse and dependent children; see pp. J2-33 of fillng instruction~.)
NONE (No reportable liabilities.)
CREDITOR
1. 2. 3. 4. 5.
DESCRIPTION
VALUECODE
VII. INVESTMENTS and TRUSTS - income, value, transactions (Includes those of spouse and dependent children; seepp. 34-60 of fillng instructions.)
NONE (No reportable income, assets, or transactions.)
A, Description of Assets (including trust assets) Place "IX)" after each asset exempt from prior disclosure B. income during reporting period (1) (2) Amount Type (e.g.. Code I div., rent, (A-H) or int.) C, Gross value at end of reporting period (1) (2) Value Value Code 2 Method (J-P) Code 3 (Q-W)
Transactions during reporting period (1) Type (e.g., buy, sell, redemption)
(2)
(3)
(J-P)
(4)
Gain Code 1 (A-H) Identity of buyer/seller (if private transaction)
CITIZENS BANK - COMMON STOCK RENTAL PROPERTY, ~L.. ~ HOPKINS COUNTY), KENTUCKY
None C Rent K
12/17/10
J M
IRA #3 (CENTRAL BANK) 5. -CASH BALANCE IN IRA #3 -COLUMBIA ACORN SMALL CAP FUND Z 7.
J J J
8. 9.
10. 11. 12. 13. 14. 15. 16.
A A
Dividend Dividend
None
T T
Buy (addl)
Sold A A Dividend Dividend None J J J T T T Buy (addl) Buy (addl) Sold (part) Sold (part)
L J J J J A A
Dividend
I. Income Gain Codes: iSee Columns B I and D4 ) 2. Value Codes (See Columns CI and D3) 3. Value Method Codes (See Column C2)
A =$1,000 or tess. F = $50.001 - $100,000 J =$15,000 or less N =$250.001 - $500,000 P3 =$25,000,001 - $50.000.000 Q =Appraisal U =Book Value
B =$1,001 - $2,500 G =$100,001 - $ 1,000,000 K =$15,001 - $50,000 O =$500,001 - $1,000,000 R =Cost (Real Estate Only) V =Other
C =$2,501 - $5,000 H 1 =$1,000,001 - $5,000,000 L =$50,001 - $100,000 PI =$1,000,001 - $5,000,000 P4 =More than $50,000,000 S =Assessment W =Estimated
D =$5,001 - $15,000 H2 =More than $ 5,000,000 M =$ I00,001 - $250.000 P2 =$5,000,001 - $25,000,000 T =Cash Market
E =$|5,001 -$50,000
VII. INVESTMENTS and TRUSTS - i.come, vatue, transactions (Includes those of spouse and dependent children; see pp. 34-60 of filing instructions.)
~] NONE (No reportable income, assets, or transactions.)
A. Description of Assets (including trust assets) Place "(X)" after each assel exempt from prior disclosure B. Income during reporting period (1) (2) Amount Type (e.g., Code 1 div., rent, (A-H) or int.) C. Gross value at end of reporting period (1) (2) Value Value Code 2 Method (J-P) Code 3 Type (e.g., buy, sell, redemption) Transactions during reporting period
(2)
(3)
(4)
Gain Code 1 (A-H) Identity of buyer/seller (if private transaction)
(Q-W)
17. 18. 19. 20. 21. 22. -VANGUARD INDEX FDS REIT~
-FEDERATED MAX-CAP INDEX INSTITUTIONAL[~ -FEDERATED PRIME OBLIGATION MONEY MKT
None
04/06/10 05/24/10
J J
A A
A B A
J L J N
T T T T Buy 09/09/10
23.
WESLEY COFFMAN DMD 401(K) PROFIT SHARING PLAN (CENTRAL BANK) -CASH BALANCE IN
None
[..~i ~ ~DMD 401(K) PSP CENTRAL BANK 24. -COLUMBIA ACORN SMALL CAP FUND Z 25. 26. 27. 28. 29. 30. 31. 32. -GOLDMAN SACHS FINCL SQUARE MONEY MARKET-PRINCPL -MATF PACIFIC TIGER -FEDERATED CAP APPRECIATION FUND 1
Dividend
J J K
A A
I. Income Gain Codes: (See Columns BI and D4) 2, Value Codes (See Columns CI and D3) 3, Value Melhod Codes (See Colunm C2)
A =$ 1,000 or less F =$50,001 - $100,000 J =$15,000 or less N =$250,001 - $500,000 P3 =$25,000,001 - $50.000.000 Q ~Appraisal U =Book Value
B =$ 1,001 - $2,500 G =$100,001 - $1,000,000 K =$15,001 - $50,000 O =$500.001 - $1,000,000 R =Cost (Real Estate Only} V =Other
C =$2,501 - $5,000 H 1 =$1,000.001 - $5.000,000 L =$50.001 - $ 100,000 Pt =$1,000,001 - $5,000,000 P4 =More than $50.000.000 S =Assessment W =Estimated
D =$5,001 - $15,000 H2 =More than $5,000,000 M =$100,001 - $250,000 P2 =$5,000,001 - $25,000,000 T Cash Market
E =$15,001 - $50,000
VII. INVESTMENTS and TRUSTS - income, volue, transactions (Includes those of spouse and dependent children; see pp. 34-60 of fillng instructions.)
~] NONE (No reportable income, assets, or transactions.)
A. Description of Assets (including trust assets) Place "(X)" after each asset exempt from prior disclosure B. Income during reporting period (1) (2) Amount Type (e.g., Code 1 div., rent, (A-H) or int.) C. Gross value at end of reporting period (1) (2) Value Value Code 2 (J-P) Method Code 3 Transactions during reporting period
(Q-W)
33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.
-VANGD INDEX REITD -FEDERATED MAX-CAP INDEX INST1TUTIONALD -FEDERATED PRIME OBLIGATION MONEY MARKET -SPDR GOLD TR None
Dividend
04/05/10 07/07/10 09/02/10 12/07/10 04/05/10 07/07/10 : 07/07/10 09/15/10 11/01/10 07/07/10 04/05/10 05121110 07/07110 07/07110 09/08/I 0
J M J J J J J J J J J J K J K
A A A A A A A
A A
Dividend
-SCHRODER EMERGING MARKET EQUITY FUND -T ROWE PRICE MID CAP GROWTH FUND #47
Dividend None
J J
T T
A A A A
J L J K
T T
1. Income Gain C0dcs: (See Columns BI and IM) 2. Value Codes (See Columns CI and D31 3. Value Method Codes (See Column C2)
A =$1,000 or less F =$50,001 - $100.000 J =$15.000 or less N = $250.001 o 5500.0110 P3 =$25.000.001 - $ 50,000,000 Q =Appraisal U =Book Value
B =$1.001 - $2,500 G =$100,001 - $1,000,000 K =$15,001 - 550.000 O = $500,001 - $ 1.000~000 R ~ (o~,1 (Real Estate Only) V :Other
C =$2,501 - $5,000 HI =$I,000,001 - $5,000,000 L =550.001 - 5100,000 P I =51,000,001 - $5,000,000 P4 More than $50,000,000 S =Assessment W =Estimated
D =$5,001 - 515,000 H2 =More than $5,000,000 M =$ 100,001 - $250,000 P2 =$5,000,001 - $25,000,000 T =Cash Market
E =$15,001- $50,000
VII. INVESTMENTS and TRU STS -i.eome, value, transactions (Includes those of spouse and dependent children; seepp. 34-60 of filing instructions.)
[~ NOblE (No reportable income, assets, or transactions.)
A. Description of Assets (including trust assets) Place "(X)" after each asset exempt from prior disclosure B. Income during reporting period (1) Amount Code I (A-H) (2) Type (e.g., div., rent, or int.) C. Gross value at end of reporting period O) Value Code 2 (J-P) (2) Value Method Code 3 (Q-W)
Transactions during reporting period
(i)
Type (e.g., buy, sell, redemptiou)
(2) (3) (4) Date Value Gain mm/dd/yy Code 2 Code 1 (J-P) (A-H)
(5)
Identity of buyer/seller (if private transaction)
(x)
D A
Rent Dividend
L J
S T
I. Income Gain Codes: (See Columns B I and D4) 2. Value Codes (See Columns IS 1 and D3) 3. Value Method Codes (See (olum~ C2)
A =$1.000 or less F =$50.001 - $100,000 J =$15.000 or loss N =$250.001 . $500,000 P3 $25.1)00.001-$50.000.000 Q =Appraisal U =Book Value
B =$1.001 - $2.500 G =$100.001 $1.000.000 K =$15,001 - $50,000 O =$500,001 - $1.000,000 R =Cost (Real Estate Only) V =Other
C =$2,501 - $5.000 H 1 =$1.000,001 - $5,000,000 L =$50,001 - $100,000 PI =$1,000.001 - $5,000,000 P4 -More than $50,000.000 S =Assessment W =Estimated
D =$5,001 - $15.000 H2 =More than $5,000,000 M -$100,001 - $250,000 P2 =$5,000,001 - $25,000,000 T =Cash Market
E =$15,001 - $50.000
IX. CERTIFICATION.
1 certify that all information given above (including information pertaining to my spouse and minor or dependent children, if any) is accurate, true, and complete to the best of my knowledge and belief, and that any information not reported was withheld because it met applicable statutory provisions permitting non-disclosure. 1 further certify that earned income from outside employment and honoraria and the acceptance of gifts which have been reported are in compliance with the provisions of 5 U.S.C. app. 501 et. seq., 5 U.S.C. 7353, and Judicial Conference regulations.
NOTE: ANY INDIVIDUAL WHO KNOWINGLY AND WILFULLY FALSIFIES OR FALLS TO FILE THIS REPORT MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS (5 U.S.C. app. 104)
Committee on Financial Disclosure Administrative Office of the United States Courts Suite 2-301 One Columbus Circle, N.E. Washington, D.C. 20544