Professional Documents
Culture Documents
Report Required by the Ethics in Government Act of 1978 (5 ,U.S. C. app. ,~ 101-111)
[] Initial
5b. [] Amended Report 7. chambers or Office Address 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.
Date
Reviewing Officer
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.
[~
1. 2. 3. 4. 5.
NAME OF ORGANIZATION/ENTITY
estate
Belot, Monti L.
III. NON-INVESTMENT INCOME. (Repo.ing individual and spouse; seepp. 17-24 of filing instructions.)
A. Filers Non-lnvestment Income ~] NONE (No reportable non-investment income.) DATE SOURCE AND TYPE
2. 3. 4.
B. Spouses Non-lnvestment Income - lf you were married during any portion of the reporting year, complete this section.
(Dollar amount not required except for honoraria.)
~
1. 2. 3. 4.
PURPOSE
V. GIFTS. (Includes those to sp ...... dependent children; seepp. 28-31 of filing instructions.) d
NONE (No reportable gifts.) SOURCE DESCRIPTION VALUE
2. 3. 4. 5.
VI. LIABILITIES. ancludcs those of spouse and dependent children; see pp. 32-33 of filing instructions.)
NONE (No reportable liabilities.) CREDITOR 1. 2. 3. 4. 5. DESCRIPTION
VALUECODE
VII. INVESTMENTS and TRUSTS - income, valae, transactions (Includes those of spouse and dependent children; see pp. 34-60 of filing instructions.)
~] NONE
(No reportable
T. Rowe Price New Era Coca Cola Co. Navy Federal Credit Union Wells Fargo Bank, N.A. U.S.A.A., Subscribers Savings Acct. Jackson Natl Life Ins.Co. IRA Annuity JNL/Mellon Cptl Mgm The American Fund IRA --Capital Income Builders Fund --Capital World Growth & Income Fund Inc --Investment Company of America --Income Fund of America, Inc. American Forerunner IRA --Loomis Sayles Small Cap --Harris Oakmark Intemational --Harris Oakmark Focused Value Portfolio --FI International Stock Portfolio --Davis Venture Value
A A A A B D D
J J J
J
T T T
T
J L N
T T T Sold 02/19/10 J A
(part)
Dividend
Sold
10/14/10 J
i; i ne0mc Gain COdes: (See Columns B! and IM) 2. Value Codes (See Columns C I and D3) 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 - $500,000 P3 =$25,000,001 - $50,000,000 Q =Appraisal U =Book Value
=$i~001 : $2,500 K =$15~00! : $50,000 O =$500,001 - $1,000,000 =Cost (Real Estate Only) =Other
C ~$2,501 - $5,000 L $50,001 - $100,000 P1 =$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, value, transactions (Includes those of spouse and dependent children; see pp. 34-60 of filing instructions.)
[]
18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.
--BlackRock Strategic Value --American Funds Growth-Income --American Funds Growth Coca-Cola~ Westar Energy~l~~ Eaton Vance Balanced Fun~ Wells Fargo Bank, N.A.~ T. Rowe Price New Horizons Fund Waddell & Reed Advisors Science and Technology Fund Waddell & Reed Advisors Accumulative A Fund Merrill Lynch CMA Money Fund American Balanced Fund - Class A A A A A E E E A A Dividend Dividend Dividend Interest Dividend Dividend Dividend Interest Dividend L T J J J J M M M T T Redeemed (part) Redeemed 07/30/10 07/30/10 02/23/10 01/04/10
01/21/10
M M K. J
J
(part)
Sold
Redeemed
(part) (part)
Redeemed
Redeemed
(part) Redeemed
01121/10
1 02/01 / 1 0
J
J
(p~)
(part)
Redeemed
05/12/10
Dividend
1. inc0me Gain Codes: (See Columns BI and D4) 2. Value Codes (See Columns C I.and D3) 3. Value Melhod Codes (See Column C2)
A =$1,000 Or less Z =$50;00] - $100,000 J =$15,000 or less N =$250,001 ~ $500,000 P3 =$25,000,00t ~ $50,000,000 Q =Appraisal U =Book Value
B =$i~001 : $2i500 G ~$]00100i - $1,000,000 K =$15,001 - $50,000 O =$500,001 , $1,000,000 R =Cost (Real Estate Only) V ~Othcr
C =$2,501 - $5,000 H 1 =$ !,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- $50,000
VII. INVES TMENTS and TRU S TS - income, value, transactions (Includes those of spouse and dependent children; see pp. 34-60 of filing instructions.)
NONE (No reportable income, assets, or transactions.)
Description of Assets (including trust assets) Place "CA)" after each asset exempt:fromprior disclosure Income during reporting period Gross value at end Transactions during reporting period
O)
Amount Code 1 (A-H)
(2)
Type (e.g., div., rent, or int.)
Date mm/dd/yy
New York Life Ins. New York Life Ins. New York Life Ins. New York Life Ins.
A A A A
] ine0m~ Ghifi ~0d~si (See Coltmms Bl and D4) 2. Value Codes (See Columns C I and D3) 3. Value Method Codes (See Colunm C2)
A =$L000 or less F =$50,001 - $100,000 J =$15,000 or less N =$250,00t - $500,000 P3 =$25,000,001 - $50,000,000 Q =Appraisal U =Book Value
B =$1,001 - $2,500 G =$ 100,00 i - $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 I =$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 $5,0001000 M =$100,001 - $250,000 P2 =$5,000,001- $25,000,000 T =Cash Market
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. I 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.
Committee on Financial Disclosure Administrative Office of the United States Courts Suite 2-301 One Columbus Circle, N.E. Washington, D.C. 20544