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BUSINESS ENTITIES: List below the name, location, and nature of activities of any business entity with <br /> • holdings of real or personal property QT with business dealings in Boulder County, in which you have any <br /> interest, and the nature of the interest. <br /> Name and Location of ' Nature of the Business Nature of Interest <br /> Business <br /> PROPERTY: List the address and location of any real property within Boulder County in which you have an <br /> interest or, if you have a controlling interest in an entity or enterprise disclosed above, the address and <br /> location of real property in which such entity or enterprise has an interest. <br /> Address and Location of Property Owner of Record <br /> - -J <br /> - <br /> ADDITIONAL INFORMATION:Add below any additional information you wish to disclose. <br /> SWORN STATEMENT: <br /> I hereby swear or affirm under penalty of perjury that,to the best of my knowledge, information and belief, <br /> the information provided in this disclosure statement is accurate and complete. I acknowledge that for the <br /> purposes of Sections 5-9 and 5-10 of the Code of Ethics(regarding standards of conduct and disclosure), I <br /> am deemed to have an interest in my own financial affairs and in the financial affairs of my spouse or other <br /> relatives as specified in the Code of Ethics,and that I must disclose such interests pursuant to Section 5-10 <br /> and comply with the non-participation provisions thereof. I further acknowledge that it is a violation of the <br /> Code of Ethics to fail to file the statement within the time required in the Code of Ethics. <br /> Candidate/I •1 bent Signature Date <br />