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62 App., 257:15-1-1 et seq., and Ethics Manual to complete this statement. 1. NAME OF FILER: (No nicknames, please) REV . 5 /0 6 BIRTH DATE: FILER'S COMPLETE MAILING ADDRESS AND WORK PLACE TELEPHONE NUMBER: Mailing address Work place telephone number City State Zip G Check for address change Number Assigned by Ethics Commission OK 2. FILING STATUS: YEARLY AMENDED Calendar Year Covered: FINAL (required w ithin 60 days of end of service) Date Service Ended: Chief ad.

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