1/6 DISCLOSURE STATEMENT of INTERESTS and ACTIVITIES under parliamentary office (Articles L.O. 135-1 and L.O. 135-2 of the Electoral Code) LAST NAME: FIRST NAME: Statement at start of term of office Election date:... /... / General Information 1) Under Article 2 of the aforementioned Act n 2103-907 of 11 October 2013, a conflict of interest is any situation of interference between a public interest and public or private interests that could influence or appear to influence the independent, impartial and objective performance of the duties of office. 2) By virtue of I of Article L.O. 135-1 of the Electoral Code, the disclosure of interests, for the purpose of preventing any conflicts of interest, applies to interests held as of the election date and during the five years preceding that date. The statement specifies the amount of compensation, allowances or incentives received for the items mentioned in 1-5, 8 and 10 of this statement. 3) The term "N/A" (not applicable) must appear in any fields that are not filled out. 4) The statement must be personally signed and each page initialled.
2/6 Personal information: Birth year: Occupation: Mailing address: Telephone number(s): E-mail address: * 1 Business activities, resulting in compensation or incentives, that were being performed as of the election date: Description of business activity Compensation or incentive received 2 Business activities, resulting in compensation or incentives, that have been performed during the past five years: Description of business activity Compensation or incentive received
3/6 3 Consulting activities being performed as of the election date and during the past five years: Identity of the employer or employing corporate structure Description of business activity Compensation or incentive received 4 Holdings in the management bodies of public or private organizations or of a company, as of the election date or during the past five years: Identity of the public or private organization or of the company Description of activity Compensation or incentive received
4/6 5 Direct financial holdings in the capital of a company as of the election date: Company identity Assessment of financial holding Compensation or incentive received 6 Business activities performed as of the election date by the spouse, civil partner or common-law partner: Identity of the spouse, civil partner or common-law partner Description of business activity 7 Volunteer positions that could generate a conflict of interest: Identity of the structure or legal person Description of activities and responsibilities
5/6 8 Duties and elected offices being performed as of the election date: Identity of duties and elected offices Start and end dates of duties and elected offices Compensation, allowances and incentives received 9 Names of parliamentary staff members as well as the activities reported by them: Names of parliamentary staff members Identity of the employer or employing corporate structure Description of performance of the business activity 10 Business or general-interest activities, even non-compensated, that the Member of Parliament plans to continue: Identity of the employer or employing corporate structure Description and methods of performing the the business activity Compensation, allowances and incentives received
6/6 11 Comments. * You are reminded that the penalty for failing to report a substantial part of one's assets or for providing a misleading assessment of one's assets is three years' imprisonment and 45,000 in fines; and the penalty for failing to disclose information and documents relevant to the mission of the French High Authority For Transparency In Public Life (HATVP) is one year's imprisonment and 15,000 in fines. In addition to the first of these penalties, a denial of civil rights may be imposed under Articles 131-26 and 131-26-1 of the French Criminal Code, and a denial of the right to hold public office may be imposed under Article 131-27 of the same Code. I the undersigned: - certify on my honour that the information provided in this statement is accurate; - understand that this statement will be made public on the website of the High Authority, except for the information covered in III of Article L.O. 135-2 of the Electoral Code 1. Given at Signature: 1 The following shall not be made public: the personal addresses of the individual required to make the report; the names of the spouse, civil partner or common-law partner, or other members of the individual's family. "For the reporting of interests and activities, the following shall not be made public, in terms of real property: information, other than the regional department name, relating to the location of the property. If it relates to a spouse, civil partner or common-law partner. "1 The names of the individuals that previously owned the property mentioned in this statement; "2 For property that is jointly owned, the names of the other joint owners; "3 For bare ownership, the names of the usufructuaries; "4 For usufruct, the names of the bare owners. "The following shall not be made public, regarding movable property: the names of the individuals who previously owned the movable assets mentioned in the asset disclosure statement; the names of the individuals who previously owned movable assets mentioned in the disclosure statement of interests and activities, if a spouse, civil partner or common-law partner [Provisions declared non-compliant with the Constitution by Constitutional Council Decision no. 2013-675 of 9 October 2013]. "The following shall not be made public, regarding financial instruments: the addresses of financial institutions and the numbers of accounts held."