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State of New Jersey Department of Community Affairs Division of Local Government Services Local Finance Board Local Government Ethics Law Financial Disclosure Statement This Financial Disclosure Statement is required annually of all local government officers in accordance with N.J.S.A. 40A:9-22.1 et seq., the Local Government Ethics Law. Year of Service: Enter the Local Government Served: Section I. Personal Information - Local Government Officer First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________ Home Address: _____________________________________________ Telephone Numbers (optional*) (Optional*) _____________________________________________ Home: ______________________ _____________________________________________ Business: ______________________ **Spouse’s First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________ * Optional information, if supplied, is subject to public disclosure as part of the Financial Disclosure Statement. ** Spouse includes a Civil Union partner. Agency Position Held Term Expires (if applicable) 1. _________________________________________ ________________________________________ ________________ 2. _________________________________________ ________________________________________ ________________ 3. _________________________________________ ________________________________________ ________________ 4. _________________________________________ ________________________________________ ________________ 5. _________________________________________ ________________________________________ ________________ Section II. Financial Information Provide the following information for yourself and members of your immediate family for the prior calendar year. If none, please indicate NONE in the space provided. If additional space is needed, please scroll down and use the Extension Forms that have been provided. A. List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the source of income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization. Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5. B. List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for personal appearances, speeches, or writing. Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5. Page 1 Woodbridge Township Fire District No. 7 1 Main st. Woodbridge n.j 07095 E. Patricia 732-738-1311 ex 3055 T. Woodbridge township Fire commissiner Board of fire comm. dist. # 7 George 2016 2013 Madison Brew 168 woodland ave. Brew Brew Fords N.J 08863
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Page 1: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

State of New Jersey Department of Community Affairs Division of Local Government Services Local Finance Board

Local Government Ethics Law Financial Disclosure Statement

This Financial Disclosure Statement is required annually of all local government officers in accordance with N.J.S.A. 40A:9-22.1 et seq., the Local Government Ethics Law.

Year of Service:

Enter the Local Government Served: Section I. Personal Information - Local Government Officer First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________ Home Address: _____________________________________________ Telephone Numbers (optional*) (Optional*) _____________________________________________ Home: ______________________ _____________________________________________ Business: ______________________ **Spouse’s First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________ * Optional information, if supplied, is subject to public disclosure as part of the Financial Disclosure Statement. ** Spouse includes a Civil Union partner. Agency Position Held Term Expires (if applicable) 1. _________________________________________ ________________________________________ ________________ 2. _________________________________________ ________________________________________ ________________ 3. _________________________________________ ________________________________________ ________________ 4. _________________________________________ ________________________________________ ________________ 5. _________________________________________ ________________________________________ ________________

Section II. Financial Information

Provide the following information for yourself and members of your immediate family for the prior calendar year. If none, please indicate NONE in the space provided. If additional space is needed, please scroll down and use the Extension Forms that have been provided.

A. List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the source of

income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization.

Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5.

B. List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for personal

appearances, speeches, or writing.

Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5.

Page 1

Woodbridge Township Fire District No. 7

1 Main st. Woodbridge n.j 07095

E.Patricia

732-738-1311 ex 3055

T.

Woodbridge township

Fire commissinerBoard of fire comm. dist. # 7

George

2016

2013

Madison Brew

168 woodland ave.Brew

Brew

Fords N.J 08863

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* The Year that you are filing the statement
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Page 2: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

C. List the name and address of each source of gifts, reimbursements or prepaid expenses having an aggregate value exceeding $400 from any single source, excluding relatives.

Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5.

D. List the name and address of all business organizations in which an interest was held.

Name Address Self Spouse Dependent Name 1. 2. 3. 4. 5.

E. List the address and a brief description of all real property in the State of New Jersey in which an interest was held.

Municipality/County Block Lot Qual. Address (if applicable) % of Ownership Self Spouse Dependent Name

1. 2. 3. 4. 5.

F. Please add any other information you believe is necessary to complete this form.

Section III. Certification I hereby certify that this Financial Disclosure Statement contains no willful misstatement of fact or omission of material fact and, together with any and all statements previously submitted in writing to the clerk of my local government or the Local Finance Board, constitutes a full disclosure with respect to all matters required by N.J.S.A. 40A:9-22.1 et seq., to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to fines and possible disciplinary action. Date:_____________________ Type your name _____________________________________ To complete the online filing process: Enter the e-mail address that was provided to you by the municipal clerk, county clerk, or other representative for the local government that you serve. LGA Email: ___________________________________________________________

Enter the Email address that you use as a local government officer (optional*). LGO Email: _______________________________________________________

E-Filing Statement – (a.) I have personally reviewed and approved the foregoing financial disclosure statement and any Extention forms attached hereto; (b.) I have personally filed or somebody has been authorized by me to file this form electronically with my consent. Accept Denied

After you click the “Submit” button below the system will populate the receipt form indicating the date and time that you electronically submitted your financial disclosure statement and assigning a receipt number. You must print the receipt and deliver a signed original copy of the receipt to your local government agency representative. SUBMIT Page 2

5/28/2013

141B

[email protected]

[email protected]

100% Madison. Brew175A

Submit

woodbridge Middlesex

George T.Brew

168 Woodland Ave. Fords N.J. 08863

Page 3: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

Section I Personal Information - Extension Forms.

Agency Position Held Term Expires (if applicable) 6. _________________________________________ ________________________________________ ________________ 7. _________________________________________ ________________________________________ ________________ 8. _________________________________________ ________________________________________ ________________ 9. _________________________________________ ________________________________________ ________________ 10. _________________________________________ ________________________________________ ________________ 11. _________________________________________ ________________________________________ ________________ 12. _________________________________________ ________________________________________ ________________ 13. _________________________________________ ________________________________________ ________________ 14. _________________________________________ ________________________________________ ________________ 15. _________________________________________ ________________________________________ ________________ 16. _________________________________________ ________________________________________ ________________ 17. _________________________________________ ________________________________________ ________________ 18. _________________________________________ ________________________________________ ________________ 19. _________________________________________ ________________________________________ ________________ 20. _________________________________________ ________________________________________ ________________ 21. _________________________________________ ________________________________________ ________________ 22. _________________________________________ ________________________________________ ________________ 23. _________________________________________ ________________________________________ ________________ 24. _________________________________________ ________________________________________ ________________ 25. _________________________________________ ________________________________________ ________________ 26. _________________________________________ ________________________________________ ________________ 27. _________________________________________ ________________________________________ ________________ 28. _________________________________________ ________________________________________ ________________ 29. _________________________________________ ________________________________________ ________________ 30. _________________________________________ ________________________________________ ________________ 31. _________________________________________ ________________________________________ ________________ 32. _________________________________________ ________________________________________ ________________ 33. _________________________________________ ________________________________________ ________________ 34. _________________________________________ ________________________________________ ________________ 35. _________________________________________ ________________________________________ ________________ 36. _________________________________________ ________________________________________ ________________ 37. _________________________________________ ________________________________________ ________________ 38. _________________________________________ ________________________________________ ________________ 39. _________________________________________ ________________________________________ ________________ 40. _________________________________________ ________________________________________ ________________ 41. _________________________________________ ________________________________________ ________________ 42. _________________________________________ ________________________________________ ________________ 43. _________________________________________ ________________________________________ ________________ 44. _________________________________________ ________________________________________ ________________ 45. _________________________________________ ________________________________________ ________________ 46. _________________________________________ ________________________________________ ________________ 47. _________________________________________ ________________________________________ ________________ 48. _________________________________________ ________________________________________ ________________ 49. _________________________________________ ________________________________________ ________________ 50. _________________________________________ ________________________________________ ________________

Page 3

Page 4: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

Section II financial Information - Extension Forms.

List the name and address of each source of income, earned and unearned, which you received in excess of $2,000. If a publicly traded security is the source of income, the security need not be reported unless you or a member of your immediate family has an interest in the business organization.

Name Address Self Spouse Dependent Name 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Page 4

Page 5: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

Section II financial Information - Extension Forms. List the name and address of each source of fees and honorariums having an aggregate amount exceeding $250 received from any single source for personal appearances, speeches, or writing.

Name Address Self Spouse Dependent Name 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Page 5

Page 6: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

Section II financial Information - Extension Forms.

List the name and address of each source of gifts, reimbursements or prepaid expenses having an aggregate value exceeding $400 from any single source, excluding relatives.

Name Address Self Spouse Dependent Name 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Page 6 ��

Page 7: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

List the name and address of all business organizations in which an interest was held.

Name Address Self Spouse Dependent Name 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Page 7

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Extension Forms.
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Page 8: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

Section II financial Information - Extension Forms. List the address and a brief description of all real property in the State of New Jersey in which an interest was held.

Municipality/County Block Lot Qual.

Address (if applicable) % of Ownership Self Spouse Dependent Name

6. 7. 8. 9. 10

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Page 9: Enter the Local Government Served: Woodbridge Township Fire … · 2013-06-13 · Enter the Email address that you use as a local government officer (optional*). LGO Email: _____

State of New Jersey Department of Community Affairs Division of Local Government Services Local Finance Board

Local Government Ethics Law Financial Disclosure Statement

This Financial Disclosure Statement is required annually of all local government officers in accordance with N.J.S.A. 40A:9-22.1 et seq., the Local Government Ethics Law.

Year of Service: *The year that you are filing this statement

ELECTRONIC FILING RECEIPT

Read the instructions at the bottom of this page. Print this receipt; sign the receipt; and deliver the receipt to your local government representative.

Date and time your financial disclosure statement was submitted electronically: _______________________________________

Receipt Number: _______________________

Name of Local Government Officer:

First Name: ______________________________ Middle:_________________ Last Name:______________________________ Suffix: ____________

Local Government Served: _________________________________________

______________________________________ Signature of Local Government Officer

Please read these instructions:

1. The system will automatically populate the fields contained on this receipt except for your signature.

2. Your financial disclosure statement will not be considered FILED until you sign this receipt and deliver it to your local government representative (e.g., municipal clerk, county clerk, ethics board secretary, etc.). The receipt must contain the receipt number that is generated automatically by the Local Finance Board’s online filing system when you submit your FDS electronically. Do not submit this receipt to the Local Finance Board.

3. If you are a local government officer for more than one local government agency you must deliver a separate receipt (containing a different receipt number) to the representative of each such agency.

Tuesday 28 May 13 8:54 am

BrewGeorge

98976711

Woodbridge Township Fire District No. 7

2013

T.

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