02. |
Last year, I was an () ()
() with the |
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()
() () and the name and address of my
()
() () () ()
() () () was
Name:
Address:
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02.1 |
As an
/
/
last year, my job title/position was
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02.2 |
Last year, the name(s) of the () () ()
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,
,
, ,
,
of which I was a Member was(were)
Ag Commitee, Local Legislation, Education Policy |
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02.3 |
Last year in the above public position(s) in 02. thru 02.2 I earned:
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03. |
Other than any public position(s) listed in 02. thru 02.2, list any occupation, employment
or business
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(including self-employment) where you or your spouse spent at least 1/3
of your or your spouse's working time:
ALFA |
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03.1 |
The name and address of my employer, listed in 03. above,
was |
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Name:
Not Applicable
Address:
Not Applicable |
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03.2 |
I was SELF-EMPLOYED last year and the NAME and ADDRESS of my business was |
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Name:
Custom Floor Covering LLC.
Address:
923 Al Hwy 14 Elmore, Al 36125 |
03.3 |
From the occupations or businesses listed in
03., I, My Spouse and/or Dependents earned last year an aggregate of: |
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(More than $10,000)
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03.4 |
Last year, ( ()
() owned 5% or more of the stock in the firm(s) listed in (03.1 and/or 03.2)
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Not Applicable
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03.5
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Last year, ( ()
()
was a consultant and earned more than $1,000 from each firm listed in (03.1 and/or 03.2)
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Not Applicable
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03.6 |
Last year, ( ()
()
served as an () () () of the firm(s) listed in (03.1
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and/or 03.2) |
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Owner/President
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04. |
Information on Family Members: |
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Spouse Information:
Spouse Name |
Business or Employer |
Amber Dismukes
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ALFA
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Names Only of LIVING ADULT CHILDREN:
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N.A. |
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Names Only of LIVING PARENTS:
(No Maiden Names)
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William N. Dismukes Jr. & Venita C. Dismukes |
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Names Only of LIVING SISTERS/BROTHERS:
(No Maiden Names)
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Nikki Brothers Traci Cox Kayla Dismukes |
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Names Only of LIVING PARENTS OF SPOUSE:
(No Maiden Names)
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Randy Adkins Willa Adkins |
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05. |
OTHER INCOME INFORMATION ON YOU, YOUR SPOUSE AND DEPENDENT CHILDREN
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List total combined household income, in addition to what is listed in 02.3 thru
03.5, the names of each business income is derived from, and the income from each
business.
Applicable
OTHER HOUSEHOLD INCOME: not reported in 03.-03.6. Provide the name(s) of each SOURCE(s) of income | TYPE OF INCOME RECEIVED: Salary, Fees, Dividends, Profits, Commissions, Bank Interest, Other Compensation | Select Appropriate Income Amount |
Pleasant Hill Baptist Church | Salary | $10,000 - $50,000 |
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05.1 |
Last year did you earn more than $5,000 as an: (Select the applicable
one)
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Not Applicable
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05.2 |
Last year did you earn more than $1,000 but less than $5,000 as an: |
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(Select the applicable one)
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Not Applicable
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05.3 |
Last year, did YOU, YOUR SPOUSE or DEPENDENTS serve as: |
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(Select the applicable one)
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Not Applicable
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05.4 |
Name any business or subsidiary thereof in which YOU, YOUR SPOUSE, or DEPENDENTS,
jointly or severally, owned 5% or
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more of the stock or in which YOU, YOUR SPOUSE or DEPENDENTS served as an OFFICER,
DIRECTOR, TRUSTEE, or CONSULTANT where the service provides income of at least $1,000
and less than $5,000; or at least $5,000 or more for the reporting period. |
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Not Applicable
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07. |
INDEBTEDNESS INFORMATION: Report debts owed to all businesses operating in Alabama**as
of December 31, of the reporting year. Include debts for YOU, YOUR SPOUSE and DEPENDENT CHILDREN.
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(**Doing
business in Alabama, regardless of where their home office is located or where you
mail your payment.) DO NOT INCLUDE indebtedness associated with HOMESTEAD - home in which you live. |
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Provide ACTUAL Number of Debts and Check Corresponding COMBINED Dollar Amount.
DO NOT list Debtor's Names or Accounts Numbers.
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TYPE |
How many do you OWE? |
How much do you OWE?
(Select one that relates to the combined total in each category)
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07.1 BANKS (include Credit Cards) |
3 |
Less than $25,000 |
07.2 CREDIT UNIONS and SAVINGS and LOAN ASSOCIATIONS (include Credit Cards)
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0 |
Not Applicable |
07.3 INSURANCE COMPANIES |
0 |
Not Applicable |
07.4 MORTGAGE FIRMS
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0 |
Not Applicable |
07.5 STOCKBROKERS or BOND FIRMS |
0 |
Not Applicable |
07.6 INDIVIDUALS or OTHER BUSINESS(ES) (include store cards) |
0 |
Not Applicable |
07.7 STUDENT LOANS |
4 |
$25,000 - $50,000 |
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