Committee on ________________________
Witness Disclosure Requirement - "Truth in Testimony"
Required by House Rule XI, Clause 2(g)

Your Name:
1. Are you testifying on behalf of a Federal, State, or Local Government entity? Yes No
2. Are you testifying on behalf of an entity other than a Government entity? Yes No
3. Please list any federal grants or contracts (including subgrants or subcontracts) which you have received since October 1, 1999:




4. Other than yourself, please list what entity or entities you are representing:




5. If your answer to question number 2 is yes, please list any offices or elected positions held or briefly describe your representational capacity with the entities disclosed in question number 4:




6. If your answer to question number 2 is yes, do any of the entities disclosed in question number 4 have parent organizations, subsidiaries, or partnerships to the entities for whom you are not representing? Yes No
7. If the answer to question number 2 is yes, please list any federal grants or contracts (including subgrants or subcontracts) which were received by the entities listed under question 4 since October 1, 1999, which exceed 10% of the entities revenue in the year received, including the source and amount of each grant or contract to be listed:





Signature:____________________________ Date:___________________