EPERS-121 1/8/2013
ANNUAL REPORT OF EXTRA INCOME IN EXCESS OF $500 FROM A PUBLIC AGENCY
Campus Where Employed:
Filing for Year:
1.	Name of Employee:	ID#
2.	Source and Amount of Income in Excess of $500:
(a)	$
(Name of Public Agency)	(Amount in Excess of $500)
(b)	$
(Name of Public Agency)	(Amount in Excess of $500)
(c)	$
(Name of Public Agency)	(Amount in Excess of $500)
(d)	$
(Name of Public Agency)	(Amount in Excess of $500)
-VERIFICATION-
I do solemnly swear that the foregoing Annual Report of Extra Income in Excess of $500 filed herewith is in all things true and correct, and fully shows all the information required to be reported by me.

State of Arkansas

County of

Employee Signature

Subscribed and sworn to before me, a Notary Public, this the	day of	.

My Commission Expires:

Notary Public

NOTE: Employees file the Annual Report of Extra Income Statements by January 31 of each year with the Office of Human Resources of the campus where employed.

The Office of Human Resources of the campus where employed files the Annual Report of Extra Income Statements by February 10 of each year with the Office of the President, University of Arkansas System, 2404 North University Avenue, Little Rock, AR 72207.