The statement of substantial interests required by Kan. Stat. Ann. §§ 46-247 through 46-252 shall be dated and signed by the individual making the statement and shall contain substantially the following:

STATEMENT OF SUBSTANTIAL INTERESTS

___________________________________ (name)

(office or position of employment for which this statement is filed)

  ________________________________________

(address)

(body of statement in form prescribed by commission)

“I declare that this statement of substantial interests (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of all of my substantial interests and other matters required by law. I understand that intentional failure to file this statement as required by law or intentionally filing a false statement is a class B misdemeanor.”

______________  ___________________________________

  (date of filing)      (signature of person making the statement)