Fillable Carroll County Ethics Commission (Commissioners of Carroll County, Maryland)

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Carroll County Ethics Commission (Commissioners of Carroll County, Maryland)

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BROWSE COMMISSIONERS OF CARROLL COUNTY, MARYLAND (MD) FORMS

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Financial Disclosure Statement – Form 2
1
Carroll County Ethics Commission
c/o Office of Administrative Hearings
225 North Center Street
Westminster, Maryland 21157
410-386-2094
PRIOR YEAR FINANCIAL and GIFT DISCLOSURE STATEMENT, Form 2:
Qualifying Employees, Appointed Members of Boards and Commissions,
or Gift Reporting Only.
For the Prior Calendar Year Reporting Period, January 1 through December 31, 20__
STATEMENT IS DUE APRIL 30th for the Prior Year Reporting Period
PART I. IDENTIFYING INFORMATION.
FIRST NAME M.I. (if used) LAST NAME
AGENCY AFFILIATION (include department and unit where applicable)
CURRENT AGENCY ADDRESS (where you can be sent correspondence)
CURRENT POSITION OR OFFICE HELD WITH THE COUNTY, IF ANY (OR office for candidacy)
CONTACT INFORMATION:
Phone No.: E-Mail address:
PART II. SIGNATURE AND AFFIRMATION.
This financial disclosure statement describes all interests and related transactions and matters required to be
disclosed by Chapter 34, Ethics, of the Carroll County Code of Public Local Laws and Ordinances (“the Ethics
Ordinance”) with respect to the period indicated and pertaining to the person filing the statement.
I hereby make oath or affirm under the penalties of perjury that the contents of this financial disclosure
statement, including the Schedules attached hereto, are complete, true and correct to the best of my knowledge,
information and belief.
Signature of Person Filing: _________________________________
Date: _________________________________
_____ Check here if you wish to be notified if someone exercises the right to review your financial disclosure statement.
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Financial Disclosure Statement – Form 2
2
PART III. GENERAL INFORMATION AND NOTICES.
Privacy Notice
The Ethics Ordinance requires the collection of this information, which will be used primarily for public
disclosure and to determine compliance with the Ethics Ordinance. The information may be presented for
review or for copying, at the requestor’s expense, upon request by any person, including officials of state, local,
or federal government, who, upon presenting proof of identification, registers their name and address, along
with the name of the person whose statement is being reviewed. The subject has the right to review, correct, and
amend the record, and the right to know who has reviewed their disclosure statement, and principal home
addresses of candidates, officers, and employees will be redacted.
Standards of Conduct
The Ethics Ordinance includes definitions and standards of conduct applicable to all financial disclosure filers
including employees and elected and appointed officials. The standards address disqualification from
participation, prohibited secondary employment, prohibited ownership interests, misuse of position, prohibited
solicitation and acceptance of gifts, misuse of confidential information, post-employment limitations, prohibited
dealings with the County, procurement specifications assistance restrictions, and other matters. The law provides
for exceptions and exemptions under certain circumstances. If you have any questions about the Ethics
Ordinance, please contact the Carroll County Ethics Commission, c/o the Office of Administrative Hearings, or
see it on the website at https://ccgovernment.carr.org/ccg/attorney/code/ .
Enforcement Provisions
Failure to file or report information required by the Ethics Ordinance by the due date could subject a filer to
administrative penalties of $2.00 per day up to a maximum of $250.00 and other disciplinary action, including
a civil fine of up to $5,000.00 per day by the Circuit Court for Carroll County, or any other court having
proper jurisdiction for the purpose of enforcing compliance.
PART IV. SCHEDULES A THROUGH D.
ALL FILERS MUST CHECK EITHER “YES” OR “NO” TO THE INITIALQUESTIONS IN
SCHEDULES A, B, AND C.
IF “YES” PROVIDE FURTHER DETAIL USING ADDITIONAL
SHEETS IF NECESSARY. PLEASE PRINT LEGIBLY.
INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED TO YOU
.
Schedule A – Ownership or interest in, or liabilities to, corporations, partnerships, limited liability
companies, limited liability partnerships, sole proprietorships, or other business entities.
To your knowledge, during the reporting period, did you or a qualified relative as defined in the Ethics Ordinance
have an
interest of greater than 3% in, or annual
income of more than $1,000.00* from, or a financial obligation** to, a business
entity (corporation, partnership, limited
liability company (LLC), limited liability partnership (LLP), sole
proprietorship, other) that:
A.
Was regulated, licensed by, or doing business with, your department, board, or commission; OR
Had, or was negotiating, a contract of at least $5,000.00 with Carroll County or with your department, board, or
commission.
*in the current year, three prior years, or entitled to in a future year
**excluding consumer credit accounts, e.g. “credit cards”
______ Yes _____ No (go to Schedule B)
If Yes, answer each question below. If No, go to Schedule B on page 4.
Financial Disclosure Statement – Form 2
3
1. State the name, the type of entity, and principal place of business of the entity where interest or debt (retail credit
accounts need not be reported) was held:
Name/Type Entity: _____________________________________________________________________________
Principal Place of Business: ______________________________________________________________________
2. Name of Person Holding Interest: __________________________________________________________________
Relationship to Filer: ____________________________________________________________________________
3. If a liability or other debt (excluding retail credit accounts) indicate any collateral or other security held by
creditor: _____________________________________________________________________________
_____________________________________________________________________________________
4. If a non-publicly traded corporation, partnership, limited liability company (LLC), limited liability
partnership (LLP), sole proprietorship, or other business entity indicate the range of value of the interest
held or, if a liability, the amount owed:
_____ under $1,000
_____$1,000 to $9,999
_____$10,000 to $24,999
_____$25,000 to $49,999
_____$50,000 and over
OR
, if the dollar value of the interest held is not reasonably estimable, then state the percentage of ownership held in the
entity:
Percentage of Ownership: _______
%
5. If in a publicly traded entity, indicate either the number of shares or the range of the value of the interest:
Number of Shares: __________ OR
Value of Shares:
_____ under $1,000
_____$1,000 to $9,999
_____$10,000 to $24,999
_____$25,000 to $49,999
_____$50,000 and over
6. Did you transfer all or part of your holdings during the reporting period?
_____ Yes _____ No
If Yes:
6a. What portion of the interest was transferred? __________________________________________
6b. Date (month and year) the interest was transferred: _____________________________________
Financial Disclosure Statement – Form 2
4
Schedule B – Employment, Officers, Directorships, and Similar Interests.
Please list below:
1. Your employer (you need not repeat information reported on Page 1, Part I but you must report any
secondary employment or business), whether or not regulated by or doing business with Carroll County or
your department, board, or
commission. Please print legibly.
____________________________________________________________________________________
____________________________________________________________________________________
2. To your knowledge, whether you or a qualified relative as defined in the Ethics Ordinance is employed by, has an
interest in, is an officer, director, or trustee in, is negotiating a contract or prospective employment with, an entity
that has, or is negotiating, a contract of at
least $5,000 with Carroll County, or was regulated by your department
or agency.
_________________________________________________________________________________
_________________________________________________________________________________
3. Any other immediate family member as defined by the Ethics Ordinance employed by Carroll County.
_______ No, none of these apply to me (go to Schedule C)
______Yes, one or more of these apply to me.
If Yes, complete the information below:
A. Name of person holding position: __________________________________________________________________
Relationship to Filer (self, spouse, child(ren), etc.): _________________________________________________
Title of position held (circle or list):
Employee; Board Member; Officer (President, Vice-President, Director, Treasurer, Secretary, etc.);
Trustee; Other Position
__________________________________________________________________________________
__________________________________________________________________________________
Employer or Entity’s Name: __________________________________________________________
Principal Place of Business: ___________________________________________________________
Category of Entity (circle or list):
Employer; regulated by your board or commission; registered under the lobbying law; or involved with
sales and contracts with Carroll County or your board or commission.
__________________________________________________________________________________
__________________________________________________________________________________
B. Name of additional person holding position: _______________________________________________________
Financial Disclosure Statement – Form 2
5
Relationship to Filer (self, spouse, child(ren), etc.): _________________________________________________
Title of position held (circle or list):
Employee; Board Member; Officer (President, Vice-President, Director, Treasurer, Secretary, etc.);
Trustee; Other Position
__________________________________________________________________________________
__________________________________________________________________________________
Employer or Entity’s Name: __________________________________________________________
Principal Place of Business: ___________________________________________________________
Category of Entity (circle or list):
Employer; regulated by your board or commission; registered under the lobbying law; or involved with
sales and contracts with Carroll County or your board or commission
__________________________________________________________________________________
__________________________________________________________________________________
Schedule C – Gifts.
During the reporting period, to your knowledge, did you or someone on your behalf, receive any single gift with a
monetary value of more than $20.00, or a series of gifts from the same donor with a cumulative value of $100.00 or
more(refer to Chapter 34, § 34.10, Solicitation or Acceptance of Gifts), from or on behalf of, directly or indirectly, a
person or entity who does business with, or is regulated by Carroll County or your department, board, or commission, or
who is registered
or required to register before Carroll County under the lobbying section of the Ethics Ordinance?
______ Yes _____ No (go to Schedule D)
If Yes, answer each question below.
If No, go to Schedule D.
1. Who gave you the gift(s)? _______________________________________________________________
2. On what date(s) was/were the gift(s) given? ________________________________________________
3. What was/were the nature of the gift(s)? (Example: cash, restaurant meal, event tickets, membership or
subscription, etc.) _____________________________________________________________________
4. What was the monetary value of the gift(s)? ________________________________________________
5. If the gift(s) was/were given to someone else at your direction or behalf, identify the recipient of the gift(s):
____________________________________________________________________________________
Financial Disclosure Statement – Form 2
6
Schedule D – Other.
Please use this schedule to report any additional information not otherwise disclosed that may create a
conflict of interest, or the appearance of one, as defined in the Ethics Ordinance (refer to Chapter 34, § 34.08)
between your personal, family, employer, business, or investment interests and your duties as a
County employee.
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Carroll County Ethics Commission (Commissioners of Carroll County, Maryland)

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Completed 5 August 2020

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